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| [[File:Mark_Hill.jpg|90px|left]] This historic 1916 textbook by Cullen describes the umbilical region.
| [[File:Mark_Hill.jpg|90px|left]] This historic 1916 textbook by Cullen describes the umbilical region.
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'''Links:''' [[Media:Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus (1916).pdf|PDF version]] | [https://archive.org/details/embryologyanatom00cull/page/n5 Internet Archive]


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{{Historic Disclaimer}}
{{Historic Disclaimer}}
=Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus=
=Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus=
 
[[File:Cullen1916 titlepage.jpg|thumb|300px]]
By  
By  


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==Contents==
==Contents==
{{Cullen1916 TOC}}
{{Cullen1916 TOC}}
 
<br><br>
# [[Book - Umbilicus (1916) 1|Embryology of the Umbilical Region]]
# [[Book - Umbilicus (1916) 1|Embryology of the Umbilical Region]]
# [[Book - Umbilicus (1916) 2|Anatomy of the Umbilical Region]]
# [[Book - Umbilicus (1916) 2|Anatomy of the Umbilical Region]]
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==List of Illustrations==
==List of Illustrations==
1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois 2
[[Book - Umbilicus (1916) Figures|Figures]]
 
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
1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus  and allantois


Length 21
2. A More Advanced Stage in the Formation of the Umbilical Region


23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm.
3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo


in Length 22
4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Showing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk


24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long 23
5. Sagittal View of a Human Embryo 5 mm. in Length


25. A Composite Representation of Abnormal Umbilical Structures, Based on the  
6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing the Umbilical Region


Work of Keibel, Lowy, and Others 24
7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length


26. A Composite Representation of Abnormal Umbilical Structures, Based on the
8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length


Work of Keibel, Lowy, and Others 24
9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in Length


27. A Composite Representation of Abnormal Umbilical Structures, Based on the
10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length


Work of Keibel, Lowy, and Others 24
11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length


28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left . . 25
12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm. Long


29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven
13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length


Months 25
14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm in Length as Viewed from within the Abdomen


30. Three Diagrams of the Umbilical Ring and Its Significance in the Development
15. Sagittal View of a Graphic Reconstruction of the Umbilical Region of a Human Embryo 5.2 cm. in Length 15


of Ventral Hernia 27
16. Intra-abdominal View of the Umbilical Region of a Human Embryo 6.5 cm. in Length


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


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


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


XVI LIST OF ILLUSTRATIONS
20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long


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


31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the
22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in Length


Embryo 5.5 cm. Long 28
23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm. in Length


32. The Umbilical Region, the Cord, and the Placenta at Term 29
24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long


33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term .... 32
25. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others


34. Normal Umbilicus according to Catteau 35
26. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others


35. A Type of Umbilical Region in the Adult, Viewed from Within 44
27. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others


36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within .... 44
28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left


37. The Umbilical Region of an Adult, Viewed from Within 45
29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven Months


38. Classic Type of Umbilicus 47
30. Three Diagrams of the Umbilical Ring and Its Significance in the Development of Ventral Hernia


39. Disposition of the Vascular Cords (Usual Type) 48
31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the Embryo 5.5 cm. Long


40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases 48
32. The Umbilical Region, the Cord, and the Placenta at Term


41. Vascular Cord Type, Noted 5 Times in 50 Cases 49
33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term


42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical
34. Normal Umbilicus according to Catteau


Ring 49
35. A Type of Umbilical Region in the Adult, Viewed from Within


43. Vascular Cords, Noted 3 Times in 50 Cases 49
36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within


44. Vascular Cords, Noted in 2 out of 50 Cases 50
37. The Umbilical Region of an Adult, Viewed from Within


45. Umbilical Fascia. Peritoneum in Place 52
38. Classic Type of Umbilicus


46. Umbilical Fascia and Umbilical Mesentery 52
39. Disposition of the Vascular Cords (Usual Type)


47. Reduplication of the Linea Alba. Peritoneum Removed 52
40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases


48. Atrophy of the Umbilical Fascia, Posterior View 53
41. Vascular Cord Type, Noted 5 Times in 50 Cases


49. Formation of a Mesentery. Peritoneum in Place 53
42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical Ring


50. Mesentery of the Urachus and of the Umbilical Arteries 53
43. Vascular Cords, Noted 3 Times in 50 Cases


51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place 54
44. Vascular Cords, Noted in 2 out of 50 Cases


52. Adipose Fringes in a Stout Subject. Peritoneum in Place 54
45. Umbilical Fascia. Peritoneum in Place


53. Peritoneal Diverticula. Peritoneum in Place 55
46. Umbilical Fascia and Umbilical Mesentery


54. Peri-umbilical Fossettes. Peritoneum in Place 55
47. Reduplication of the Linea Alba. Peritoneum Removed


55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Ab
48. Atrophy of the Umbilical Fascia, Posterior View
dominal Wall 57


56. Extra-abdominal Multilocular Fibrocystoma of the Ovary 5S
49. Formation of a Mesentery. Peritoneum in Place


57. An Extra- abdominal Multilocular Fibrocystoma 59
50. Mesentery of the Urachus and of the Umbilical Arteries


58. Superficial Lymphatics of the Umbilical Region 64
51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place


59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side 65
52. Adipose Fringes in a Stout Subject. Peritoneum in Place


60. The Umbilical Vessels about the Time of Birth 72
53. Peritoneal Diverticula. Peritoneum in Place


61. The Umbilical Vessels in the Adult 72
54. Peri-umbilical Fossettes. Peritoneum in Place


62. 63. Method of Treating the Umbilical Stump at Birth 98
55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Abdominal Wall


64. Nature's Method of Checking Bleeding from the Umbilical Arteries 107
56. Extra-abdominal Multilocular Fibrocystoma of the Ovary


65. An Umbilical Granulation 117
57. An Extra- abdominal Multilocular Fibrocystoma


66. The Gradual Atrophy of the Omphalomesenteric Duct 121
58. Superficial Lymphatics of the Umbilical Region


67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord . . 121
59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side


68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord 121
60. The Umbilical Vessels about the Time of Birth


69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia : . . 123
61. The Umbilical Vessels in the Adult


70. A Polypoid Outgrowth from the Umbilicus 129
62. 63. Method of Treating the Umbilical Stump at Birth


71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70 129
64. Nature's Method of Checking Bleeding from the Umbilical Arteries


72. A Diverticular Tumor at the Umbilicus 132
65. An Umbilical Granulation


73. A Glandular Tumor from the Umbilicus 132
66. The Gradual Atrophy of the Omphalomesenteric Duct


74. A Glandular Growth at the Umbilicus 133
67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord


75. Section in the Long Axis of a Small Umbilical Growth 134
68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord


76. Adenoma of the Umbilicus 135
69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia


77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord. 138
70. A Polypoid Outgrowth from the Umbilicus


78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord . . . 138
71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70


79. An Umbilical Polyp 139
72. A Diverticular Tumor at the Umbilicus


80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression 139
73. A Glandular Tumor from the Umbilicus


81. An Umbilical Polyp 140
74. A Glandular Growth at the Umbilicus


82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression .... 141
75. Section in the Long Axis of a Small Umbilical Growth


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


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


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


LIST OF ILLUSTRATIONS XV11
79. An Umbilical Polyp


Fia. Fage
80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression


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


85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach 150
82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression


86. Appearance of the Umbilical Depression in von Rosthorn's Case 152
83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus


87. Gastric Mucosa at the Umbilicus 153
84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Resembling those of the Pylorus


88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in
85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach


Fig. 87 154
86. Appearance of the Umbilical Depression in von Rosthorn's Case


89. Persistence of the Outer End of the Omphalomesenteric Duct 156
87. Gastric Mucosa at the Umbilicus


90. Atrophy of the Inner End of the Omphalomesenteric Duct 156
88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in Fig. 87


91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct 156
89. Persistence of the Outer End of the Omphalomesenteric Duct


92. Meckel's Diverticulum 159
90. Atrophy of the Inner End of the Omphalomesenteric Duct


93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus. . 160
91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct


94. An Abnormally Large Meckel's Diverticulum 161
92. Meckel's Diverticulum


95. A Meckel's Diverticulum with a Lobulated Extremity 161
93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus


96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface 162
94. An Abnormally Large Meckel's Diverticulum


97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment . . 163
95. A Meckel's Diverticulum with a Lobulated Extremity


98. An Accessory Pancreas in the Tip of Meckel's Diverticulum 163
96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface


99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel 164
97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment


100. A Diverticulum Tying Off a Loop of Small Bowel 165
98. An Accessory Pancreas in the Tip of Meckel's Diverticulum


101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum. . . . 166
99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel


102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a
100. A Diverticulum Tying Off a Loop of Small Bowel


Hole in the Mesentery of a Meckel's Diverticulum .170
101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum


103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel 171
102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a Hole in the Mesentery of a Meckel's Diverticulum


104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary 175
103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel


105. An Intestinal Cyst 176
104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary


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


with the Bowel 176
106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected with the Bowel


107. Volvulus of Meckel's Diverticulum 177
107. Volvulus of Meckel's Diverticulum


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


109. Intestinal Cysts in the Abdominal Cavity 182
109. Intestinal Cysts in the Abdominal Cavity


1 10. An Intramesenteric Cyst 183
1 10. An Intramesenteric Cyst


111. A Patent Omphalomesenteric Duct 190
111. A Patent Omphalomesenteric Duct


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


113. A Very Short Omphalomesenteric Duct 190
113. A Very Short Omphalomesenteric Duct


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


1 15. A Patent Omphalomesenteric Duct 192
1 15. A Patent Omphalomesenteric Duct


116. A Patent Omphalomesenteric Duct 193
116. A Patent Omphalomesenteric Duct


1 17. A Patent Omphalomesenteric Duct 197
117. A Patent Omphalomesenteric Duct


118. A Patent Omphalomesenteric Duct 197
118. A Patent Omphalomesenteric Duct


119. A Patent Omphalomesenteric Duct 202
119. A Patent Omphalomesenteric Duct


120. A Patent Omphalomesenteric Duct 205
120. A Patent Omphalomesenteric Duct


121. A Patent Omphalomesenteric Duct 206
121. A Patent Omphalomesenteric Duct


122. Part of a Patent Omphalomesenteric Duct 206
122. Part of a Patent Omphalomesenteric Duct  


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


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


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


126. A Patent Omphalomesenteric Duct 211
126. A Patent Omphalomesenteric Duct


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


128. A Patent Omphalomesenteric Duct 216
128. A Patent Omphalomesenteric Duct


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


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


131. A Patent Omphalomesenteric Duct of Large Diameter 224
131. A Patent Omphalomesenteric Duct of Large Diameter  


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


147. A Small Umbilical Concretion 249
147. A Small Umbilical Concretion


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


149. Cholesteatoma from the Umbilicus in Case 1 251
149. Cholesteatoma from the Umbilicus in Case 1


150. Cholesteatoma from Case 2 251
150. Cholesteatoma from Case 2


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


152. Enlargement of Fig. 151 252
152. Enlargement of Fig. 151


153. Subumbilical Phlegmon 262
153. Subumbilical Phlegmon


154. The Subumbilical Space 264
154. The Subumbilical Space


155. Paget's Disease of the Umbilicus 270
155. Paget's Disease of the Umbilicus


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


157. Paget's Disease of the Umbilicus 271
157. Paget's Disease of the Umbilicus


158. Paget's Disease of the Umbilicus 274
158. Paget's Disease of the Umbilicus


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


160. Syphilis of the Umbilicus 284
160. Syphilis of the Umbilicus


161. Atrophic Tuberculid Starting at the Umbilicus 286
161. Atrophic Tuberculid Starting at the Umbilicus  


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


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


164. Escape of Pleural Fluid from the Umbilicus 289
164. Escape of Pleural Fluid from the Umbilicus


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


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


167. Small Papilloma in the Umbilical Depression 365
167. Small Papilloma in the Umbilical Depression


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


169. Glands from a Small U\iisiLirALTuMOR 377
169. Glands from a Small Umbilical Tumor


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


171. Glands in a Small Umbilical Tumor 379
171. Glands in a Small Umbilical Tumor


172. Dilated Glands in a Small Umbilical Tumor 380
172. Dilated Glands in a Small Umbilical Tumor


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


174. Uterine Glands in an Umbilical Tumor 381
174. Uterine Glands in an Umbilical Tumor


175. Gland Hypertrophy in a Small Umbilical Tumor 382
175. Gland Hypertrophy in a Small Umbilical Tumor  


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


177. Uterine Mucosa in an Umbilical Tumor 384
177. Uterine Mucosa in an Umbilical Tumor


178. A Small Umbilical Tumor Containing Numerous Glands 388
178. A Small Umbilical Tumor Containing Numerous Glands


179. Glands in a Small Umbilical Tumor 389
179. Glands in a Small Umbilical Tumor


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


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


182. Adenomyoma of the Umbilicus 397
182. Adenomyoma of the Umbilicus


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


184. Appearance of the Carcinomatous Umbilicus After Removal 424
184. Appearance of the Carcinomatous Umbilicus After Removal


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


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


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


188. Adenocarcinoma of the Umbilicus 441
188. Adenocarcinoma of the Umbilicus


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


190. Secondary Carcinoma of the Umbilicus 443
190. Secondary Carcinoma of the Umbilicus


191. Telangiectatic Myxosarcoma of the Umbilicus 450
191. Telangiectatic Myxosarcoma of the Umbilicus


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


193. Myxosarcoma of the Umbilicus 451
193. Myxosarcoma of the Umbilicus  


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


195. A Telangiectatic Myxosarcoma 452
195. A Telangiectatic Myxosarcoma


196. A Case of Congenital Umbilical Hernia 460
196. A Case of Congenital Umbilical Hernia


197. An Amniotic Hernia 462
197. An Amniotic Hernia  


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
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  


199. A Serous Umbilical Hernia 469
199. A Serous Umbilical Hernia  


200. Freeing the Umbilical Hernial Sac from the Abdomen 472
200. Freeing the Umbilical Hernial Sac from the Abdomen


201. Closure of the Hernial Opening at the Umbilicus 473
201. Closure of the Hernial Opening at the Umbilicus


202. Closure of the Hernial Opening at the Umbilicus 474
202. Closure of the Hernial Opening at the Umbilicus


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


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


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


206. An Umbilical Cyst 478
206. An Umbilical Cyst


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


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
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


209. Exstrophy of the Bladder 483
209. Exstrophy of the Bladder


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


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


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


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


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


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


216. A Patent Urachus 497
216. A Patent Urachus


217. A Urachus Open from Bladder to Umbilicus 498
217. A Urachus Open from Bladder to Umbilicus


218. An Open Urachus 499
218. An Open Urachus


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


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


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


222. A Partially Patent Urachus 515
222. A Partially Patent Urachus


223. A Patent Urachus 517
223. A Patent Urachus


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


225. Portion of a Urachus Ten Times Enlarged 518
225. Portion of a Urachus Ten Times Enlarged


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


227. Spindle-Shaped Dilatations of the Urachus 520
227. Spindle-Shaped Dilatations of the Urachus  


228. A Small Cyst of the Urachus 532
228. A Small Cyst of the Urachus


229. A Patent Urachus 534
229. A Patent Urachus


230. A Multilocular Cyst of the Urachus 535
230. A Multilocular Cyst of the Urachus


231. Section of a Patent Urachus .' 536
231. Section of a Patent Urachus


232. Transverse Section of a Patent Urachus 537
232. Transverse Section of a Patent Urachus


233. A Small Cyst of the Urachus 538
233. A Small Cyst of the Urachus


234. A Diffuse Neuroma of the Bladder 542
234. A Diffuse Neuroma of the Bladder


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


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


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


238. Section of the Segment of Urachus Which Passed between the Bladder and the Cyst- wall, as Seen under a Low Power 552  
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
239. The Abdominal Contour in a Case of Very Large Urachal Cyst


240. A Urachal Cyst Turned Inside Out and Showing Papillary Masses, Particularly in the Lower Part of the Picture 559  
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
241. Infected Urachal Remains
 
242. An Infected Urachus Opening between the Umbilicus and Bladder 570


243. Urachal Cyst 576
242. An Infected Urachus Opening between the Umbilicus and Bladder


244. A Dilated Urachus Communicating with the Bladder 579
243. Urachal Cyst


245. Large Accumulation of Urine in a Partially Patent Urachus 579
244. A Dilated Urachus Communicating with the Bladder


246. An Infected Urachus Opening at the Umbilicus 580
245. Large Accumulation of Urine in a Partially Patent Urachus


247. A Patent Urachus Dilated in Its Middle Portion 580
246. An Infected Urachus Opening at the Umbilicus


248. Accumulation of a Large Quantity of Urine in a Urachal Pouch 581
247. A Patent Urachus Dilated in Its Middle Portion


249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac 584
248. Accumulation of a Large Quantity of Urine in a Urachal Pouch


250. A Phosphatic Deposit on the End of a Long Bone 585
249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac


251. A Dilated Urachus Communicating with the Bladder 598
250. A Phosphatic Deposit on the End of a Long Bone


252. Urachal Cyst 599
251. A Dilated Urachus Communicating with the Bladder


253. Urachal Cyst 603
252. Urachal Cyst


254. Urachal Cyst 603
253. Urachal Cyst


255. A Patent Urachus Containing a Vesical Calculus 625
254. Urachal Cyst


256. Carcinoma of the Patent Urachus 632
255. A Patent Urachus Containing a Vesical Calculus


257. A Multilocular and Malignant Cyst of the Urachus 637
256. Carcinoma of the Patent Urachus


258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus 638
257. A Multilocular and Malignant Cyst of the Urachus


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


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


261. Adenocarcinoma of the Urachus 642
260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus


262. A Papillary-like Area i.\ an Adkxocarcinomatous Cystofthe Urachus 643
261. Adenocarcinoma of the Urachus


263. Metastasis from Adenocarcinoma of the Urachus 644
262. A Papillary-like Area in an Adkxocarcinomatous Cystofthe Urachus  


264. An Umbilical Cyst 645
263. Metastasis from Adenocarcinoma of the Urachus


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


266. Giant-cells in the Wall of an Umbilical Cyst 646
265. \\ aj.i of an Umbilical Cyst


267. Tuberculosis of the Urachus 652
266. Giant-cells in the Wall of an Umbilical Cyst


268. An Area Suggesting a Tubercle 653
267. Tuberculosis of the Urachus
 
269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus 654


268. An Area Suggesting a Tubercle


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


==List of Plates==
==List of Plates==
[[Book - Umbilicus (1916) Figures#List of Plates|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 III. Umbilical Infections in the New-Born==
General considerations.
Autopsy findings.
Clinical history.
Gangrene.
An epidemic of erysipelas of the abdominal wall in new-born infants. Trousseau, 1844.
An epidemic of erysipelas and gangrene of the umbilicus. Meynet, 1857.
An epidemic of gangrene of the umbilicus. Bergeron, 1866.
Xon -puerperal erysipelas of the new-born infant. Yot, 1873.
Runge on wound infection of the new-born.
Mild disturbances in healing of the wound of the umbilicus.
Omphalitis.
Gangrene of the umbilicus.
Diseases of the umbilical vessels.
Erysipelas in the first days of life.
Septic pyemia and infection of the umbilicus of the new-born. Cohn, 1896.
Umbilical sepsis in the new-born occurring in the nursery and child's hospital, New York, during
1896. S. W. Lambert.
Tetanus in the new-born.
Treatment of the umbilical cord. Dickinson's method.
Care of the umbilical stump — a bacteriologic study. Adair.
Persistent vitality of the umbilical cord.
L'ntil the advent of asepsis, myriads of children succumbed to umbilical infection within a few days or a few weeks after birth. To give a thorough digest
of the literature of the subject here would be out of the question, and I shall confine
myself to a consideration of the more important articles bearing on the subject.
Meynet, in his monograph published in 1857, mentions the fact that Hippocrates drew attention to umbilical infections. He also refers to the writings of
Ambroise Pare, of Mauriceau in 1712, of Hamilton in 1785, of Underwood in 1786,
and of Billard.
Personally I have derived much information on the subject of umbilical infections from the articles of Trousseau (1844), Bednar (1850), Lorain (1855), Meynet
(1857), Bergeron (1866), Pollak (1869), Yot (1873), Nicaise (1881), Meyer (1891),
Runge (1893), Gremillon (1895), Lambert (1896), Cohn (1896), Dickinson (1899),
Hinsdale (1899), Pinkerton (1900), Tarnier and Budin (1901), Wassermann (1901),
Porak (1901), Maygrier (1901), Salge (1904), Porak and Durante (1905), and
Cumston (1905).
Umbilical infections may be frank or masked. Unmistakable evidences of
inflammation, such as redness, swelling, and discharge, may be present, or the umbilicus may show little or no evidence of disease, superficial healing occurring even
when an infectious process is going on in the underlying tissues.
The umbilical infections have been designated as erysipelas, puerperal fever of
the new-born, or gangrene, according to the different clinical manifestations ex
70
UMBILICAL INFECTIONS IN THE NEW-BORN. 71
hibited. They are all due to infection through the umbilicus, and are usually
caused by the same organisms.
AUTOPSY FINDINGS.
A careful study of the autopsy findings will not only give a clear idea of the
general condition, but will also permit a correlation of the various symptoms with
the avenues of infection concerned. Infection may occur before or at birth, but the
symptoms usually first appear at some time between the third and the eighteenth
day after birth.
Appearance of the Umbilicus. — -In some cases the umbilicus
looks perfect!}' normal; in others there is a small opening from which pus is seen
escaping; or the umbilicus is represented by a small ulcerated area. The tissue
surrounding the umbilicus is sometimes soft, sometimes red and indurated, and
occasionally, by gently stroking the abdominal wall from the symphysis upward,
one can express a few drops of pus from the umbilicus. This pus may be watery,
yellowish or greenish-yellow in color, the difference depending in large measure
upon the pathogenic organism present and the duration of the infection.
When we cut into the abdominal wall, we may find the umbilical vein and the
umbilical arteries perfectly normal, although the surrounding tissue is infiltrated.
The umbilical arteries and the umbilical vein as they appear at birth are seen
in Fig. 60. These vessels rapidly atrophy and become impervious cords, as indicated in Fig. 61.
Much controversy has arisen as to the mode of extension of the infection from
the umbilicus. Some authors claim that extension of the disease takes place through
the umbilical vein; others that the arteries are responsible for the dissemination
of the purulent process, and still others that the virus is carried by the umbilical
lymphatics. A careful study of the autopsy findings in numerous epidemics clearly
shows that in some epidemics the vein, in other epidemics the arteries, often showed
marked changes; in not a few cases, however, the arteries, vein, and lymphatics were
all implicated. Practically it matters little along which avenue the infection travels ,
the chief thing to remember is that, in the past, infection through the umbilicus
at birth has been very frequent and has led to most disastrous results. The umbilical arteries may show no change, or one or both may contain partially or completely organized clots. When it is infected, the vessel often contains purulent
material, and in some cases, as a result of the accumulation of pus, presents a fusiform swelling. The surrounding tissue in such cases often shpws a considerable
amount of edema or even a purulent accumulation. When the umbilical vein is
implicated, pus may be present in its umbilical portion; frequently, however, it
contains here an organized thrombus, but in the neighborhood of the liver is filled
with purulent material.
Implication of the Various Organs. — Liver. — When the
umbilical vein is partially or completely filled with pus, it is only natural that the
liver should be implicated. Sometimes the organ is a little enlarged. It may
contain small abscesses, and an acute inflammation of the veins of the hepatic
lobules may be noted. As a result of the extension of the infection a subphrenic
abscess may develop.
Lungs. — In some epidemics the lungs have shown marked changes. Some
72
THE UMBILICUS AND ITS DISEASES.
times these took the form of a hemorrhagic pneumonia, multiple hemorrhagic
foci being scattered throughout the lung. In other instances pulmonary infection manifested itself by blackish-green
patches of gangrene, and in some cases
scattered multiple abscesses as large as
hazel-nuts were found in the lungs. As
would naturally be expected, when
these foci of consolidation had reached
the surface of the lung, a pleurisy had
developed.
Heart. — Only slight changes
are the rule, but purulent endocardial
exudates have been noted associated
with a purulent pericarditis. In such
cases the blood from the heart has been
found to contain the organism responsible for the infection.
Kidneys. — Signs of a parenchymatous nephritis are sometimes
demonstrable.
Fig. 60. — The Umbilical Vessels about the Time
of Birth.
The umbilical vein (a) conveys placental blood to
the fetus. At a' it is joined by the portal vein, the combined trunk forming the ductus venosus. The arrows
indicate the course of the blood to the heart. The blood
passes from the fetus back to the placenta through the
two umbilical arteries <b and V), only the left of which is
clearly seen in the picture. It was chiefly through the
umbilical vein and the umbilical arteries that fatal infections of the child were so prone to occur in former
years. As will be noted in Fig. 61, these vessels become
obliterated after birth.
Fig. 61. — The Umbilical Vessels in the Adult.
As soon as the cord is tied the usefulness of the umbilical arteries and of the umbilical vein is over, and these
vessels become gradually transformed into solid cords.
a-a' represents the situation of the obliterated umbilical
vein from umbilicus to portal vein. The ductus venosus
has vanished. The location of the left umbilical artery is
indicated by the dotted line b-b'. The artery is obliterated from the umbilicus to the point of origin of the superior vesical artery. The umbilical artery is the continuation of the anterior division of the internal iliac.
UMBILICAL INFECTIONS IN THE NEW-BORN. 73
Brain. — Occasionally a meningitis or multiple cerebral abscesses are present.
Peritoneal Cavity. — 'As a rule, there is little or no peritonitis
unless there has been an extension of the infection directly through from the umbilicus to the peritoneum by continuity.
Terminal Infections. — Sometimes one of the first signs may be a
circumscribed patch of erythema on the abdomen, buttock, cheek, eyelid, or the
ear, or, in fact, on any part of the body. Swelling in the abdominal wall, between
the umbilicus and symphysis, together with swelling of the testicle, with or without
abscess formation, is not uncommon.
Infection of various joints — of the phalangeal joints, wrist,
elbow, shoulder, hip, knee, ankle, and toes— has been noted in some epidemics.
In such cases, when the process has been a very rapid one, a terminal joint has
been found at autopsy to be the only one implicated, whereas when the disease had
been of some duration, the pathologic process had extended toward the trunk. In
some cases gangrene of the extremities had developed and the joints showed disorganization.
In the early days bacteriologic examinations, of course, were not made, and fortunately at the present time epidemics of umbilical infection are rare. The organisms most commonly found are Streptococcus, Staphylococcus aureus and albus,
and Bacillus coli. Occasionally Bacillus pyocyaneus has been noted. Tetanus
will be discussed elsewhere.
CLINICAL HISTORY.
As a rule, the chMd appears well for several days after birth, but then commences to lose weight. At a period varying from three to eighteen days it grows
restless and cries frequently. Its symptoms strongly suggest an intestinal upset,
but an examination of the umbilical region will often clear up the diagnosis. On
the other hand, the umbilicus may appear to be perfectly normal. As the infection
advances the child will in some instances develop a fatal pneumonia or a cerebral
abscess; or a blush on the buttock, abdomen, cheek, or elsewhere, or the swelling
of an index-finger or of one of the smaller joints, may be the first indication of a
general infection. In such cases one should always think of the umbilicus, and once
more carefully examine it, since we know that in the vast majority of cases this is
the avenue through which the infection occurs.
There is no definite set of symptoms; the clinical phenomena will depend in a
large measure upon the organ or organs of the body that are secondarily infected.
If the infection be of a mild grade, the child may gradually recover, but where
"massive infection" exists, great depression soon develops and the patient speedily
dies.
GANGRENE.
In the description of the autopsy findings and clinical picture of umbilical infections I have purposely omitted a description of gangrene of the umbilicus, preferring to consider it separately, although it is only another manifestation of an
umbilical inflammation and is undoubtedly caused by the same organism or organisms. In the former cases the local manifestations of the disease are often overshadowed partly or completely by those of the general infection, whereas in cases
of gangrene the local condition receives the greater part of the physician's attention.
74 THE UMBILICUS AND ITS DISEASES.
Several days after labor the skin in the umbilical region may be slightly raised
and assume a yellowish tinge, while the tissue surrounding it shows some reddening
and is indurated. This slough may come away, leaving a very superficial skin
wound. In many cases, however, the area gradually increases in size and the central portion of the slough becomes black, while along its edges there appears a
narrow, violet-colored line — the line of demarcation. Liquefaction takes place,
and the slough gradually comes away in pieces .
If the septic absorption be abundant, the child soon shows signs of toxemia and
death may rapidly follow. Bednar, in 1852, when this malady was relatively common, gave a most vivid description of the local conditions in the severe cases. He
spoke of the grayish-black or gray appearance of the umbilical slough, and of the
surrounding zone of inflammation, which was often as large as a dollar or even as
the palm of a hand. In such cases the blood-vessels were filled with dark thrombi
or with pus. The peritoneum in the vicinity was often of a dirty red color, markedly
injected, and covered with a plastic, purulent exudate; and in some cases peritonitis
developed. The general symptoms were naturally those of septic absorption, and
in the severe cases the patients rapidly succumbed.
In rare instances the slough involves the entire thickness of the abdominal wall,
and when it comes away, the intestines escape through the break. A most interesting case of this character was reported by Pollak. The patient (J. W.) was
well developed, and, when eight days old, weighed 63^ pounds. When six weeks
old he became very restless, and gangrene developed at the umbilicus. The tissue
surrounding the umbilicus showed a grayish-brown appearance, was soft and foulsmelling, and surrounded by a zone of redness. The abdomen was markedly distended. By the end of two days the area of gangrene had become the size of a
four-kreuzer piece. On the fifth day the gangrenous patch was as large as a thaler,
and the child refused the breast and appeared to be dying. It revived, however,
and two days later the abdomen opened at the umbilicus, a loop of bowel protruded, and a perforation occurred on the following day. The child died on the
ninth day of the disease. By this time the slough had come away completely and
there was a granulating surface.
After this brief discussion of the autopsy and clinical findings in cases of
umbilical infection in the new-born, I shall briefly refer to some of the former
epidemics, and describe somewhat fully some of their more interesting features,
as from these one can obtain a graphic picture of the unfortunate conditions that
formerly existed.
AN EPIDEMIC OF ERYSIPELAS OF THE ABDOMINAL WALL IN NEW-BORN INFANTS.
Trousseau, in 1844, reported a most disastrous epidemic that occurred in the
months of September and October, 1843. As will be noted, the erysipelatous inflammation in most of the cases attacked the abdominal wall, and in nearly all
instances there was an infection of the umbilicus or of the tissues immediately
beneath it.
In the beginning of his article Trousseau quotes Paul Dubois as saying that
he has never seen an infant recover from erysipelas during the first month of life.
After discussing the subject of erysipelas in the nursing infant, he gives a short
UMBILICAL INFECTIONS IN THE NEW-BORN. 75
report of a family of 19, including the servants, in which, in the space of six weeks,
10 people were affected by what appeared to be a form of erysipelas. He then gives
reports of several cases in detail.
Case 1 . — A boy, forty days old, developed signs of acute peritonitis associated with erysipelas. He died forty hours after the commencement of the
trouble. There was some slight suppuration at the umbilicus.
Case 2 . — When the cord came away on the fifth day, there remained at the
umbilicus a small area of suppuration with a surrounding zone of inflammation.
The health of the child at that time, however, was perfectly good. Erysipelas
developed on the twentieth day and the child died.
Case 3 . — A boy, eight days old, was affected with erysipelas. Applications
of mercurial ointment were made, but death took place eight days after the onset
of the disease. The umbilicus was the seat of an abundant suppuration and the
erysipelas had spread to the lower extremities.
Case 4 . — A boy, three weeks old, was suffering from phlegmonous erysipelas
and developed peritonitis. Death took place fifteen days after the onset of the
disease. The mother had a grave puerperal sepsis. A great many of the women
had died from puerperal sepsis in the hospital about the time of this patient's birth.
There was an erysipelas of the scrotum and of the symphysis, but the umbilicus
showed no evidence of reddening or of suppuration. At autopsy the cellular tissue
of the abdominal wall was found infiltrated with pus; there was a seropurulent
fluid in the peritoneum, and a false membrane on the convex surface of the liver.
Trousseau says that these observations are sufficient to show the extreme
gravity of erysipelas, in the new-born.
AN EPIDEMIC OF ERYSIPELAS AND GANGRENE OF THE UMBILICUS.
In reporting this epidemic in 1857, Meynet points out that the disease was
readily divisible into two groups. In the one an erysipelatous inflammation of the
umbilicus was the dominant symptom; in the other, ulceration or gangrene of the
umbilicus.
Zinc chlorid, in the form of Canquoin's paste (zinc chlorid with wheaten flour),
yielded most unusual results in this epidemic.
Meynet, in the beginning of his article, draws attention to the remarks of
Pare, who regarded this malady as being so grave that he warned the surgeon not
to raise a hand for fear that he might be accused of causing the death of the infant.
Following a lucid description of the literature on the subject, he gives an epitome
of two epidemics. One began in April, 1856, and lasted throughout May and a part
of June. Early in December of the same year a second epidemic occurred. It was
one of great severity, and lasted until January of the following year. It was similar
to the first epidemic in that it ceased abruptly as a result of the preventive measures
which were employed.
Meynet says that after the epidemic and up to the month of March, when he
left the service, they had not had another case in the Infirmary in Paris. During
the first epidemic puerperal fever was not prevalent, but in the second the umbilical
infection in children coexisted with puerperal fever in women.
Symptoms. — The progress and the termination of the disease were the same in
both epidemics.
76 THE UMBILICUS AND ITS DISEASES.
Of 230 infants received at the Maternity during the month of April and to the
end of June of 1856, 17 were born dead, leaving 213 living infants. Of this number,
53 were attacked — 14 in the month of April, 25 in the month of May, and 14 in the
month of June. Thirty-six of the infants died.
In the second epidemic, which occurred in December and January, 175 children
were delivered at the Maternity: 12 were born dead, 163 living. Of this number,
36 were attacked and 8 died. Meynet says nothing is more variable than the period
of incubation in cases of this disease. In some, symptoms were noted a few hours
after birth, in others about the fourth or fifth day. Only rarely did they appear
after the eighth day. In these last cases the cord was black and horny, but had not
separated from the umbilicus.
In both epidemics he describes the condition as nothing more than an exaggeration of an ordinary phlegmon, by which he means a moderate inflammation of the
umbilicus accompanied by the dropping off of the cord. This inflammation was
accompanied by ulceration at the base of the cord, and a more or less abundant
suppuration, which retarded the dropping off of this appendage and the cicatrization of the umbilicus. Very soon this inflammatory condition became more intense, and the moderate inflammation was succeeded by an intense phlegmon.
In the umbilical region could be noted a redness which became more and more
marked; it disappeared upon pressure, and formed a circle around the umbilicus.
At the same time there appeared numerous circumscribed swellings. The tissue
around the cord became ulcerated, the margins were undermined, the ulceration
extended deep downward, and the surface of the depression was covered with a
false membrane, grayish white in color and soft, from which a bloody, purulent,
thick, fetid discharge frequently exuded. The ulceration increased in size. The
reddish zone also became larger and took on the color of wine-lees. The swelling
became more and more voluminous and was hard. In a large number of cases the
red areola was surrounded by a circle of small vesicles more or less confluent, dirty
white, round, not umbilicated, and containing a seropurulent fluid. Sometimes
there was a circle of erysipelatous redness, surrounded by numerous blebs containing
a serosanguineous fluid. The blebs ruptured and exposed the skin, which readily
became involved in the area of ulceration.
The general condition of the child was not affected at the beginning, but after a
time the appetite diminished and was entirely lost. The child refused the breast
or any nourishment and cried continuously. Its skin became dry and withered.
The pulse was accelerated, and the general satisfactory condition of the infant
was replaced by emaciation. The face was drawn from severe suffering, and the
nasolabial folds became hollow; the tongue was dry and red at the tip; in some
cases it showed a thick coating, and occasionally a coincident thrush. The abdomen was distended and an obstinate constipation, but more frequently a diarrhea,
was present. The case progressed with alarming rapidity, and the little infant often
died in from thirty-six to forty-eight hours. Sometimes the course of the disease
was more gradual, but even then a fatal termination was frequent.
In other cases the clinical course was different. The cord was sometimes friable
and soft; sometimes it was dry or ready to drop as the result of ulceration. The
ulceration commenced at the margin of the cord, and proceeded from the center to
the circumference. It occupied all the bottom of the cavity, and extended in different directions, sometimes destroying the attachment to the skin. It followed
UMBILICAL INFECTIONS IN THE NEW-BORN. 77
along the umbilical vessels for quite a distance, transforming their interior surface
into a vast focus of suppuration. Sometimes, on the contrary, it would jump over
the cutaneous external ring and invade the abdominal wall, spreading over a large
area. In form it was also irregular; its margins were sometimes undermined.
Most frequently, however, its surface was dull, of a grayish-violet color, and exhaled
a gangrenous odor; or it was covered with a false membrane, which was thick, soft,
and very adherent — the condition being analogous to what is known as "hospital
gangrene." In such a case the reddish, circular area was less circumscribed, but
livid in color. The swelling was less pronounced, the pustular eruption sometimes
lacking. With an increase in the severity of the general symptoms the infant
would pass first into a state of great agitation, but speedily into a condition of collapse and death would ensue.
Duration. — The duration of the disease was extremely variable. In certain cases
the suffering lasted from thirty-six to forty-eight hours; in others it was prolonged
to three or four days, but rarely longer.
Recovery. — Where recovery took place, it was slow. The inflammation diminished in intensity, the ulceration ceased to spread, the false membrane disappeared
gradually, and granulation tissue took its place. The secretion gradually became
of a healthier nature, and the redness and tumefaction disappeared little by little.
At the same time the general symptoms improved, the skin recovered its moisture
and lost its heat; and finally, after a more or less prolonged convalescence, the
infant recovered.
Meynet says that it is easy to see that the disease presents two distinct forms :
one is characterized by the erysipelatous inflammation and by swelling of the
subcutaneous cellular tissue, with a pustular eruption and ulceration. The other,
on the contrary, commences as an ulceration and presents the appearance of hospital gangrene. In several cases he observed an extensive ulceration which always
occupied the center of the surface of the abdomen.
In all of Meynet's 18 autopsies the extent of putrefaction was carefully observed.
Twenty-four hours after death the abdominal walls showed a greenish tint, the
epidermis was raised as if undergoing maceration, the reddish color of the erysipelas
was transformed into a blackish tint, and the abdomen was distended. Beneath
the skin the cellular tissue around the umbilicus was thickened, indurated, more
dense, and more friable. This induration was due to infiltration into the matrix
of the tissue, sometimes with an amorphous plastic material, sometimes with serum.
Meynet says that he never found this process localized as a distinct focus, and
he draws attention to the fact that his results coincide with those of Trousseau and
Bouchet. The thickness and induration became more marked toward the margin
of the' umbilical ring. At this point the peritoneum sometimes presented a circumscribed redness, evidently clue to vascular arborization, but in only two instances did Meynet find a well-developed general peritonitis.
In these two cases the peritoneum showed marked reddening and there was a
false membrane, slightly adherent to the convex surface of the fiver and spleen, and
between the intestinal convolutions. In the two cases of general peritonitis there
was phlebitis of the umbilical vein. The lumen of this vessel between the umbilicus
and its termination was filled with thick, whitish pus; the inner surface of the vein
was bright red, and did not present any ulceration. The inflammation terminated
abruptly at the ridge at the portal vein.
78 THE UMBILICUS AND ITS DISEASES.
In 10 cases there was a partial peritonitis, limited to the umbilical region. In
three instances Meynet found inflammation of the umbilical arteries, with purulent
material in their lumina. These arteries, which were formerly permeable from the
umbilicus to the bladder, contained pus for a distance of from 1 to 2 cm.; in the
remaining portion of their course they had been obliterated by fibrinous clots.
In 6 cases he found only serous infiltration and seropurulent infiltration in the cellular tissue beneath the umbilicus.
In a resume (p. 24) he again says there were two distinct forms of the disease
noted in these epidemics, the one corresponding to erysipelas of the new-born, and
characterized by its tendency to invade large surfaces; the other by malignant
ulceration with a tendency toward putrefaction and gangrene.
It may be of interest to refer to the notes on the individual cases in these two
epidemics.
The observations are divided into two groups — those with erysipelatous inflammation and those showing a marked tendency to ulceration.
Group i.
Case 1 . — The onset was marked on the third day after birth by an erysipelatous inflammation, followed by ulceration. Death occurred three days later.
At autopsy there was a moderate degree of peritonitis; nothing in the umbilical
vessels.
Case 2 . — The child was stricken on the seventh day after birth. At the
beginning ulceration was noted. The disease lasted three days and was fatal.
There was general peritonitis and phlebitis of the umbilical vein.
Case 3 . — The onset was noted six days after birth. There was an erysipelatous inflammation followed by ulceration. The actual cautery was used.
The child died on the eighth day.
Case 4 . — Invasion on the fourth day; erysipelatous inflammation followed
by ulceration. The actual cautery was employed. Death on the seventh day.
Case 5 . — The umbilicus was invaded on the third day. Ulceration took
place. The actual cautery was used, but the child died three days after the beginning of the inflammation.
C a s e 6 . — Invasion on the second day. The erysipelatous form was noted
at the beginning, and later ulceration. The actual cautery was used. Death took
place on the third day of the disease. At autopsy a general peritonitis and inflammation of the umbilical vein were noted.
Case 7 . — Invasion on the fourth day. Erysipelas of the umbilicus followed
by ulceration. The actual cautery was ineffectual. Later zinc chlorid paste was
used. Convalescence by the fifteenth day.
Case 8 . — Invasion on the third day. Ulceration took place. Cauterization with zinc chlorid paste; the child was convalescent in seven days.
Case 9 . — Invasion on the fifth day, with ulcer formation. Zinc chlorid
was employed; convalescence by the tenth day.
Case 10 . — Invasion on the second day. Erysipelatous form. The wound
was cauterized with zinc paste and the child was convalescent by the ninth day of
the disease.
UMBILICAL INFECTIONS IN THE NEW-BORN. 79
Group 2. — In "Which Ulceration was the Prominent Feature.
Case 1 . — Invasion on the third clay. Erysipelas followed by ulceration.
The wound was cauterized with zinc paste. The child was convalescent by the
eighth day of the disease.
C a s e 2 . — Invasion twelve hours after birth. Erysipelatous form. Wound
cauterized 'with zinc paste. Healing by the ninth day of the disease.
Case 3 . — Invasion on the fourth day and an ulcer formed. The wound was
cauterized with zinc paste, and by the ninth day the child was convalescent.
Case 4 . - — Invasion on the third day. Erysipelas followed by ulceration.
Cauterization with zinc paste; the child was convalescent by the eighth day. The
mother of this child had puerperal fever.
Case 5 . — Invasion on the fourth day. Erysipelas with coexisting ulceration. Cauterization with zinc paste; by the seventh day the child was convalescent. The mother had a severe, almost fatal, attack of puerperal sepsis.
Case 6 . ■ — ■ Invasion on the second day. Erysipelas was first noted. Convalescence had ensued by the seventh day after the use of zinc paste.
Case 7 . ■ — ■ Invasion on the seventh day. There was erysipelas in the beginning, and the cord was still adherent. There was ulceration of the outer part
of the wound, and in this case the child had thrush. Zinc chlorid paste was employed, and healing had taken place by the tenth day after the commencement of
the inflammation. The mother was suffering from a severe puerperal infection.
Case 8 . — Invasion on the second day. Erysipelas of the umbilicus was soon
followed by ulceration. The wound was cauterized with zinc paste, but death
occurred on the sixth day of the disease. The mother had a moderately severe
attack of puerperal infection.
Case 9 . — Invasion on the third day. There was ulceration without apparent gravity at the beginning; the wound was cauterized with zinc paste on the
third day, but death took place that evening.
Case 10. — On the third day there was ulceration of a grave character; at
the base of the cord tumefaction and redness. The actual cautery was used, and
four days later zinc paste was applied. Convalescence ensued on the seventh day.
Case 11. — L., born January 10th. The mother left the hospital in good
condition on the eighth day, but the child on the third day after birth showed a
reddish, erysipelatous tumefaction at the umbilicus. There was a pustular erysipelas, with ulceration at the base of the cord, but no general symptoms. The
wound was cauterized with zinc paste. The child recovered and was sent to the
country on the eighth day.
Case 12. — J. M., born January 12th. The mother had mastitis. The
child was attacked on the third day with erysipelas and swelling at the umbilicus.
The cord had ulcerated to some extent at its base. It was dry and adherent. The
cord was cut, and the cautery applied to the surfaces. The child was well on the
twenty-second of January.
Case 13.- — A. P., born January 6th. The mother left the hospital on the
eighth day in good condition. The child was attacked on the fourth day with an
erysipelatous condition at the umbilicus, with ulceration of a serious aspect. Immediate cauterization with zinc paste; recovery by the ninth day.
Case 14. — Charles V., born January 8th. Mother in good condition.
80 THE UMBILICUS AND ITS DISEASES.
The child was attacked on the second day after birth. There was erysipelas, with
tumefaction in the umbilical region. On the third day ulceration of a severe nature
was noticed in the base of the cord. The wound was cauterized with zinc paste.
Convalescence ensued on the seventh day after the beginning of the disease.
Case 15. — -M.S., born January 15th, was attacked on the fourth day with
marked ulceration of a severe character. There was a pseudomembrane with
elevated margins, and the wound showed an erysipelatous character. It was
cauterized on January 20th, and zinc paste applied. The child recovered and was
taken to the country on January 27th.
Case 16. — D., born January 21st. He was a fine, healthy child, but on
the second day after birth developed an erysipelatous inflammation of the umbilicus. The cord was soft. On January 24th the ulceration involved the skin
margins in the umbilical region. The wound was cauterized with zinc paste, and
he was convalescent by January 28th.
Meynet said that he could multiply these examples, but that those given were
sufficient to show the gravity of the disease. He dwelt upon the efficacy of cauterization with the chlorid of zinc paste.
AN EPIDEMIC OF GANGRENE OF THE UMBILICUS.
Bergeron discusses an epidemic which occurred in the Hospital Necker in 1865.
Before taking up the description of his cases he discusses the writings of Hippocrates, Ambroise Pare, Mauriceau, Hamilton, Underwood, Billard, Trousseau, and
Meynet. In speaking of his own cases Bergeron regrets the incompleteness of the
pathology. In 11 cases he had 9 autopsies which yielded the following results.
The portion of the gangrenous skin was black, moist, and situated at a lower level
than that of the surrounding normal skin. It was separated from the normal skin
by an irregular, slightly reddish zone. Sections through the affected part showed
in the center a dry layer, which was easily detachable from the underlying tissue
and was held in place by several filaments at its periphery. It was 2 mm. in thickness, and its margins seemed to conceal an underlying part of normal skin. The
gangrene was always superficial, and penetrated only through the skin. The vessels
surrounding the slough were obliterated, but in no case was phlebitis found in the
umbilical veins ox inflammation of the umbilical arteries. One important point
was that the peritoneum was always healthy except in one case (Case 3), in which
it was injected. These observations differ from those reported by Lorain. In
the epidemic in 1865 Bergeron did not observe the second form of the disease
noted in the one reported by Meynet.
Symptoms. — Gangrene of the umbilicus in the beginning usually presents a
benign aspect, the only sign being a little redness at the umbilicus and at the inguinal folds. Sometimes there are fretfulness, a mild diarrhea, and a slight cough.
The infant refuses the breast, and death soon follows, as a rule peacefully, without
convulsions, but with marked pallor of the skin everywhere.
The local manifestations present certain special points of interest. The lesion
usually appears at the umbilicus before the separation of the cord. There is moderate redness, or more frequently an erysipelatous erythema, which invades usually
at the onset the region which is later occupied by the gangrene. By the following
day the cellular tissue has become indurated. Later, as a consequence of the mor
UMBILICAL INFECTIONS IN THE NEW-BORN. 81
tification of the skin, there appears in the inguinal fold or in a fold of the skin surrounding the cord a yellowish plaque which has a tendency to extend. It is more
or less bright in the center, and moist at the margins. The yellowish color sometimes changes to black in the center, and the black usually extends to the margin
of the lesion in the last minutes of life. The skin surrounding this part is of a light
violet color for a distance of 1 mm. The violet border follows all the contours of
the slough, which is more or less irregular.
In the more favorable cases this violet strip disintegrates. The slough softens,
separates at the margins, and comes away in small pieces, but is never detached in
a single piece. It leaves behind it a more or less deep ulceration, covered over with
granulation tissue, which is sometimes very pale. The depth of the ulcer varies.
In certain cases it extends through the entire thickness of the abdominal wall, so
that it would appear that the intestine must come out. This, however, does not
occur. As a matter of fact, the necrosis is only skin deep. In more severe cases,
which are very rapidly fatal, sloughing takes place not only at the umbilicus but
also in the inguinal fold. Finally, occasionally sloughs occur over the malleoli,
the scapulae, from the ears or from any region where the skin is exposed to continued rubbing or to humidity.
In one of Bergeron's cases there was gangrene of the eyelids which occurred
very early. He says that the abdomen was never distended, and, if there was
swelling, its point of departure was chiefly in the abdominal wall, not in the cavity
of the abdomen itself. The final symptoms were always those of profound weakness. Seeing the children in the last day of the disease, one would have been led
to think that they had been ill for a long time.
Diagnosis. — It 'is hardly possible to confound gangrene of the umbilicus with
any other affection. The prognosis is always very grave.
Etiology. — Bergeron says that gangrene of the umbilicus was epidemic, and he
thinks it possible that the virus of gangrene belongs to the same family as that
producing erysipelas, puerperal fever, and analogous conditions. In the beginning
of the year 1865 there were in the Hospital Necker 8 cases of puerperal fever with
3 deaths. Several days after, 5 children showed multiple abscesses, and 3 deaths
followed. Of the 5 infants, 4 had been with their mothers before the puerperal
fever appeared. For the greater part of 1865 the sanitary state of the lying-in
ward was excellent; only 4 children had erysipelas of the cord. In the later
months of this year, however, 11 were attacked and only 2 recovered.
Case 1 . — Simple Erysipelas of the Umbilicus; Recovery. — The girl was born May 26, 1865. On June 5th the mother noticed
a small area of redness around the umbilicus, and the physician found a small round
ulcer from which there was a slight suppuration. There was a reddish thickening
which extended for several centimeters around the umbilicus. The umbilicus had
cicatrized by about the fifteenth of July.
Case 2. — Gangrenous Erysipelas of the Umbilicus. —
Gangrene of the skin at various points. Death after fifteen days' illness. The
child was born October 23, 1865. The mother nursed the child, but did not have
much milk. On November 3d a little redness was noted at the level of the umbilicus. The child was brought to the physician on November 5th. The cord had
come away four days before, and at the point of detachment was seen an elevation
and some swelling. In the umbilical depression was a sort of yellowish, adherent
7
82 THE UMBILICUS AND ITS DISEASES.
membrane, which in reality was a slough of the superficial portions. The skin
was loosened and rolled up at the margins. By the seventh the plaque at the
umbilicus had increased in size, and the redness occupied a circle about 2 cm. in
diameter. The slough was yellowish, 6 by 3 mm., and arranged transversely.
The small patch in the left inguinal region had a yellowish point about the size of a
pin-head. The right inguinal region commenced to show a slight erythema. On
the ninth the umbilicus was in the same condition, but in the left inguinal
region was a yellowish discoloration, about 4 mm. in diameter, and in the right
inguinal region a small superficial ulcer without a slough. By the tenth the
umbilical lesion had increased, and the epidermis was implicated over an area 3 cm.
in diameter. The yellowish slough was 1 cm. in its transverse diameter and 0.5
cm. from above downward. The slough in the left inguinal region had increased,
and the area of ulceration of the right inguinal region had a yellow discoloration.
By the eleventh the gangrenous ulcer in the right inguinal region had increased
in size, and at the lower angle of the scapula on the left side could be noted a redness, in the center of which was a small black point. There was likewise redness
behind the right ear. The general condition of the child was not so good, although
it continued to nurse. The umbilical slough had not increased, but in its center
showed a little black point. By November 15 the child was much weaker. The
area of induration at the umbilicus had increased. The slough in the inguinal
region had become intensified in color, and the one at the scapula showed a similar
change. The small plaques on the ears were brownish and had a gangrenous odor.
The child died the same evening. The autopsy showed that the abdominal viscera
were normal.
Case 3. — Spontaneous Multiple Gangrenous Erysipelas, Involving the Eyelids. — Female child, born on October
31. Two days later the lids of the left eye were seen to be inflamed and presented
a marked yellowish color. On November 5 the conj unctival margins of the eyelids
were covered with a false membrane, whitish gray in color. On the eighth, a
gangrenous patch was noted at the umbilicus, and a livid redness at the level of the
folds of the buttocks. The child died on November 10. At autopsy it was found
that the sloughs were superficial. The one at the umbilicus was insignificant.
Case 4. — Gangrenous Erysipelas of the Umbilicus,
Multiple Gangrene.- — Female infant, born November 13, 1865. It
must be mentioned that a child suffering from a similar affection had slept in the
next bed in the same room and had died three days previously. On November
20 the mother brought the child to the physician. The cord had dropped off
the day before. The surrounding skin was red. Palpation showed that there was
induration, imperfectly outlined and occupying an area around the umbilicus.
The epidermis had disappeared from over an area 1 cm. in diameter, and presented whitish or grayish patches, evidently sloughs. The right inguinal region
presented a similar aspect. By November 22 the gangrenous plaques had become
brownish and commenced to give off an odor of gangrene. The child died on November 22. At autopsy it was found that the slough hardly extended to the
bottom of the skin. The umbilical veins were normal. The umbilical arteries
had been transformed into hard cords and were surrounded by yellowish, plastic
lymph. The peritoneum was not injected.
Case 5 . — Male infant, born October 27, 1865. On the next day a moderate
UMBILICAL INFECTIONS IN THE NEW-BORN. 83
degree of redness was noticed around the umbilicus. By the evening, the redness
had increased and had a radius of 2.5 cm. By October 29 the redness had not
increased, but the underlying cellular tissue was slightly indurated. In the umbilical fold was noted a yellowish plaque, 3 mm. broad and 5 mm. long. This
was moist, and its margins were irregular. By October 30 the redness around the
umbilicus had increased. In the inner fold in the groin a reddish plaque the size of
a franc was noticed, in the center of which was a yellowish point about the size of
a pin-head. The child improved, but was taken away by the mother before it
was perfectly well.
Case 6. — Gangrene; Erysipelas of the Umbilicus and
of the Inguinal Regions. — ■ Male infant, born November 24, 1865.
On November 30, the mother brought the child for examination. The cord
was just about ready to drop off. On lifting it with the scissors the examiner found
that the tissues were grayish and formed a small elevation where a slough with a
gangrenous appearance had formed. There was a slight redness of the skin at the
fold of the groin on the right side. The child was well nourished. The umbilicus
presented a raised blackish point, and around it was an ulceration and a yellowish
depression. At the internal malleolus on the left there was seen a plaque having
a yellowish center and reddish margins. The nurse said that this had had the
appearance of a boil, and that she had opened it with a needle. The child died on
the fifteenth of December. The umbilical ulcer was black and the skin around it
greenish.
Case 7. — Spontaneous Gangrene. — A male child, born November 27, 1865, a*t a time when cholera existed in the hospital. On December
2, the child was brought for examination. The cord had not come away completely,
but around its base, and attached to the skin, was a blackish point and a noticeable
elevation. The blackish area was surrounded by a yellowish circle; there was a
diffuse redness, and the skin was indurated. There were no general symptoms, and
the child was well nourished. By December 4, the tumor of the umbilicus appeared
as a roundish nodule, the size of a franc piece. It had a reddish circumference and
was yellowish in other portions. In its center was a small black slough, ready to
separate. By December 11, the ulcer had practically healed. The child, however, died on December 12. At autopsy it was found that the ulcer at the
umbilicus was insignificant, and that it had never extended beyond the skin. The
peritoneum was intact, but adherent over a large area. There was no trace of
peritonitis. The child had died of pneumonia.
Case 8. — Multiple. Gangrene. — A female child, two months old,
entered the hospital on November 27. About a month before, the mother had
noticed a small reddish ulcer in the right inguinal fold. The umbilical cicatrix,
which had never completely healed, was also the site of a small ulcer. Two or three
days before her entrance the skin in the lower part of the abdomen had become
reddened and there was some induration,' as in erysipelas of the umbilicus of the
new-born. On her admission, at the umbilicus was a deep fold. At the bottom it
was grayish yellow. There was some slight discoloration at other points. The
right inguinal fold presented a patch of the same color, about 1 cm. in diameter.
The child died on December 1. The umbilical slough had reached a considerable
depth. At the bottom, on a level with the umbilical vein, was a small mass of
purulent material. The vein itself was perfectly healthy, free, without clots.
84 THE UMBILICUS AND ITS DISEASES.
There was no trace of peritonitis. The iliac vein and arteries were free. The
slough in the inguinal region was deeper than that of the umbilicus. The peritoneum was normal.
Case 9 . — Female child, born January 7, 1866. About the fifth day a
slight redness was noted at the umbilicus, which extended for a distance of 2 cm.
On admission to the hospital it was found that the left eye was the seat of a limpid
secretion and contained several yellowish fiocculi. The eyelids were a little swollen,
but not red. At the umbilicus there was reddening and a little induration. The
cord had probably come away only a few days before. At the site of the umbilical
cicatrix, in a fold of the skin, was an ulcer, yellowish at the bottom, and about the
size of a hemp-seed. In the left inguinal fold was an ulcer, 1 cm. in diameter, and
yellowish at it's bottom. On January 19 it was noted that the umbilical ulcer had
increased, and pus was escaping from it. By January 28, the ulcer at the umbilicus had cicatrized, but the one in the inguinal region had made considerable progress. Its margins were marked by a fine black line, and the center was occupied by
a dry yellowish plaque. This gangrenous ulcer was limited by the inguinal fold.
The anterior surface of the left inguinal fold was red, indurated, and denuded of its
epidermis for a distance of 2 cm. In the center was a yellowish crust. The child
died on January 31. At autopsy it was found that the sloughs were superficial,
and that they had implicated the skin only. The underlying cellular tissue was infiltrated. The peritoneum contained an abundance of fluid with a reddish tinge.
There was no false membrane. The intestines were healthy.
Case 10. — A female child, born January 19, 1866. On January 28 a redness was noted at the umbilicus. Poultices were applied, but by the next day the
redness had increased. On January 30 an ulcer was noticed at the umbilicus.
By February 4 the redness had diminished to the size of a five-franc piece. By
the next day the crust had disappeared and there was an area of ulceration 0.5 cm.
deep. The general condition was good. By March 1 the child was completely
well.
NON-PUERPERAL ERYSIPELAS OF THE NEW-BORN INFANT.
Yot, in his thesis published in 1873, dealt with erysipelas of the new-born and
described a number of cases. In a few instances the lesions started at the umbilicus.
Case 6 . — The child was brought into the hospital when it was nine days
old with an erysipelas in the subumbilical region. The skin was of a reddish tint,
and there was tumefaction of the parts. The inflammation extended to the symphysis and also to the inner parts of the thighs. On the right side it extended to the
vertebral column, but on the left it had not gone beyond the fold of the inguinal
region. The umbilical cicatrix presented at its center a small surface of ulceration
which may have been the point of departure of the erysipelas. From the tenth to
the seventeenth day the process ran the usual course. On the seventeenth day an
abscess opened in the coccygeal region. By the twenty-eighth day the child was
well.
Case 9 . — The child was brought into the hospital when it was five days old.
An erysipelatous inflammation covered the entire umbilical region, the lower
portion of the abdominal wall, the lumbar region, the scrotum, the penis, the right
side of the thigh, and the right leg, except in front. The parts were livid, and the
temperature was 38.8° C. The child died on the same day.
UMBILICAL INFECTIONS IN THE NEW-BORN. 85
Case 11. — -A female infant was brought to the hospital when it was twelve
days old. The umbilical cicatrix was imperfect and showed a bloody discharge.
There was an erysipelatous inflammation over the entire region below the umbilicus
to the thighs and legs, and a large part of the anterior portion of the thorax anteriorly. The temperature was 37.8° C; the pulse, 184. The child died the same
evening. The umbilical vein was found to be normal. There was no trace of peritonitis. The thymus was enormous, and on incision there escaped a purulent liquid.
Case 13. — A boy, born December 6, 1867, entered the hospital on December 16, 1869, showing erysipelas around the umbilicus and in the suprapubic region.
The scrotum, penis, and the inner portions of the thighs and legs were implicated
and there was edema of the lower and lateral part of the abdomen. At the umbilicus
was an area of sloughing, 20 cm. in diameter, which was blackish in color. Pulse,
144; temperature, 36.6° C. The child died on December 19. A general peritonitis was present. Under the gangrenous area the abdominal wall was adherent
to the large intestine, which had likewise become gangrenous.
Case 14. — The infant was ten days old when it was brought to the hospital. She had thrush. There was an erythema and a purulent discharge from
the umbilicus. The tissues around the umbilicus were covered with exfoliated
epithelium. There were redness and tumefaction below the umbilicus, and to the
right and on the anterior surface of the thigh on the right side. The labia majora
were tumefied and reddish in color. The erysipelas had apparently started from
the umbilicus. The child died on the next day, the temperature being 30.5° C.
At autopsy small vegetations were found on the mitral valve. The umbilical vein
and arteries were filled with pus, and there were signs of a general peritonitis. The
kidneys contained coagulated blood-globules and pus. The calices contained a
blackish material resembling coffee-grounds, and the papillae were of a brownish
color.
Yot then goes on to consider the nature of — (a) puerperal, (b) traumatic erysipelas. He discusses the symptoms and the complications. He concludes that there
are two kinds of erysipelas in the new-born — one puerperal, epidemic, infectious,
and fatal in its course, and terminating as puerperal infection in women who have
recently been confined; the other he designates as an "inflammation." He says
the fatality in this group is nothing in comparison to that in puerperal erysipelas.
RUNGE ON WOUND INFECTIONS OF THE NEW-BORN.
Runge, in his ''Wound Infections of the New-born" (1893), has given us the
best monograph on the subject that we possess. On account of their importance
I have given Runge's findings and his interpretations somewhat fully, even at the
risk of some repetition, as I am particularly anxious that the reader should be cognizant of his views, although these at times fail to coincide with those of others who
have had much experience in the handling of these cases.
The umbilical wound is most frequently the point of entry of infective material.
This was proved in 30 out of 36 autopsies. The pathologic lochia contain a pathogenic organism and can lead to very severe wound infection. The carrying of infective material to a wound in the new-born is almost entirely through contact, and
infection through the air is, to say the least, doubtful. In the new-born the organisms most frequently found are streptococci and staphylococci (Runge, p. 58).
86 THE UMBILICUS AND ITS DISEASES.
On page 65 he says that the portion of the cord remaining on the child
beyond the point of ligature dies and becomes, as it were, a foreign body. A
reactive inflammation occurs in the skin of the umbilicus. Death of the. cord
is usually by mummification; high temperature and dryness increase mummification. Moisture and exclusion of air hinder the extraction of the water and
lead to a moist gangrene. Simultaneously with the mummification there begins
an active inflammation at the umbilicus. A few hours after birth the capillary
network is found markedly distended and filled. Then the redness spreads over
the entire skin umbilicus. This swells, and the distal portion of the umbilical
remains takes on a yellowish-white color. Microscopic examination shows emigrating white blood-corpuscles in abundant numbers. They soften the dead tissue,
which is gradually loosened and falls off, leaving a granulating surface. The dropping off of the cord takes place, on an average, on the fifth day. In premature and
in weak children it usually drops off later, because in such cases the energy of the
inflammation is less marked. The amnion first loosens, then usually the arteries,
and finally the vein. The granulation surface of the umbilical wound after the cord
drops off is frequently at a deeper level than the abdominal wall, because the intraperitoneal portion of the umbilical vessels has contracted. In those cases, however,
in which the skin has been carried out for a long distance over the cord, the wound
lies above the level of the abdomen and appears as a definite umbilical stump.
By retraction of the umbilical vessels there is gradually formed an upper and a
lower umbilical fold, i. e., a duplication of the skin covers the deep-lying umbilical
wound, and further retraction of the umbilical vessels goes on simultaneously.
From the day that the cord drops off the redness and swelling begin to recede,
and the healing process ends from the twelfth to the fifteenth day. The umbilical
scar is usually covered over with folds of skin. As a result of adhesions of the
endothelial surfaces the intra-abdominal portion of the umbilical vein closes and
now forms the ligamentum teres. The degree of obliteration of the vein varies
greatly. Baumgarten (quoted by Runge) says that the closure is never complete.
A thrombosis of the vein is by most authors considered as pathologic.
Runge says that in the arteries the closure is due to the growing together of the
arterial walls, especially of the intima. Small thrombotic plugs sometimes exist
where the arteries bend in the bladder region.
Mild Disturbances in Healing of the Wound of the
Umbilicus. — Runge says (p. 71) that the determination of the line between
the healthy and diseased umbilical wound is difficult. The degree of reactive inflammation of the umbilicus depends on various conditions. With the dropping
off of very succulent umbilical cords the reaction is more marked than in the case
of those that are somewhat dry. In strong children the inflammatory reaction
comes on earlier and is more intense; more cells are produced than in the weaker
ones, and in the case of the latter the cord drops off later.
Runge quotes Widerhofer, who says that if the umbilical wound begins to be
moist, it secretes "mucus" and pus. If the umbilicus takes on the character of a
mucous membrane there is produced a condition termed by the authors "blennorrhea of the umbilicus." In these conditions it becomes difficult to determine
whether or not the wound is infected. When the umbilical wound increases in
area and is covered with a whitish and necrotic layer, and when, in addition, it
discharges an abundance of pus or purulent material, there can be no doubt that an
UMBILICAL INFECTIONS IN THE NEW-BORN. 87
extensive local reaction exists and we have an "ulcer of the umbilicus." Ulcer of
the umbilicus hardly ever exists if the process remains localized.
In all his autopsies on infants who had umbilical ulcer, Runge found either disease of the vessels of the umbilicus or a peritonitis to account for the death. If
neither of these was present, he was able to find some other cause of death independent of the ulcer.
On page 81 he takes up the subject of omphalitis and says that it is characterized not so much by marked inflammation of the umbilicus as by an infiltration of
the abdominal wall around it.
Symptoms. — In cases of well-marked omphalitis the umbilical region is
markedly reddened and the umbilicus projects conically outward. The area is
rarely cicatrized, but usually appears as a wound or a discolored ulcer. The redness and the inflammation extend beyond the raised portion and form a circle around
it. The skin is tense and glistening; the folds have disappeared. On palpation
a hard infiltration of the abdominal wall can be felt, and examination gives rise to a
great deal of pain. The extent of the infiltration varies. It may be limited to the
immediate vicinity of the umbilicus, or the greater portion of the abdominal wall
may be implicated. It may extend deep down and take in the entire thickness of
the abdominal wall as far as the peritoneum.
In every case of marked omphalitis the general condition of the child is affected.
It is restless, does not take its nourishment, and has fever. There is pain with
every movement of the body. The legs are stiff and drawn up on the lower abdomen. The breathing is costal in type. The markedly engorged and dilated
veins of the stomach region sometimes appear as thick, bluish strings seen through
the skin. The duration of the disease depends on its intensity. It may last several
days or many weeks.
Healing is the rule where the phlegmon is small. The exudate is absorbed, the
umbilical wound cicatrizes, or there may be several small abscesses which break
outward and discharge a few drops of pus. Healing then takes place in a few days.
If inflammation is associated with the phlegmon, it extends far out in the abdominal wall and healing is much less likely to occur. The most favorable outcome is
obtained when there is rapid abscess formation before the infant has been prostrated
by the fever. If the inflammation extends markedly inward, death from peritonitis is likely to follow. If an involvement of the umbilical vessels is found at
autopsy, a general sepsis has existed. Another unfavorable termination is in
gangrene. This is more apt to occur in weak children.
From the foregoing it is seen that all cases of wide-spread omphalitis are to be
considered as dangerous to life. The younger the child, the more unfavorable the
prognosis. Breast-fed children have a better chance than bottle children. Children suffering from some congenital cachexia — syphilis, scrofula — and children of
tuberculous parents are predisposed to this disease.
Gangrene of the Umbilicus. — Runge, on page 84, says that gangrene may be
the consequence of a pathologic umbilical wound, an ulcer, or of an omphalitis; or it
may develop in cases of severe general infection. Gangrene as a localized infection of
the umbilicus does not appear to be very frequent. Many authors, particularly
Wiclerhofer, say that it develops from a severe omphalitis. Ill-nourished children
and those born prematurely show a tendency toward the development of local gangrene. Severe diseases of the umbilicus, such as gangrene, which were of frequent
88 THE UMBILICUS AND ITS DISEASES.
occurrence formerly, especially in foundling hospitals, have recently diminished
greatly. Fiirth, in the Vienna Foundling Hospital, before antiseptic days saw
191 infants suffering from gangrene of the umbilicus, and 169 of this number
died.
Symptoms. — The wall of an inflammatory umbilical wound becomes
discolored, breaks down, and shows more or less loss of substance; or there develops,
especially as a result of an omphalitis, a blister with cloudy contents. This ruptures and a defect is produced. An area of moist gangrene then appears and
extends rapidly, sometimes superficially, sometimes penetrating deeply. The cases
in which the process goes inward are much more dangerous. The gangrenous
area is surrounded by bright reddening of the skin and reactive inflammation.
Gradually the gangrenous portion becomes loosened. It emits a fetid odor. Usually the fever is not high, but rapid collapse is unfortunately the rule. Where the
child's constitution is good and the morbid process is not wide-spread, healing takes
place at this stage, the reactive inflammation producing pus, which throws off the
dead portion, a defect of greater or lesser extent being left, which heals by granulation. If the child's strength has been overtaxed, it dies before the loosening of the
gangrenous area can occur. The average duration of the disease in fatal cases,
according to Fiirth, was 5.64 days. In several cases death took place on the second
day. "When the child recovered, the duration of the disease at the minimum was
twelve, at the maximum thirty-seven days. Again, the gangrenous process may
spread, and in certain cases reported two-thirds of the abdominal wall was implicated. Where the gangrene involves the whole thickness of the abdominal wall,
intestinal loops may become adherent and perforate, with a resulting peritonitis or
a fecal fistula. Gangrene may lead to general sepsis, in which either the peritoneum
is directly involved or the septic material gains entrance through the umbilical
vessels to the general system.
Much more frequently there is a second kind of gangrene affecting the umbilicus,
which appears to be the result of general sepsis. According to Widerhofer, there is
a gangrene which follows cholera infantum. In these cases a localized necrosis
occurs, and gangrene is also found in other portions of the body, this condition
being produced by emboli. This gangrene is characterized by its rapid development and the complete absence of reactive inflammation.
Often in the course of a few hours the gangrenous area reaches the size of a dollar.
It is remarkable that this gangrene occurs not only in the first days of life, but also
in well-nourished children several months old. Widerhofer observed secondary
gangrene of the umbilicus in children suffering from cholera, in the foundling hospital in Vienna, 63 times within four years. In each case death occurred very quickly.
The prognosis in cases of gangrene of the umbilicus, accompanied by cholera
and sepsis, is absolutely fatal. Even in those of localized gangrene the outcome is
doubtful and depends upon the resistance of the child. The absence of inflammatory reddening is proof positive of a fatal outcome.
Diseases of the Umbilical Vessels.
Runge says (p. 88) that where infection of the umbilical vessels exists, the disease first starts in the perivascular connective tissue, which becomes infiltrated with
a serous fluid and shows evidences of edema. Often the process extends to the adventitia, and the vessel itself is involved. The inflammatory infiltration of the
UMBILICAL INFECTIONS IN THE NEW-BORN. 89
vessel-wall causes a paresis of the muscularis and a dilatation of the vessels, or
gives rise to a thrombus which soon breaks clown. Runge regards the thrombus
and its disintegration as a secondary manifestation. He draws special attention
to the fact that the arteritis and phlebitis invariably start with an inflammation in
the outer coats of the vessels.
He then quotes various authors who had made experiments, with results agreeing
with those obtained from his own autopsies. In 55 cases from the obstetric clinic
of the Charite Hospital in Berlin, in which autopsies were made on children dying
of diseases of the umbilicus, Runge found arteritis in 54 cases — 22 times in combination with pneumonia, 16 times with other evident septic complications. Only
once could he determine a phlebitis, and in this instance it was associated with a
very intense arteritis. As a result of these observations Runge concludes that of
all the fatal diseases of the umbilicus, arteritis is the most frequent and most important. He says that this view as to the great fatality in infants from arteritis as
compared with phlebitis has been corroborated by the more recent observations of
Epstein, Monti, Birch-Hirschfeld, and of Lomer.
[Careful study of the various epidemics leads one to conclude that in some epidemics the arteries are more frequently involved, in others, the veins. — T. S. C:]
On opening the abdomen and throwing outward the right abdominal wall Runge
found that the diseased arteries were to be seen as thick, tense, usually slightly
brownish-tinged cprds, with marked thickening and development of the vessels of
the adventitia, and that there were also an edema and infiltration of the surrounding connective tissue. In several cases the arteries were implicated for their
entire length from the umbilicus to the bladder.
Runge says that frequently remnants of the umbilical cord, after dropping off,
leave the umbilical wound covered with crusts and changed into an irregular ulcer
with bays running off from it. In other cases, on the contrary, the wound shows a
perfectly normal appearance; in fact, it may have completely healed and yet an
intense arteritis may still exist. If the remnant of the umbilical cord is still intact,
it is usually completely mummified. In other cases the cord gives out a very foul
odor. After the softening of the crust from the wound, one occasionally can see
the gaping umbilical arteries and note that they are filled with pus or friable material. If an incision is made through the umbilical wound, it is sometimes possible
to see with the naked eye that the infiltration at its base extends directly into the
diseased perivascular connective tissue; and when the vessels are incised transversely, there is an escape of yellowish-green pus from them, or they contain a
friable, cheesy material mixed with blood. The surrounding connective tissue
often presents a glistening appearance.
An incision in the long axis of the arteries, that is, from the umbilicus toward the
bladder, indicates the degree of extension of the pus, which usually is associated
with an infiltration of the surrounding connective tissue. Occasionally, at the far
end of the accumulation of pus in one of the arteries, a reddish-colored thrombus is
found attached to the vessel-wall. The intima of the artery is cloudy; it has lost
its brilliancy, and there may be numerous unevennesses, due to loss of substance
in the vessel-wall. The dilatation of the arteries bears no relation to the intensity
of the inflammation in the perivascular tissue. On the contrary, the inflammation
90 THE UMBILICUS AND ITS DISEASES.
of the connective tissue may be enormous, and yet the lumen of the vessel may be
hardly large enough to admit the passage of a probe.
Sometimes the dilatation of the vessels is marked throughout their entire course ;
or again, at certain points, sac-like dilatations occur in which an abundance of pus
and caseous masses are found. In no case of phlegmonous infiltration, however,
was he able to follow the vessel as far as the bladder. The extraperitoneal connective tissue and iliac arteries were always free.
Pneumonia is the most frequent complication. Runge says that in 55
cases of arteritis it was present 22 times. This occurred in two forms, either as a
lobar pneumonia, often complicated with a fibrinous, serofibrinous, or purulent
pleurisy; or there were numerous pea-sized and bean-sized foci scattered throughout the lung. Where these reached the surface, there was an accompanying circumscribed pleurisy.
Runge found hyperplasia of the spleen with marked softening of the tissue, cloudy swelling of the liver, parenchymatous nephritis, serofibrinous or seropurulent peritonitis, joint affections, periostitis, and finally phlegmonous inflammation of the subcutaneous connective tissue, with or without pus formation.
Erysipelas, when observed as a complication, usually extends from the umbilical
wound outward; nevertheless, Runge says, it may be primary in the face or in other
portions of the body.
Very frequently the bodies show a slight degree of jaundice, especially when
the death occurs between the fourth and sixth days, although no direct connection
between the arteritis and the jaundice can be traced. In such a case one is dealing
with the so-called physiologic icterus of the new-born. When, as happens more
rarely, there is an intense icterus, the complication is to be attributed to a parenchymatous hepatitis. Runge says that very frequently the lungs show partial
atelectasis.
Bacteriologic investigations in cases of umbilical arteritis have been rare.
Runge drew attention to those of Baginsky, Meyer, and Babes. The most frequent
cause of the infection was found to be a streptococcus. In a case described by Baginsky Streptococcus pyogenes was found in the internal organs and there was a
pyemia as a result of inflammation of the umbilical arteries.
Runge gives a table of 55 cases in which an autopsy was performed and an anatomic diagnosis of umbilical arteritis was made (p. 95). These 55 cases of umbilical
arteritis were taken from a group of 340 autopsies. This means that 16.1 per cent,
of the children who came to autopsy in the gynecologic clinic of the Charite Hospital in Berlin, from 1879 to 1882, showed inflammation of the umbilical arteries.
From his table it is seen that in 9 cases arteritis only was found. This was undoubtedly the cause of the death. In 16 cases there were complications (syphilis,
etc.) which apparently bore no relation to the arteritis.
In this group were 8 cases in which the complication, for example, hemorrhage
of the brain, had been definitely the cause of death, and the arteritis in 5 cases was
not marked. In 30 cases, however, there were complications which undoubtedly
were dependent upon the arteritis. In 16 cases these were of a septic nature.
In one case, in addition to the arteritis, there was an abscess of the vein in its lower
portion.
These anatomic results are in opposition to the findings of Buhl, according to
whom, in cases of arteritis, the secondary changes were found in the abdominal
UMBILICAL INFECTIONS IN THE NEW-BORN. 91
cavity. Widerhofer and P. Mtiller emphasize the frequency of peritonitis. This
complication Runge found only 5 times — in 9 per cent, of the cases. He never found
a perforation into the abdominal cavity from the diseased vessels, as described by
Bednar.
The pathogenesis is taken up on page 101. From the pathologic findings there can be no doubt that umbilical arteritis is a wound infection which has
its point of origin in the umbilical wound and which gives rise to a general sepsis.
Buhl explains the unfavorable effect produced by puerperal infection upon the
umbilicus and upon the changes in the vessel-walls which had already existed in
the intra-uterine life. Runge, in discussing the possibility of the transference of
septic material through the placenta, draws attention to the fact that in the cases
of 24 patients there was not a mother who during pregnancy or during or after
labor had had any septic phenomena, and in the remaining cases only now and then
had such symptoms been noted.
Symptoms. — A characteristic symptomatology is wanting (Runge) . We
have no clinical picture from which we can make the diagnosis in the living child.
Usually the death is unexpected. The child appears perfectly normal. Suddenly
it becomes restless, refuses nourishment, collapses, and dies. An accident may be
thought of. The autopsy shows arteritis. In every case, however, the umbilical
wound showed some inflammation; usually it was covered with pus, although the
general condition of the child was not changed. Then there were sudden restlessness, crying, collapse, and death. Since most of these cases occur in groups, the
diagnosis was finally reached without any special difficulty.
More rarely the course of the disease is prolonged. In these cases the indications of a severe general infection nearly always become evident. The children
have fever, loss of weight, increasing weakness, and symptoms of collapse. That
the severe symptoms are due to disease of the umbilical vessels there is at times no
evidence, especially if, as is frequently the case, the umbilical wound shows little
or no inflammation or has healed completely. If, on the other hand, an ulcer of the
umbilicus is present, a diagnosis of a general infection due to an extension of the
umbilical disease is readily made. In all cases, nevertheless, where there is disease
of the umbilicus, the danger of inflammation of the arteries exists. The diseased
organs do not always present the characteristic picture. A lobar pneumonia is
easily recognized by percussion and auscultation. Small disseminated foci, however, Runge was never able to diagnose. Where marked distention and pain of
the abdomen are noted, peritonitis is probable, but, according to Runge's experience, in the first days of life this is not easy to diagnose. Marked icterus indicates
hepatitis, which may, however, prove to be not serious. From Runge's table it is
seen that the eldest child dying of arteritis was eighteen days old, the youngest,
four days. The largest number of deaths occurred on the eighth day.
Prognosis. — No positive data can be given. In the case of premature
children, the outlook is very grave. Of the 55 children autopsied, 21 had been born
prematurely. In 50 cases in which inflammation of the umbilical arteries was found,
21 (42 per cent) of the infants were premature. Runge says that premature children who develop arteritis nearly always die; in the case of a child born at term,
the possibility of recovery exists.
Etiology. — Runge says that contact of the umbilical wound with septic
material, but not necessarily only after the cord has come away, may be the cause
92 THE UMBILICUS AND ITS DISEASES.
of the disease. The most virulent infection seen by Runge was in a case in which
the cord had not yet been completely loosened. The infection has always been
most prevalent in lying-in hospitals and foundling institutions, and has occurred
in groups, whereas in private practice it is rare. Runge also draws attention to the
fact that it was often associated with an epidemic of puerperal fever, but maintains
that there may be an epidemic of inflammation of the umbilical vessels entirely
independent of any puerperal infection. He had observed such an epidemic in the
obstetric department of the Strassburg Hospital, in 1876, and in the obstetrical
department of the Charite Hospital in 1880. In both instances the health of the
mothers was splendid.
Prophylaxis. — Absolute cleanliness is essential. If arteritis is once
established, little or nothing can be done.
In discussing inflammation of the umbilical vein Runge says
that Bednar and Widerhofer consider phlebitis the more important and more frequent disease, whereas recent authors, such as Epstein, Birch-Hirschfeld, and
others, dwell upon the preponderance of arterial infection. Birch-Hirschfeld, in
60 autopsies of septic infection which had extended from the umbilicus, found phlebitis 11 times, in 4 instances a simple thrombus of the vein; whereas in 32 cases the
arteries alone, and in 3 cases both arteries and vein, were simultaneously affected.
In all his autopsies Runge met with phlebitis only twice without arteritis; he regards phlebitis of the umbilical vessels as a much rarer affection.
Autopsies in which inflammation of the veins was
found . — Runge says that the condition is usually similar to that found where
arteritis exists. The perivascular connective tissue is edematous, the adventitia
thickened, and the vessel tortuous; there are punctiform hemorrhages. On transverse section of the vessel, pus, bloody pus, or pus-like masses escape from the lumen.
The longitudinal section of the vessel shows an extension of the disease into the
inner surface. The intima is cloudy; in places it has been destroyed, and there are
deep ulcers which have eaten out large areas of the vessel-wall. The disease extends
usually along the entire length of the vein from the umbilicus to the liver, which
may itself be implicated. According to Widerhofer, Glisson's capsule alone may be
implicated; or the portal vein and its branches may show changes similar to those
noted in the umbilical vein. Most writers on phlebitis draw attention to the fact
that the perivascular tissue is first involved, and that the vessels are invaded
secondarily. A general septic condition is the rule, and peritonitis and parenchymatous hepatitis are very frequent.
Symptoms. — Runge mentions fever and icterus, and agrees with Widerhofer that inspiration is short, expiration is prolonged, and the breathing more
rapid than normal. The movements of the thorax are scarcely detectable. The
abdominal musculature is nearly always contracted. The abdomen, particularly
in the upper portion, is distended. Pressure in the region of the umbilical vein
causes pain, which accounts for the drawing up of the legs. The child is restless,
but more or less toxic.
In conclusion (p. 116), Runge gives a full bibliography on diseases of the umbilical vessels.
Erysipelas in the first days of life . — Runge (p. 158) says that
in the earlier days erysipelas of the new-born was wrongly included with puerperal
UMBILICAL INFECTIONS IN THE NEW-BORN. 93
infection of the new-born, and that some of the cases of septic erj'thema were classed
as instances of erysipelas. Clinically, there are two forms of erysipelas in the newborn. One of them is a true erysipelas. In the table of children dying from umbilical arteritis, erysipelas was noted twice — once on the abdomen and once on the
face. According to Gusserow, the course of such a double infection — erysipelas
associated with septic inflammation — is always fatal. The second form of erysipelas
attacks children that have heretofore been healthy. The infection spreads partly
from the umbilical wound and partly from some slight injury of the genitals.
Erysipelas in the new-born almost always causes death.
SEPTIC PYEMIA AND INFECTION OF THE UMBILICUS OF THE NEW-BORN.
Cohn, writing in 1896, says that although these diseases are not so common as
formerly, they are not rare. He then goes on to report two interesting cases:
Case 1. — Umbilical Phlebitis; Phlegmon of the Forearm; Spontaneous Rupture of the Purulent Phlegmon
Through the Umbilicus; Recover 3'. — A. S. was brought to
the clinic when fourteen days old. On the second day the umbilical cord had been
tied for a second time by the midwife because it was thought to be too large. On
the fourth day it came away during the bath. About the thirteenth day the mother
noticed that the left hand of the child was red and swollen. Local applications
were made, but the swelling did not diminish. By the afternoon it had reached to
the forearm, and by evening to the elbow, and early the next day up the arm. The
child had fever, was very restless, and cried a great deal, especially on being disturbed. On admission it was found that the umbilicus was drawn in and in the
depression was some slight secretion. The forearm was markedly reddened and
swollen, and any movement caused great pain. Swelling and fluctuation were noticeable in the neighborhood of the wrist-joint. The back of the hand was edematous and swollen. At operation not much pus was evacuated, but the tissue
of the forearm showed infiltration, which reached to the hand, so that it was necessary to lay open the musculature of the thumb and of the ball of the little finger.
Further operations were subsequently necessary. Later on the mother noticed to
her surprise that the umbilicus was fully a "segment of a finger" high, and that it
was bluish red; that there was swelling for at least 5 cm. in the neighborhood of the
umbilicus, and that it was edematous and painful. Pressure caused a discharge
from the umbilicus of a thin, fluid pus. Following the introduction of a probe the
escape of pus was much more free. The probe could be carried upward 4 cm. and
beneath the abdominal muscles. From the mother it was now learned that the
umbilicus had up to this time always shown a little purulent discharge. At the
end of a year the child was well and the umbilicus was well drawn in.
Case 2 . — Umbilical Phlebitis; Phlegmonous Erysipelas; Suppurative Peritonitis; Death. — Paul B. The
cord came away on the fifth day, but as a piece, 2 cm. long, remained attached to
the abdomen, it was tied off by the midwife with a white thread. After this the
wound is said to have suppurated for about six days and then remained dry. Five
days later, over the ankle-joint of the left leg definite swelling and redness were
noted. Two days later redness was noted on the right leg; still two clays later the
scrotum and the surrounding parts were swollen, and it was with difficulty that the
94 THE UMBILICUS AND ITS DISEASES.
child could urinate. On the following day it was found necessary to open the left
ankle. The redness and swelling over the back and the extremities had extended.
Four days later vomiting began. The abdomen was distended, being as hard as a
board. The abdominal walls were glistening, and the veins were markedly distended. Any movement of the body occasioned pain. The umbilicus was closed,
dry, and not prominent. The buttocks were covered with an erysipelatous inflammation, chiefly noticeable along its advancing margin. This extended to the
nipple line and nearly to the scapula. Along the lower border of the scrotum was
an ulceration the size of a five-pfennig piece, covered with yellow, smeary material.
The child died.
At the autopsy, which was performed the same day, the umbilical wound was
found healed. There was edema of the abdominal wall. The peritoneum was
thickened and showed a purulent inflammation. When the abdominal cavity was
opened, there escaped a yellowish, clear fluid, which contained white flocculi, seropurulent in character. From a quarter to half a liter of fluid lay between the distended intestinal loops. The umbilical vein was found markedly distended,
especially in the neighborhood of the liver, where it was almost as thick as the
little finger. It contained yellow pus. The purulent contents of the vein could
be followed to the portal vein, and on section to the liver. Pus escaped from
a large branch of the portal vein. The liver was enlarged and showed cloudiness.
Cocci in chains were detected.
Cohn then refers to several other epidemics, and quotes Epstein, who wrote in
1888 from the Foundling Asylum in Prague. This author says that the mortality
was 30 per cent in preantiseptic days, and that it had dropped to 5 per cent, but
that, from January, 1887, to April 30, 1888, out of 116 children that had died from
a total of 1816 that had been received, in not less than 36 (31 per cent) the histologic
diagnoses showed that the sepsis had started as an inflammatory infection of the
umbilicus and of the umbilical vessels. Miller, quoted also by Cohn, found that
in the Moscow Foundling House from about 6 to 8 per cent of the children died of a
purulent process, the great majority of these septic infections emanating from the
umbilicus. From the Innsbruck Clinic, Ehrendorfer reported 1764 cases occurring
from May 5, 1888, to the end of April, 1892. Of these infants, 95 died and 81 came
to autopsy. Of this number, 16 — about 20 per cent of the cases that came to
autopsy — showed infection of the umbilical arteries or veins.
Eross, also quoted by Cohn, found that, out of 1000 infants born in the Obstetric Clinic in Budapest, in over 320 (32 per cent) the mummification of the umbilicus took place normally. In 680 (68 per cent) there were not only deviations from
the normal, but often marked pathologic changes at the umbilicus, such as inflammation and the formation of ulcers. Routine temperature observations further
demonstrated that, of the 680 infants, 220 had a rise of temperature, and 5 of
these died during their stay in the clinic.
Cohn speaks of the use of alum, of tannin, and of sugar, and comes to the conclusion, as a result of various investigations, that it is wiser to avoid bathing the
child after the first day, until the cord has come away. He speaks of treating the
cord by the dry method, not even allowing it to be exposed to the air.
UMBILICAL INFECTIONS IN THE NEW-BORN. 95
UMBILICAL SEPSIS IN THE NEW-BORN OCCURRING AT THE NURSERY AND CHILD'S
HOSPITAL, NEW YORK, DURING 1896.
S. W. Lambert, in his interesting description of an epidemic occurring in New
York, says that the obstetric department of the Nursery and Child's Hospital lost
five babies from umbilical sepsis during 1896. The epidemic occurred in July,
August, and September. During the three months there were 40 children born, and
of these, only 4 remained free from fever; the remainder developed a temperature
of 100° F. or over. The real epidemic was characterized by a peculiar skin eruption and was coincident with the delivery in the ward of a woman who became very
ill with a virulent sepsis from which she died. I shall briefly outline the fatal cases.
Case 1 . — The child lost weight from the date of birth to the fifth day and
died on the twenty-second day. In this case the right foot became swollen and the
heel and toes gangrenous. At autopsy the umbilicus appeared to be normal, but
in the umbilical vein there was a fusiform clot, three inches in length, also small
clots in the arteries, and beneath them small collections of pus in the tissues. Cultures from the pus in the tissues gave staphylococci.
C a s e 2 . • — This child was born after a dry labor of fifty-eight hours, lost 17
ounces in three days, and died on the twentieth day. At autopsy, the umbilical
vein appeared normal, but the right hypogastric artery was swollen and reddish for
three-fourths of an inch from the umbilicus. On manipulation grayish-brown,
grumous pus escaped from the umbilicus. A probe was readily introduced into the
artery. The pus yielded pure cultures of Staphylococcus aureus and albus. The
cord was still adherent.
Case 3 . — *The infant had lost 14 ounces in weight by the fourth day, and
was jaundiced during the first week. At autopsy there was noted a fusiform swelling of the right hypogastric artery just below the umbilicus. This contained bloody
pus. The left artery and the umbilical vein were normal. The cord was attached
to the umbilicus, and at its base was an excoriation extending an inch in each direction. No cultures were made.
Case 4 . — The labor was normal. The child had lost 12 ounces by the fourth
day and died on the twelfth day. A pemphigoid eruption was noted on the neck
on the fourth day, and spread rapidly over the shoulders. The cord came away on
the sixth day. At autopsy the umbilicus, when opened, was found to contain a discolored, yellow, liquid mass, which seemed to extend through into the artery and vein.
Case 5 . — The cord came away on the tenth day. The umbilicus contained
pus. There was no autopsy.
TETANUS IN THE NEW-BORN.
Prior to the aseptic treatment of the cord, children often developed tetanus
through the umbilicus. The cases usually occurred singly, but now and then there
was an epidemic with a high mortality. At the present time umbilical infection
with this organism is rare, except in countries in which the natives have no medical
attention and are accustomed to treat the cord in a very crude and primitive
fashion.
Runge's description of the symptoms of tetanus in the new-born is so lucid
that I will quote it in detail:
On page 145 he says: "In this vicinity it is not frequent, in fact in the obstetric
96 THE UMBILICUS AND ITS DISEASES.
institutions, since the introduction of antisepsis, it has become very rare. On the
other hand, in some places tetanus is endemic. The new-born in the tropics, and
especially children of the colored races, are frequently attacked by it. The probability is that this infection is due to a lack of cleanliness." On page 148 he says
that, within two years, according to Keber, in the practice of one midwife who cared
for 308 infants, 99 died of tetanus. This was in the years 1863 to 1865.
Symptoms. — "The trouble manifests itself suddenly. The lower jaw
remains stiff, and is kept only a short distance from the upper. The muscles are
so strongly contracted that it is impossible to open the mouth. At the same time
there is a change in the countenance. The forehead is markedly furrowed, the
space between the lids smaller, the lips are pressed together and often drawn up
in a snout-like fashion, showing radiating folds. There is marked drawing together
of the musculature of the back, bringing the head backward and producing an
opisthotonos. Owing to contraction of the abdominal muscles the abdomen becomes as hard as a board, and is usually deeply drawn in. The extremities are
affected also by the contraction, but to a less extent. The arms are drawn up, the
hands clenched to form fists. The legs are stretched, the toes abducted. In wellmarked cases the body is as stiff as an iron plank (Soltmann) . One can grasp the
child and lift it up as one would lift a statue. The commencement of the tetanic
convulsion, especially where the disease is advanced, may be brought about by any
disturbance of the child, by an attempt at nursing, by a change in its position,
or by a strong current of air. Later the intervals between attacks become shorter
and shorter, and finally the contraction is continuous.
"The respiratory muscles are usually not markedly involved at first. As the
disease progresses, however, dyspnea develops; the child becomes cyanotic, and,
owing to contraction of the muscles of the throat, swallowing becomes impossible.
The laryngeal muscles are often affected, so that the cries of the child are interrupted
or it cannot give any vocal evidence of its great pain.
"The pulse-rate is usually increased, from 160 to 200; the temperature is elevated, and may reach 41° to 42° C. Defecation and urination are only rarely much
disturbed. The course of the disease is usually unfavorable. The attacks increase
in number, and finally the intermissions between them become very short. A
severe grade of cyanosis supervenes, and as a result of the impossibility to take
nourishment there is marked emaciation. Death may take place on the first or
second day, but it usually occurs between the fifth and sixth days. Recovery is
rare. In favorable cases the attacks gradually diminish in strength and in duration.
Occasionally bones are broken, muscles are torn, and paralysis of individual muscles
occurs."
REMARKS.
After reading the records of the appalling epidemics of fatal umbilical infections
that occurred from the earliest days of medicine up to the era of asepsis, one instinctively turns back to those two modest scientific investigators, Louis Pasteur
and Joseph Lister. More than any others, these two have been the direct means of
saving the lives of thousands upon thousands of new-born babes, and have in a large
measure removed the nightmare of childbed fever.
The above detailed report of the records of so many epidemics may seem somewhat superfluous, in view of the fact that in the future we shall, fortunately, have
UMBILICAL INFECTIONS IN THE NEW-BORN. 97
little to fear from this quarter. Such reports, however, will serve to emphasize the
powerlessness of the older physicians in the face of such emergencies. Moreover,
it is clearly evident that even at the present time an insidious umbilical infection
occasionally exists and that it may lead to the child's death, before the original
focus of infection has ever been suspected. In every instance of illness in a new-born infant it should always be the
rule to inspect and, if necessary, reinspect the navel.
TREATMENT OF THE UMBILICAL CORD.
This subject is dealt with so fully and satisfactorily in the text-books on obstetrics that it would be superfluous to discuss it in any detail. It will not be out
of place, however, to consider a very interesting paper by R. L. Dickinson,* entitled, "Is a Sloughing Process at the Child's Navel Consistent with Asepsis in
Childbed?" Although the article was published in 1899, it has not received the
attention it merits. "This paper is a plea for the application, in amputating the
cord, of the surgical principles that govern other amputations. The following
principles are directly opposed to the prevailing practice, but would seem to bear
upon the matter:
" (1) Mass ligature should be avoided. Hemorrhage follows the present method
occasionally, because shrinkage of the gelatin loosens the seizure. Ligatures belong
on bared vessels.
" (2) A hernial opening should not be closed by a granulation scar. Primary
union is readily substituted.
" (3) If the location of the future line of demarcation is known, removal should
be practised at or beyond that point. In the case of the funis, one knows where the
line of separation is to be.
" (4) That form of operation should be chosen which will do away with sloughing
or pus production. Prevention of suppuration, of putrefaction in the stump, and
of systemic infection has been attempted by means of numberless devices and dressings, spread through a voluminous literature of failure. Removal alone is prevention. The obstetric nurse will then no longer go from a pus dressing on the baby's
abdomen to the fissured nipple, the perineal wound, the catheter, or, in small maternities, to the vulva of the woman in labor.
"And, conversely, septic maternal discharges will cease to endanger the child's
open wound.
"To frankly sever the cord at the skin margin, with ligature of the vessels or
suture, one or both, brings about safe, clean, prompt healing. Even the pressure
of a pad and an adhesive strap may suffice. Thereby the navel of the second day
looks like the navel of the tenth or fifteenth day under other methods. After succeeding with many cases of complete primary amputation, the writer found that
Flagg had recently published the method in part."
Dickinson then gives a most painstaking and thorough review of the literature,
draws attention to the large number of children that die of a sepsis starting from the
umbilicus, when the family physician, even after the death of the child, is totally
unaware that the infection commenced in the umbilicus or that the death was due
to sepsis.
* Dickinson, R. L.: Amer. Jour. Obstet., 1899, xl, 14.
98
THE UMBILICUS AND ITS DISEASES.
He then describes his mode of amputating the cord: "Elaborate detail concerning the various methods classified above is hardly necessary. A typical example
of each class may be given :
"Preliminaries to All Three Methods.— As the child's
trunk makes its exit, a sterile or clean towel is so applied to the abdomen that the
cord and the umbilical region make no contacts once outside the grasp of the vulvar
ring. The trunk is wrapped in the towel as the baby is laid down or resuscitated.
As soon as pulsation grows feeble, the cord is clamped beyond the towel between
two Keith forceps and cut. Artery clamps have an insufficient bite for large cords.
The child is laid aside until the placental stage is completed and the perineum has
received attention.
"The material is prepared. The choice of method is made, and now the child
is laid on a table. A towel is wound about its arms, and another about its legs, to
keep it quiet and to insure a clean field. The towel is unwrapped from about the
abdomen. The nurse draws the cord out by the forceps that has been placed six
Fig. 1
Fig. 62. — (After Dickinson.)
Fig. 1. — The scissors free the cord from the skin,
and then push up the sheath and the jelly.
Fig. 2. — The trousers-leg slipped upward with the
gelatin, exposing the vessels. The ligature is placed
as low as possible.
Fig. 3. — After ligature and cutting away.
Fig. 4. — The stump rolls in at once.
Fig. 5
Fig. 6.
Fig. 63. — Method of Teeating the Umbilical Stump
at Birth. (After Dickinson.)
Fig. 5. — Removal of cord at one snip of the scissors, the fingers holding the stump, as shown in the
next cut.
Fig. 6. — The fingers still hold the stump while
suturing.
Fig. 7. — One form of suture.
Fig 8. — A suture ligature.
or eight inches away from the navel. Her hands need not be safe, but the operator's are prepared as for an operation.
"A. Simple Ligature. — With blunt-pointed scissors snip all around
the skin margin, avoiding the place where the vein shows near the surface (Figs. 62
and 63) . At this place it is not always easy to cut the sheath without opening the
vein. The sheath and gelatin are stripped backward with as much jelly as possible.
The vessels thus span the gap, standing alone. A fine silk or catgut ligature, around
all three or about the vein alone, is placed. The ends of the vessels are cut short,
and the cord is off. The stump tends to roll inward. No antiseptic solution should
have been used unless one has ground for fearing gonococcus infection. No powder
is to be used. A dry gauze pad under the binder suffices. Scissors, ligature material, and one or two forceps are needed, besides the gauze for sponge or dressing.
Fine silk cuts itself out, the end of the tied vessel seeming to reorganize. This
method is much more sure to control bleeding than mass ligature of a cord.
"B. Suture. — The cord is drawn upward by the nurse as before. The
cuff of the skin is caught between the palmar surfaces of the left thumb and index
UMBILICAL INFECTIONS IN THE NEW-BORN. 99
finger, and one closure of the scissor-blades severs the cord through the capillary
ring (Fig. 63). A reflux of blood comes from the cord. Without letting go with the
left hand, an artery clamp pulls the vessels up ; the needle is taken up in the right
hand, and a simple continuous stitch is run across and its ends are tied together;
or a subcuticular (Kendal-Frank) is put in place. If it is desired to ligate as well
as to sew with the same silk, one loop of the stitch sweeps around the arteries and
the other about the vein. Superficial bites may be taken in order that the little
stitch of fine silk will cut itself out.
"Capillary oozing, or a few drops from the vein, are arrested by a little pressure
from a plain sterile gauze dressing under a binder. Scissors, a sharp cutting needle
to penetrate rather tough skin, fine black silk, gauze, and artery forceps are needed.
The timid may place the stitch or stitches before cutting at all, as Dr. George R.
Fowler suggested to the writer.
" Objections to Complete Primary Amputation. — (1)
Increased danger of contact-infection, owing to operation on parts supplied with
lymphatics, as compared with the ordinary ligation of vessels and jelly on parts
having no nutrient capillaries or absorbents.
" (2) Lack of drainage in case of infection.
" (3) Danger of concealed secondary hemorrhage (hematoma) after the suturing
method.
" (4) Inaccessibility of vessel-ends in case of bleeding, as compared with facile
placing of second ligature where stump is long.
" (5) Tharisk of striking an umbilical hernia.
" (6) As this is surgery, it is not yet adapted to the general practitioner, and to
the midwife only the pressure method can be trusted, if that method proves safe.
"To admit most of these objections is to confess that we, as instructors and
surgeons, fail in our attempt to drill the student in hand cleaning and instrument
boiling and avoidance of unclean contacts, and that, as to this generation of general
practitioners, we give them up. Our method requires hands no cleaner than for a
vaginal examination, and far less wound knowledge than for the repair of that
perineal injury which zigzags through fascial and muscular planes, their anatomy
disguised by stretching and edema.
"Even in the matter of secondary hemorrhage not controllable by pressure, any
one can roll open a superficial wound, draw up its center with an artery forcep, and
seize and ligate an oozing vessel end. A hernia at birth calls for closure of the canal
by sutures in any case. Hernia is exceedingly rare at this time (Tarnier and Budin) ,
though common enough a month or two later.
" After-care. — A small square of plain gauze lies on the wound and may
become adherent to it. Over this a larger dressing is placed, and a moderately
snug binder is pinned or sewed on. As with any other clean wound, the dressing
must not be changed except for cause. The baby is not tubbed for a week until
union is secure.
"The first washing immediately after the operation has been just sufficient to
get rid of any vernix caseosa that is present, and during the week no general washing is needed.
"Flagg speaks of his case healing under a scab. This is produced by the dermatol. It is better to permit drainage. Sanious oozing, as from any fresh wound,
usually occurs. In some instances, on rolling the wound outward on the third or
100 THE UMBILICUS AND ITS DISEASES.
fifth day, the inverted skin-cuff is found to be moist. It may be that there is a
watery discharge from the gelatin within the ring of skin. Some of the inversion
of the stump may be prevented, and a handsomer flush result secured by taking
off part or all of the skin-cuff. Dry primary union is thus more certain. Most
adult navels are dirt accumulators — accumulators not easy to clean. Deep inversion, with the line of union solidly fixed, 1 to 1.5 cm. below the level of the skin
of the abdomen, may be found by the ninth day if the whole skin projection is used
as flap."
I wrote Dr. Dickinson asking what his experience had been in the ten years intervening since his paper, and received the following answer :
"Your query about my immediate amputation of the cord did me good. Nothing ever fell as flat and as hard as that proposition. The principles of surgery don't
apply to the only operation done on every living being, savage, civilized, or fourfooted. I can be satisfied to wait, but the method will not be general till every
practitioner can do a little clean work. Meanwhile I have gone straight on with the
second procedure. The cord is lifted by nurse or assistant. A really sharp curved
needle, armed with No. or No. 1 catgut or fine silk or linen, is passed into the very
tough skin, beginning below the navel, just where the skin-cuff rises from the bellywall. It circles beneath the skin, and comes out above at the base of the skin-cuff.
The needle reenters close to its first entrance and circles the remaining half, coming
out near the original second entrance. It is an over and over stitch of a round
space that sweeps about the circle as well, thus acting as suture and encircling ligature in two bites and one tie. The stitch is placed before the cord is cut.
"The cord is cut just at the skin margin, under a little traction, in order that
most of the jelly may come away in the scissors. Then an anatomic forceps slips
the loop of the middle part of the stitch over the center of the raw surface, and one
ties. It falls out or is nipped out in two or three days.
"The only contraindications are unclean contacts between exit of child's navel
and operation, umbilical hernia, and a circulation badly started, so that there is
back pressure in the vein.
"I have never seen oozing or temperature in my own cases. The only case I
know of that did badly is a baby whose navel was sutured by an intern in a Brooklyn
hospital, that died after some temperature, with a clean navel and no autopsy."
Buckmaster, in 1906, suggested a treatment of the cord very similar to that
carried out by Dickinson, although he was evidently unaware of the latter's work.
Buckmaster in substance said that for several years he had been impressed with
the idea that if the umbilical wound could be made to heal by first intention, it
would be of great advantage. He made no claim to priority in suggesting a method
by which this could be done, and said that he did not know who deserved credit for
such a suggestion, since the more reasonable the plan, the more likely it is to occur to
a number of men. He had tried the new plan in 8 cases : in 6 the results were all
that could be wished for. In 2 cases of the 8 there was a slight trouble in the healing of the wound, but not enough to affect the general result. In all cases the wound
was closed in ten days, and instead of a cicatrix, there was a slight linear scar.
These children had been started in life without an umbilicus, and he has, therefore,
used the term " anomphalosis " as the title of his article. His operation is as follows :
"With a sharp pair of scissors free the belly-wall, reflected on the cord like a cuff,
and push it back. When this has been done, the cord may be divided. Sometimes
UMBILICAL INFECTIONS IN THE NEW-BORN. 101
an artery may spurt a little, but torsion or a thin catgut ligature will quickly control the hemorrhage. It will be noticed that in cutting through the cord near the
wall how much more fibrous tissue is found than one would expect.
"The condition now present is a circular pit surrounded by a ridge of skin, the
top of which is raw. By drawing two points on opposite parts of the ridge from
each other, the circle is changed to an ellipse. The sides of the ellipse are now drawn
together by sutures, preferably silver wire, and in from six to ten clays the wound is
closed, practically by first intention.
"The condition is like an amputation of an arm: in both cases we have a flap
which is made from the skin and which covers the stump. Since I first commenced
to discuss this procedure among my friends who are interested in obstetrics I find
that many have tried it. But while they have no good objection to the procedure,
it did not seem to impress them favorably. I believe time will change all this.
Xo anesthetic is necessary, because the child suffers next to nothing, but the operator should work quickly and not where the mother or non-professional spectators
might, through their ignorance, fancy the child was maltreated."
Simple Surgical Treatment of the Umbilical Stump.
— The method recommended by Nadory * complies with the three requirements of
Ahlfeld, i. e., that there be positive prevention of an infection, protection against
secondary hemorrhages, and no necessity for after-treatment. As soon as the pulsation of the umbilical cord ceases the cord is tied tightly with a heavy silk ligature
at the line of demarcation between the skin and Wharton's jelly. The cord is then
cut short. The stump and umbilical ring are painted with tincture of iodin. The
child can be bathed daily if an application of the tincture of iodin is made after the
bath. The umbilical stump will fall off on the second or third day. The umbilical
funnel heals rapidly (J. Voigt).
CARE OF THE UMBILICAL STUMP— A BACTERIOLOGIC STUDY.
After briefly considering the clinical aspect of the infections and referring to the
recent literature on the subject, Adairf gave the results of his bacteriologic examinations. "In order to prove the presence or absence of organisms on and around
the umbilical cord immediately after birth, the following procedure was adopted:
"A platinum loop was used to scrape the cord and surrounding skin immediately
after birth and before the cord was handled or manipulated in any way. Agar plate
cultures were made from the material caught on the platinum loop. All these
cultures were made under as nearly the same conditions as possible in the Elliot
Memorial Hospital at the University of Minnesota. No attempt was made to
isolate the anaerobic organisms.
"There were 65 cases examined in all. In 17 of these there was no growth.
Xon-pathogenic organisms were found independently of any pathogens in 33 cases,
or over 50 per cent of those examined. Pathogenic organisms were found alone or
associated with non-pathogens in 12, or 19.46 per cent. Some variety of staphylococcus was found in 8 instances, and some form of the Bacillus coli group in 4
cases.
* Xadory, B.: Einfache chirurgische Versorgung des Nabelschnurrestes. Zentralbl. f. Gynak.,
1913, xxxvii, 765. Surgery, Gynecology and Obstetrics, November, 1913, 556.
t Adair: Jour. Amer. Med. Assoc, August 23, 1913, 537.
102 THE UMBILICUS AND ITS DISEASES.
"The significance of this is evident. The cord and its surroundings show the
presence of pathogenic organisms in nearly one-fifth of the cases immediately after
birth. This is true where the cases are conducted amid the aseptic surroundings of
a delivery room. The percentages might easily be much higher where less rigorous
asepsis is carried out. This, of course, is no argument for carelessness in the subsequent handling of the cord, for it may be infected at any time.
"What are the essentials for the growth of organisms? (1) The presence of the
germs; (2) the proper degree of temperature; (3) a suitable culture-medium and
environs; and (4) the presence of moisture.
"It is evident that it will be very difficult .to eliminate entirely the presence of
bacteria, but we can avoid contaminating the parts with germs, and we can assist
in their removal by the use of aseptic and antiseptic measures. The body heat
furnishes the proper temperature, and, of course, cannot be interfered with.
"The devitalized tissue of the cord forms a fine medium for the growth and
development of the organisms. This can be removed by ligating or clamping the
cord close to the skin margin. It has been pretty well demonstrated that better
results are obtained by leaving as little cord as possible. Doubtless the methods of
amputation proposed by Dickinson, which in his hands have given almost ideal
results, accomplish this most thoroughly.
"The presence of moisture may be controlled by having a small stump of cord
and keeping it under conditions which favor rapid drying. Various experiments
have been conducted along this fine, and it has been found that exposure to air is
one of the best means of accomplishing this end. Hygroscopic powders have been
used with some success; good results have been obtained by the use of astringent
and inert powders. Equally good, or better, results have been obtained without
any dusting powder. Oily dressings have not given as good results. Dry occlusive
dressings have been used. Gauze seems to permit of better and more rapid mummification than cotton.
"In order to fulfil these conditions, the new-born babies have been treated as
follows at the University of Minnesota Hospital:
"After cessation of pulsation, the cords were clamped near the skin margin, the
surrounding skin and cord cleansed with alcohol, and the clamp removed, to be
replaced by a ligature in the groove made by the clamp. The end of the cord and
the surrounding skin were painted with one-half strength tincture of iodin in some
cases, and in others left untreated. A sterile gauze dressing was then tied over
the end of the cord. The babies were oiled for three days, then washed, but no
tub-baths were given until the navel was healed. Each day the stump and surrounding skin was washed with alcohol and the dressing changed when necessary.
"A study of the clinical courses of these cases subsequent to delivery may be of
interest and profit.
"First in order is a consideration of those cases from which cultures were taken.
In all there were 65 cases; one of these was a still-birth; there were 3 unsatisfactory
cultures, which leaves 61 for study.
"There were 17 cases which showed no growth; of these, 4, or 23.5 per cent,
showed a febrile reaction of over 100° F. There was one case with jaundice, and
the average maximum weight loss was 209 gm.
"Of the 32 cases from which non-pathogenic organisms were recovered, there
UMBILICAL INFECTIONS IN THE NEW-BORN. 103
were 8, or 25 per cent, with febrile reaction; 3 infants were jaundiced, and the
average maximum loss of weight was 188 gm.
"There was a temperature rise in 3, or 25 per cent, of the 12 cases in which
pathogenic organisms were found; one was jaundiced, and the average maximum
weight loss was 202 gm.
''The figures are so close for the different groups that the only conclusion one
could draw would be that, so far as this series is concerned, it made little difference
whether or not the organisms were present at birth.
" There was no definite evidence of any serious infection of the navel. Two were
somewhat reddened without any febrile reaction, jaundice, or marked loss of weight.
There were two with some foul odor, one had a febrile reaction of 102° F. and a
weight loss of 340 gm. The other had no reaction. Neither had any jaundice.
A number of others did not heal so rapidly as usual, but showed no signs of infection.
None of these babies died, and all left the hospital in good condition.
"Fifty-eight infants were treated, as outlined above, with alcohol and dry dressings. Of these, 14, or 24.13 per cent, had a rise in temperature to 100° F. or over;
8, or 13.08 per cent, were jaundiced, and of these 4 had fever and there was an
average maximum loss of weight of 246.2 gm. The average loss of weight in the
febrile cases was 314 gm. Five, or 8.6 per cent, had slight local evidence of navel
infection, but none of them had a temperature rise to 100° F. The cord came off
in five and one-half days on an average.
"In the second series of cases tincture of iodin was used to paint the cord and
surrounding skin. Otherwise the treatment was the same as in the preceding series.
"There were 186 babies treated in this way. The temperature rose to 100° F.
or above in 42, or 22.58 per cent, of these; 15, or 8 per cent, were jaundiced, of
which 5 had a febrile reaction. The average loss of weight was 228.05 gm. In the
cases with fever, this loss amounted to 285.19 gm. Ten, or 5.37 per cent, had
slight local evidence of infection of the navel, only 3 of which had any fever. The
cord came off in seven and one-half days on an average. None of the babies in
either series had any evidence of serious or fatal infection originating at the navel.
How many of these febrile cases were caused by absorption of some toxic substance
or the entrance of organisms through the umbilicus it is not possible to state.
Many conclusions cannot be drawn from this rather small amount of material.
"It is evident that some facts can be stated.
"1. The cord is contaminated with pathogenic or non-pathogenic organisms
at or immediately after birth in a large percentage of cases.
"2. It is possible quite effectively to combat serious umbilical infections by
comparatively simple methods, as shown by this report of over 200 cases with no
mortality from this cause.
"3. There seems to be little choice between the two methods used in these cases.
"4. Jaundice in the new-born child is frequently associated with fever. It
would not be illogical to suspect that this might originate by some agent introduced
through the umbilical vein or lymphatics.
"5. Febrile reactions are common in the new-born infant, and are associated
with other disturbances, such as a high primary weight loss and jaundice. They are
due, no doubt, to many causes, but we, as obstetricians, should see that those due
to infections entering; at the umbilicus are reduced to an irreducible minimum."
104 THE UMBILICUS AND ITS DISEASES.
PERSISTENT VITALITY OF THE UMBILICAL CORD.
Occasionally the cord does not come away promptly. This is prone to occur if
the cord has been tied at a point too far remote from the umbilicus. This phenomenon was very well shown in a case reported by Williams in 1880, and in cases described by Dorland in 1897.
Williams' patient was a child three weeks old. A fleshy outgrowth an inch long
projected from the umbilicus. It was rigid, had a raw, granulating appearance,
and bled on the slightest touch. It was sensitive and had a little central opening
on its free extremity. The dressings were frequently changed on account of a
watery oozing. The central depression did not lead into a canal. A strong silk
ligature was applied to the base of the projection. The next day nothing was visible
but a small shred of dead tissue, which was nipped off after three days. The child
made a perfect recovery.
Dorland said that within a period of ten months he had two cases in which the
cord did not come away readily. He mentioned a case in which the cord had not
come away at the end of the eighth week, and was then amputated close to the
umbilicus. In this case the tissue was almost cartilaginous. In Dorland's cases
the cord did not separate until the ninth and sixteenth days respectively. In
Case 1 there was fissuring of the cord close to the abdominal wall. The child, on
the eighth day, developed convulsions, a persistent high temperature, and inflammation of the umbilicus. It died on the following day.
In the second case the cord was amputated on the sixteenth day. There was a
slight oozing for two days, but the child recovered.
LITERATURE CONSULTED IN THE PREPARATION OF UMBILICAL INFECTIONS IN
THE NEW-BORN.
No attempt has been made to cover the subject.
Adair, Fred. L.: Care of the Umbilical Stump. A Bacteriologic Study. Section on Obst.,
Gyn., and Abdom. Surg, of the Amer. Med. Assoc, at the Sixty-fourth Annual Session held
at Minneapolis June, 1913. Jour. Amer. Med. Assoc, August 23, 1913, 537.
Bednar, A. : Die Krankheiten der Neugeborenen und Sauglinge. Wien, 1852, 168.
Bergeron, H. : Une epidemie de gangrene de l'ombilic. These de Paris, 1866, No. 59.
Buckmaster, A. H. : Anomphalosis. Trans. Amer. Gyn. Soc, 1906, xxxi, 306.
Cohn, M.: Zur Lehre von den septico-pysemischen Nabelinfectionen der Neugeborenen und ihrer
Prophylaxe. Therap. Monatsschr., 1896, x, 130; 192.
Cumston, C. G. : Infection of the Umbilicus in the Newly Born. New York and Phila. Med.
Journal, 1905, lxxxi, 81.
Dickinson, R. L. : Is a Sloughing Process at the Child's Navel Consistent with Asepsis in Childbed? An Introduction to the Study of Complete Primary Amputation. Amer. Jour. Obst.,
1899, xl, 14.
Dorland, W. A. N. : Persistence of the Umbilical Cord. Phila. Polyclinic, 1897, vi, 254.
Gremillon: Anomalies et des complications de la cicatrisation de l'ombilic. These de Paris,
1895, No. 453.
Hinsdale, G. : Purulent Encephalitis and Cerebral Abscess in the New-born Due to Infection
Through the Umbilicus. Amer. Jour. Med. Sci., N. S., 1899, cxviii, 280.
Lambert, S. W. : Umbilical Sepsis in the New-born Occurring at the Nursery and Child's Hospital,
New York, during 1896. Med. News, Phila., 1897, lxx, 557.
Lorain, Paul: De la fievre puerperale chez la femme, le foetus, et le nouveau-ne. These de Paris,
1855, No. 161.
Maygrier, M. C: Infection generalisee d'origine ombilicale probable chez un nouveau-nc.
Bull, de la Soc. d'obst. de Paris, 1901, iv, 146.
UMBILICAL INFECTIONS IN THE NEW-BORN. 105
Meyer: Puerperal-Infection eines Neugeborenen. St. Petersburger med. Wochenschr., 1891,
xvi, 423.
Meynet, C. H. P.: Epidemie d'erysipele et d'ulceration de l'ombilic. These de Paris, 1857, xi,
No. 156.
Nadory, B.: Einfache chirurgische Versorgung des Nabelschnurrestes. Zentralbl. f. Gynak.,
1913, xxxvii, 765; Surgery, Gynecology and Obstetrics, November, 1913, 556.
Nicaise: Ombilic. Dictionnaire encycloped. des sci. med. Paris, 2. ser., xv (1881), 140.
Pinkerton, J.: A Case of Omphalitis, Umbilical, Closure of Ulcer by a Plastic Operation; Recovery with a Firm Cicatrix. The Lancet, 1900, i, 1656.
Pollak: Nabelbrand, Darmfistel, Tod. Jahrb. f. Kinderheilk. u. phys. Erziehung, 1869-70, iii,
227.
Porak: Infection generalisee chez un nouveau-ne consecutive a une phlebite ombilicale suppuree. Bull, de la Soc. d'obst. de Paris, 1901, iv, 142.
Porak, C, et Durante, G. : Infections ombilicales du nouveau-ne. Arch, de med. des enfants,
1905, viii, 449.
Ribbert: Abscesse des Gehirns, veranlasst durch Embolien des Oidium albicans. Berl. klin.
Wochenschr., 1879, xvi, 617.
Runge: Die Krankheiten der ersten Lebenstage. Stuttgart, 1893, 56.
Salge, B. : Ein Beitrag zur septischen Infektion des Nabels des Neugeborenen. Charite-Annalen,
1904, xxviii, 263.
Tarnier et Budin: Traite de l'art des accouchements, 1901, iv, 728.
Trousseau, M.: De l'erysipele chez les enfants a la mamelle. Jour, de med. et de chir., 1844,
ii, 1.
Wassermann, M.: Ueber eine Epidemie-artig aufgetretene septische Nabel-Infection Neugebo
rener: ein Beweis fiir die pathogenetische Wirksamkeit des Bacillus pyocyaneus beim Men
schen. Virchows Arch., 1901, clxv, 342.
Williams, C. R. : Persistent Vitality of the Umbilical Cord. The Lancet, 1880, i, 701.
Yot, E. : De l'erysipele innammatoire ou non-puerperal des enfants nouveau-nes. These de Paris,
1873, No. 240.
==Chapter IV. Umbilical Hemorrhage==
General consideration.
Causes of umbilical hemorrhage.
Treatment.
Instances of umbilical hemorrhage in the new-born.
Umbilical hemorrhage in patients after infancy.
Hematoma of the abdominal wall near the umbilicus.
To discuss thoroughly the enormous amount of literature on this subject would
occupy many pages. I shall merely give the salient facts, and report enough cases
to give a clear idea of the fatalities resulting from umbilical hemorrhage.
The manner in which umbilical hemorrhage is checked, even though no ligature
be applied, is probably explained by Fig. 64. The inner longitudinal muscular
coat contracts and thickens, thus tending to obliterate the lumen of the vessel.
We know that in many animals, in fact in practically all, the cord is bitten or torn
off, no ligature being applied.
Craig (1894), in his article on Umbilical Hemorrhage, quoted J. Foster Jenkins,
who in 1858 published a monograph giving the histories of 178 cases, and mentions
Grandidier, who had collected 202 cases. In about one-third of the cases the hemorrhage occurred in female children; in two-thirds, in male children.
Craig states that the time of greatest danger is when the cord comes away —
from the fifth to the fifteenth day. As the chief causes of hemorrhage he mentions
a faulty condition of the blood, pathologic conditions of the vessel-walls, hemophilia.
He adds that a condition of ill health or anemia in the mother, due to any cause,
produces, to a certain degree, a like condition in her offspring.
Without any premonition of the impending danger, the clothes are found
soaked with blood. In 41 out of 175 of Craig's cases the hemorrhage was
preceded by jaundice. The most dangerous hemorrhages occurred at night.
About 90 per cent of the children die. Where jaundice and hemophilia are present, the condition is most hopeless (Craig).
Cumston, in 1905, writing on infections of the umbilicus in the new-born, says
that certain accidents, such as late umbilical hemorrhages arising from the changes
in the vessels, are often due to hemophilia, hereditary syphilis, and a kind of hereditary family predisposition. These conditions have been observed by Boissard.
Demelin (quoted by Cumston) divides umbilical hemorrhages occurring secondarily or spontaneously into the three following groups: (1) Hemorrhage due to an
arteritis occurring about the time the cord falls off. (2) Hemorrhage occurring in
acute degeneration of the infant, "with icterus of infective origin. (3) Hemorrhage
in cases of septicemia of the newly born, which is produced by the same mechanism as holds in cases of congenital syphilis following umbilical inflammation.
Gallant, in 1907, gave a good resume of the subject of umbilical hemorrhage,
and added an excellent table of the reported cases.
106
UMBILICAL HEMORRHAGE.
107
Runge (op. cit., p. 197) says that cases of umbilical hemorrhage in which, on
anatomic examination, no syphilis was present, have been reported by Wachsmuth,
Weiss, Hryntshak, Fischel, and others.
According to Mracek, the hemorrhage is caused by disease of the small and
large veins. In the walls, especially of the veins, is found a thickening due to multiplication of the nuclei. He found the lumen narrow, and in several cases completely closed.
Runge (p. 198) asserts that septic diseases of the new-born have been proved to
be the cause of idiopathic bleeding by the observations of Weber, Ritter, and Epstein. Capillary hemorrhages are
relatively common in septic cases,
but in addition severe bleeding
from various organs has been observed in septic diseases of the
new-born, especially in foundling
hospitals. Epstein found bleeding 24 times in 51 children suffering from a well-developed acute
septicemia. Runge notes that,
in cases in which bleeding took
place, there was often gangrene of
various parts of the surface of the
body. In cases of general septicemia there is a tendency toward
hemorrhage; various organs may
be affected, and as a result we
may have bleeding from the umbilicus.
The hemorrhage is sometimes
noted a few hours after birth. In
each of the three cases recorded
by Kommerell the bleeding occurred a few hours after birth,
but all the infants recovered.
In his first case the mother
reported that her first child
had had severe umbilical hemorrhages, and she had asked the
midwife to be particularly careful. The midwife accordingly had tied the cord twice
with firmness and extra care, and, when she left, it was in good condition. Later,
however, a severe hemorrhage occurred. The bleeding ceased spontaneously and
the child recovered.
In Kommerell's second case the midwife had tied the cord a second time and the
father had seen that it was properly done. During the night the child was restless;
in the morning it was very pale, and there had been severe bleeding from the cord.
The hemorrhage stopped spontaneously and the child recovered.
The fact that these bleedings occurred several hours after birth, according to
Kommerell, is easy of explanation. After being cut the blood-vessels contract,
wV
II, ,
Coturacte ct> ;
Itmgitdfdinal
| m use lei- closing
til iH ,'iLuThen ,■:'■:.
m
Fig. 64. — Natuhe's Method op Checking Bleeding fbom the
Umbilical Arteries.
On the left we have transverse and longitudinal sections of
an artery showing the intima, the thick longitudinal muscular
coat, and the outer circular coat. When the vessel is cut across
in the living, the longitudinal muscle probably contracts, as indicated by the arrows, forming an effectual barrier to the further
escape of blood. Were it not for some such mechanism as this,
many animals would perish, since in their case the cord is left to
take care of itself.
108 THE UMBILICUS AND ITS DISEASES.
while at the same time the blood-pressure is diminishing. The intra-abdominal
portion of the umbilical artery continues to pulsate after pulsation has ceased in the
extra-abdominal portion. If, now, the soft mass within the umbilical pedicle loses
in energy, while in the intra-abdominal part the umbilical vessels are still filled,
hemorrhage can readily occur.
Kommerell reports another case in which, several hours after the midwife had
tied the cord, fatal hemorrhage occurred. The midwife was sentenced to eight days
in jail. Kommerell then goes on to discuss the responsibility in such cases. In
Sibert's case the infant died of umbilical hemorrhage thirty hours after birth. The
cord was three-quarters of an inch in diameter. On account of "unusual excitement" in the cord, tying was delayed. Sibert saw the child twenty hours after
birth. It was pale and was bleeding from the umbilicus. The ligature was not
found when the cord was examined. A second was applied. After a time the
bleeding recurred. The mother's health during gestation had been bad. There
was no history of a hemorrhagic diathesis.
The hemorrhage may occur two or three days after the birth of the child, or an
interval of several weeks may elapse before bleeding is noted. In Craig's case, for
example, oozing from the umbilicus was noted on the second day. There may
be hemorrhages at irregular intervals, extending over a period of from a few
hours to two or three days, or, as in Garcin's case, the hemorrhage may be so severe
that the child dies in a few minutes after the bleeding has been detected.
In some cases the bleeding is intermittent, in others, constant. Stuart's description of the bleeding in his case is graphic: "It reminded one of the water bubbling through sand at the bottom of a spring; only the oozing and welling up from
the stump of the cord were very deliberate and slow."
CAUSES OF UMBILICAL HEMORRHAGE.
The most frequent causes of umbilical hemorrhage appear to be heredity, infection, and syphilis.
Heredity.- — ■ Tajdor, in 1893, reported three cases occurring in one family;
the mother's first cousin had lost two children from umbilical hemorrhage.
Infection. — Umbilical infection, with its subsequent general infection
and jaundice, evidently plays a very important role in the development of hemorrhage from the umbilicus. In Chapter III it has been noted that, before the days
of asepsis, when outbreaks of puerperal sepsis developed and many mothers succumbed, there was a correspondingly large percentage of umbilical infections in the
new-born. Fortunately, this is in large measure a thing of the past. Thus Garcin, in 1903, when reporting a fatal secondary hemorrhage from the umbilicus eight
days after birth, could say: "I have never had one like it, although I have officiated
or assisted in upward of a thousand obstetrical engagements."
Syphilis. — Runge says that not only Grandidier, but also other authors,
have noted syphilis in the parents of children that have developed umbilical bleeding. Several writers have described in detail the syphilitic changes that were
present in the children during life and after death, and are inclined to regard this
disease as the etiologic factor. Behrend described a "syphilis hemorrhagica."
Runge says that this form of syphilis only rarely affects children. When the
disease is noted at birth, it is most frequently encountered in premature children,
UMBILICAL HEMORRHAGE. 109
who, if not born dead, die almost immediately or live only a few hours, rarely a day.
In these cases, in addition to the marked changes, which are usually those found in
syphilis, can be noted numerous hemorrhages under the skin and in the internal
organs. Sometimes there are hemorrhages into the stomach and intestine, into the
peritoneal cavity and the meninges.
When such children live for a longer period, there occur new hemorrhages in the
skin or in the various organs. Runge cites the case of a child showing marked syphilitic changes, in which hemorrhage occurred from the edges of the anus and from
the tip of the tongue, and finally, on the eighth day, from the umbilicus. The blood
came out of the skin, just as drops of sweat would do, and on the ninth day marked
icterus developed and the child died. At autopsy extensive syphilitic changes were
found in the internal organs.
TREATMENT.
Astringents, such as silver nitrate, tannic acid, and iron persulphate, have been
used with little or no effect. Adrenalin has proved of little value.
Attempts have been made to check bleeding by encircling the umbilicus with a
catgut or silk ligature, or by transfixing it with two straight needles placed at right
angles, and tying a ligature beneath them. In this way temporary cessation of the
bleeding has occasionally been effected, but it soon recurs. Our hope for the future
seems to lie, in large measure at least, in bringing about a coagulation of the blood.
The condition being, in some cases at least, analogous to melsena neonatorum, a
practical line of treatment should be sought for along the same lines.
The following case recorded by Reichard is of interest, although the bleeding
was not from the umbilicus, but from the bowel. It will be noted that a child of
this mother had died of hemorrhage on the fourth day.
Spontaneous Hemorrhage of the New-born, with
Recovery. — V. M. Reichard * reported the following case:
"Spontaneous hemorrhage of the new-born is so obscure and so fatal a disease
that any experience pointing the way out is worth recording. All treatment detailed in the literature of the subject is so difficult a technic as to require either
special skill or special apparatus or both. In view of these facts the following case
is worthy of report:
"Mrs. R., aged forty-two, white, was delivered rapidly and easily of her ninth
child at 4 p. m. August 26, 1912. She was not in labor more than thirty minutes,
and the baby was born fully half an hour before the attendant's arrival. The child,
a girl, weighed nine and one-half pounds and appeared perfectly well and normal.
Of the eight children previously born, two had died, one, the first-born, of some
bowel complication at four months; and one, the fourth, of hemorrhage on the
fourth day. The ninth child was well for thirty-six hours, when the nurse found
her listless and flaccid. On examination it was discovered that a large quantity of
blood had been passed by bowel. Some of the blood was red, but a much larger
part was dark and tarry-looking. I saw her at 9 a. m., August 28th. The child
was then of a deep lemon color and in profound shock. She had vomited some blood.
During the day she had half a dozen bloody stools, and at 9 p. m. the pulse was rapid
and weak. She had been very languid and relaxed all the day, though she had
taken the breast at three-hour intervals. At 9 p. m. she was given about 15 c.c. of
* Reichard, V. M.: Jour. Amer. Med. Assoc, October 26, 1912, 1539.
110 THE UMBILICUS AND ITS DISEASES.
normal horse serum subcutaneously. August 29th and 30th small amounts of
blood were passed, but each time the amount was less, running possibly from half
an ounce down to a teaspoonful. At 7 p. m. on the thirtieth the child was given
20 c.c. of normal horse serum, and from that time on there has been no blood. Both
injections were made into the buttocks, one on each side. On September 1st the
stools were the usual yellow color of a nursing infant, and have continued so ever
since. On September 16th, when last seen, she was a splendid specimen of baby,
skin clear and healthy, and nursing well, bowels regular, stools natural, and every
evidence of perfect health.
"Twenty cubic centimeters is a fairly large subcutaneous dose for an infant,
and in this case put the skin on the stretch decidedly. This tension subsided rapidly, and in an hour's time the tumor had disappeared."
In .Reichard's case the employment of horse serum gave good results. Serum
in another form was employed by Chartier in a case of umbilical hemorrhage, with
recovery of the child.
It is also possible that the newer and simpler methods of transfusion may yield
good results. These children are, as a rule, too far gone to permit of the linking-up
of a vessel with that of a donor.
INSTANCES OF UMBILICAL HEMORRHAGE IN THE NEW-BORN.
Umbilical Hemorrhage in the New-born. * — Hemorrhage
occurred two days after the cord came away. During the first three days the
weight of the child diminished from 2910 to 2480 gm. There were also vomiting
and diarrhea. On the seventh day there was an umbilical hemorrhage and the
child became blanched. The umbilicus was cauterized with nitrate of silver. The
same evening another hemorrhage followed, and several drops of 1 : 1000 adrenalin
were applied. The next morning free hemorrhage still persisted. The child was
absolutely colorless, the pulse hardly perceptible. Thirty cubic centimeters of
the serum were injected, and two hours later 20 c.c. of serum gelatin. On the next
day another injection of 20 c.c. of serum gelatin was given. The child made a good
recovery.
Chartier employed a sterilized solution of 25 gm. of gelatin in 1000 gm. of
Hayem's serum.
Umbilical Hemorrhage. — C. F. Craig f reports a fatal case : " On
the second day blood oozed from the umbilicus where the cord was attached.
Compresses were applied, and the bleeding ceased. On the third morning the
umbilicus appeared to be in good condition, but the child had vomited blood
several times. On the following morning there had been no more vomiting, but
the child was jaundiced. A few hours later there was more bleeding from the
umbilicus and the child died in the course of a few minutes."
Hemorrhage from Umbilicus. — Fry J reports the case of a colored
child weighing seven pounds and four ounces. On the eighth day the cord came
away. On the twelfth there was bleeding from the umbilicus. Compresses and
* Chartier: Omphalorragie grave, traitement par le serum gelatine, guerison. Arch, de m6d.
des enfants, 1905, viii, 477.
t Craig, C. P. : The Medical News, 1894, lxv, 569.
J Fry, Henry: Omphalorrhagia Neonatorum. Amer. Jour. Obst., 1907, lv, 856.
UMBILICAL HEMORRHAGE. Ill
an abdominal binder were applied. On the following day a solution of 1:10,000
of adrenalin chlorid was used, and forty-eight hours later a purse-string of catgut
was tried. The bleeding still continuing, two hours later two needles were passed
through the umbilicus at right angles, the tissues were constricted with a silk ligature, and five grains of calcium lactate were given every four hours. A temporary
cessation of the hemorrhage ensued. Styptic collodion was tried, and a compress of
10 per cent gelatin solution, changed every two hours. A dram of gelatin solution
in two drams of normal salt solution was injected under the skin. The blood on the
second day showed: Red corpuscles, 3,500,000; white corpuscles, 9000; hemoglobin, 70 per cent. The hahy died four days after the onset of the bleeding.
Fatal Secondary Hemorrhage From the Umbilicus
Eight Days After Birth. — In Garcin's* case the hemorrhage from the
umbilicus began on the eighth day after birth. The labor, which was uncomplicated, occurred on October 23, 1902, and the cord came away in a normal manner.
On October 31, the child was bleeding to death from the umbilicus. The father
discovered blood on the bed when going to work. On the doctor's arrival the child
was just alive. The hemorrhage was promptly controlled by compresses of sterile
gauze saturated with suprarenal extract. The child, however, died in a few minutes.
A Case of Fatal Umbilical Hemorrhage.! — The infant
died of umbilical hemorrhage thirty hours after birth. The cord was three-quarters
of an inch in diameter. On account of "unusual excitement" in the cord, tying
was delayed. Sibert saw the child twenty hours after birth. It was pale and was
bleeding from the umbilicus. The ligature was not found when the cord was examined; a second was applied. After some time the bleeding recurred and the
child died. The mother's health during gestation had been bad. There was no
history of a hemorrhagic diathesis.
Three Cases of Umbilical Hemorrhage Occurring in
the Same Family. J — Case 1 . — A female infant, thirteen days old,
seen on September 29th. She was the eighth child of a healthy family. The mother's first cousin had lost two children from umbilical hemorrhage. The child was
a fine large baby. The cord was very thick, and did not separate until the seventh
day. Before the separation a visitor had seized hold of the front of the child's
clothing, and after that time the navel had been inclined to weep. The bleeding
was more severe on the thirteenth day. The umbilicus was dusted with tannic
acid. On September 30th the bleeding continued. On October 1st the hemorrhage
was profuse. The child died at 5 a. m. October 2d. During the illness it was noted
that the elbows and ankles were becoming discolored.
Case 2 . — A female child, eight days old, seen on December 19th. She was
the tenth child. The umbilical cord had not come away. The clothes were stained
with blood, and the child was blanched. Above the umbilicus for one inch the
surface was red and the skin abraded. The blood was oozing from this area, and
also welling from the umbilical scar. Styptics were of no avail. Two harelip pins
stopped the bleeding. Two days later, however, the bleeding again commenced,
and the child died three days after the onset of the hemorrhage.
Case 3 . — November 10, 1887, male child, ten days old. This was the
* Garcin, R. D.: Virginia Med. Semi-Monthly, vii, April, 1902-March, 1903, 376.
t Sibert, D. E.: Arch, of Pediatrics, 1884, i, 307.
t Taylor, James: Bristol Med. and Chir. Jour., 1893, xi, 237.
112 THE UMBILICUS AND ITS DISEASES.
twelfth child. The cord came away on the seventh day. On November 10th a
patch of dark-colored blood was noted on the dressing from the navel. On November 12th, a bruise was detected on the shoulder. In this case the child was well six
years later.
Taylor says this disease appears to be more common in male children, and that
the tendency to hemorrhage is transmitted through the female members of the
same family.
Fatal Umbilical Hemorrhage in the New-born.* — A
woman, who had been weakened greatly by several pregnancies occurring in rapid
succession, developed jaundice, and her child was delivered four weeks too soon.
The woman died several hours later from hemorrhage.
The child was weak. Forty-eight hours after birth it developed jaundice. It
did not take the breast well. In the night between the third and fourth days
bleeding came on in the umbilical region, from between the cord and the umbilicus.
The child died.
Hemorrhage From the Umbilical Cord on the Tenth
Day .f — ■ The baby was ten days old. Two hours before Stuart saw him there
had been a hemorrhage from the umbilicus. The cord in this case had come off on
the fifth or sixth day, and blood was oozing and welling up drop by drop from the
apparently non-ulcerated but healthy-looking stump. Stuart says: "It reminded
one of the water bubbling through sand at the bottom of a spring; only the oozing
and welling up from the stump of the cord were very deliberate and slow."
Monsel's solution, silver nitrate, powdered tannic acid with subsulphate of iron,
and transfixion of the stump were tried, but with no result. The child died the
next morning. Stuart says: "A remarkable feature of this case was the location
of the collateral hemorrhage in the eyes, from the conjunctival mucous membrane,
when the bleeding seemed to be controlled for a time at the umbilicus."
UMBILICAL HEMORRHAGE IN PATIENTS AFTER INFANCY.
We have records of two cases, one reported by Strecker and one by Colombe.
Strecker's patient was a small, pale lad of eleven, who two days after jumping
down a short distance was seized with bleeding from the umbilicus, associated with
alarming abdominal symptoms. As the patient recovered, the cause of the bleeding was never discovered.
Colombe's patient was a woman thirty-six years old. She had a small nodule
at the umbilicus, and from it severe bleeding took place. The bleeding ceased with
the removal of the nodule.
Umbilical Hemorrhage at Eleven Years of Age.J —
John S., aged eleven, a small, pale, blond boy, on March 9, 1902, jumped from a
porch floor to the ground, — about three feet, — but felt no ill effects. On March
11th he complained of pain at the navel, and blood was discovered coming from it.
The umbilicus with the surrounding tissue for one inch was much higher than the
rest of the abdominal wall. An elastic truss was applied. On March 12th there
* Sadler: Todtliche Blutung aus dem Umfange des Nabels bei einem Neugeborenen.
Schmidt's Jahrb., 1840, xxvii, 177.
t Stuart, A. R.: The Medical News, 1895, Ixvi, 159.
t Strecker, J. E.: The Medical World, 1903, xxi, 211.
UMBILICAL HEMORRHAGE. 113
was another umbilical hemorrhage, and the abdomen was markedly distended,
almost to the bursting point. Opiates were given. The patient vomited bile,
mucus, and fecal matter, and was in a state of collapse. On March 13th the abdomen was less tense, but at 4 p. m. there was a still more alarming hemorrhage.
Calcium chlorid was given. On March 15th an operation was contemplated, but was
put off, as the patient was better. On March 25th the patient seemed well. In this
case there may have been hemorrhage into the abdomen coming through the umbilical opening. As the patient recovered and no operation was performed, it is
impossible to determine the nature of the case with absolute certainty.
A Small Vascular Tumor at the Umbilicus; Hemorrhage. Recovery.* — This patient was a woman thirty-six years of age.
She was in good health and had had a child at nineteen. About ten years before
admission the patient had noticed a small tumor, the size of a grain of wheat, at
the umbilicus. This had gradually increased in diameter. It was purple, rather
soft, painless, but inconvenient. About a week before her admission it was the
size of the end phalanx of the little finger.
Two years before coming under observation there had been hemorrhage from
the tumor. The blood had come in jets. This bleeding had lasted for two days,
but had not been continuous, and had been controlled with iron perchloric!. Three
days before admission she had had a second hemorrhage. Perchlorid of iron was again
used. The volume of the tumor could be compressed to the diameter of the femoral
artery, and the bleeding was intermittent. The patient was in a sea of blood.
She was pale and apparently in a serious condition. Forceps were applied, and the
area ligated en masse, but control was difficult, as the bleeding was from the bottom
of the umbilicus. Seven days later bleeding occurred again. A new ligature was
applied, and the bleeding stopped and never returned. The tumor disappeared.
The origin of this condition remained unknown.
HEMATOMA OF THE ABDOMINAL WALL NEAR THE UMBILICUS.
This condition is exceptional. Hartz, after giving a splendid resume of the
various methods of treating the umbilical cord, says that Westphalen mentions a
hematoma of the umbilicus due to a double rupture of the umbilical vein.
On January 10, 1903, in consultation with Dr. Thomas Linthicum, I saw a
middle-aged woman who had a marked cardiac lesion, which had been associated
with swelling of the extremities and with dropsy. She also gave a definite history
of gall-stones. In April, 1902, she had had erysipelas which had lasted four weeks,
and shortly afterward had had swelling of the wrists and noticed an abdominal
enlargement. Two weeks later jaundice developed, which lasted three or four
weeks. About this time cardiac symptoms were noted. Later on she was seized
with a violent pain in the left leg, which lasted several hours and then extended to
the right leg, reaching from the hip to the toes. Dr. Wells said that the circulation
had stopped in the leg. When Dr. J. M. T. Finney saw her a few days later pulsation was again perceptible in the leg, but he agreed with Dr. Wells that the trouble
was in the arterial circulation. The patient was ill for weeks, and when she was
able to sit up, the limbs became markedly swollen. On December 15, 1902, she
* Colombe: Tumeur vasculaire de l'ombilic; hemorrhagie, guerison. Gaz. med. de Paris ;
1887, lviii, 245.
9
114 THE UMBILICUS AND ITS DISEASES.
was seized with a severe pain, which seemed to be in the region of the liver, and on
December 18 she was thought to be dying. After the circulation stopped in the
leg black spots, evidently subcutaneous hemorrhages, developed. These were
noted from time to time, but were most marked in December. They varied in
size from that of a cent to that of two hands. A gradual improvement followed,
until she was admitted to the hospital for operation.
When I saw her, just above and to the right of the umbilicus was a deep-seated
and apparently cystic mass, fully 16 cm. in diameter. On January 15th the patient
was removed to Baltimore. She stood the journey poorly, but under ether the
pulse became more regular.
An incision was made to the outer side of the right rectus, directly over the
center of the cystic mass. The swelling was due to a large hematoma between the
transversalis fascia and the peritoneum. The cavity was irregularly circular, and
had numerous little bays running off in all directions. The walls and floor of the
sac were thickened, and consisted of granulation tissue. The cavity was filled with
dark, clotted blood. I packed this cavity loosely with iodoform gauze.
An incision was now made to the left of the median line, and curved upward to
the right. After the gall-bladder adhesions had been separated two gall-stones,
each about 5 mm. in diameter, were removed, and the gall-bladder was drained.
The hematoma cavity rapidly granulated and closed completely. The gallbladder wound also closed, and the patient was discharged in a relatively good
condition.
I have given the symptoms somewhat fully in order that the reader may see that
the cardiovascular system was in such a condition that a rupture of one of the bloodvessels was much more prone to occur than in a healthy individual. This hematoma had undoubtedly been due to a rupture of either an artery or a vein.
In a personal communication dated Sydney, Australia, March 14, 1911, Dr.
Fiaschi tells me that his father had a very interesting case just before Christmas,
1910. A young woman developed a hematoma of the left rectus above the umbilicus during or just after labor. She came from the country, and Dr. Fiaschi and his
father thought prior to operation that they might find a ruptured or suppurating
hydatid of the abdominal wall or of the left lobe of the liver.
LITERATURE CONSULTED ON UMBILICAL HEMORRHAGE.
Chartier: Omphalorragie grave, traitement par le serum gelatine, guerison. Arch, de med. des
enfants, 1905, viii, 477.
Colombe: Tumeur vasculaire de l'ombilic; hemorrhagic, guerison. Gaz. med. de Paris, 1887,
lviii, 245.
Craig, C. F.: Umbilical Hemorrhage, Etiology, Pathology, and Treatment. The Medical News,
Phila., 1894, lxv, 569.
Cumston, C. G. : Infection of the Umbilicus in the Newly Born. New York and Phila. Med.
Jour., 1905, lxxxi, 81.
Fry, Henry: Omphalorrhagia Neonatorum. Amer. Jour. Obst., 1907, lv, 856.
Gallant, A. E. : Disorders of the Umbilicus with Special Reference to the New-born and the Infant — III. Umbilical Infections. Internat. Clinics, 1907, 17th series, i, 151.
Garcin, R. D.: Fatal Secondary Hemorrhage From the Umbilicus Eight Days After Birth. Virginia Med. Semi-Monthly, vii, April, 1902-March, 1903, 376.
Hartz, A.: Abnabelung und Nabelerkrankung. Monatsch. f. Geb. u. Gyn., 1905, xxii, 77.
Kommerell: Ueber Nachblutungen bei unterbundener Nabelschnur. Aerztl. Rundschau, Mlinchen, 1896, vi, 627.
UMBILICAL HEMORRHAGE. 115
Reichard, V. M.: Spontaneous Hemorrhage of the New-born with Recovery. Jour. Amer. Med.
Assoc, October 26, 1912, 1539.
Runge: Die Wundinfectionskrankheiten der Neugeborenen. Die Krankheiten der erst en Lebens
tage. Stuttgart, 1893, 56.
Sadler: Todtliche Blutung aus dem Umfange des Nabels bei einem Neugeborenen. Schmidts
Jahrb., 1840, xxvii, 177.
Sibert: A Case of Fatal Umbilical Hemorrhage. Arch, of Pediatrics, 1884, i, 307.
Strecker, J. C: Umbilical Hemorrhage at Eleven Years of Age. Med. World, 1903, xxi, 211.
Stuart, A. R.: Hemorrhage From the Umbilical Cord on the Tenth Day. The Med. News,
1895, lxvi, 159.
Taylor, J.: Three Cases of Umbilical Hemorrhage Occurring in the Same Family, ©ristol Med.
and Chir. Jour., 1893, xi, 237.
==Chapter V. Granulation Tissue or Granuloma of the Umbilicus==
General description.
Differential diagnosis.
Treatment.
Without doubt this is the most frequent umbilical abnormality met with,
and probably every physician in general practice has at some time noted the presence
of a small red mass in the umbilical depression shortly after the cord has come away.
In England attention has been drawn to the subject by Millar, in Germany by
Ledderhose, Pernice, and others; in France the subject has been interestingly
handled by Lannelongue and Fremont, Forgue and Riche, and by Florentin;
in the American literature we find articles on the subject by Holt and by de Villiers.
Immediately or shortly after the cord comes away, a slightly purulent or yellowish discharge may be noted at the umbilicus, and on separation of the umbilical
folds a small red tumor mass is seen on the umbilical floor. It is usually the size
of a pea, more or less pedunculated, light or dark red in color, has a rather smooth,
glistening surface, and, although sometimes firm, is generally soft and mushy and
may bleed readily. It is nothing more than typical granulation tissue. It represents that portion of the umbilical cord distal to the ligature, which in the process
of separation has not completely come away.
On histologic examination the entire mass is found to consist of young granulation tissue. Its blood capillaries are very abundant and scattered throughout the
field are many small round-cells. In 4 out of 27 cases collected by Pernice the surface of the granulation was partly covered over with a delicate epithelium.
Millar has pointed out that the superficial cells of the granulation tissue may be
so flattened that they produce a quasi-epithelial covering.
These small tumors, consisting of granulation tissue, were formerly often confused with another small umbilical tumor found immediately or shortly after the
cord has come away. These nodules, however, are very firm, are not apt to disappear, and are remnants of the omphalomesenteric duct. With a little practice
the two varieties can be readily differentiated clinically. The chief points of difference are discussed in the chapter on Umbilical Polyp (c/. p. 124).
I append the report of a case of a small granulation tumor at the umbilicus that
came under my notice in consultation with Dr. George L. Wilkins, December 31, 1910:
Granuloma or Granulation Tissue at the Umbilicus.
—Baby A. The child was two months old. The mother said that, when the cord
was tied, the midwife noted that it was very much larger than usual at the umbilicus.
A Her the cord came away there was an abundant discharge of what the mother
said was corruption. This had been very free until a short time previously.
The umbilical margins were raised fully 2 mm. from the surface (Fig. 65). In the
center was a little red mass, globular in form, which showed a whitish mottling,
just as if there were a mucosa with areas of skin covering it at certain points. It
lay directly in the center of the umbilicus. Dr. Wilkins had from time to time
applied nitrate of silver. The nodule had diminished somewhat in size. It was
116
GRANULATION TISSUE OR GRANULOMA OF THE UMBILICUS. 117
removed without much difficulty, and found to be exceedingly friable. Histologic
examination showed that it was composed entirely of granulation tissue. There
was no evidence at any point of an epithelial covering.
Treatment . — In some cases it will suffice to snip off the excessive granulation tissue with the scissors, and then apply an astringent. On account of the
smallness of the umbilical opening it is usually better merely to apply an astringent
and then keep the parts dry. The granulation tissue then soon dries up and drops off.
It is sometimes possible to tie off the granulation mass, but, as a rule, it is too mushy.
Fig. 65. — Ax Umbilical Gra.nttla.tiom.
The umbilical ring is unusually prominent, protruding at least 2 mm. above the abdominal wall. In the center
is a small, globular, red mass. It was very friable, was readily removed, and did not recur. On histologic examination it was found to consist essentially of young granulation tissue rich in blood-capillaries. It contained no epithelial
elements.
LITERATURE CONSULTED ON GRANULATION TISSUE OR GRANULOMA OF THE
UMBILICUS.
Florentin, P.: Fungus de l'ombilic, chez le nouveau-ne et chez 1' enfant. These de Nancy,
1908-9, Xo. 22.
Forgue et Riche: Montp?ll. med., 1907, xxiv, 145-169.
Holt, L. Emmett: Umbilical Tumor in an Infant formed by Prolapse of the Intestinal Mucous
Membrane of Meckel's Diverticulum. Med. Record, 1888, xxxiii, 431.
Lannelongue et Fremont: De quelques varietes de tumeurs congenitales de l'ombilic et plus
specialement des tumeurs adenoides diverticulaires. Arch. gen. de med., 1884, 7e ser., xiii, 36.
Ledderhose, G.: Deutsche Chirurgie, 1890, Lieferung 45b.
Millar, W. Heptinstall: Umbilical Polypi. St. Thomas's Hospital Reports, New Series, xix, 287.
Pernice, L.: Die Xabelgeschwlilste, Halle, 1892.
de Villiers, J. H.: The Nature of Umbilical Growths of Infants and Young Children. Pediatrics, 1897, hi, 337.
==Chapter VI. Remnants of the Omphalomesenteric Duct==
General consideration.
Umbilical polyp.
Historical sketch.
Symptomatology.
Macroscopic appearance of the tumor.
Microscopic appearance of the tumor.
Multiple umbilical polyps.
Differential diagnosis.
Treatment.
Cases in which umbilical polyps have been noted.
These comprise one of the most interesting groups of pathologic conditions
found in the umbilical region. The literature on the subject is abundant, manyauthors having studied and described more or less in detail remnants of one or
more portions of the omphalomesenteric duct. Among the more important articles dealing with the subject are those of Cazin (1862), Roth (1881), Tillmanns
(1882), Fitz (1884), Barth (1887), Zumwinkel (1890), Pernice (1892), Deschin
(1895), Ophuls (1895), Kirmisson (1898), Morian (1899), and Florentin (1908).
In the following pages I shall discuss at some length the various remnants of
the omphalomesenteric duct that have been described in the literature, and shall
also deal with remnants of the omphalomesenteric vessels as they have been noted
at operation or at autopsy. Barth, Zumwinkel, and Morian have each given a
scheme, illustrating the various remnants of the omphalomesenteric duct that have
been met with. After a thorough survey of the literature I have amplified to some
extent the schemes heretofore published.
Umbilical Polyps. — The most common remnant of the omphalomesenteric duct
is a small red polyp noted in the umbilical depression, when the cord has come
away. It is bright red in color and secretes mucus. On microscopic examination
its outer surface is seen to be covered with mucosa similar to that of the small
bowel, and its center is composed of non-striped muscle. It may persist for years
unless tied off or cut off.
There is a group of small umbilical polyps or umbilical fistulse in which the outer
covering, or the lining, as the case may be, consists of a mucous membrane that
secretes a fluid more or less similar to gastric juice. The mucosa itself bears a
striking resemblance to gastric mucosa. Only a few of these cases have been observed.
The outer portion of the omphalomesenteric duct may remain patent, there
being evident at the umbilicus a small projection into which a probe can be passed
for a variable distance. The projection, and also the canal extending into the
depth, are covered or lined with mucosa similar to that of the small bowel.
Meckel's diverticulum is the patent inner end of the omphalomesenteric or
vitelline duct. It usually arises from the convex surface of the bowel, but occa
118
REMNANTS OF THE OMPHALOMESENTERIC DUCT. 119
sionally projects from the mesenteric border. It may or may not be attached to
the umbilicus. The various forms of Meckel's diverticulum will be considered, and
then the complications that may be associated with its presence.
Intestinal cysts may develop in various ways. Those originating from a portion
of the omphalomesenteric duct may be situated beyond the convexity of the bowel;
occasionally they lie in the mesentery of the ileum. As they originate from the
omphalomesenteric duct, they are lined with mucosa similar to that of the small
bowel.
A review of the literature shows that, in a certain number of cases, as soon as
the cord comes away, more or less discharge comes from an opening at the umbilicus.
This is usually due to a patent omphalomesenteric duct. The opening at the umbilicus may lie in the umbilical depression, but quite frequently there is at the umbilicus a reddish projection, in the center of which is the opening of the duct. The
amount of discharge depends, in a large measure, on the caliber of the duct. When
this is small, just the faintest amount of colorless or brown, watery fluid may escape;
on the other hand, if the opening be large, feces and gas escape. Occasionally the
fistula develops on the side of the cord near the abdomen before the ligature drops
off, and we have the record of one case in which the outer end of the omphalomesenteric duct opened into the abdominal cavity near the umbilicus. In this case
Orth found feces in the abdominal cavity among intestinal loops.
When the patent omphalomesenteric duct is of relatively large caliber, there is
a tendency for the small bowel to prolapse through the duct and turn inside out on
the abdominal wall, forming a sausage-like mass on the exterior of the abdomen.
The mass assumes various shapes, is bright or dark red in color, and at either end
has an opening corresponding with the lumen of the bowel at the upper and lower
end of the prolapsed loop. This prolapsus may occur within a day or two after
birth or after several months. When this complication develops, death nearly
always speedily follows.
In rare instances remnants of the omphalomesenteric duct have been found
between the peritoneum of the abdominal wall and the muscles. They have occurred as small cysts which sometimes communicate with the umbilical depression.
Naturally, they are lined with mucosa similar to that of the small bowel.
Sometimes, when all trace of the omphalomesenteric duct has disappeared,
remnants of the omphalomesenteric vessels still persist. These may extend from
the mesentery of the small bowel to the umbilicus, or be recognized as free filaments attached either to the umbilicus or to the mesentery. These remnants,
by becoming adherent to some structure, occasionally cause intestinal obstruction.
After this brief summary dealing with the remnants of the omphalomesenteric
duct or its vessels that may be found, we shall consider each abnormality in detail.
The various remnants of the omphalomesenteric duct are as follows :
Umbilical polyps.
Gastric mucosa at the umbilicus.
A patent outer portion of the omphalomesenteric duct.
Meckel's diverticulum.
Intestinal cysts.
A patent omphalomesenteric duct.
A patent omphalomesenteric duct opening at birth on the side of the cord.
A patent omphalomesenteric duct with other intestinal lesions.
120 THE UMBILICUS AND ITS DISEASES.
A prolapse of the bowel through a patent omphalomesenteric duct.
Cysts of the abdominal wall.
Remains of the omphalomesenteric vessels.
LITERATURE CONSULTED ON REMNANTS OF THE OMPHALOMESENTERIC DUCT
IN GENERAL.
Barth, A.: L'eber die Inversion des offenen Meckel'schen Divertikels und ihre Complication
mit Darmprolaps. Deutsche Ztschr. f. Chir., 1887, xxvi, 193.
Cazin, H.: Etude anatomique et pathologique sur les diverticules de l'intestin. These de Paris
1862, No. 138.
Deschin: Zur Frage der chirurgischen Behandlung bei dem Vorfall des Dotterganges. Centralbl .
f. Chir., 1895, xxii, 1154.
Fitz, Reginald H. : Persistent Omphalomesenteric Remains; their Importance in the Causation of Intestinal Duplication, Cyst-formation, and Obstruction. Amer. Jour. Med. Sci.,
1884, lxxxviii, 30.
Florentin, P.: Fungus de l'ombihc, chez le nouveau-ne et chez l'enfant. These de Nancy,
1908-09, No. 22.
Kirmisson: Maladies congenitales de l'ombilic. Traite des maladies chirurgicales d'origine
congenitale, Paris, 1898, 208.
Morian: Ueber das offene Meckel'sche Divertikel. Langenbeck's Arch. f. klin. Chir., 1899, lviii,
306.
Ophiils, W. : Beitrage zur Kenntniss der Divertikelbildungen am Darmkanal. Inaug. Diss.,
Gottingen, 1895.
Pernice, Ludwig: Die Nabelgeschwtilste, Halle, 1892.
Roth, M.: Ueber Missbildungen im Bereich des Ductus omphalomesentericus. Virchows
Arch., 1881, lxxxvi, 371.
Tillmanns, H.: Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring
(Ectopia ventriculi) und liber sonstige Geschwulste und Fisteln des Nabels. Deutsche
Ztschr. f. Chir., 1882-83, xviii, 161.
Zumwinkel: Subcutane Dottergangscyste des Nabels. Langenbeck's Arch. f. klin. Chir., 1890,
xl, 838.
UMBILICAL POLYPS.
Incomplete healing of the umbilical stump is not of very rare occurrence. The
tissue is dull red in color, rather soft, and soon disappears after the use of astringents.
Now and again, after the cord has come away, a small, polyp-like mass is found
in the umbilical depression (Figs. 66, 67, 68, and 91). This is brighter in color
than the ordinary granulation tissue, and is unaffected by astringents.
Brun, in 1834, reported the case of a female child, three years old, who came
under Dupuytren's care. When the cord came away on the eighth or ninth day,
a tumor was noted. It was the size of a cherry and had a mucous surface. It was
ligated at its base, and dropped off five days later; the wound healed. Brun says
that this child's sister had a similar nodule at the umbilicus. The second child
died when four and one-half years old. During the last eight months of her life
she complained continually of abdominal pain.
Fabrege, in 1848, reported two cases. The first patient was a boy, one month
old. The mother noticed a moisture at the umbilicus as soon as the cord came
away. At the umbilicus was a reddish, pedunculated tumor the size of a pea.
This was cut away with scissors and the base cauterized. The growth apparently
returned. It was again treated in a similar manner, and the umbilicus then remained healed. His second case was in a baby girl three weeks old, who had a peasized nodule situated in the umbilical depression. It was red, bled readily on being
REMNANTS OF THE OMPHALOMESENTERIC DUCT. 121
It was gradually constricted with a ligature
touched, and had a definite pedicle
and dropped off on the third day.
Polyp
Fig. 66. — The Grahcal Atrophy of the Omphalomesenteric Duct. (Schematic.)
The outer end of the duct is closed and represented
by a polyp-like projection which is covered over with
intestinal mucosa. If this were ligated, when the ligature came away, a patent omphalomesenteric duct
would undoubtedly result. The duct is patent from
the intestine to the umbilicus. For the subsequent
stages in the atrophy of the omphalomesenteric duct
see Figs. 67, 6S, S9, 90, and 91.
Muscle
Fig. 67. — An Umbilical Polyp Connected with
Meckel's Diverticulum by a Fibrous Cord.
(Schematic.)
The umbilical polyp is covered with intestinal mucosa and has a central stem composed of non-striped
muscle and fibrous tissue. The central portion of the
omphalomesenteric duct is represented by a fibrous
cord, the inner end by Meckel's diverticulum. This
condition has been noted in a number of cases. For
further atrophy of the omphalomesenteric duct see
Figs. 6S, 89, 90, and 91.
Simpson, in the Obstetrical Memoirs and Contributions, published in Philadelphia in 1856, referred to a case that he saw with
Dr. Findlay. The umbilical excrescence resembled
a cherry in size and color. It was apparently not
painful to the touch, but blood oozed from its surface on handling. Silver nitrate was used several
times, but with no effect. A few weeks later a ligature was applied around its base and it dropped off
in a few days.
Virchow, in 1862, in referring to "fungus of the
umbilicus," mentions two kinds: the more common
one is rich in blood-vessels, bleeds easily, and is
found after the cord comes away. It consists of
granulation tissue. It soon disappears after the
use of astringents. The second kind of tumor is a
congenital growth.
Holmes, in his " Surgical Treatment of Children's
Diseases," published in London in 1868, says that
warty or nipple-like tumors projecting from the umbilicus are f airly often seen in children, and that they
seem to be due to some morbid condition left by
separation of the umbilical cord. He gives Athol
Johnson credit for the first reference to this condition noted in the English language. Johnson speaks
of it as a stout, nipple-shaped papilla or tubercle arising from the center of the main umbilical depression.
Holmes says that these may attain the height of an inch
none as large as this. In his cases the tumors were ligated.
Muscl.
Fig. 68. — An Umbilical Polyp Attached to the Small Bowel by
a Fibrous Cord. (Schematic.)
The outer end of the omphalomesenteric duct is here represented by
an umbilical polyp, which is covered
over with intestinal mucosa and which
consists in a large measure of nonstriped muscle. A slight depression in
its tip is all that remains of the lumen
of the duct. In the majority of the
cases in which a pol>-p is found, all
trace of the cavity has disappeared.
In this case the intra-abdominal portion of the omphalomesenteric duct is
represented by a cord extending from
the umbilicus to the convex surface of
the small bowel. It is the possible
existence of this cord that must always
be thought of in patients who have, or
give a history of ever having had, an
umbilical polyp.
He saw several, but
122 THE UMBILICUS AND ITS DISEASES.
While all the foregoing tumors were undoubtedly umbilical polyps, Kolaczek
seems to have been the first to give us the complete picture of this disease. In
1871. under the title " Enteroteratoma of the Umbilicus," he reported the case of a
boy four years old who had a small umbilical tumor. On microscopic examination
it was found that the outer surface of the tumor was covered with cylindric epithelium, and opening on the surface were Lieberklihn's glands, while between the
glands were lymphatic tissue and connective tissue. The center of the nodule was
composed of smooth muscle.
In 1875 Kolaczek reported a second case, which presented a precisely similar
picture.
Kustner, in 1876, reported a similar case. He examined a fungus removed from
the umbilical depression of a three months old child, not expecting to find anything
but granulation tissue, and was not a little surprised to note, instead of this simple
structure, a relatively complicated picture. In the center was connective tissue;
external to this were round cells and granulation tissue, and embedded in the periphery, numerous tubular glands. The tumor, which was the size of a pea, was
covered with beautiful cylindric epithelium.
Parker, in the Archives of Clinical Surgery, published in New York in 1876,
reported the findings in a boy two and one-half years old. Soon after birth the
parents noticed that the navel did not heal. There was a hard mass situated at the
connection of the cord with the abdominal wall, and to the right of the cord a naked,
non-cicatrized surface discharging a thin mucous fluid. The area failed to cicatrize,
and the tumor increased in size. When the boy was three years old an attempt was
made to remove the growth, but only part was taken away, as it extended into the
abdomen. Fifteen months later the tumor was harder and firmer and was increasing in size. An elliptic piece of the abdominal wall including the tumor was cut
away, and the child made a good recovery.
Dr. Alonzo Clark made the microscopic examination and thought the growth
was a cancer. It was, however, in all probability, an adenoma or polyp of the abdominal wall.
Since that time isolated cases have been recorded. Dr. William D. Booker, in a
very large pediatric practice, tells me that he has observed only one case. As will
be seen from the accompanying abstract of the literature, Giani reports 4 cases
and Hue 5 cases.
Symptomatology.
Umbilical polyps are usually noted when the cord comes away. Some have
come under observation during the first few weeks of the child's life; others have
not been treated until the child was several months old, and in quite a number of
instances not until it was from three to eight years of age. Walther's patient was
eighteen years old; Hektoen's, fifteen years; Stori's, twenty years; Gernet's.
twenty-four years; Hartmann's, twenty-nine years, and in a case reported by
myself the patient was twenty years old.
Apart from a slight umbilical discharge and, where the tumor was rather large,
some bleeding, the umbilical nodules have given rise to little or no discomfort.
Macroscopic Appearances of the Tumor.
Those small tumors in the majority of the cases are not larger than a pea, an
olive-stone, a cherry, or a grape. In a few cases, however, the nodule has been large.
REMNANTS OF THE OMPHALOMESENTERIC DUCT.
123
In Gernet's case it reached the size of a walnut, measuring 2.5 cm. x 2 cm. Hektoen's was 2.5 cm. long and 3 cm. in its greatest circumference (Fig. 70). Walther's patient had a tumor 2.5 cm. long and 2 cm. broad. In Kirmisson's patient
the tumor reached 4 cm. in length.
These tumors are generally bright red in color, but occasionally of a darker hue.
They are covered over with a smooth, velvety membrane which looks like intestinal
mucosa. Where the tumor is small and protected by the umbilical folds, it is usually
bright red and smooth, but when large, it rises above the level of the abdomen, and
as a result of the rubbing of the clothing may become irritated.
The nodule often secretes a small amount of alkaline fluid. This is mucus.
When irritation has occurred, the mucus may be mixed with a small amount of pus.
The nodule at its tip is usually rounded and intact, but occasionally, at its most
prominent point, there is a depression into which a probe may be inserted for 2 mm.
or more. In Sheen's case it could be carried one inch inward. The tumor on
palpation is firm and elastic and cannot be reduced in size. Manipulation sometimes causes slight bleeding. Although some of these polyps are sessile, they are
more apt to be attached to the center of the umbilical depression by a definite pedicle.
The skin surrounding the umbilicus is usually
normal. In Capette and Gauckler's case, however, it was drawn up around the polyp, forming
a definite prepuce. When there is much discharge
from the polyp, the surrounding skin occasionally
shows some reddening.
In Broca's case, and also in the one recorded
by Capette and Gauckler, there was a small umbilical hernia and the polyp was seated upon the
summit of the hernial projection.
Fig. 69. — An Umbilical Polyp on the
Prominent Part of an Umbilical
Hernia. (Schematic.)
Small umbilical hernia? are relatively
common. Umbilical polyps are occasionally met with. The combination of a
polyp on the top of a hernia has been
noted, but is most unusual.
Microscopic Appearance of the Polyp.
The surface of the polyp is covered over with
typical intestinal mucosa. The external layer is
composed of cylindric epithelium, and opening on the surface are tubular glands
(Fig. 74, p. 133; Fig. 75, p. 134; Fig. 76, p. 135; Fig. 123, p. 207). These resemble
Lieberkuhn's glands, but occasionally those of the Brunner type are also present,
and now and then glands that bear a striking resemblance to those of the pyloric
end of the stomach. The stroma between the glands is similar to that noted in
the small bowel. The central portion of the polyp consists of non-striped muscle
and connective tissue.
When the polyp has been of long standing, and on account of its size has been
subjected to contact with the clothing, the surface epithelium may be lacking and
the superficial layers of the mucosa replaced by granulation tissue.
The line of junction between the mucosa covering the polyp and the squamous
epithelium of the umbilicus is usually abrupt, the normal skin beginning at the point
where the intestinal mucosa ends (Fig. 75, p. 134; Fig. 81, p. 140).
In cases in which a channel occupies the center of the polyp this itself is lined
with intestinal mucosa.
From the above it is seen that the umbilical polyp is covered over with typical
124 THE UMBILICUS AND ITS DISEASES. ,
intestinal mucosa. It is a remnant of the outer end of the omphalomesenteric duct,
which has persisted outside the abdominal cavity. When the cord has sloughed
off, the remnant contracts down, producing the polyp.
Various names have been applied to these growths — fungus, enteroteratoma,
adenoma, and polyp. Such a growth has a definite structure, and should not be
called a fungus. Its mode of origin precludes the use of the term enteroteratoma,
and, as Holt has pointed out, the name adenoma is not correct. Umbilical
polyp seems to be the most suitable name, since there is no abnormality at the
umbilicus except granulation tissue that can possibly be confused with it clinically.
Multiple Umbilical Polyps.
Henke reports a case in which a pea-shaped umbilical polyp, 5 mm. long, was
divided into three small lobes. Kirmisson, in the examination of a child three
years old, found a small umbilical tumor which also consisted of three lobes. These
were situated in the umbilical cicatrix. The combined tumor was the size of a
cherry.
This formation of several lobes is of no significance. The explanation is that
the remnant of the vitelline duct has merely split off into several pieces instead of
forming one sharply defined and intact nodule.
Differential Diagnosis.
Granulation Tissue. Umbilical Polyp.
Found only during the first few weeks. May persist for years.
Dull red, or pink. Bright red in color.
Soft. Firm and resistant.
A purulent secretion is present. Secretes mucus unless the surface has become
irritated — then mucopus.
Disappears after the use of astringents. Usually not affected by astringents.
Consists of typical granulation tissue. Has an outer covering of intestinal mucosa
and a center consisting of non-striped
muscle.
Usually disappears in a few months. Persists until removed.
From this tabulation it is seen that, both clinically and histologically, the differences between granulation tissue and umbilical polyps are so sharp that a diagnosis can usually be readily made.
Treatment.
Silver nitrate and other caustics have often been used with no effect.
In many of the cases the tumor was simply ligated and dropped off in a few days ;
in others it was ligated and cut off at once. If only a portion of the growth is removed, the remainder will, of course, persist, and possibly increase a little in volume.
In some of these polyps the omphalomesenteric artery still persists, hence the necessity for careful ligation of the pedicle of the polyp. This vessel persisted in Lannelongue and Fremont's Case 2.
In a certain percentage of the cases when an umbilical polyp is present, other
portions of the omphalomesenteric duct also persist (Figs. 66, 67, 68, 90). In
Lowenstein's case, for example, after the umbilical polyp had been cut away, it was
found that the omphalomesenteric duct near the bowel was patent. Here it was
6 mm. in diameter.
REMNANTS OF THE OMPHALOMESENTERIC DUCT. 125
In Hartmann's patient, a man of twenty-nine, a typical umbilical polyp was
present. The man gradually developed definite signs of intestinal obstruction.
Hartmann, on opening the abdomen, found the small bowel dilated and injected.
The obstruction was due to a partially patent omphalomesenteric duct. Meckel's
diverticulum was markedly compressed at its insertion into the small bowel. The
diverticulum was 6 mm. in diameter and 4 cm. long. From that point to the abdominal wall it was continued as a fibrous cord which terminated in the umbilical
polyp.
In every case of umbilical polyp it is the duty of the
family physician or surgeon to explain carefully to the
parents the possible coexistence of an intra-abdominal
portion of the omphalomesenteric duct, which may be
adherent to the umbilicus and later give rise to intestinal obstruction. The parents should be instructed
to watch such children carefully, and if in later life
the slightest sign of intestinal obstruction develops,
an abdominal operation should be immediately undertaken, the surgeon making an incision encircling the
umbilicus and looking immediately for an adherent
Meckel's diverticulum.
Cases in which Umbilical Polyps have been Noted.
That the literature on the subject is relatively small is evidently due in part to
the fact that these small polyps often give rise to but little inconvenience. Most
of those who have had much to do with children have observed one or more cases.
A Case of Umbilical Polyp.* — -A child, six months old, had a
small growth at the umbilicus. It was deep red in color, had a granular-looking
surface, and was attached to the umbilicus by a narrow pedicle. The growth was
ligated by Dr. Falkiner and cut away. On microscopic examination Ball found
that the pedicle consisted of muscle. Covering the outer surface was glandular
tissue with adenoid tissue between the glands. The glands closely resembled those
of the stomach. This case appeared to be one of simple umbilical polyp.
An Umbilical Polyp. — Bidonef reports the case of a child two years
old, in which a small umbilical growth had been noted after the cord came away.
This little growth was removed with the thermocautery. It was a typical intestinal polyp. Bidone gives very good pictures of the case, and also a resume of the
literature.
Umbilical Polyp. — Blanc and Weill report two small tumors of the
umbilicus. The larger was the size of a pea. Both were pedunculated. Many
of the glands covering them resembled Lieberkuhn's glands. The tumors were
remains of the omphalomesenteric duct.
Adenoid Tumors. — With regard to the etiology, Blanc, § working in
* Ball, C. B.: Illustrated Med. News, 18S9, iv, 149.
t Bidone, E.: Enteroteratonia ombelicale. Bull, delle scienze med., Bologna, 1901, ser. S, i,
374.
I Blanc and Weil: Paris Anatomical Society, 1899. Rev. in Centralbl. f . allg. Path. u. path.
Anat., 1900, xi, 748.
§ Blanc, H. : Contribution a, la pathologie du diverticule de Meckel. These de Paris, 1899,
No. 393.
126 THE UMBILICUS AND ITS DISEASES.
Broca's service, says that in 16 cases there was granulation of the umbilicus, but
after personal examination of two of the cases he found the tumors to be adenomatous, suggesting that they had originated from Meckel's diverticulum. They
appeared in the umbilical region following birth, immediately after the cord had
come away. Such tumors are congenital. They vary in volume from the size of a
cherry to that of a pea. They are solid in consistence, and occupy the center of the
umbilicus.
Blanc then goes on to report two cases that he had observed. These resembled
in practically every particular the small glandular bodies so often noted. He ends
with an able discussion of diverticula.
An Umbilical Polyp. — Dr. Wm. D. Booker,* of Baltimore, said that
in all his experience he had encountered only one case of adenoma or polypoid
outgrowth from the umbilicus. A section showed that it was covered over externally with characteristic intestinal mucosa.
Polyp of the Umbilicus, f — In Broca's clinic a boy, two months
old, had a small polypoid mass the size of a pea implanted on the surface of an umbilical hernia. The hernia was about the size of the little finger. The tumor was
segmented and projected about 2 cm. from the surface of the umbilicus; it was
reddish in color. This polyp was noted on the fourteenth day, i. e., three days after
the cord had come away. Broca cut it off with scissors.
An Umbilical Polyp. % — A girl, three years old, came under Dupuytren's care. The cord came away on the eighth or ninth day, and the tumor,
the size of a cherry, was then noted. It had a mucous surface but no fistulous
opening. It was tied off with silk at its base. It dropped off on the fifth day and
the umbilicus healed.
Brun says that this child's sister had had a similar nodule at the umbilicus. She
lived for four and one-half years, but for eight months prior to her death she complained continually of pain in the abdomen. Brun drew attention to the fact that
both children had the same abnormal congenital formation.
Umbilical Polyp. § — An infant boy, born at term, had a large inguinal hernia and an umbilical hernia the size of a hazel-nut. On the surface of the
umbilical hernia was a small, oval, red, engorged, and inflamed nodule, about the
size of an olive-stone. One pole was free, the other lay in the umbilicus, the skin
fold of which formed a prepuce for it. The nodule was cut off with scissors and
cauterized, with satisfactory results. Microscopic examination showed that the
nodule was a typical adenoma. These authors give Kolaczek credit for describing
the first case of this character.
Umbilical Polyp. — In Colman's 1 1 case the polyp was the size of a
split-pea, distinctly pedunculated, and was removed from just within the dimple
of the umbilicus of a child two months old. It was first noticed when the child was
two weeks old.
* Booker: Personal communication.
t Broca, A.: Polype de l'ombilic. Jour, de med. et de chir., 1904, lxxv, 172.
+ Brun, L. A. : »Sur une espece particuliere de tumeur fistuleuse stercorale de l'ombilic. These
de Paris, 1834, No. 238.
§ Capette et Gauckler: Note sur un cas d'adenome ombilical. Revue d'orthopedie, 1903,
xiv, 271.
I Colman, W. S. : Adenomatous Polypus of Umbilicus. Trans. Path. Soc. London, 1888,
xxxix, 110.
REMNANTS OF THE OMPHALOMESENTERIC DUCT. 127
Microscopic examination of the polyp showed that it was composed of ordinary
non-striated muscle, and that it was covered with a thick layer of mucous membrane which contained Lieberkuhn's follicles and adenoid tissue, being exactly
like the normal mucous membrane of the small intestine.
An Umbilical Polyp or Enteroteratoma. — Diwawin*
reports the case of a male child who had a pea-sized tumor situated to the left of
the center of the umbilicus. It was red in color and painless. When examined,
it was the size of a cherry and was freely movable. In its center was an almost
imperceptible opening into which a small sound could be passed for 2 mm. The
tumor secreted four or five drops of bloody mucus in the course of a day. It was
removed under cocain. The growth was covered with intestinal mucosa.
Polypoid Excrescences at the Umbilicus in Newborn Infants. — Fabregef reported several cases.
Case 1 . ■ — In a small boy, one month old, the mother noticed a moisture at
the umbilicus as soon as the cord came away. At the umbilicus was a reddish,
pedunculated tumor, the size of a pea. This was cut away with scissors and the
base cauterized. The growth apparently returned. It was treated in the same
manner, and the wound healed. After a time, however, an abscess developed at
the umbilicus. This was opened, and there escaped with the pus a piece of wildoat straw which had evidently been the cause of the abscess.
Case 2 . ■ — A baby girl, three weeks old, was found to have a tumor the size
of a pea lying between the umbilical folds. The polyp was red, bled readily on
being touched, and had a definite pedicle. It was gradually constricted by a ligature and dropped off on the third day.
In neither of these cases was there any microscopic examination, but it must be
remembered that these patients were operated upon more than sixty years ago.
An Umbilical Polyp. J — A man, twenty-four years of age, came
to the hospital on July 17, 1893. He had had a small tumor at the umbilicus as
long as he could remember. It had never become any larger. It secreted a thin,
somewhat sticky mucus, but a fecal discharge had never been noted. He had
had no pain, but there was a certain amount of discomfort from moisture.
The patient had always suffered from constipation, and three years previously
had had obstipation for three days, associated with great abdominal pain and with
vomiting. Five days before admission he again had had sudden pain in the abdomen. He had had no stool, but had vomited. The pain had continued, but the
vomiting had ceased.
The abdomen was markedly distended, and the entire umbilical region was
moist. The skin was eczematous in appearance and was peeling off. The umbilicus was occupied by a moist, glistening, scarlet-red tumor the size of a walnut.
The surrounding skin was thickened and in folds. The tumor was soft, elastic,
and slightly movable on its pedicle.
Operation. — The abdomen was opened and the bowel found drawn up and adherent to the umbilicus in a tent-like manner. On being loosened, the small bowel
* Diwawin, L. A.: Ein Fall von Enteroteratom des Nabels. Russ. med. Rundschau, 1904,
ii, 590.
t Fabrege : Note sur les excroissances polypeuses de la fosse ombilicale chez les enfants nouveau-nes. Revue medico-chir., 1848, iv, 353.
t von Gernet, R.: Ein Enteroteratom. Deutsche Ztschr. f. Chir., 1894, xxxix, 467.
128 THE UMBILICUS AND ITS DISEASES.
tore slightly. The wound in the bowel was closed. In separating the tissues
from the ligamentum teres the operator found the umbilical vein patent. The
abdomen was closed. The man made a good recovery. The tumor was 2.5 cm.
broad and 2 cm. long.
On microscopic examination the outer surface of the tumor was found to be
covered with mucosa. The glands of the mucosa were tubular, and the surrounding tissue showed marked inflammation. The gland epithelium was cylindric. Von
Gernet failed to find goblet cells, but the glands resembled those of Lieberkiihn.
In the center of the tumor were delicate bundles of non-striated muscle. Von
Gernet thought the case one of enteroteratoma due to prolapsus of the mucosa from
remains of the omphalomesenteric duct.
An Umbilical Polyp. — Giani* reports four cases of enteroteratoma
or umbilical polyp, and gives excellent illustrations. These cases were noted in
the pediatric clinic of Professor Bajardi.
A Congenital Mucous Polyp of the Umbilicus. —
Gould'sf patient was a male, five months old. He had a bright-red, soft, pedunculated, smooth growth, about the size of a large currant, springing by a narrow pedicle from the umbilical cicatrix. At the upper end of this nodule was a small hole
admitting a probe for one-eighth of an inch. The tumor was moistened with thin
mucus, but there was no discharge of urine or feces. This small nodule was first
noticed when the cord fell off. It was then nearly the same size. The nodule was
ligated and cut off. Its surface was covered with branching glands and there was
the typical interglandular substance. It was covered over with intestinal mucosa.
Intestinal Occlusion Caused by Persistence of the
Omphalomesenteric Duct. Resection of the Strangulated Intestine. End-to-end Anastomosis. Recover y . t — A man, twenty-nine years of age, a carter, on June 12th had colic and
had to go to bed. Gradually -signs of obstruction developed. Five days later
he was seen by Hartmann. At that time he had fecal vomiting and great distention.
On examination there was seen in the umbilical depression a granular-like nodule
from which there was some discharge. A probe could not be introduced. No history as to the appearance of this nodule could be obtained from the patient.
Operation. — When the abdomen was opened, a large quantity of serous fluid
escaped. The small bowel was dilated and injected. The point of obstruction
was located, and the bowel was seen to be divided into three branches of equal
volume. All three branches were distended. Remembering the appearance of the
umbilicus, Hartmann at once thought of a patent omphalomesenteric duct. The
abdominal incision was now extended, and the omphalomesenteric duct and the
obstructed loop were brought out and removed. The bowel was brought together
with an end-to-end suture and the patient recovered.
The diverticulum was noticeably compressed at its insertion into the small bowel.
It was 6 mm. in diameter and 4 cm. long. It was continued as an apparently fibrous
* Giani, R.: Per la casistica degli entero-teratomi dell'ombelico. Clinica moderna, 1902,
viii, 4!*S.
t Oould, A. Pearce: Trans. Path. Soc. London, 1881, xxxii, 204.
+ Hitrtrnann: Occlusion intestinale par un canal omphalo-mesenterique persistant. Bull.
el Mem. de la Hoc. de chir. de Paris, 1898, n. s., xxiv, 202.
EEMNANTS OF THE OMPHALOMESENTERIC DUCT.
129
Fir,. 70. — A Polypoid Outgrowth
peom the Umbilicus. (After Hektoen.)
Histologic examination showed
that it was a so-called adenoma of the
umbilicus; in other words, remains of
the omphalomesenteric duct. For the
histologic picture see Fig. 71.
cord, 3.5 cm. long and 4 mm. in diameter, which terminated in the granulation noted
at the umbilicus. The patient made a good recovery.
Vitelline Duct Remains at the Navel.* — "In November,
1892, a boy, fifteen years old, was brought to me by
his father because the navel, which he stated had ,,.-■■,. ; '
never healed, had become a source of discomfort to
his son, especially when walking. It was learned
that there had been something wrong with the navel
since birth, and the blame for this was placed on the
midwife, who was supposed to have made a mistake
in cutting the cord. There had been no special inconvenience felt until very recently, when it was
noticed that the navel became tender and sore, particularly after walking or running; a little matter
had also appeared, staining the clothes. It was noticed that the boy walked carefully, bending his body
forward. The previous history was otherwise negative, and the father had no knowledge of any such or
similar conditions in any of the other members of the
family. Physical examination showed a well-developed boy, in good general health, whose body was
free from all blemish except at the umbilicus, which
presented the following appearance:
"Projecting from its lower third is a pedunculated, polypoid outgrowth
(Fig. 70) 2.5 cm. in length and 3 cm. at its widest circumference, near the
rounded, free end. This mass is of a uniform, deep-red color, its surface
delicately smooth and velvety, covered with grayish, mucoid shreds. The narrow peduncle is apparently attached to the fibrous
g > a ; ~ structures in the floor of the umbilical depression,
as the volume cannot be diminished the slightest
by pressure toward the abdominal cavity. In other
words, this red mass is not reducible. There is no
opening found upon the surface nor depression that
might suggest the previous existence of any orifice
or canal. The line of junction of the skin with the
covering of the peduncle at the bottom of the umbilicus is even and abrupt. The pedicle crowds upward the folds of the integument covering the navel,
and it is somewhat compressed as it escapes from
the grasp between these folds and the circumference
of the umbilicus below, upon which are small but exceedingly sensitive ulcers. The mass itself is not
sensitive to the touch, but it bleeds readily, bright
red blood oozing out when handled a little roughly.
"A diagnosis of a so-called adenoma or diverticular prolapse at the umbilicus was
made, a ligature was placed around the pedicle near its attachment, and the polypoid outgrowth was cut away with scissors. No hemorrhage followed. In a week
* Hektoen, Ludvig: Amer. Jour. Obst., 1893, xxviii, 340.
10
f
Fig. 71. — Tubular Glands from
the Umbilical Polyp shown
in Fig. 70. (After Hektoen.)
These covered the outer surface of the specimen. The growth
was evidently a so-called adenoma
of the umbilicus.
130 THE UMBILICUS AND ITS DISEASES.
the ligature fell off, and in a few weeks afterward the little red spot left was completely cicatrized.
"Immediately after its removal the mass was divided into numerous suitable
pieces, fixed in Flemming's solution, washed in water, dehydrated in alcohol, embedded in paraffin, and microtomized. The sections thus obtained were stained in
various fluids, and the microscopic appearances may be summarily described as
follows : There are two principal layers to be taken into account — a peripheral or
glandular zone, and an internal central mass consisting of smooth muscular fibers
and connective tissue. The surface is lined or covered with tall, symmetrically
nucleated, columnar cells without any demonstrable cilia, placed upon an unbroken,
quite homogeneous basement membrane. Projecting from this surface are villous,
club-shaped masses consisting of loosely meshed connective tissue, in which are
many nuclei and small blood-vessels. Between these rather short, club-shaped villi
are the openings of the gland tubules, which compose the glandular zone of the outgrowth. The tubules are lined with more or less cuboid epithelial cells, disposed
in a single layer, with a tendency to assume the appearance of cylindric cells as the
free surface is approached. The tubules terminate in blind extremities which are
buried in the intertubular connective tissue deep down in the mass; their lumina
are empty; the cells present distinct outlines, a granular protoplasm, and deeply
stained nuclei. In many of the cells, both of those lining the tubules and the free
surfaces, are seen typical karyokinetic figures in the sections prepared for the
purpose of bringing them into prominence." In Fig. 71 is presented a portion of the
deeper strata of the glandular zone with the tubules in transverse section. In
Hektoen's next figure (which we have omitted) is a portion of the periphery, with
a villous projection, which had been cut in a direction somewhat oblique with reference to the main or longitudinal axis of the outgrowth, and this fact will explain
the presence in its center of hollow spaces lined with tall columnar cells. The intertubular tissue contains quite a number of blood-vessels of medium size, the majority
containing blood; there are also a few foci of round-cell infiltration here and there,
suggesting some inflammatory process.
' ' Internally, to the blind extremities of the tubules and the accompanying intertubular connective tissue, is a zone of smooth muscular tissue whose arrangement
cannot be said to follow any definite plan, and in the very center of the whole mass
is a quantity of rather firm, fibrillated connective tissue. No lymphatic gland
structure was found in any part of the sections examined.
"The microscopic structure of the outgrowth consequently corresponds very
closely with the structure of the mucous membrane of the small intestine, with its
Lieberkiihn follicles or the characteristic cylindric-cell lining of its exterior. The
structure of the central part of the mass also reproduces the smooth muscular and
the connective tissue found in the wall of the small intestine, although the arrangement of these tissues is not typical of that in the intestine. It is, therefore, plain
that the polypoid umbilical outgrowth described is an instance of the so-called
diverticular prolapse at the navel, which is somewhat unusual from the fact that,
although congenital, it was first brought under observation fifteen years after birth."
On page 344 Hektoen gives excellent pictures of the nuclear division
A Possible Umbilical Polyp.* — In a boy, six weeks old, the
* Henke: Zur Casuistik der vollkommenen Nabel-Darm-Fisteln durch Persistenz des Ductus
omphalo-entericus. Deutsche Zeitschr. f. prakt. Med., 1877, iv, 486.
REMNANTS OF THE OMPHALOMESENTERIC DUCT. 131
umbilical groove was filled with a fungus-like growth, 1.5 cm. in diameter. It
had a glistening red color and was covered with a clear, whitish, sticky secretion.
There was a slight erythema around the umbilicus. Nothing abnormal had been
noted in the cord at the time of labor, but some days later clear fluid had escaped
from the umbilicus and the nodule was detected. Astringents were used and it
disappeared. From the history this may have been either an umbilical polyp or
granulation tissue.
A Probable Umbilical Polyp.* — The boy was four weeks old.
Springing from the umbilicus was a pear-shaped tumor, 0.5 cm. long, and divided
into three lobes. Where the third lobe joined was a minute opening, from which a
drop of white, opalescent fluid could be squeezed. Neither the pedicle nor the
tumor bore any resemblance to granulation tissue. They were covered with a
bright-red mucous membrane. The nodules were noted soon after the cord came
away. They were cauterized and disappeared.
An Umbilical Polyp, f — The patient, a healthy boy three years
old, had had a small umbilical tumor ever since the cord came away. This had bled
severely recently. The umbilicus was prominent. In the umVjilical groove was a
pea-sized tumor with a dull-red surface. It was attached by a short pedicle and
was covered with a mucus-like fluid. It was removed.
Microscopic examination showed that the surface was covered over with mucosa
containing Brunner's and Lieberktihn's glands. The central portion consisted of
non-striped muscle.
Remains of the Omphalomesenteric Duct. — Holmes*
says that warty or nipple-like tumors projecting from the umbilicus are fairly often
seen in children, and that they seem to be due to some morbid condition left by the
separation of the umbilical cord. He gives Athol Johnson credit for the first reference to it in the English language. Johnson speaks of the tumor as a stout, nippleshaped papilla or tubercle arising from the center of the main umbilical depression.
Holmes says that these may attain the height of an inch. He saw several, but
none as large as this. They were ligated.
Umbilical Tumor in an Infant Formed by Prolapse
of the Intestinal Mucous Membrane of Meckel's Diverticulum. § — The patient was seven months old. A bright-red mass,
34 of an inch in diameter, projected for % of an inch from the bottom of the umbilical cicatrix. This projection was cylindric and slightly rounded at its extremity.
It was pedunculated at its cutaneous attachment. Its surface resembled mucous
membrane, and was smooth and shiny. At one point where the epithelium had
been rubbed off there was capillary bleeding. The mass was solid, did not protrude
more on coughing or crying, and had no opening.
In this case the cord had fallen off on the sixth day and the wound did not heal
completely for six weeks. On one occasion there was hemorrhage from the umbilicus. The tumor was discovered six weeks after birth and was quite small. It
steadily increased in size in spite of the use of astringents and caustics. From it
* Henke: Loc. cit.
t Hollaendersky, Sara: Zur Kasuistik der Nabeltumoren. Inaug. Diss., Freiburg i. Br.,
1905.
X Holmes, T.: Surgical Treatment of Children's Diseases, London, 1868, 181.
§ Holt, L. E.: Med. Record, 1888, xxxiii, 431.
132
THE UMBILICUS AND ITS DISEASES.
Fig. 72. — Diverticular
Tumor at the Umbilicus. (From Hue's Case
1.)
A button-like growth
protrudes from the umbilicus, being attached by a
narrow pedicle.
there was a slight water}' discharge, but no fecal masses and no fecal odor. The
tumor was ligated and cut off.
Its outer surface was covered with mucosa similar to that of the small intestine.
Here and there it was slightly necrotic.
Holt gives two good pictures of the condition. He holds that the term adenoma
is unfortunate, misleading, and inexact. He credits Kustner
with the first accurate description of these growths.
Umbilical Polyps. — Hue * refers to Villar's
article, published in 1886, and to that of Le Blanc, published
in 1889. He then reports five cases.
Case 1 . — A child, four years old, had a small tumor
at the umbilicus which had been noticed eight days after
birth, as soon as the cord came away. In the umbilical
scar was a pedunculated tumor the size of a cherry (Fig.
72). The pedicle was fibrous and hard. The tumor was
velvet}', bright red in color, moist, but did not bleed, and
there was no hernia. An elastic ligature was applied with
good results.
Case 2 . — The patient was four and one-half months
old. After the cord dropped off, a tumor the size of a pea
was noted at the umbilicus. It was red, velvety, and had a
pedicle 3 mm. long (Fig. 73). It was ligated satisfactorily.
Case 3 . • — A child, three months old, had a tumor the size of a pea at the
umbilicus. It was red and moist, but there was no suppuration. It was cut off
with scissors and the child recovered completely.
C a s e 4 presented practically the same picture.
Case 5 . — The child was two years old. The tumor was similar in size and
was noted when the cord came away. It was excised. Deve,
who made the microscopic examination (Fig. 74) of the speci- / i
men for Hue, found that it was covered with intestinal mucosa. The surface epithelium was cylindric. There were no
papillary outgrowths. The glands of the mucosa varied
considerably: some resembled Lieberkuhn's glands, others
those of the pylorus, and still others those of Brunner. Between the glands were lymph-follicles. The pedicle was made
up of non-striped muscle and fibrous tissue. The mucosa
joined the skin of the abdomen.
An Umbilical Pol y p . f — The patient was three
years old. The mother said that at birth nothing unusual
was noted, but about the third week a small tumor made
its appearance. The midwife advised the wearing of a bandage, and this had been done. Despite its use, however, there
had been a good deal of bleeding from the tumor, which was
about as large as a cherry, reddish, and consisted of three
lobes implanted directly in the umbilical cicatrix. It looked as if it were covered
with mucosa. Its surface was smooth and no orifices were seen. It was resistant
* Hue, Francois: Tumeurs adenoides diverticulaires. La Xormandie med., 1906, xxi, 165.
t Kirmisson, E.: Ad&iome diverticulaire de l'ombilic. Revue d'orthopedie, 1904, xv, 47.
Fig. 73. — A Glandular
Tumor from the Umbilicus. (From Hue's
Case 2.)
Here we have a prominent projection growing
from the umbilicus. The
pedicle is rather broad.
REMNANTS OF THE OMPHALOMESENTERIC DUCT.
133
and irreducible. Kirmisson says the diagnosis lay between granuloma and diverticular adenoma. At the same time he points out that a granuloma is softer and
appears immediately after the cord comes away. This tumor, on the other hand,
was not noted until the end of three weeks; it was firm in consistence, and was
apparently covered with mucosa. It was excised without difficulty.
Microscopically, the center of the tumor was found to be composed of connective tissue and muscle; its outer surface was covered with mucosa. At the base
of the pedicle the surface for a distance of 2 mm. was covered with squamous epithelium. The mucosa covering the tumor was of the type found in the small in
f. ci.
gi. k.
pi. m.
Fig. 74. — A Glandular Growth at the Umbilicus. (From Hue's Case 5.)
It is relatively round, and has grown from the umbilicus. Its line of junction with the skin is sharply outlined.
B, The submucosa; C, the muscle; D, the cellular tissue. In the center of this is a nerve ganglion, gl k., a cystic
Lieberkiihn gland; m. m., muscularis mucosae; /. cl., a closed follicle; pi. m., Auerbach's plexus; pyl., pyloric glands;
br., Brunner's glands; lieb., Lieberkiihn's glands; pav., the squamous epithelium. The line of junction between the
squamous epithelium and the mucosa is sharply outlined.
testine. In Fig. 75 Kirmisson gives us an excellent example of a diverticular
adenoma of the umbilicus — an umbilical polyp.
An Umbilical Polyp. — Kirmisson* reports the case of a child eight
days old. At the umbilicus was a raised tumor, reddish in color, irregular in form,
smooth, and covered with a shiny mucus. This tumor was 4 cm. long and had several purulent pockets on its surface. It presented no orifice and was irreducible.
Kirmisson said that it was without doubt of diverticular origin. Its surface was
covered with mucosa containing glands.
Umbilical Polyps. — Case 1 . — In 1871 Kolaczekf reported, in the Jour
* Kirmisson: Les tumeurs de l'ombilic. Rev. gen. de clin. et de therap., Paris, 1907, xxi, 726.
t Kolaczek: ZweiEnteroteratomedesNabels. Langenbeck's Arch. f.klin.Chir.,1875,xviii, 349.
134
THE UMBILICUS AND ITS DISEASES.
nal of the Pathological Institute of Breslau the following case : A boy four years
of age had a small umbilical tumor. The hardened specimen showed a milky outer
surface and a reddish center. On microscopic examination its surface was found to
be covered with cylindric epithelium, and opening upon the surface were Lieberkuhn's glands. Between the glands were lymphatic tissue and connective tissue.
The center of the nodule was composed of smooth muscle. Kolaczek thought he
was dealing with an enteroteratoma of the umbilicus.
Case 2 . — Kolaczek, in 1874, saw a boy eighteen months old who had a
cylindric tumor, 8 mm. by 4.5 mm. thick, at the umbilicus. The growth showed a
d —
/....
Fig. 75. — Section in the Long Axis of a Small Umbilical Growth. (After Kirmisson.)
a, The mucosa; b, glands of Lieberkiihn; b', indicates the superficial portion of the glands which can be traced
through their entire length; c, the glands in their depth; c', the dichotomous branching noticed in their depth; d, the
muscular fibers; e, the vessels; /, squamous epithelium; g, the pedicle of the tumor.
small, granulation-like top. It was noted shortly after the cord came away, and
was removed with the knife with satisfactory results.
Microscopically the picture was similar to that noted in the first case. There is
no doubt that both of these tumors were remains of the omphalomesenteric duct.
An Umbilical Polyp. — Kiistner * says that about a year before he
published his article he examined a fungus which had been removed from the umbilicus of a child three months old. He did not expect to find anything but granulation tissue, and was not a little surprised to find, instead of this simple structure,
* Kiistner, O.: Notiz uber den Bau des Fungus umbilicalis. Arch. f. Gyn., 1876, ix, 440.
REMNANTS OF THE OMPHALOMESENTERIC DUCT. 135
a relatively complicated picture. In the center was connective tissue, and outside
of this were round cells and granulation tissue. Embedded in the periphery were
numerous tubular glands. The tumor, which was the size of a pea, was covered
with beautiful cylindric epithelium.
Umbilical Polyps. — Lannelongue and Fremont* reported three cases.
Case 1 . — The child was four months old. When the cord came away on
the ninth day a small reddish tumor was noted at the umbilicus. It was cauterized
with silver nitrate several times, but continued to grow. It was cuboid in form,
red in color, firm and irreducible, and measured 8 mm. in diameter. It was cut off.
Lannelongue and Fremont give a beautiful plate showing an outer covering of in
6 ■■:■ \
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**>-. vx "*
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'-it j ■? .- .. » -' ._ a - - . .
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Fig. 76. — Adenoma of the Umbilicus. (After Lannelongue and Fremont.)
The specimen represents a transverse section through a so-called adenoma of the umbilicus. The central stem is
made up of non-striped muscle-fibers cut transversely. Surrounding this is a zone of the fibrous tissue, and the outer
surface is covered with a mucosa consisting essentially of glands of the small intestine (from Case 1).
testinal mucosa, and beneath a submucosa. The center was composed of nonstriped muscle (Fig. 76).
Case 2 . — The child was in its ninth month. At labor the cord looked normal, but when it came away on the eighth day there was left at the umbilicus a
small tumor, over 1 cm. long and about 1 cm. in diameter. Silver nitrate was used
several times without success. On examination the tumor was found to be solid,
was bright red, and suggested the mucosa of a prolapsed rectum. It secreted a
serous liquid. On one side was a slight depression. When the growth was cut off,
a small artery spurted. On microscopic examination it was found to be covered
with intestinal mucosa; the center was composed of non-striped muscle.
Their Plates 2 and 3, illustrating this case, are excellent.
* Lannelongue et Fremont: De quelques varietes de tumeurs congenitales de l'ombilic et
plus specialement des tumeurs adenoides diverticulaires. Arch. gen. de med., 1884, 7 e ser., xiii, 36.
136 THE UMBILICUS AND ITS DISEASES.
Case 3 . — The record is incomplete, but the microscopic findings were similar to those of the other cases.
An Umbilical Polyp Associated with a Partially
Patent Omphalomesenteric Duct.* — The patient was a boy.
On the eleventh day the cord came away and a cylindric tumor, with an elevation
the size of one phalanx, was found at the umbilicus. This had a "wild-flesh" appearance, and discharged blood and pus. It was removed with a knife. At once
a loop and then a large quantity of the small bowel came out of the wound. The
omphalomesenteric duct near the bowel was patent, the lumen measuring 6 mm. in
diameter. The opening was sutured, and the abdomen closed. The child made a
good recovery. On microscopic examination the polypoid tumor was found covered with mucosa containing Lieberkuhn's glands. Its central portion consisted
of non-striped muscle.
[In this case there was a patent omphalomesenteric duct, open at its inner end,
with slight obliteration in its middle portion; and in addition to this a remnant of
the duct in the form of a polyp at the outer end.]
Congenital Umbilical P o 1 y p . f — ■ The boy was three years of
age. An umbilical tumor had been noted since birth. It was the size of a small
bean, and was bright red in color, soft and fleshy to the touch, perpetually moist,
and tended to bleed on manipulation. There was no sinus. It had a narrow pedicle.
On microscopic examination it was found to present the typical appearance.
It was covered with mucosa, which contained glands resembling those of Lieberkuhn.
An Umbilical Polyp. — In Magnanini's + case there was a small
tumor at the umbilicus from which there was persistent hemorrhage. It was diagnosed as an adenoma. It belonged to the class of cases described by Ktistner.
Umbilical Polyp. — In Morton's § case the child was seven months
old. At the umbilicus was a bright-red, sessile growth, the size of a pea. Silver
nitrate was used without effect. Later the growth was ligated and snipped off.
On microscopic examination the surface epithelium was absent, but in the underlying tissue were found Lieberkuhn's glands.
Case 2 . — The child was " a few years old." At the umbilicus was a red
growth the size of a pea. It had a smooth, slightly moist, weeping surface and
was pedunculated. Caustics were applied with but little effect. On microscopic
examination Lieberkuhn's glands were found; they lay in the center, however,
instead of on the periphery of the tumor.
Probably an Umbilical Polyp. — Parker, ] | in his report of cases of
excision of the umbilicus for malignant disease, reports the findings in the case of a
boy twenty-nine months old. Soon after birth the parents noticed that the navel
did not heal. There was a hard mass occupying the place where the cord joins the
abdominal wall; and to the right of the cord a naked, non-cicatrized surface, discharg
* Lowenstein: Der Darmprolaps bei Persistenz des Ductus omphalomesentericus mit Mittheilung eines operativgeheilten Falles. Langenbeck's Arch. f. klin. Chir., 1894-95, xlix, 541.
! M.i kins and Carpenter: A Case of Congenital Umbilical Polyp. Illustrated Med. News,
London, 1889, ii, 268.
\ Magnanini, X.: Tumor diverticular del dmbligo. Anales del circulo medico Argentino,
L898, xxi, 449.
§ Morton, Charles A.: The Umbilical Growths of Infants and Young Children. Pediatrics,
1896, ii, 409.
|| Parker, Willard: Excision of Umbilicus for Malignant Diseases. Arch. Clin. Surg., New
York, 1870-77, i, 71.
REMNANTS OF THE OMPHALOMESENTERIC DUCT. 137
ing a thin sanious fluid. This area failed to cicatrize, and the tumor increased in size.
When the boy was three years old, an attempt was made to remove the growth, but
only part was taken away, as it was found to extend into the abdomen. Fifteen
months later the tumor was harder and firmer and increasing in size. An elliptic
piece of the abdominal wall, including the tumor, was excised. The child made a good
recovery. [Dr. Alonzo Clark, who made the microscopic examination, thought that
the growth was cancerous. It was, however, in all probability an adenoma of the
abdominal wall.]
Adenoma of the Umbilicus.* — The patient was a boy three
months old. When the cord came away the mother noticed a small moist nodule
at the umbilicus. It was the size of a pea, red, uniform, and covered with mucosa.
It had no opening and was irreducible. It was removed, and on microscopic examination showed an outer surface of intestinal mucosa with non-striped muscle beneath. It was a typical adenoma. Phocas then gives a resume of the literature
on the subject.
An Umbilical Polyp. — Simpson f reported a case which he saw with
Dr. Findlay. The excrescence was the size of a cherry, which it likewise resembled
in color. It was apparently insensible to touch, but blood oozed from its red surface
on slight handling. Silver nitrate was applied to it several times with no effect.
After several weeks a ligature was passed around its base, and in a few days it
dropped off.
An Umbilical Polyp.f — A boy twenty-one months old was admitted
to Maas's clinic. After the cord came away a prominence, 1.5 cm. high and 5 mm.
thick, was noted at the umbilicus. The tumor was reddish and suggested a red
granulation, but the color was brighter. It was pedunculated and was noted when
the cord came away. It had a slightly nodular surface and was rounded on the
end. It was moist and secreted an alkaline fluid. There was no central lumen.
It was removed with the cautery.
On microscopic examination it was found to be covered with mucosa containing
Lieberkiihn's glands. The surface epithelium had evidently been rubbed off. The
center was composed of bundles of smooth muscle. It was a remnant of the
omphalomesenteric duct.
An Umbilical Polyp. § — The patient was twenty years old. At
the umbilicus moisture and a reddish, cupped tumor the size of a cherry were detected. Its surface was irregular and lobulated, and it was covered with a viscid
secretion. It was removed.
Microscopically it resembled an adenoma, but Stori considered it a papilloadenoma originating at the umbilicus from remains of the omphalomesenteric duct.
An Umbilical Polyp. — Tikhoff , 1 1 in his Fig. 44, shows a polypoid
projection from the umbilicus, and in Fig. 46, accompanying his article, the typical
picture of an adenoma covered over with intestinal glands. The description of this
case is in Russian.
* Phocas: Adenomes de l'ombilic. Nord medical, 1S98, iv, 52.
t Simpson, J. Y.: Obstetric Memoirs and Contributions, Philadelphia, 1856, ii, 423.
X Steenken, C: Zur Casuistik der angebornen Nabelgeschwiilste. Inaug. Diss., Wurzburg,
1886.
§ Stori, Teodoro : Contribute alio studio dei tumori dell'ombehco. Lo Sperimentale Archivio
di biologia normale e patologia, 1900, liv, 25.
|| Tikhoff, P.: Khirurg. lyetop., Mosk., 1893, iii, 581.
138
THE UMBILICUS AND ITS DISEASES.
Fig. 77. — Ax Umbilical Polyp Attached to Meckel's Diverticulum bt a Fibrous Cord. (After
Walther.)
A, Meckel's diverticulum; B, adenoma of the umbilicus; C, the fibrous
cord; D, the skin; E, aponeurosis; F,
a serous band uniting the loop of small
bowel from which the fistula springs
with another loop of small bowel.
An Umbilical Polyp. — ■ Villar * reports the case of an infant, four
months old, who was admitted to the service of Nicaise in December, 1885. The
report was communicated to him by Le Roy. Since
birth this child had presented at the umbilicus a
small, reddish elevation which had never changed
much in volume. Nothing unusual was detected in
the cord, but the mother noticed this little mass just
as soon as the cord came away. The child had never
had any intestinal trouble. At the umbilical cicatrix
was a tumor the size of a small pea. It was spheric,
and attached to the umbilical depression by an extremely short pedicle. It was dark red, smooth, and
irreducible. It was removed.
Microscopic sections showed that the surface
was covered with cylindric epithelium, beneath
which were tubular glands similar to those of the
small intestine.
Umbilical Polyps. — Virchow f refers
to the umbilical fungus. He says there are two
kinds of tumor: (1) The one more commonly met
with is rich in blood-vessels and bleeds easily; it is
found immediately after the cord comes away. It
represents a case of granulation, and after the use
of astringents soon disappears. (2) A congenital
tumor. He refers to two of these cases, reported
by Maunoir and Lawton.
An Umbilical Polyp Associated with Meckel's Diverticulum, which was Attached to the
Umbilicus by a Fibrous Cord. J —
A youth, eighteen years old, had a tumor at
the umbilicus the size of a large cherry. It was
about 2.5 cm. long and 2 cm. broad, was red,
velvety, moist, and resembled intestinal mucosa.
It was connected with the umbilicus by a pedicle. It secreted a serous fluid which became
slightly purulent on account of irritation from
the clothes. The skin in the vicinity was red
and erythematous. There was no trace of an
umbilical hernia. The boy had had this tumor
since birth. It had grown ver\- little.
An elliptic incision was made around the umbilicus, and it was found that this polyp was connected with Meckel's diverticulum
by a solid fibrous cord (Figs. 77 and 78). Recovery took place.
* Villar, Francis: Tumeurs de TombiUc. These de Paris, 1886, No. 19, obs. 28.
t Virchow, R.: Die krankhaften Geschwiilste, 1862-63, iii, erste Halfte, 467.
i Walther, C. : Tumeur adeno'ide de l'ombilic et diverticule de Meckel. Revue d'orthopedie,
1904, xv, 23.
Fig. 78. — Ax Umbilical Polyp Attached
to Meckel's Diverticulum by a
Fibrous Cord. (After Walther.)
A, Meckel's diverticulum; B, adenoma of the umbilicus; C, fibrous cord. The
transverse dark area indicates the abdominal wall.
REMNANTS OF THE OMPHALOMESENTERIC DUCT.
139
Fig. 79. — Umbilical Polyp.
Gyn.-Path. No. 16866. (Specimen sent by Dr. E. W. Meredith, of Pittsburgh. The patient was a young adult.)
The upper picture shows the umbilicus with the smooth nodule springing from the umbilical depression. This nodule
was covered with intestinal mucosa. The lower picture is twice the natural size, and shows the relation of the polyp
to the umbilicus on cross-section. The mucous surface of the polyp merges directly with the skin surface of the umbilical depression. The center of the polyp consisted of non-striped muscle. For the low and high power pictures of
the polyp see Figs. 80, 81, and 82.
Fig. 80. — A Small Intestinal Polyp Almost Filling the Umbilical Depression. (X 5 diam.)
The section is through Fig. 79. The squamous epithelium covering the umbilical depression is clearly visible ,and
beneath it one finds the rarefied stroma. The polyp is covered over with intestinal mucosa, which in the specimen is
rather hazy. The dark areas in the polyp are aggregations of small round cells or lymph cells. For the higher power
picture see Fig. S2.
140
THE UMBILICUS AND ITS DISEASES.
Microscopic Examination. — The umbilical nodule was surrounded by inflamed
skin. The nodule was covered with intestinal mucosa. The surface was necrotic.
A cord consisting of fibrous tissue connected the polyp with Meckel's diverticulum.
A Personal Observation.
An Umbilical Polyp in an Adult. — On October 7, 1911, I
received the following from Dr. E. W. Meredith, from St. Margaret's Memorial
Hospital, Pittsburgh, Pa.:
"I am forwarding to you a specimen of an 'Umbilical Tumor.' The patient
is a healthy young man, twenty years of age. The tumor had been present since
birth, was brilliant red in color, and secreted a clear mucoid fluid.
x6
<r%
>>
i I
S K
i v
Fig. 81. — An Umbilical Polyp.
Gyn.-Path. No. 16866. The photomicrograph (Fig. 80) gives the general relation of the polyp, but naturally lacks
somewhat in detail. Mr. Brodel has given us a very clear drawing of the low-power findings. The polyp is covered
with typical intestinal mucosa. The confines of the pedicle are indicated by X. It consisted in a large measure of
non-striped muscle. The mucosa covering the polyp ends abruptly where the squamous epithelium of the umbilical
depression begins. The squamous epithelium at some points is much thickened. Here the papilla; are elongated.
The area indicated by the circle has been enlarged and is shown in Fig. 82.
"It was largely on account of the constant moisture about the umbilicus that
the patient sought operative relief. At the operation the umbilicus with its central
tumor was removed, and a small opening made into the peritoneal cavity to explore
the under surface of the umbilicus. This was found to be smooth and free of any
adhesions. I have made a provisional diagnosis of an adenoma of omphalomesenteric duct origin."
Gyn.-Path. No. 16866. — The specimen consists of the umbilicus
and of a small amount of the surrounding tissue. The umbilical opening is spheric,
has a slightly undulating surface, and is about 1.3 mm. in diameter. Occupying
the greater portion of the umbilical depression is a rounded polypoid growth.
This has a smooth surface, is translucent, and reminds one in the hardened state of
a section through intestinal mucosa (Fig. 79). The umbilicus was cut in two, and
REMNANTS OF THE OMPHALOMESENTERIC DUCT.
141
it was found that this tumor sprang from the umbilical depression and had a fairly
broad base (Fig. 80). Its surface was directly continuous with the skin surface of
the umbilical depression.
Histologic Examination. — Numerous sections were made through
the umbilicus and the growth. The skin covering the umbilicus in the outer portion of the section is perfectly normal (Figs. 81 and 82). As one approaches the
umbilical polyp the squamous epithelium becomes somewhat thinner, but pro
■:\
S
xl6
Fig. 82. — Portion of an Intestinal Polyp Partially Filling the Umbilical Depression. (X 16 diam.)
In the upper part of the picture is seen the squamous epithelium, which is practically normal. The stroma beneath it shows much rarefaction. The squamous epithelium ends abruptly at the margin of the polyp, which consists
of intestinal mucosa. The surface of the polyp consists almost entirely of granulation tissue due to irritation from the
clothing.
longations of the epithelium are continued for a considerable distance into the
depth. The squamous epithelium ends abruptly where the polyp begins. The
stroma beneath the squamous epithelium near the umbilicus is normal, but nearer
the umbilical depression there is a marked change; the stroma immediately beneath the squamous epithelium becomes rarefied, takes the bluish stain instead of
the pink, and reminds one very much of myxomatous tissue. Scattered throughout
it are a moderate number of small round cells.
142 THE UMBILICUS AND ITS DISEASES.
The polyp filling the umbilical depression is covered over with intestinal mucosa.
Where the squamous epithelium ends, the mucosa commences, or the squamous
epithelium in some places slightly overlaps the intestinal mucosa. The mucosa
resembles in almost every particular that of the small intestine. In the more prominent portions of the polyp, however, the surface epithelium has disappeared and
fibrin covers the surface. The tissue immediately beneath shows many dilated
capillaries; there is much small-round-cell infiltration and a moderate number of
polymorphonuclear leukocytes. The intestinal glands are, however, seen opening
directly on the surface, and the inflammatory reaction, without doubt, has been
caused by exposure of the polyp to irritation from the clothing. The stroma forming the central portion of the polyp consists in large measure of smooth musclefibers. Here and there in the muscle, and also directly beneath the mucosa, are
clumps of small round cells.
We have here a definite intestinal polyp originating from a remnant of the outer
portion of the omphalomesenteric duct. The low-power picture of the entire
umbilical growth is seen in Fig. 81. With the higher magnification the line of
junction between the squamous epithelium of the umbilical depression and the
intestinal mucosa is clearly seen in Fig. 82. Here also the rarefied condition of the
stroma beneath the squamous epithelium is clearly visible.
LITERATURE CONSULTED ON UMBILICAL POLYPS.
Ball, C. B.: Case of Umbilical Polyp. Illustrated Med. News, 1889, iv, 149.
Bidone, E. : Enteroteratoma ombelicale. Bull, delle scienze med., Bologna, 1901, ser. 8, i, 374.
Blanc et Weil: Soc. anat. de Paris, 1899. Rev. in Centralbl. f. allg. Path. u. path. Anat., 1900,
xi, 748.
Blanc, H. : Contribution a la pathologie du diverticule de Meckel. These de Paris, 1899, No. 393.
Booker, W. D. : Personal communication.
Broca, A. : Polype de l'ombilic. Jour, de med. et de chir., 1904, lxxv, 172.
Brun, L. A. : Sur une espece particuliere de tumeur fistuleuse stercorale de l'ombihc. These de
Paris, 1834, No. 238.
Capette et Gauckler: Note sur un cas d'adenome ombilical. Revue d'orthopedie, 1903, xiv, 271.
Colman, W. S.: Adenomatous Polypus of Umbilicus. Trans. Path. Soc. London, 1888, xxxix,
110.
Diwawin, L. A.: Ein Fall von Enteroteratom des Nabels. Russ. med. Rundschau, 1904, ii, 590.
Fabrege : Note sur les excroissances polypeuses de la fosse ombilicale chez les enf ants nouveau
nes. Revue medico-chir., 1848, iv, 353.
Fox and MacLeod : Remains of the Omphalomesenteric Duct at the Umbilicus Giving Rise to
Paget's Disease. Brit. Jour. Dermatol., 1904, xvi, 41.
von Gernet, R. : Ein Entero-teratom. Deutsche Zeitschr. f . Chir., 1894, xxxix, 467.
Giani, R. : Per la casistica degli entero-teratomi dell'ombelico. Clinica Moderna, 1902, viii, 498.
Gould, A. P.: A Congenital Mucous Polypus of the Umbilicus. Trans. Path. Soc. London, 1881,
xxxii, 204.
Hartmann: Occlusion intestinale par un canal omphalo-mesenterique persistant. Bull, et Mem.
de la Soc. de chir. de Paris, 1898, n. s., xxiv, 203.
Hektoen, L.: Vitelline Duct Remains at the Navel. Amer. Jour. Obst., 1893, xxviii, 340.
Henke: Zur Casuist ik der vollkommenen Nabel-Darm-Fisteln durch Persistenz des Ductus
omphalo-entericus. Deutsche Zeitschr. f. prakt. Med., 1877, iv, 486.
Hollaendersky, Sara: Zur Kasuistik der Nabeltumoren. Inaug. Diss., Freiburg i. Br., 1905.
Holmes, T.: Surgical Treatment of Children's Diseases, London, 1868, 181.
Holt, L. E.: Umbilical Tumor in an Infant Formed by Prolapse of the Intestinal Mucous Membrane of Meckel's Diverticulum. Med. Record, 1888, xxxiii, 431.
Hue, Francois: Tumcurs adenoides diverticulaires. La Normandie medicale, 1906, xxi, 165.
REMNANTS OF THE OMPHALOMESENTERIC DUCT. 143
Kirmisaon, E. : Adenome diverticulaire de l'ombilic. Revue d'orthopedie, 1904, xv, 47.
Kirmisson: Les tumeurs de l'ombilic. Rev. gen. de clin. et de therap., Paris, 1907, xxi, 726.
Kolaczek: Zwei Enteroteratome des Nabels. Langenbeck's Arch. f. klin. Chir., 1875, xviii, 349.
Kiistner, O.: Notiz liber den Bau des Fungus umbilicalis. Arch. f. Gyn. 1876, ix, 440; also
Virchows Arch., lxix, 286.
Lannelongue et Fremont: De quelques variety de tumeurs congenitales de l'ombilic et plus
specialement des tumeurs ad^noides diverticulaires. Arch. gen. de med., 1884, 17. ser., 13, 36.
Lowenstein: Der Darmprolaps bei Persistenz des Ductus omphalomesentericus, mit Mittheilung
eines operativ geheilten Falles. Langenbeck's Arch. f. klin. Chir., 1894-95, xlix, 541.
Makins and Carpenter: A Case of Congenital Umbilical Polyp. Illustrated Med. News, London, 1889, ii, 268.
Magnanini, N. : Tumor diverticular del Ombligo. Anales del circulo medico Argentino, 1898, xxi,
449.
Morton, Charles A. : The Umbilical Growth of Infants and Young Children. Pediatrics, 1896,
ii, 409.
Parker, Willard: Excision of Umbilicus for Malignant Diseases. Arch. Clin. Surg., New York,
1876-77, i, 71.
Pernice, L. : Die Nabelgeschwiilste, Halle, 1892.
Phocas: Adenomes de l'ombilic. Nord medical, 1898, iv, 52.
Sheen, W. : Some Surgical Aspects of Meckel's Diverticulum. Bristol Medico-Chir. Jour., 1901,
xix, 312.
Simpson, J. Y.: Obstetric Memoirs and Contributions, Philadelphia, 1856, ii, 423.
Steenken, C: Zur Casuistik der angebornen Nabelgeschwiilste. Inaug. Diss., Wiirzburg, 1886.
Stori, Teodoro: Contributo alio studio dei tumori dell'ombelico. Lo Sperimentale Archivio di
biologia normale e patologia, 1900, liv, 25.
Tikhoff, P. : Case of anomalous prolapse of omphalomesenteric duct. Khirurg. lyetop., Mo6k.,
1893, hi, 581-594. 1 pi.
Villar, Francis: Tumeurs de 1'ombihc. These de Paris, 1886, No. 19.
Virchow, R.: Die krankhaften Geschwulste, 1862-63, iii, erste Halfte, 467.
Walther, C. : Tumeur adeno'ide de l'ombilic et diverticule de Meckel. Revue d'orthopedie, 1904,
xv, 23.
==Chapter VII. Congenital Polyps - Fistula or Cystic Dilatations at the Umbilicus==
CHAPTER VII. CONGENITAL POLYPS; FISTULA OR CYSTIC DILATATIONS AT THE UMBILICUS; WITH A MUCOSA MORE OR LESS SIMILAR TO THAT OF THE PYLORIC REGION OF THE STOMACH, AND SECRETING AN IRRITATING FLUID BEARING A MARKED RESEMBLANCE TO GASTRIC JUICE. PERSISTENCE OF THE OUTER PORTION OF THE OMPHALOMESENTERIC DUCT.
So-called gastric mucosa at the umbilicus.
General consideration.
Macroscopic appearance.
[Microscopic picture.
The fluid secreted by the polyp or fistula.
Action of the fluid on the skin surrounding the umbilicus.
Symptomatology.
Origin.
Treatment.
Report of cases of congenital polj'p or fistula at the umbilicus and having a mucosa
resembling that of the stomach.
Persistence of the outer portion of the omphalomesenteric duct.
Report of cases in which the outer end of the omphalomesenteric duct remained patent.
Tillmanns, in 1882, made a most interesting observation .on a boy thirteen
years old. On questioning the parents it was learned that the umbilical cord was
unusually thick, and that it had dropped off on the fourth day, leaving a tumor the
size of a cherry. This grew slowly. When Tillmanns saw it, it was the size of a
walnut, bright red in color, and covered with mucosa (Fig. 87). It had no central
opening. It was attached to the umbilical depression by a thin pedicle. After
the boy had eaten, the tumor would sometimes swell perceptibly; it would become
redder, and its mucosa thicker.
This umbilical tumor secreted a tenacious mucus, which was especially abundant
when the tumor was irritated. At such times 2 to 3 c.c. of fluid could be collected
in fifteen minutes. The discharge was so copious that it was necessary to wear
dressings, and even then it would at times saturate the boy's clothes.
The fluid secreted was acid, but when old, it became alkaline. The fluid
digested fibrin in an acid solution at 39° C. A chemical examination, made by Dreschel, showed that it corresponded more or less closely with gastric juice.
Microscopic examination of the tumor revealed the fact that the mucosa was
similar to that of the stomach.
The digestive action of the fluid secreted by this tumor had caused a maceration
of the abdominal skin surrounding the umbilicus. The pedicle of the tumor was
severed, and the wound soon healed (Fig. 88). No connection with the abdominal
cavity was found.
The literature on this subject is rather scanty, but several subsequent observers
have reported mucosa at the umbilicus that bore more or less resemblance to stomach
mucosa. Cases have been recorded by Roser (1887), Siegenbeek van Heukelom
144
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS. 145
(1888), von Rosthorn (1889), Reichard (1898), Weber (1898), Lexer (1899),
Strada (1903), Minelli (1905), and Denuce (1908).
MACROSCOPIC APPEARANCE OF THE UMBILICAL REGION.
In the majority of the cases the umbilical abnormality was observed just as soon
as the cord had dropped off. The local picture varies considerably. It may be
roughly classified as follows:
1. An umbilical polyp attached to the umbilical depression by a short pedicle.
2. An umbilical polyp with a cystic cavity opening on the surface of the polyp.
3. An umbilical fistula with or without a small projection.
The umbilical polyp in van Heukelom's case, and also in Reichard's case, was
the size of a hazel-nut; and in Minelli's, Strada's, and Tillmanns' cases the tumor
was considerably larger.
Roser's patient, a boy a year and a half old, had a bright-red swelling at the
umbilicus, and opening on the surface of it was a cystic cavity 1 cm. in diameter.
In Denuce's, Lexer's, von Rosthorn's, and Weber's cases there was seen at the umbilicus a fistulous tract which extended directly inward for a distance of 1.5 to 2 cm.
In Lexer's case no nodule was found at the umbilicus, but in the other cases the
cutaneous end of the fistula had raised margins, producing a small red thickening.
Where a polyp exists, it is bright red in color, covered with mucosa, and is
attached to the umbilical depression by a definite pedicle. In those cases in which a
fistula exists, and where it is wide enough to allow one to see its inner surface, it is
found lined with mucosa.
THE MICROSCOPIC PICTURE.
The surface of the polyp is covered with mucosa, the glands of which resemble
more or less closely those found at the pyloric end of the stomach. In certain cases,
some of the glands look more or less atrophic. At times both Lieberkuhn's glands
and also pyloric glands have been noted in the mucosa.
The central portion of these polyps consists of non-striped muscle, and occasionally a little adipose tissue is present.
The fistulse are lined with mucosa, which is for the most part similar to that of
the pyloric region, but here also the mucosa at one point may contain Lieberkuhn's
glands, and at another, pyloric glands. This was particularly well shown in
von Rosthorn's case. The outer walls of the fistulous tract are composed of
non-striped muscle.
THE FLUID SECRETED BY THE POLYP OR FISTULA.
The polyp or fistula, as the case may be, secretes a fluid which may be watery,
clear, and stringy, or cloudy and tenacious. The amount varies greatly. In Denuce's
case, 3 c.c. were secreted in thirty-six hours; in von Rosthorn's case, 5 c.c. were discharged in twenty-four hours, while in Tillmanns' case 2 to 3 c.c. were collected in
fifteen minutes. In Weber's case the father estimated that half a wineglassful came
away daily; so abundant was the flow that the child's clothes were soaked.
In Denuce's case, as soon as the child commenced to eat, the flow increased, and
Tillmanns drew attention to the fact that irritation of the tumor in his case caused
an abundant secretion.
11
146 THE UMBILICUS AND ITS DISEASES.
The fluid is usually acid. In Weber's case, however, it was alkaline. In Tillmanns' case the fresh fluid was acid, but after it had been kept for some time it
became alkaline.
Lexer said that in his case the fluid chemically resembled gastric juice. The
fluid in Tillmanns' case digested fibrin in an acid solution at 39° C, and Drechsel
found that it corresponded to gastric juice.
Yon Jaksch made a careful chemical examination of the fluid in von Rosthorn's
case, and found albuminous bodies, peptone, pepsin in small quantities, but no
free hydrochloric acid. Denuce found free hydrochloric acid and peptone, but no
pepsin. He describes the fluid as a "sort of gastric juice."
From these findings it is clear that the fluid secreted in these cases bears a strong
resemblance to gastric juice.
Action of the Fluid on the Skin Surrounding the Umbilicus. — In von Rosthorn's
case the abdominal wall around the umbilicus was slightly irritated.
In Tillmanns' case the skin in the vicinity of the polyp was macerated. In
Denuce's case the skin surrounding the fistula was ulcerated for a certain distance.
This ulcerated area was bright red in color, and the tissue surrounding it was tumefied. The total area of ulceration was about the size of a five-franc piece.
In Reichard's case, commencing just below the fistula and extending downward
6 cm. toward the pubes, was "a digestive ulcer" which had indurated margins.
The ulceration was situated just where the fluid from the fistula trickled down the
abdominal wall. The patient was a child five years old. He was able to walk
around; hence the fluid flowed downward instead of irritating the parts all around
the umbilicus.
Weber's patient was a boy three years old. Four months before coming under
observation a canal-shaped wound developed. This commenced at the umbilicus
and extended 4 cm. downward toward the symphysis. It was increasing in
size and had callous walls. The umbilicus itself and the surrounding tissue over an
area the size of the palm of the hand were markedly macerated. The umbilical
region presented the typical picture of a digestive process.
The action of the fluid alone would make one strongly suspect the presence of
gastric juice.
SYMPTOMATOLOGY.
These polyps or fistulas are more common in males than in females. They are
congenital, and accordingly are usually noted at, or shortly after, the time the cord
comes away. They are recognized by the appearance of a small red polyp or fistula
at the umbilicus. The secretion from the navel varies in amount, is usually acid
in reaction, and tends to increase at meal-times or when the polyp is mechanically
irritated. In at least half of the cases there is more or less digestion of the
abdominal wall in the umbilical region. This digestive action clearly differentiates
these from ordinary umbilical polyps, and suggests the presence of mucosa identical
with or strongly resembling that of the stomach.
ORIGIN.
Considerable speculation has been rife as to the origin of these so-called gastric
polyps or fistulas. Naturally the easiest explanation would be that in embryonic
life there has occurred a displacement of patches of gastric mucosa.
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS. 147
In Denuce's case the fistulous tract was removed without any opening into the
peritoneum. The peritoneum was transparent, and it was possible to see a little
to the left of the deep attachment of the fistula a cylindric cord, which passed from
the umbilicus to a loop of bowel. This cord was evidently the remnant of the
omphalomesenteric duct.
In Reichard's case the abdomen was opened and the tumor found to be cystic,
bluish, and translucent. Sharply defined and passing from it was a very thin
pedicle, which extended upward in the abdominal cavity. Further examination
could not be made on account of the weak condition of the child.
Weber, in removing the umbilical fistulous tract in his case, opened the peritoneum. From the fistulous tract a thin cord passed upward and led to the under
surface of the liver. He thought that this cord represented the remains of the
umbilical vein.
We have no positive evidence in any of the cases that the umbilical growth was
connected with the stomach. On the other hand, it is quite probable that in one
of them it was connected with the small bowel by a fibrous cord.
Judging from the embryologic development of the umbilical region, one would
naturally conclude that such growths are remnants of the omphalomesenteric duct.
Furthermore, we learn, from the microscopic descriptions of the fistula?, that in
some parts the glands resembled intestinal glands; in other places glands of the
pyloric region. Again, in Lexer's case (Fig. 85) the fistulous tract was almost
continuous with a patent Meckel's diverticulum. The fistula was fined with what
resembled a gastric mucosa; the Meckel's diverticulum, with a mucosa similar to
that of the small bowel.
As is well known, the entire digestive tract develops from the yolk-sac. It has
been claimed that, prior to the passage of the various fluids, such as bile and pancreatic fluid, over the intestinal mucosa, it is identical with or bears a strong resemblance to that of the stomach. Be that as it may, it is certain that we have a small
group of cases in which polyps or fistula? have developed at the navel, and that
these are covered or fined with a mucosa that histologically closely resembles gastric
mucosa; and that this mucosa secretes a juice that acts very much as gastric juice
will do. Personally, I believe that these growths are remnants of the omphalomesenteric duct.
TREATMENT.
Where a polyp exists, it is only necessary to tie the pedicle and cut off the growth.
In those cases in which a fistula exists, the umbilicus should be encircled, the abdomen opened, and the growth removed. If it be connected with the bowel, the
intestinal stump should be treated as an appendix stump. In those cases in which
much maceration exists, local alkaline applications should be employed until the
skin is healthy, after which removal of the growth can be readily carried out.
CASES OF CONGENITAL POLYPS OR FISTULiE AT THE UMBILICUS AND HAVING A
MUCOSA RESEMBLING THAT OF THE STOMACH.
A Pseudopyloric Congenital Fistula at the Umbilicus. — ■ Denuce* speaks of a rare variety of fistula occurring at the umbilicus.
* Denuce: Fistules pseudo-pyloriques congenitales de l'ombilic. Revue d'orthopedie, 1908,
xix, 1.
148 THE UMBILICUS AND ITS DISEASES.
A secretion is present, which gives an acid reaction, and on chemical examination
is found to be practically identical with gastric juice. Moreover, the digestive
action of this fluid manifests itself on the tissues surrounding the fistula. Histologic examination shows that the structure of the mucosa lining the fistulous tract
is exactly similar to that of the stomach and the pyloric region.
Denuce saw a case of this character in the surgical clinic at Bordeaux, and the
diagnosis was made before operation. The patient, a boy twenty-one months
old, was admitted to the hospital on account of a congenital umbilical fistula. The
umbilical cord in its outer aspect showed nothing abnormal at birth. When it
came away, there was left what appeared to be a granulation at the umbilicus.
This was cauterized. There was a discharge, which at first was slight, but later
at times became very abundant. The fluid, as a rule, was colorless, but sometimes it had a hemorrhagic tint.
On admission the child's general condition was poor; the fistulous tract was
painful. Methylene-blue was administered, but none was discharged from the
fistula, showing that the latter was not urinary in character. Urination was normal. Digestion was normal and the bowels moved regularly. At the umbilicus
was a small orifice from which there came a liquid discharge. The surrounding
skin was ulcerated for some distance. This ulcerated area had a bright-red color,
and the tissue around it was tumefied. At the summit of the ulceration was a
fistulous orifice. The total area of ulceration at the umbilicus was about the size
of a five-franc piece. A probe could be introduced into the fistula for about 1.5
cm. The fluid, when first examined, was clear, but when the child started - to eat,
there was an immediate increase in the quantity of the discharge from the umbilicus.
In about thirty-six hours 3 c.c. of liquid were secured. An analysis of this fluid
gave the following:
Glucose
Sulphocyanid
Albumin +
Lactic acid
Free hydrochloric acid +
Peptone +
Lab ferment
Pepsin
Further examination of the " gastric juice" from the same patient showed an
estimated total acidity of 2.4 gm. to the liter. The presence of free hydrochloric
acid, peptone, and lab ferment was detected. The conclusions drawn were that
this liquid might be considered as a sort of gastric juice.
The fistulous tract was removed without any opening into the peritoneum. The
peritoneum was transparent, and it was possible to see a little to the left of the deep
portion of the fistula the attachment of a cylindric cord, which, at its inner extremity,
was inserted into one of the intestinal loops. It was easily recognized that this
cord represented Meckel's diverticulum, which, at its distal extremity, was attached
to the umbilicus. The umbilical fistula was ligated at its base and burned off with
the thermocautery. The child made a good recovery.
Sections through the fistulous tract showed a mucous structure analogous to
that of the stomach. Fig. 83 represents a transverse section of the fistulous tract.
Owing to the presence of the villus-like projections the general appearance of this
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS.
149
tract reminds one somewhat of the Fallopian tube projections. The cavity contained
granular remains, and round or oval cells. The fistula might be described as a sort
of small cul-de-sac lined with a kind of gastric mucosa. Denuce speaks of this case
as an instance of pseudopylorus, and says such cases are exceedingly rare. He
then goes on to discuss the cases of Tillmanns and Roser, and considers the various
hypotheses as to the origin of these fistulae. In young embryos, he points out, the
intestinal tract is lined with epithelium which is the same throughout, and the
differentiation between the epithelium of the stomach and that of the intestine is a
later development.
WKt/rJfc
u
w
Fig. 83. — Transverse Section- of a Pseudopyloric Congenita! Fistula at the Umbilicus. (After Denuce.)
The mucosa resembled somewhat that of the intestine, somewhat that of the stomach. The finger-like and papillaryoutgrowths are, however, unusually long. For the appearances under the high power see Fig. 84.
Gastric Mucosa in a Persistent Omphalomesenteric
Duct . — Lexer* says there is a small group of cases which, on account of their
individual structure and the character of the mucous lining, are obscure. These
cases have a mucosa that not only closely resembles that of the pyloric region but
also secretes a fluid resembling gastric juice. He then refers to the cases of Tillmanns
and Siegenbeek van Heukelom.
Lexer's patient was one year old. It had a congenital umbilical fistula, and the
surrounding skin was eroded. The fluid which was collected for several hours was
clear, stringy, contained no intestinal contents, was strongly acid, and chemically
* Lexer: Magenschleirrihaut im persist irenden Dottergang.
Chir., 1899, lix, 859.
Lanaenbeck's Arch. f. klin.
150
THE UMBILICUS AND ITS DISEASES.
resembled stomach juice. It rapidly digested albumen (fibrin). At operation the
fistulous tract was found attached to the convexity of the small bowel (Fig. 85).
It closed at a point 1.5 cm. behind the umbilicus. Meckel's diverticulum was
lined with intestinal mucosa, but that of the umbilical portion of the fistula was
totally different, consisting of what Lexer termed pseudopyloric mucous membrane. The cylindric epithelium lining the outer portion of the fistula was high,
and the mucosa itself resembled that of the pylorus, but was drawn out into fingerlike projections.
According to Lexer, the picture as a whole demonstrated the persistence of the
omphalomesenteric duct, the outer portion
of which differed entirely from that communicating with the bowel. This variation
in type, he thought, is probably due to an
early severance of the outer portion of the
fistulous tract from the inner portion.
An Umbilical Polyp. — Minelli*
gives a low-power picture showing a tumor
l which suggested an adenoma of the umbili
( ,,':•" cus. He then gives a resume of the liter
U
/
/"*
J'i
Fig. S4. — High-power Picture of a Fistulous
Tract at the Umbilicus, Showing Glands
Resembling those of the Pylorus. (After
DenucS.)
1, Excretory glands: 2, 2, 2, 2, acini; 3, 3,
cells bordering acini; 4, 4, eosinophiles; 5, 5,
mast cells; 6, island of lymphoid tissue.
Fig. 85. — An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach. (After Lexer.)
This sketch is from Plate 16 accompanying Lexer's article.
It shows the lack of continuity of the fistulous tract. The inner
portion is from Meckel's diverticulum, and is lined with a mucosa like that of the small bowel. The outer portion of the tract
was cut off entirely from the inner and was lined with mucosa
resembling that of the pylorus.
ature. His was a congenital tumor, which later had increased to the size of a
walnut. Histologically, it presented the picture of a gastric adenoma.
A Cystic Umbilical Tumor Secreting a Fluid that
Tended to Digest the Abdominal Wall.f — In the case of a
boy five years old, moisture had been noticed in the umbilical region since his birth.
Four months before entering the hospital he developed a serpiginous ulcer, which
extended from the umbilicus downward. On admission the child was pale. In the
* Minelli, S.: Adenoma Ombelicale a struttura gastrica. Gaz. med. Italiana, 1905, lvi, 101.
t Reichard: Centralbl. f. Chir., 1898, xxv, 587.
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS. 151
umbilical region was a tumor, the size of a hazel-nut, which showed a fine fistulous
opening from which clear fluid escaped. The digestive ulcer extended down the
abdominal wall for a distance of 6 cm. Its margins were indurated.
The abdomen was opened, and the tumor was found to be cystic, bluish, translucent, and sharply defined. Passing from it was a very thin pedicle which extended
upward in the abdominal cavity. Further examination could not be made on
account of the weak condition of the child. The entire umbilical area was removed,
and the child recovered.
The cavity was lined with mucosa which microscopically seemed to be of the
gastric type. Reichard says that this reminded him of Tillmanns' case, although
neither inversion nor prolapsus of the tumor had occurred.
An Umbilical Fistula.* — The boy, a year and a half old, entered
the hospital November 4, 1886. The umbilicus was swollen, and from it an acid,
watery fluid escaped. The surrounding tissue was slightly macerated. The opening at the umbilicus was red and granular, and the walls were indurated and thickened. The cavity was 1 cm. in diameter.
Operation. — The thickened skin was cut out and the red, granulating mucosa
removed with forceps and scissors. Roser thought that he had cut down to the subperitoneal connective tissue and did not enter the abdominal cavity. Several weeks
later he noticed that some of the mucosa had been left behind, and a sound could be
carried 3 mm. downward. The discharge was small in amount, but slightly acid
in reaction. A small tampon saturated with a solution of zinc chlorid was placed
in the cavity, and several weeks later all trace of the fistula had disappeared. The
scar was hardly visible when the child left the hospital in December.
Microscopic examination by Professor Marchand showed that the mucosa was
similar to that of the stomach. The tubular glands were closely packed, and beneath them was an abundant layer of smooth muscle.
Roser says that when one remembers that, in the early fetal life, the pylorus is
in a different position to that which it occupies later, — that is to say, the stomach is
perpendicular, and the pylorus is in the umbilical region, — one can surmise that a
portion of the wall of the stomach may be detained at the umbilicus and when the
stomach draws back, may be held there. In this way a diverticulum might form,
and as a result a cyst would develop.
A Congenital Umbilical Fistula, f — A boy, seven years old,
was admitted on account of an umbilical fistula. Its presence had been noted when
the cord dropped off. On the fourth day a projection 4 cm. long and of about the
thickness of a little finger was noted at the umbilicus. It was glassy in appearance
and pale. In the course of a month a small opening developed in the center of it,
from which came a continuous flow of clear, watery fluid. The projection gradually
diminished until it disappeared, but the opening grew larger until its diameter
reached that of a penholder. No feces, no fecal odor, and no urine were at any time
detected at the umbilicus.
On admission the boy was strong and well nourished. At the umbilicus was a
tumor the size of a hazel-nut. It was round, red, and glistening, 1 cm. in diameter,
* Roser, W.: Zur Lehre von der umbilikalen Magencvstenfistel. Centralbl. f. Chir., 1887,
xiv, 260.
t Von Rosthorn: Ein Beitrag zur Kenntniss der angeborenen Nabelfisteln. Wien. klin.
Wochenschr., 1889, ii, 125.
152 THE UMBILICUS AND ITS DISEASES.
soft in consistence, and had a velvety covering. Through the central opening a
probe could be passed directly inward for 2 cm. The abdominal wall around the
opening was slightly irritated.
The secretion from the umbilical tumor amounted to about 5 c.c. in twentyfour hours. It was acid in reaction. Von Jaksch made the chemical examination.
Organic : Albumin bodies, peptone and albumose, ferments and
pepsin, in small quantity; sugar, urinary salts, bile-coloring matter,
urobilin, absent.
Inorganic : Reaction for free hydrochloric acid negative. Chlorids
in large quantities. No phosphates or sulphates.
Microscopic examination of the diverticulum, which extended to the peritoneum,
showed typical Lieberkuhn's glands; near the middle portion were glands with
clear cells resembling closely those of the pyloric region.
A Congenital Umbilical Fistula Lined with a Mucosa
Possibly Resembling that of the Stomach.* — The child, two
and one-half years old, had had trouble at the umbilicus since the cord came away.
The umbilical region was never dry, and in the depression was a tumor the size of a
hazelnut, red in color, and with a granular, moist surface. It was attached to the umbilical depression by
a short, thin pedicle. It looked like a typical granu•d loma of the umbilicus. The pedicle was cut, but so
much oozing took place that the thermocautery was
necessary to check the bleeding. On microscopic ex
Fig. 86. — Appearance of the Um- _ " ° x
bilical depression in von animation a transverse section of the polyp showed
rosthorn's case. ^at the surface was covered with glands. The cen
o, the umbilical opening; b, the , ■> ,. • .l 1 c i • i ,• , • •
bottom of the depression; c, the peri- tral portion consisted of adenoid tissue contaimng
toneum. many smooth muscle-fibers. The epithelium and
glands of the tumor resembled those of the intestine.
An Umbilical Polyp. — Stradaf gives a short survey of the literature,
and then reports the case of a young woman of twenty who had a tumor at the umbilicus. This grew slowly to the size of a walnut, was round, red, and covered with
mucosa. It was attached by a short pedicle and was irreducible. It was removed.
On microscopic examination it was found to be covered with cylindric epithelium.
The majority of the glands, according to Strada, were of the pyloric type; others
resembled Lieberkuhn's glands. In the center of the tumor was adipose tissue;
surrounding it, non-striped muscle. Strada gives a splendid picture of this case,
and then carefully reviews the cases in which the mucosa at the umbilicus resembled
gastric mucosa.
Congenital Prolapsus of Stomach Mucosa Through
the Umbilical R i n g . % — In July, 1881, August W., aged thirteen, was
brought to Tillmanns. With the exception of an unusual condition at the umbilicus, the child was perfectly healthy, although somewhat anemic.
* Siegenbeek van Heukelom: Die Genese cler Ectopia ventriculi am Nabel. Virchows Arch.,
1888, cxi, §475.
Strada, Ferdinando: Adenoma Congenito Ombelicale a tipo gastrico. Lo Sperimentale
Archivio di biologia normale e patologia, 1903, lvii, 637.
| Tillmanns, H.: Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring
(Ectopia Ventriculi; und iiber sonstige Geschwtilste und Fisteln des Nabels. Deutsche Zeitschr.
f. Chir., 1882-83, xviii, 161.
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS.
153
At the umbilicus was a bright-red tumor the size of a walnut (Fig. 87j. It
was painless on manipulation, but caused the patient some feeling of discomfort.
The surface of the tumor secreted a cloudy, tenacious, mucus-like acid juice, which
was especially abundant when the tumor was irritated. At no point was there
any evidence of an opening downward, and no canal could be made out. The entire
tumor was covered with mucosa. It was attached to the umbilicus by a thin
pedicle. It was not increased in size by coughing or by pressure on the abdominal wall. The skin in the vicinity of the tumor had been macerated by
the secretion.
The secretion was relatively abundant. It was possible, in the course of fifteen
minutes, to collect from 2 to 3 c.c. and, when the tumor was mechanically irritated
with the ringer or a sound, the secretion increased. Tillmanns first thought that he
was dealing with a Meckel's diverticulum with prolapse of the
intestinal mucosa, or possibly
that a urachal fistula existed.
Thiersch also saw the boy and
came to the same conclusion, but
the acid reaction of the mucus,
the experiments as to its power
of digestion, and later the histologic examination of the tumor,
made them conclude that they
had to deal with stomach mucosa.
The secretion digested fibrin
in an acid solution at 39° C. Pepsin was evidently present. The
fresh secretion was strongly acid.
That which had been secreted for
some time and lay in the vicinity
of the tumor in several instances
gave an alkaline reaction. Professor Drechsel, of the Chemical
Department, examined the secretion and found that it corresponded to that coming from the
stomach.
The mother said that the cord dropped off about the sixth day, and that immediately a reddish tumor, about the size of a cherry, was seen at the umbilicus.
The umbilical cord was unusually thick, and it was thought possible that the midwife had tied the cord too close to the umbilical ring. Several days after the
cord had come away the tumor became more prominent. During the last few years
it had grown very slowly, and in the four months previous to his admission there
had been hardly any increase in size. After the boy had eaten, this tumor would
sometimes swell perceptibly; it would become reddish, and the mucosa would increase in thickness. At this time it would also secrete abundantly. The discharge
had been so copious that it was necessary for the patient to wear dressings. These
would sometimes be saturated and his clothes would be wet. There was no evi
Fig. 8.. — Gastric Mucosa at the Umbilicus. (After Tillmanns.)
Projecting from the umbilicus is a bright-red, velvety tumor
mass. This was covered over "with mucosa, which on histologic
examination resembled mucosa of the pyloric region. It had an
abundant secretion.
154
THE UMBILICUS AXD ITS DISEASES.
dence of fecal matter or of stomach-contents at the umbilicus. The boy had never
suffered from indigestion, and his defecation was normal.
On account of the discharge the boy was anxious to have the tumor removed.
This was readily accomplished. The pedicle was cut across, and the few small
vessels were controlled with the Paquelin cautery. Within a few days all trace
had disappeared, and the patient, up to the time Tillmanns reported the case, had
been perfectly well (Fig. 88).
Microscopic examination of the tumor by Professor Weigert showed that it
consisted of stomach-wall, all the layers being present. In the center was serosa,
then came subserosa, then a layer of muscle, and covering the outer surface, mucosa.
The glands were very abundant, but were in part atrophic. Several portions on
casual examination might very readily have been mistaken for intestinal mucosa;
but others at once indicated their origin from the pylorus.
Tillmanns says that, from the chemical and anatomic examination, it was evident
that a portion of the stomach-wall in the vicinity of the pjdorus had prolapsed
through the umbilical ring in such a way
that the mucosa was on the outer surface,
while the muscular coats formed the center. He said he was unable to find a
similar case reported in the literature.
To explain the origin of the condition he
supposed that there had probably been
an umbilical hernia, in which a portion
of the stomach diverticulum had been included; that the thick, funnel-shaped
umbilicus had probably been tied too
close to the umbilical ring, and in all
probability a portion of the stomach
diverticulum had been tied off with the
cord. He added that, at the time of
labor, the diverticulum of the stomach
was probably no longer in connection
with the stomach proper.
An Umbilical P o 1 y p Covered with Stomach Mucosa.*
— A boy, three 3-ears old, was admitted January 5, 1897. The labor had been
normal, but the cord did not come away on time. When it did drop off, a small,
red tumor was found at the umbilicus. This was cauterized by the attending
physician. From that time it secreted a fluid which was whitish and contained
brown flocculi or white clots, and occasionally mucous threads. There was never
any indication of the escape of intestinal or stomach-contents. According to the
father, about half a wineglassful of fluid escaped daily. The clothes and dressing were always soaked.
The flow increased at midday, and at that time was often accompanied by
colicky pain. In the morning, on the other hand, the child was comfortable.
Four months before his admission a canal-shaped wound developed from the
umbilicus downward. This would not heal, but continued to increase in size.
The boy's appetite was good; the bowels were regular.
* Weber, W. : Zur Kasuistik der Ectopia ventriculi. Beitrage z. klin. Chir., 1898, xxii, 371.
Fig. 88. — Appearance of the Umbilicus after Removal of the Stomach Mucosa seen in Fig. 87.
- Tillmanns.;
The umbilical depression is very uneven, but perfectly
intact. There was no opening into the abdomen.
SO-CALLED GASTRIC MUCOSA AT THE UMBILICUS. 155
On admission the child was anemic. On separation of the umbilical folds a
drop of clear, serous fluid escaped. Passing down the abdominal wall from this
point was a canal-shaped, ulcerated area, about four cm. long, having callous walls.
The wound itself and the surrounding epidermis over an area the size of the palm of
the hand were markedly macerated. The umbilical region presented the typical
picture of a digestive process.
Operation. — An incision including this area was made and the peritoneum
opened. From the fistulous tract a thin cord passed upward and led to the under
surface of the liver. The umbilical growth was sharply defined, bluish, and cystic.
There was no connection with the intestine or with the stomach. The tumor was
removed. In three weeks only two small areas of granulation remained.
The cystic tumor was lined with a thick mucosa, macroscopically resembling
that of the stomach. The mucosa was alkaline in reaction. On microscopic
examination it was found to be of the pyloric type. Beneath it was a submucosa,
then layers of non-striped muscle. Weber says that, from this description and the
microscopic picture, it is certain that we are dealing with normal stomach mucosa
from the pyloric region. The microscopic examination was made in the Berlin
Pathological Laboratory by Privatdocent Krause.
Weber thought that the cord passing to the under surface of the liver represented
remains of the umbilical vein.
Although the secretion was alkaline, the free secretion at noontime, and the
maceration, together with the anatomic appearance above noted, indicated that
the growth had developed from the stomach. Weber gives a resume of the literature on the subject.
LITERATURE CONSULTED ON CONGENITAL POLYPS, FISTULiE, OR CYSTIC DILATATIONS AT THE UMBILICUS, SHOWING A MUCOSA MORE OR LESS SIMILAR
TO THAT OF THE PYLORIC REGION OF THE STOMACH, AND SECRETING AN
IRRITATING FLUID BEARING A MARKED RESEMBLANCE TO GASTRIC JUICE.
Denuce: Fistules pseudo-pyloriques congenitales de l'ombilic. Revue d'orthopedie, 1908, xix, 1.
Lexer: Magenschleimhaut im persistirenden Dottergang. Langenbeck's Arch. f. klin. Chir.,
1S99, lix, 859.
Minelli, S.: Adenoma Ombelicale a struttura gastrica. Gaz. med. Italiana, 1905, lvi, 101.
Reichard: Centralbl. f. Chir., 1898, xxv, 587.
Roser: Zur Lehre von der umbilikalen Magencystenfistel. Centralbl. f. Chir., 1887, xiv, 260.
Von Rosthorn: Ein Beitrag zur Kenntnis der angeborenen Nabelfisteln. Wien. klin. Wochenschr.,
1889, ii, 125.
Siegenbeek van Heukelom: Die Genese der Ectopia ventriculi am Nabel. Virchows Arch., 1888,
cxi, 475.
Strada, F.: Adenoma Congenito Ombelicale a tipo gastrico. Lo Sperimentale Archivio di bio
logia normale e patologia, 1903, lvii, 637.
Tillmanns, H. : Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia
Ventriculi) und iiber sonstige Geschwulste und Fisteln des Nabels. Deutsche Zeitschr. f.
Chir., 1882-83, xviii, 161.
Weber, W.: Zur Kasuistik der Ectopia ventriculi. Beitrage z. klin. Chir., 189S, xxii, 371.
PERSISTENCE OF THE OUTER PORTION OF THE OMPHALOMESENTERIC DUCT.
The picture presented is practically the same as where a simple umbilical
polyp exists. (See Fig. 89.) Situated at the umbilicus is a red nodule, varying
from a pea to a chestnut in size. Occasionally it may be longer, as in Wheaton's
156
THE UMBILICUS AND ITS DISEASES.
case. In Chandelux' case it was 6 cm. long. This length, of course, is exceptional.
Occupying the center of the prominent part of the nodule is a canal, into which
a sound can be introduced (Figs. 89, 90, and 91), sometimes only for a short dis
Fig. 89. — Persistence of the Outer End of the
Omphalomesenteric Duct. (Schematic.)
The persistence of the outer end of the omphalomesenteric duct as a wide funnel is most unusual, but
has occasionally been noted. The duct can be traced
for about half its length, and then ends in a fibrous cord
which extends to and is adherent to the convex surface
of the bowel.
Polyp
Fig. 90. — Atrophy of the Inner End of the Omphalomesenteric Duct. (Schematic.)
At the umbilicus is a polyp-like outgrowth covered
with intestinal mucosa in the center of which is a canal
— the outer end of the omphalomesenteric duct. The
intra-abdominal portion of the duct is represented by a
fibrous cord which extends from the umbilical region to
the convex surface of the bowel.
tance, usually for from 1.5 to 2.5 cm. From the fistula a glairy mucus or a clear
fluid escapes. In one of Florentin's cases the fluid coagulated, resembling apple
jelly. In this case, in addition to the fistula, there was a pus-pocket, the size of
a small mandarin orange, lying to one side of the fistulous tract. These projections, and also the fistulous tract, are covered with
mucosa of the small bowel.
The condition is usually noted at the time that
the cord comes away, or shortly afterward.
When the abdomen is opened for the removal
of the umbilical fistula, the abdominal end of the
tract will usually be found to end in a fibrous cord,
which is attached to the convex surface of the small
bowel. When removing the fistula it is always wise
to treat the stump at the bowel as a patent tube, as
one never knows when a fistulous tract or a thick
adhesion may contain a minute opening that connects with the lumen of the bowel.
Fig. 91.
-A Long Umbilical Poltp as
a Remnant of the Omphalomesenteric Duct. (Schematic.)
A short, round umbilical polyp is
the most common remnant of the duct
noted clinically. Such a long penile projection as here depicted is exceptional.
In such a case as this there is a long reddish projection springing from the umbilical depression. It is covered with
intestinal mucosa. In its center is a
fistulous opening into which a probe
can be carried for a variable distance.
Traces of the intra-abdominal portion
of the duct may or may not be present.
Cases
IN WHICH THE OUTER END OF THE OMPHALOMESENTERIC Duct Remained Patent.
Persistence of the Outer Portion of the Omphalomesenteric
Duct.* — A child, two and one-half years old,
had had at the umbilicus, since birth, a projection, about 6 cm. long, resembling a
portion of umbilical cord. When the child was admitted to the hospital, the growth
was still about cm. in length. Its extremity was free and somewhat enlarged. In its
center was a slight depression which admitted a probe for a short distance. The
Chandelux, A.: Observation pour servir a l'histoire de l'exomphale. Arch, de physiol.
norm, et pathologique, 1881, xiii, 2. ser., 93.
PATENT OUTER PORTION OF OMPHALOMESENTERIC DUCT. 157
growth bore some resemblance to a penis. The surface was not smooth, but had a
granular aspect and was reddish in color. Here and there were pale areas suggesting islands of skin. Its surface was covered with an abundant viscid discharge.
This was never yellow, nor could a fecal odor be detected. Urination was normal.
The nodule could not be reduced by taxis. The patient's health was good. This
nodule was successfully removed. On histologic examination its outer surface was
found to be covered with intestinal mucosa, and its central portion was made up of
non-striped muscle.
A Partially Patent Omphalomesenteric Duct. — Florentin* refers to a boy, five weeks old, who came to Professor Froelich's clinic.
The cord had been ligated 3 cm. from the umbilicus. Eight days after birth,
when the cord came away, a small umbilical tumor was noted which discharged
a clear liquid. The nodule did not change in volume and was not painful.
When the child came to the clinic, the umbilicus looked somewhat tumefied, and
in its center was a small pedunculated tumor about the size of a pea. It was
dark red, firm, irreducible, and showed but little tendency to bleed. In its center
was a small depression from which mucus escaped in small amount. A probe
could be introduced for 2 cm. The fistulous tract was removed.
It was found to be continuous with a cord, which was implanted in the intestine. This cord was cut off near the intestine with the thermocautery, covered
over, and the abdomen was closed. The child made a good recovery. The outer
surface of the tumor was covered with Lieberkuhn's glands, and the cord itself
presented a lumen lined with cylindric epithelium. This tumor was a partially
patent omphalomesenteric duct.
A Partially Patent Omphalomesenteric Duct. — Florentinf refers to an umbilical fungus in a child two months old in Froelich's clinic.
Just as soon as the cord came away a small reddish mass, the size of a pea, was
noted at the umbilicus. There was no history of intestinal trouble. The umbilical
nodule did not increase in size. It was firm, hard, and did not resemble a simple
granulation. It had a short pedicle. It was dark red in color, smooth, and only
slightly painful. It was irreducible. At its summit was a fistulous tract from
which a small amount of clear liquid without odor escaped. A probe could be
introduced for 3 cm.
At operation it was found that the under portion of this fistulous tract was
adherent to a cord, and that the base of it was attached to the intestine. This
cord was burned off, and the base turned in as in an appendix operation.
Histologic examination showed that the outer or umbilical surface of the fistula
was covered with glands, beneath which was muscle. The condition was due to a
partially patent omphalomesenteric duct.
Umbilical Polyp with a Partially Patent Omphalomesenteric Duct. — Florentin J describes a fungous diverticulum with a
fistula at the umbilicus and a pocket of pus, in a boy one year old. This patient
was observed in Froelich's clinic. After the cord came away a tumor of considerable size was found at the umbilicus. It discharged a clear liquid similar to apple
jelly. After the third month the fistula closed, but it reopened four months later,
* Florentin, P. : Fongus de l'ombilic chez le nouveau-ne' et chez l'enfant. These de Nancy,
1908-09, No. 22, p. 83.
t Florentin: Op. cit., 82. J Florentin: Op. cit., 80.
158 THE UMBILICUS AND ITS DISEASES.
at which time a little pus escaped from the orifice. The general health of the child
was excellent.
At the umbilicus was a tumor the size of a large horse chestnut. It was solid
in consistence and uniform in outline. Its surface was glistening, brilliant, and
pink in color. At one point it was possible to introduce a probe for a short distance.
On removal it was found that, at the bottom, the umbilical tissue was very firm and
much thicker than usual. At a point 1.5 cm. beneath the cord-like thickening the
operator opened into a pocket the size of a small mandarin orange, which contained
bloody pus. The fistulous tract was about 3 cm. long. The tumor was removed,
the pocket was cureted, and the wound healed thoroughly.
On histologic examination numerous tubular glands were found. Outside of
these there were muscular tissue and connective tissue. The condition was undoubtedly due to remains of the omphalomesenteric duct.
An Omphalomesenteric Duct Open in its Outer Portion but Closed at the Intestinal End.* — The specimen was
removed from a male infant ten weeks old. A small pink tumor had been noted
at the umbilicus two weeks after the cord came away. It had steadily increased
in size. It was the size of a filbert, one inch long and half an inch in diameter.
It was attached to the umbilicus by a narrow pedicle. At the upper end of the
tumor was a small orifice, situated in the middle of a depression. A probe passed
into the abdomen for 2^ inches and then met an obstruction. The surface of the
tumor was pink and velvety, and a mucoid fluid constantly flowed from it. It was
removed by means of a ligature and the stump treated with silver nitrate.
Microscopic Examination.— The mucosa in the canal and also on the surface
was found to resemble that of the intestine, escept that the villi and solitary glands
were lacking. The growth represented a partially patent Meckel's diverticulum,
open almost to the bowel.
* Wheaton, S. W. : Prolapse of Meckel's Diverticulum in an Infant, Forming an Umbilical
Tumour. Obst. Trans., London, 1892, xxxiv, 184.
LITERATURE CONSULTED ON PERSISTENCE OF THE OUTER PORTION OF THE
OMPHALOMESENTERIC DUCT.
Chandelux, A. : Observation pour servir a l'histoire de l'exomphale. Arch, de physiol. norm, et
pathologique, 1881, xiii, 2. ser., 93.
Florentin, P. : Fongus de l'ombilic chez le nouveau-ne et chez l'enf ant. These de Nancy, 190S-09,
Xo. 22, p. 83.
Wheaton, S. W.: Prolapse of Meckel's Diverticulum in an Infant, Forming an Umbilical Tumour.
Obst. Trans., 1892, London, xxxiv, 184.
==Chapter VIII. Meckel's Diverticulum==
Historic sketch.
Hernise of the tip of Meckel's diverticulum.
A mesenteric diverticulum.
An accessory pancreas situated at the tip of the diverticulum.
Meckel's diverticulum in animals.
Intestinal obstruction due to Meckel's diverticulum.
Cases of intestinal obstruction caused by a Meckel's diverticulum adherent to the umbilicus.
Intestinal obstruction due to the tip of Meckel's diverticulum becoming adherent to a distant
point.
Obstruction due to the passage of intestine through a hole in the mesentery of Meckel's diverticulum.
Inversion of Meckel's diverticulum into the bowel.
Treatment of obstruction due to Meckel's diverticulum.
Meckel's diver-h'cul
Persistence of the intra-abdominal portion of the omphalomesenteric duct produces the so-called Meckel's diverticulum (Fig. 92). The subject has been so fullyconsidered by many writers that I shall here give only a brief survey, not attempting
to in any way give a full resume of the literature. Kern, in his Inaugural Dissertation, says that, according to Morgagni, this
diverticulum was first observed by J. H.
Lavater, who in 1671 saw a case of this
character with Bienaisius in Paris.
Fitz says: "The pouch-like formation of
intestine occasionally seen projecting from
the lower part of the ileum is universally
known as Meckel's diverticulum. Not that
this distinguished anatomist was its discoverer, for early in the eighteenth century
Ruysch* presented an admirable illustration
of this malformation. Its frequent congenital nature was also recognized before the time
of Meckel, and it seems probable that suggestions relative to its origin from the vitelline duct had been presented previous to
the publication of this investigator.
"We owe to Meckel not only the almost
universal acceptance of his theory of origin
of the pouch in question, but are also indebted to him for calling conspicuous attention to its importance in the causation of serious disease."
In his "Darmanhang," published by Meckel in Leipzig in 1812, will be found a
most careful and detailed description of the literature and of the anatomy of the
diverticulum which now bears his name.
* Thesaurus Anatomicus, 1701.
159
Umb. k:
Fig. 92. — Meckel's Diverticulum. (Schematic.)
The diverticulum may pass off from the convex surface of the bowel at right angles or on a
slant as here. In the latter case, if the slant be
very acute, a valve-like opening may be the result. The mucosa of the small bowel and of the
diverticulum is of exactly the same character.
The omphalomesenteric vessels originate from
the superior mesenteric vessels and pass over or
under the bowel to reach the duct.
160
THE UMBILICUS AND ITS DISEASES.
Among the many contributions to the subject there may be mentioned those of
King (1843), Struthers (1854), Schroeder (1854), Cazin (1862), Fitz (1884), Lowenstein (1894), Richardson (1894), Treves (1897), Blanc (1899), and Kelly and Hurdon (1905).
Fitz says: "There are certain well-recognized variations in the seat, size, and
shape of this appendage to the ileum. Since the diverticulum is present in the
earliest weeks of fetal life, it is obvious that its position with reference to the ileocecal valve must change with the growth of the intestine.
"The diverticulum is usually found in the vicinity of the valve. In the newborn child the distance between the two is about 12 inches, while in the adult the
diverticulum is found sometimes three feet above the ileocecal valve. The limits
within which it may be present are thus differently
stated by various authors. Rokitansky * found its seat
to be one to two feet above the cecum, while Forster f
extends the limit to upward of four feet."
Fitz says that Major J described a diverticulum
which arose from the jejunum. He also refers to a diverticulum, seven inches in length, which was found on
the border between the jejunum and ileum. §
Fitz also says that Fagge|| refers to a diverticulum
which was 54 inches from the cecum and to another
which rose above the middle of the ileum.
Length.- — ■ Fitz says that, although the diverticulum is commonly found to be less than 4 inches long,
Rokitansky assigns to it a maximum length of 10 inches.
One of the best descriptions of Meckel's diverticulum is
to be found in Kelly and Hurdon's "Appendicitis and
Diseases of the Vermiform Appendix" (p. 594).
This diverticulum projects from the convex surface
of the intestine, and may be short or long; sometimes
it is free, at other times attached to the umbilicus by a
fibrous cord. Occasionally it extends in its continuity
to the umbilicus (Fig. 93), and where it is attached to
the intestine the two are often of the same diameter.
The outer portion of the diverticulum may be of the
same caliber and then end in a rounded extremity
similar to the bottom of a test-tube ; or the duct may
gradually taper off toward its extremity.
The walls of the diverticulum are continuous with those of the intestine, and
are .similar to them both macroscopically and microscopically.
The diverticulum may or may not have a mesentery. Where none exists, the
blood supply comes from the intestine. In those cases in which a mesentery is
found, it naturally is on one side, the other being perfectly smooth. The blood
* Rokitansky: Lehrbuch der path. Anat,, 1861, 3. Aufl., 182.
t Forster: Handbuch der path. Anat., 1863, 2. Aufl., 97.
t Major: The Lancet, 1839-40, i, 362.
§ Aerztlichcr Ber. aus dem K. K. Allg. Krankenhause zu Wien, 1862, 221.
|| Fagge: Guy's Hospital Reports, 3. series, 1869, xiv, 359.
Fig. 93. — Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus. (After Beck.)
The picture shows the inner
surface of the anterior abdominal
wall, to which Meckel's diverticulum has become attached, a is
the small bowel; B, the inner surface of the abdominal wall; C, the
umbilicus. In the lower part of
the picture is seen the bladder.
Passing upward from the vertex of this is the urachus. E, E,
are the umbilical arteries seen on
either side. Passing outward from
the small bowel to the umbilicus
is Meckel's diverticulum. G, G,
represent the omphalomesenteric
arteries; H, the omphalomesenteric vein.
MECKEL'S DIVERTICULUM.
161
vessels come from the mesentery of the small bowel, pass over the ileum, and then
spread out in a plexus over the diverticulum. Where the diverticulum is adherent
to the umbilicus, its peritoneum may be continuous with that of the abdominal wall,
and small vessels from the abdominal wall may extend over to the duct (Fig. 91).
If the diverticulum be free and the mesentery short, the former may be drawn
down toward the bowel on one side, so that this appendage presents a curved or
snout-like appearance. Lowenstein says that Riefkohl reported the cases of three
children of one mother, each of whom had a Meckel's diverticulum.
The fibrous cords occasionally found extending from the tip of the diverticulum
to the umbilicus are usually remnants of the omphalomesenteric vessels. These
are referred to at length in Chapter XIV.
H e r n i se of the tip of the diverticulum have been referred to by King, Fitz,
Kelly and Hurdon, and others.
Fig. 94. — An Abnormally Large Meckel's Diverticulum. (After
Richardson.)
The Meckel's diverticulum here is practically as large as the small
bowel. It is attached directly to the umbilicus.
Fig. 95. — A Meckel's Diverticulum with
A LOBULATED EXTREMITY. (After
King.) (Prep. 1818, Guy's Hospital
Museum.)
Meckel's diverticulum has a diameter
nearly as large as the small bowel from
which it arises. The diverticulum ends in
several round hernial projections.
King, in 1843, referred to a very interesting case of this character (Fig. 95).
The tip of the diverticulum was free and ended in seven or eight rounded cystic
dilatations.
Fitz, in the examination of the Meckel's diverticula in the Harvard Medical
School (Improvement Collection, No. 1033), found a chverticulum with two rounded
bulgings at its free end. These were large enough to suggest an incipient bifurcation.
Fitz quotes Hyrtl* as saying that branched diverticula are extremely rare. In
making an autopsy on a hemicephalic monster, Hyrtl found a diverticulum an inch
long. This toward the end was divided into five parts.
Kelly and Hurdonf show a long diverticulum with several small, cyst-like dilatations or hernia? near its tip (Fig. 96).
The opening of the diverticulum into the bowel may be large and oval or round;
* Hyrtl: Handbuch der topographischen Anatomie, 1860, i, 642.
t Kelly and Hurdon: The Vermiform Appendix and its Diseases, Fig. 314, p. 598.
12
162
THE UMBILICUS AND ITS DISEASES.
occasionally it is valve-like. This last condition occurs where the diverticulum
leaves the bowel tangentially.
Cazin, in 1862, referred to a case in which Meckel's diverticulum opened into
the intestine by two orifices, separated by a bridge. The superior one was surrounded by a circular valve.
A Mesenteric Diverticulum.- — ■ Although diverticula usually
spring from the convexity of the bowel, in rare instances they are noted at its mesenteric attachment.
King, in 1843, referred to a specimen in Guy's Hospital Museum (Fig. 97).
The diverticulum was very short. It sprang from the mesenteric border of the
Nonvascular serous fold.
between ileum and
diverticulum
W\tuf. P"fooUf. ft* g 'n .
Fig. 96. — A Meckel's Diverticulum with Hernial Protrusions from its Surface. (After Kelly and Hurdon.)
small bowel, and was adherent to the mesentery. This subject is considered at
length in the chapter dealing with Intestinal Cysts.
An Accessory Pancreas Situated at the Tip of the
Diverticulum. — Bize, in 1904, gave an interesting account of a case in
which an accessory pancreas was found at the tip of a Meckel's diverticulum (Fig.
98). He gives both macroscopic and microscopic pictures of the case, and draws
attention to the fact that cystic tumors may possibly develop from such accessory
pancreases.
Deve, in 1906, records a case in which Meckel's diverticulum was 7 cm. long. At
its extremity was a thickening the size of a small bean. It was an accessory pancreas.
Denuce, in 1908, referred to a case reported by Albrecht. In this case Meckel's
diverticulum had at its extremity a yellowish nodule the size of a pea. This nodule,
on histologic examination, was found to consist of pancreatic tissue.
MECKEL S DIVERTICULUM.
163
It will be interesting to see if, as Bize suggests, pancreatic cysts may possibly
develop in the tip of the diverticulum. If such a condition were probable, one would
naturally expect the literature to contain records of a few such conditions, but I
have not been able to locate a cyst of Meckel's diverticulum that in any way suggested a pancreatic origin.
Meckel's Diverticulum in Animals . — Tillmanns says that the
observations of Cazin have shown that true diverticula, having no connection with the abdominal wall, are regularly present in the waterhen, snipe, and swan.
Fitz quotes Morgagni as saying that he had
observed the diverticulum on more than one
occasion in geese.
Cazin, in his thesis on Intestinal Diverticula,
published in 1862, reported an observation of
Guobaux. Guobaux, on January 15, 1855, made
an autopsy on a sheep. In the lower portion of
the small intestine was a diverticulum 9 cm. in
Fig. 97. — A Short Meckel's Diverticulum Springing from the
Mesenteric Attachment. (After King.) (Prep. 1819",
Guy's Hospital Museum.)
Fig. 98. — An Accessort Pancreas in
the Tip op Meckel's Diverticulum.
(After Bize.)
Meckel's diverticulum (.4) was dilated,
and at its tip was a nodule the size of a small
nut (B) . This nodule on histologic examination was found to consist of pancreatic tissue.
length, and of a caliber equal to that of the small bowel. It had the same structure
as the intestine. On examining this canal he found that a Peyer patch had extended a short distance into the interior of the diverticulum. Guobaux also
referred to diverticula occurring; in birds.
INTESTINAL OBSTRUCTION DUE TO MECKEL'S DIVERTICULUM.
As the reader is thoroughly familiar with obstructions of this character, and as
the literature on this subject is so large, I shall not attempt to cover the subject,
but shall merely give a few examples of some of the manifold ways in which a
Meckel's diverticulum may occasion obstruction.
A Case of Intestinal Obstruction in which Meckel's
Diverticulum was Free. — The following case gives a graphic picture
164
THE UMBILICUS AND ITS DISEASES.
of what a free Meckel's diverticulum may do. The specimen was kindly placed
at my disposal by Dr. Joseph C. Bloodgood: August L., aged forty-two, came under
the care of Dr. H. Jones, of Irvington, Mel., early on the morning of June 9, 1914.
Fig. 99. — Meckel's Diverticulum Completely Tying off a Loop of Small Bowel.
This specimen was removed by Dr. George A. Stewart at St. Agnes' Hospital, Baltimore, June 9, 1914. The
arrows indicate the cut ends of the bowel. The intestinal loop is greatly distended. The pear-shaped cyst is a Meckel's
diverticulum. Its extremity is perfectly free, and on its upper surface its blood-vessels stand out prominently. It
ha- in some manner become tied around the gut. (For the key, see Fig. 100.)
At 1 a. m. he had nausea and vomiting, and shortly afterward abdominal pain.
His bowels had moved once, but later were obstinately constipated. Twelve
hours later he had tenderness all over the abdomen.
Operation (at St. Agnes' Hospital). — Fifteen hours after the symptoms de
MECKEL S DIVERTICULUM.
165
veloped Dr. George A. Stewart opened the abdomen and found a large loop of bowel
much distended and very dark. Its mesentery appeared to be gangrenous. The
bowel was so knotted at one point that no attempt was made to unravel it, and
the entire area was removed. The ends were closed, and a lateral anastomosis
was made. The abdomen was
closed without drainage. The
patient made a good recovery.
Dr. Bloodgood, in his description, says: "The specimen consists of about 18
inches of small gut, dark
brown in color, and of the
hardness of paper. At one
end there is a peculiar knot,
which was the cause of the
volvulus and thrombosis (Fig.
99). From the picture it is
seen that the bowel is markedly distended. The ends of
the resected gut are indicated
by the arrows. The cystic
mass (M) is the greatly dilated Meckel's diverticulum.
It is perfectly smooth, and on
its upper surface are its mesenteric vessels. ' ' From the picture it is very difficult to say
just how the obstruction occurred. Fig. 100, made by
Max Brodel, gives the key to
the situation. A loop of
bowel had become twisted,
Meckel's diverticulum had
dropped over this, encircling
it completely, and the tip had
then passed through the space between its own base and the small bowel,
result of the obstruction all the affected parts soon swelled up.
Early operation afforded the only hope of saving such a patient.
Fig. 100. — A Diverticulum Tyixg off a Loop of Small Bowel.
This indicates the manner in which the obstruction occurred (ef.
Fig. 99) . Meckel's diverticulum has dropped over a loop of bowel which
has been partly twisted. After passing under the loop it curves upward
and passes through the space between the base of the diverticulum and
the adjacent small bowel. With the consequent distention of the constricted bowel, complete obstruction has resulted.
As a
CASES OF INTESTINAL OBSTRUCTION CAUSED BY A MECKEL'S DIVERTICULUM
ADHERENT TO THE UMBILICUS.
Intestinal obstruction is more likely to occur when the diverticulum extends to
and is fixed to the umbilicus, or when it is attached to the umbilicus by a fibrous cord.
Strangulation of Meckel's Diverticulum Caused by
Volvulus of the Ileum.* — Elliot's patient was a man, aged thirty,
* Elliot, J. W.: Trans. Amer. Surg. Assoc, 1894, xii, 217.
166
THE UMBILICUS AND ITS DISEASES.
who was admitted to the Massachusetts General Hospital. He had been sick for
four days. He gave a history of vomiting, chills, and abdominal pain. On
admission his temperature was 103.6° F. ; pulse, 160.
The abdomen was distended and exceedingly tender,
especially to the right of and below the umbilicus ; there
was free fluid in the abdominal cavity.
Operation. — When the abdomen was opened, there
was an escape of turbid fluid. The appendix was normal.
The mass encountered looked like a large, dilated, and
gangrenous knuckle of intestine, but without a mesentery. It sprang from the lower part of the convex surface of the ileum and was tightly twisted at its point of
attachment to the bowel. (See Fig. 101.) It extended
upward into a dense mass of adhesions, and was found
to be attached to the under surface of the umbilicus.
It was a strangulated and gangrenous Meckel's diverticulum, 7 inches long, and about the same size as the
ileum. During dissection it ruptured. The ileum at
this point was found to be twisted on itself and held in
position by adhesions. The gut was not wholly obstructed by the twist. The diverticulum, having its
outer end fixed at the umbilicus, was twisted and
strangulated at its base by the turning over of this coil
of ileum. The gangrene of the diverticulum was most
intense near the ileum, the end at the umbilicus being
only moderately inflamed. The patient died on the
second day.
Fatal Intestinal Obstruction Due
to Remains of the Omphalomesenteric Duct.* — Mrs. M. C, aged twenty-four,
admitted to St. Francis' Hospital, Pittsburgh, June 6,
1906. The patient had always been healthy until the
onset of the present illness. Three days previous to
admission she was seized with sudden severe pain
in the abdomen. This was followed by vomiting.
There was a slight elevation of temperature; the pulse
was rapid.
The diagnosis of intestinal obstruction was made,
and immediate operation advised. When the abdomen
was opened, a gangrenous loop of ileum was found.
This was twisted twice about a narrow band which was
attached at one end to the umbilical site; at the other
end, to the convex surface of the ileum, about six inches
from the cecum. A resection of the bowel was made,
but the patient died three days later of peritonitis.
Examination of the section of the band which was removed showed clearly that
it was the obliterated remnant of the vitelline duct.
* Muggins, R. R. : Personal communication.
Fig. 101. — Strangulation op
Meckel's Diverticulum
Causing Volvulus op the
Ileum. (Redrawn after
Elliot.)
The specimen was from a
man aged thirty who had signs
of intestinal obstruction. The
abdomen contained turbid fluid.
In the incision a mass presented
which looked like a large, dilated
gangrenous loop of intestine, but
had no mesentery. It sprang
from the lower part of the convex surface of the ileum, and was
slightly twisted at its point of
attachment to the bowel. It
extended upward into a dense
mass of adhesions, and was
found to be attached to the under surface of the umbilicus. It
was a strangulated and gangrenous Meckel's diverticulum. It
was about seven inches long, and
had about the same diameter as
the ileum. The small bowel at
thia point was twisted on itself
and held in position by adhesions. The gut was partially
obstructed at the twist. The
patient died on the second day
after operation.
Meckel's diverticulum. 167
Ileus Caused by Persistence of the Omphalomesenteric Duct.* — The patient, a man nearly twenty years of age, had always
been strong and hearty. He was suddenly seized with vomiting and pain in the
umbilical region. The vomiting was frequent, and two days later assumed a fecal
character. The abdomen, particularly in the lower half, was much distended.
Operation. — When the abdomen was opened, a part of the bowel was found
distended; the rest was contracted. One loop of bowel was green and gangrenous.
The gangrene had been caused by a half-turn made by a cord the size of the little
finger passing from the umbilicus. This cord was inserted in the gangrenous loop.
It was an omphalomesenteric duct. The gangrenous loop of small bowel was 1.1
meters long, and reached to within 7 cm. of the ileocecal valve. A resection was
made but the patient died almost immediately.
Fatal Intestinal Obstruction in Consequence of a
Twist in the Mesentery and the Falling of Some Folds
of Intestine over a True Diverticulum. f — The patient, a
strong, robust boy, was seized with a violent pain in the abdomen after drinking a
cup of hot coffee. He had no movement of the bowels for six days. General
peritonitis developed, and he died on the ninth day.
Autopsy. — On section, general peritonitis was found. The mesentery of some
loops of the small bowel was twisted on itself. The intestines were deeply injected
and quite black. Loops of intestine had fallen over a diverticulum, which extended
from the small gut to the linea alba, about one inch below the umbilicus. The
diverticulum was 5 inches long and 34 inches distant from the cecum.
Strangulation of Intestine by Diverticulum Ilei.| —
Eliza W., aged ten, was admitted with symptoms of strangulated bowel. Peritonitis developed, and she died in a few hours. The symptoms had begun ten days
before death, with an attack of sickness attributed to the eating of some indigestible
fruit.
Autopsy. — On section, an acute peritonitis was found. When the abdominal
wall was lifted up, a band was seen passing from the umbilicus to the lower part of
the ileum, to which it was attached. The portion of the gut above was much distended; the part below was contracted. The constricting band was found to be a
diverticulum of the ileum which had become obliterated at the umbilicus. At its
origin it was of the same caliber as the contracted portion of the ileum below it.
"The only practical consideration arising from such a case is to remember that,
in an exploratory operation in a case of obstruction, a cord passing to the umbilicus
is very likely to be a diverticulum of intestine."
Wilks says that, in the Guy's Hospital Museum, there are four specimens of
this malformation causing obstruction of the intestine. In one case the patient
had reached forty-three years of age. In another, a child, the patient had previously undergone a successful plastic operation for a fecal discharge from the umbilicus.
* Jordan, Max: Ueber Ileus verursacht clurch den persistirenden Ductus omphalo-mesaraicus. Berlin, klin. Wochenschr., 1896, xxxiii, 25.
t Ward, Nathaniel: Trans. Path. Soc. London, 1856, vii, 205.
% Wilks, Samuel: Trans. Path. Soc. London, 1865, xvi, 126.
168 THE UMBILICUS AND ITS DISEASES.
INTESTINAL OBSTRUCTION DUE TO THE TIP OF MECKEL'S DIVERTICULUM
BECOMING ADHERENT TO A DISTANT POINT.
The following case reported by Sheen is a very good example of this group of
cases :
Fatal Intestinal Obstruction Due to Meckel's Diverticulum.* — Case 2 . — A. L. W., male, aged forty-one. Admitted
to the Cardiff Infirmary, November 7, 1899.
" History. — Loss of flesh for one year. Present illness began with an attack of
abdominal pain after supper nine days ago. Since then absolute constipation and
constant vomiting, which has been fecal for the last six days. Has had two enemata
without effect. Abdominal pain and latterly hiccough have been constant.
"Present Condition. — The man looks very ill, with cold extremities; pulse, 72,
feeble; temperature, 97° F. Has vomited a little brown fluid matter, smelling
fecal. Abdomen moderately distended, flanks and hypochondriac region somewhat
flattened; some dulness above pubes; remainder resonant, peculiar hollow, highpitched note over position of sigmoid flexure ; no visible peristalsis ; splashing sounds
on manipulation; rectal examination negative; pain referred to umbilicus.
' ' The patient was given ether immediately, and the abdomen opened in the left
iliac region. The colon was found empty; some distended coils of small intestine
presented themselves, and the hand could feel something like a band on the right
side, and apparently near the pelvic brim. The closure of the wound was commenced with a view to opening in the middle line, when, somewhat suddenly, the
patient, whose condition was extremely serious throughout, collapsed and died.
The trachea was opened, and various measures resorted to to restore animation,
but without effect.
"Postmortem (Twelve Hours After Death). — Abdomen only opened through a
crucial incision. No peritonitis. Small intestine distended and injected. Without disturbance, the seat of obstruction was at once seen in the form of a diverticulum of the bowel passing downward and outward from the median line, at a point
about opposite to the third lumbar vertebra, toward the pelvic brim. On examination the diverticulum, which was devoid of a mesentery, was found to be about four
inches long, bulbous at its commencement, then narrowing suddenly, but patent to
its extremity. It sprang from the posterior aspect of the ileum, about two feet
above the ileocecal valve, curved forward and inward round the bowel from which
it came, and passed downward and inward, to be attached by its apex to the small
intestine again, about five inches from the ileocecal valve. The obstruction of the
ileum took place at the point of attachment of the apex of the diverticulum, which
attachment was made by a few short, firm adhesions. The bowel was very near
perforation at this point. The gut was also pressed upon somewhat at two points
above the actual seat of obstruction: (1) Where the diverticulum wrapped itself
around the ileum at its point of origin; (2) where a loop of bowel passed under the
diverticulum. It was evident that the more distended the bowel became, the more
would the diverticulum pull upon and kink its point of attachment."
Sheen, William: Some Surgical Aspects of Meckel's Diverticulum. Bristol Medico-Chir.
Jour., 1901. xix, :ni).
Meckel's diverticulum. 169
OBSTRUCTION DUE TO THE PASSAGE OF INTESTINE THROUGH A HOLE IN THE
MESENTERY OF MECKEL'S DIVERTICULUM.
I have not found the record of a similar case in the literature. The mesentery
of the diverticulum, as a rule, is very slender and narrow, and even if a hole existed,
the bowel would tend to pass not through but over it.
Umbilical Polyp; Intestinal Obstruction Due to
Hernia through the Mesentery of Meckel's Diverticulum. Death.* — "E. T. L., male, aged one year, nine months, admitted
to the Cardiff Infirmary April 22, 1897.
"History. — Swelling at the navel since birth. The confinement was not attended by a doctor. The swelling has always been the same size. About a halfpint of glairy fluid comes from it in twenty-four hours, staining and stiffening
the linen. The general health has always been good.
" Present Condition. — A healthy, well-nourished child. Attached to the center
of the navel is a bright-red, bluntly lobulated, pedunculated tumor the size of a
grape, with skin reaching only to its margin. The surface resembles intestinal
mucous membrane and exudes a viscid fluid of alkaline reaction. In the center is a
channel one inch deep. Through the parietes a cord the thickness of a cedar
pencil can be felt passing backward for about 13^2 inches. Urination and defecation are normal.
"After admission the fluid was collected as far as possible in a small glass vase
strapped to the child's abdomen. The total amount in twenty-four hours was 10
to 15 c.c. ; on two occasions, 22 c.c. ; sometimes there were only 5 c.c, but then some
was lost. It was a colorless, viscid fluid, and could be poured from vessel to vessel
like a thin jelly; it was alkaline in reaction and contained a little albumin. It had
no digestive action on fibrin or starch. So far as our examination went, therefore,
it resembled succus entericus. On July 31st the tumor was removed with scissors
and the base cauterized, the procedure being quite a slight one. The child vomited
continuously after the anesthetic. On August 3d a simple enema was given, and
the bowels moved twice; on the following days the child was fretful and became
thinner; the milk was peptonized, but the vomiting continued, the vomitus consisting of undigested milk; the abdomen was distended and tender. The child
grew worse. On August 7th a blood-streaked motion is stated to have been passed
after an enema, but it was not saved by the nurse. Nutrient enemata were given
toward the end, but the child died at 5 p. m. on August 7th, one week after operation.
The cause of death was thought to be peritonitis.
"August 8th, Postmortem. — No peritonitis. Death was found to be due to
intestinal strangulation. The parts involved were removed for separate examination. In the specimen removed were the lower part of the small intestine, cecum,
appendix, and a small piece of ascending colon. Connected with the small intestine
was a Meckel's diverticulum, patent to within an inch of the umbilicus, to which
it was attached by a solid cord (Fig. 102). The skin around the umbilicus was
removed by an elliptic incision.
" On dissection the following points were made out : (1) The bowel is strangulated
by being herniated through a hole (A) in the mesentery of the diverticulum ilei.
(2) The constricted bowel is 25 inches in length. (3 J Practically all the bowel
* Sheen, W.: Op. cit.
170
THE UMBILICUS AND ITS DISEASES.
between the origin of the diverticulum and the ileocecal valve is strangulated. (4)
The strength of the constricting cord of mesentery is largely due to a vessel traversing it. (5) The bowel is twisted within the ring and near perforation at its proximal
end. (6) The diverticulum is bulbous in shape, and its lumen is much narrowed
where it joins the intestine.
" Fig. [102] shows the condition, the strangulated loop represented as being
turned out of the constricting ring (A). The polypus is shown. The position of
the appendix was interesting. It lay against
the diverticulum, with its apex pointing toward the liver.
" Microscopic examination of the polypus
showed a connective-tissue basis, with a
layer of intestinal glands — exactly like Lieberkiihn's follicles. In places the intestinal
glands were proliferating, so as to produce
a mass resembling an ordinary intestinal
adenoma.
"Clinically disappointing, this case is of
great interest pathologically. The writer
has been able to find no other record of a
case of strangulation through the mesentery
of a Meckel's diverticulum."
Fig. 102. — Fatal Intestinal Obstruction Due
to the Passage of the Bowel through a
Hole in the Mesentery of a Meckel's
Diverticulum. (After Sheen.)
Attached to the umbilical depression was a
bright red, bluntly lobulated, pedunculated tumor
the size of a grape. Its surface was covered with
mucosa. In the center was a channel one inch
deep, and through the abdominal walls a cord the
size of a lead-pencil could be felt extending backward into the abdomen. The child developed intestinal obstruction and died. At autopsy 25
inches of small bowel were found to have passed
through the hole (A) in the mesentery of Meckel's diverticulum. Practically all the bowel between the diverticulum and the ileocecal valve
had become strangulated. The strength of the
constricting cord of mesentery was due largely
to a vessel traversing it. Meckel's diverticulum
was bulbous in shape and much narrowed where
it joined the small bowel.
INVERSION OF MECKEL'S DIVERTICULUM
INTO THE BOWEL.
The following case, recorded by Ktittner,
is a very rare one. The diverticulum had
turned inside out, just as when one inverts
the finger of a glove. It projected into the
bowel and had caused obstruction and subsequent intestinal perforation.
Ileus Due to Intussusception of Meckel's Diverticulum.* — This case was observed by
Bruns. A woman, forty-nine years of age,
had always been well up to eight weeks previously, when she suddenly showed signs of intestinal obstruction. There was fecal
vomiting for five days. The patient then improved, but did not get perfectly well.
Three days before her admission the symptoms returned and rapidly grew worse.
At operation the peritoneum was found to be markedly injected. The intestines
were covered with fibrin and were lightly adherent, and in the pelvis was a thin,
odorless fluid. Part of the small intestine was dilated, and the rest collapsed. No
obstruction could be found, and there was no evidence of perforation. The fluid was
wiped out, and an anastomosis made between the dilated and collapsed bowel. A
drain was left in the lower angle of the wound. The patient died three days later.
* Kuttner, H.: Ileus dureh Intussusception eines MeckeFschen Divertikels. Beitrage zur
klin. Chir., 1898, xxi, 289.
MECKEL S DIVERTICULUM.
171
Autopsy. — The peritonitis had progressed. About 90 cm. from the beginning
of the jejunum was an area of thickening 4 cm. long. Here there was a polyp-like
structure 7 cm. long, having at its base a breadth of a thumb. It was a Meckel's
diverticulum that had turned inside out and projected into the bowel (Fig. 103).
The intestinal lumen at this point was somewhat narrowed. The portion of the
bowel at the point of the insertion of the diverticulum had also become drawn into
the lumen. Near the base of the diverticulum was a gangrenous spot and a small
perforation.
Kiittner then gives the report of seven other cas.es which he had collected
from the literature. These were those of Maroni, Ewald, St. Bartholomew's
Hospital, Adams, and three recorded by
Heller.
TREATMENT OF OBSTRUCTION DUE TO
MECKEL'S DIVERTICULUM.
Fitz, who devoted to this subject a most
thorough and exhaustive study in 1884,
arrives at the following conclusions:
"1. Bands and cords as a cause of acute
intestinal obstruction are second in importance to intussusception alone.
"2. Their seat, structure, and relation
are such as frequently to admit their origin
from obliterated or patent omphalomesenteric vessels, either alone or in connection
with Meckel's diverticulum, and oppose
their origin from peritonitis.
"3. Recorded cases of intestinal strangulation from Meckel's diverticulum, in
most instances, at least, belong in the above series.
"4. In the region where these congenital causes are most frequently met with, an
occasional* cause of intestinal strangulation, viz., the vermiform appendage, is also
found.
" 5. It would seem, therefore, that, in the operation of abdominal section for the
relief of acute intestinal obstruction not due to intussusception, and in the absence
of local symptoms calling for the preferable exploration of other parts of the
abdominal cavity, the lower right quadrant should be selected as the seat of the
incision. The vicinity of the navel and the lower three feet of the ileum should then
receive the earliest attention. If a band is discovered, it is most likely to be a persistent vitelline duct, Meckel's diverticulum, or an omphalomesenteric vessel, either
patent or obliterated, or both these structures in continuity. The section of the
band may thus necessitate opening the intestinal canal or a blood-vessel of large size.
Each of these alternatives is to be guarded against, and the removal of the entire
band is to be sought for, lest subsequent adherence prove a fresh source of strangulation."
"The chief practical conclusion thus reached in this article is essentially the same
Fig. 103. — Inversion of Meckel's Diverticulum
into the Lumen of the Bowel. (Redrawn
after Kiittner.)
The patient was a woman aged forty-nine. In
this case Meckel's diverticulum was virtually turned
inside out, and is seen lying in the bowel. The condition produced obstruction and death.
* If Reginald Fitz were living today and rewriting this paragraph he would, remembering his
epoch -making studies on appendicitis, replace "occasional" by the word "frequent."
172 THE UMBILICUS AND ITS DISEASES.
as that of Nelaton.* This surgeon advised that the incision through the abdominal
wall for the relief of intestinal obstruction should be made a little above Poupart's
ligament, preferably in the right side. The knuckle of intestine first presenting
was to be united to the edges of the wound and incised, an intestinal fistula being
thus established. His recommendation was based upon the applicability of this
operation — enterotomy — to all cases of intestinal obstruction, since it is usually
impossible to make a differential diagnosis of the cause of ileus. The place was
selected because a loop of small intestine above the seat of obstruction is likely to
be found in this part of the abdomen, and it is also likely to be so far from the
stomach that a sufficiency of intestine for digestive purposes will be left intact.
' • The due appreciation of the relative f requency of congenital causes of intestinal
obstruction acting in the region recommended by Nelaton as the place of operation
adds force to his arguments. The operation of enterotomy in the best favored
position is still available, provided the above causes of obstruction are not found."
These suggestions, made by Nelaton in 1857, and by Fitz in 1884, are in thorough
accord with the surgical views of to-day. Thirty years have elasped since Fitz
wrote his article. To-day the cases are, fortunately, often recognized early.
The surgeon will make a right rectus incision, which can be extended upward or
downward and the obstruction relieved or the cause removed, as the case may be.
In addition to this, due consideration must be given to the question whether the
partly paralyzed bowel can expel its contents even after the obstruction has been
removed. If there is any doubt on this point, it is the duty of the surgeon to bring
up a loop of bowel above the point where obstruction has existed, attach it to the
abdominal wall, and open it a few hours later.
In the late cases, when the patient is too weak for any prolonged operation looking to the relief of the obstruction, a loop of the distended bowel should be brought
up into the incision and an enterostomy made with the hope that in a few days the
patient will be strong enough to withstand the more radical procedure.
* Xelaton: I/Union medicale, 1857, xi, Xos. 89, 91, 93.
LITERATURE CONSULTED ON MECKEL'S DIVERTICULUM.
Beck, B.: Ueber das angeborne Divertikel des Rrummdarms. Illustr. Med. Zeitung, Munchen,
1852, ii, 294.
Bize: Etude anatomo-clinique des pancreas accessoires situes a l'extremite d'un diverticule intestinal. Revue d'orthopedie, 1904, xv, 149.
Blanc, H. : Contribution a la pathologie du diverticule de Meckel. These de Paris, 1899, No. 393.
Cazin, Henry: Etude anatomique et pathologique sur les diverticules de l'intestin. These de
Paris, 1862, No. 138.
Denuce: Fistules pseudo-pyloriques congenitales de l'ombilic. Revue d'orthopedie, 190S, xix, 1.
Deve, F.: Des teratomes "enteroides." A l'occasion d'un cas de "tumeur entero'ide pancrcati
forme." La Normandie med., 1906, xxi, 169.
Elliot, J. W.: Strangulation of Meckel'-S Diverticulum Caused by Volvulus of the Ileum. Trans.
Amer. Surg. Assoc, 1894, xii, 217.
Fitz, R. H.: Persistenl Omphalomesenteric Remains: their Importance in the Causation of In
tesl inal Duplication, Cyst-formation, and Obstruction. Amer. Jour. Med. Sci., 1884, lxxxviii,
30.
Huggins, R. R.: Personal communication.
Jordan, Max: Ueber Ileus verursacht durch den persistirenden Ductus ornphalo-mesaraicus.
B'-rlin. klin. Wochenschr., 1896, xxxiii. 25.
Kelly and Hurdon: The Vermiform Appendix and its Diseases. W. B. Saunders Co., 1905.
Meckel's diverticulum. 173
Kern, T. : Leber die Divertikel des Darmkanals. Inaug. Diss., Tubingen, 1874.
King, T. W.: A Feculent Discharge at the Umbilicus from Communication with the Diverticulum Ilei. Guy's Hospital Reports, 1843, i, 2. series, 467.
Ki'ittner, H.: Ileus durch Intussusception eines Meckel'schen Divertikels. Beitrage zur khn.
Chir., 189S, xxi, 289.
Lowenstein: Der Darmprolaps bei Persistenz des Ductus omphalo-mesentericus, mit Mittheilung
eines operativ geheilten Falles. Langenbeck's Arch. f. khn. Chir., 1894-95, xlix, 541.
Meckel, Johann Friedrich: Handbuch der pathologischen Anatomie, 1812, i, 553.
Richardson, W. G.: A Case of Abnormally Large Meckel's Diverticulum found Postmortem.
Quart, Med. Jour., 1894-95, iii, 267.
Schroeder, G. : Ueber die Divert ikel-Bildungen am Darm-Kanale. Inaug. Diss., Augsburg, 1854.
Sheen, W.: Some Surgical Aspects of Meckel's Diverticulum. Bristol Medico-Chir. Jour., 1901,
jrix, 310.
Struthers, John: Anatomical and Physiological Observations, Edinburgh, Part I, 1854, 137.
Tillmanns, H. : Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia
Ventriculi) und iiber sonstige Geschwulste und Fisteln des Nabels. Deutsche Zeitschr. f.
Chir., 1882-83, xviii, 161.
Treves, Frederick: Allbutt's System of Medicine, 1897, iii, 802.
Ward, X.: Fatal Intestinal Obstruction in Consequence of a Twist in the Mesentery and the
Falling of Some Folds of Intestine over a true Diverticulum. Trans. Path. Soc. London,
1856, vii, 205.
Wilks, Samuel: Strangulation of Intestine by Diverticulum Ilei. Trans. Path. Soc. London,
1865, xvi, 126.
==Chapter IX. Intestinal Cysts==
Classification.
Intestinal cysts developing from the omphalomesenteric duct or Meckel's diverticulum.
1. Intestinal cysts lying relatively free in the abdomen.
2. Intestinal cysts lying between the layers of the mesentery.
3. A cyst of the central portion of the omphalomesenteric duct.
Symptoms of intestinal cysts.
Treatment.
Interesting cases of intestinal cysts were recorded by Cazin in 1862, and by
Hennig in 1880, but it is to the splendid article of Roth, published in 1881, that we
are indebted for the first clear and exhaustive presentation of the subject.
Fitz, in his monograph in 1884, dealt with intestinal cysts at length.
Runkel reported an interesting series of cases in 1897, and his admirable article
should be read by all who desire to acquire a full knowledge of the subject. In
addition to his own cases he reported the observations of Roth, Tscherning, Dittrich, Nasse, Buchwald, Kulenkampff, Huter, Rimbach, and Lohlein.
In 1906 Colmers published an article upon intestinal cysts and their treatment.
He says that Raesfeld was the first to describe an enterocystoma, and that he drew
attention to the fact that it developed from what we now call Meckel's diverticulum.
Roth says that these sacs are filled with fluid, and that the structure of their
walls resembles more or less that of the intestinal canal. He divides intestinal
cysts into two groups:
Group I . ■ — ■ Those in which the originally normally formed intestinal
tract is divided into several isolated cystic sacs. The division of the intestine occurs
usually as a result of a peritonitis, and according to Rokitansky, occasionally as a
result of a twisting of the mesentery. In such cases the nipping-off of the bowel into
isolated segments naturally severs its continuity and soon causes the death of the
child.
Group II. — To the second group belong the intestinal cysts which originate from an abnormal development of the intestinal tract. The cysts are present,
but we also have a permeable intestinal canal; consequently from this standpoint
the life of the child is not in danger.
Roth subdivides Group II into three varieties:
A. Superfluous and cystically dilated portions of the intestine belonging to
rudimentary twin pregnancies, as in Case E of Scharer-Klebs, in Klebs' Handbuch
der spec. path. Anat,, i, 1013.
B. Intestinal cysts occurring in combination with abnormal deposits, and
occasionally with growing organs and portions thereof. In this group he included a
case of Sanger and Klopp. In this connection it may be of interest to refer to a case
observed by Simmons and reported by Cazin in 1862. The patient was a wellformed female child, two years old. At autopsy a tumor was found situated at the
base of the vertebral column. It consisted of fat, bones, etc., and also contained a
174
INTESTINAL CYSTS.
175
large quantity of intestine, part of which belonged to the ileum and part to the colon,
the appendix being attached to the latter.
[Several years ago, while opening a dermoid cyst the size of a child's head at the
Johns Hopkins Hospital, I found that it contained a relatively large cavity partly
filled with fluid. This cavity also contained a perfectly formed loop of small bowel
(Fig. 104). The tumor was opened immediately after its removal and while still
.
Fig. 104. — -A Well-developed Loop of Small Bowel ix a Dermoid Cyst of the Ovary.
Gyn. No. 14118. Path. No. 11728. The patient was a white woman, twenty-eight years old, who had a cyst of
the left ovary about 16 cm. in diameter. When the cyst was opened, a large cavity, partly filled with sebaceous-like
material and hair, was found, and at one side was a well-developed loop of small bowel. This had a well-defined mesentery, and on being handled the bowel contracted, showing a definite peristalsis. August Horn at once made a sketch
of this rare condition. The specimen has disappeared, and Mr. Brodel has made the drawing from Horn's original
sketch.
warm. It was easy to follow the wave of contraction in the bowel, just as in the
normal intestine.]
C. A simple intestinal cyst developing from the adherent normal lateral
appendages of the intestine, most frequently from Meckel's diverticulum.
A full discussion of the entire subject of intestinal cysts does not come within
the province of this book. We must, however, carefully consider Class C, in Roth's
Group II, to which belong intestinal cysts probably arising from remnants of the
omphalomesenteric duct or from Meckel's diverticulum.
176
THE UMBILICUS AND ITS DISEASES.
Fig. 105. — An Intestinal Cyst. (Schematic.)
Most of the intestinal cysts found have
been due to partial or complete torsion of
Meckel's diverticulum, which had taken
place so gradually that no gangrene occurred. In rare instances both the outer and
inner ends of the omphalomesenteric duct
become obliterated, while the central portion remains patent. The accumulation of
the secretion from the mucosa in time produces an intestinal cyst. The above is a
schematic representation of a small intestinal cyst of this nature.
INTESTINAL CYSTS DEVELOPING FROM THE OMPHALOMESENTERIC DUCT OR
MECKEL'S DIVERTICULUM.
From a survey of the recorded cases it is perfectly clear that these cysts may be
divided into two groups:
1. Intestinal cysts lying relatively free in the abdomen.
2. Intestinal cysts lying between the layers
of the mesentery.
INTESTINAL CYSTS LYING RELATIVELY FREE IN
THE ABDOMEN.
Tiedemann, Carwardine, Hendee, Rimbach,
Roth, and Fitz have reported cases of this character. In Tiedemann's case, published in 1813,
a pear-shaped cyst, 14.5 x 7 Linien* was attached
to the convex surface of the bowel by a pedicle
3.5 Linien long. The cyst communicated with
the bowel through the pedicle.
In Carwardine's case the tumor occupied the
right upper abdomen and was twisted. Its pedicle was attached to the small bowel. The cyst
was densely adherent.
In Hendee 's case the tumor consisted of two
portions. One portion lay in an inguinal hernia.
The tumor was attached to the convex surface of
the small bowel.
In Rimbach's case the tumor was the size of
a man's head, wrapped up in omentum, and attached to the small bowel by a solid co*rd.
In Roth's case the tumor measured 6.2 x 5.3 x
3.6 cm. ; it was cystic and enveloped in omentum.
It sprang from the mesenteric attachment of the
bowel by a twisted pedicle. The pedicle had a
lumen which was patent.
It is evident that in these cases the cystic
tumor had originated from a Meckel's diverticulum (Fig. 105).
The tumor tends to become adherent to the
omentum and to the neighboring structures
(Fig. 106). The inner surface of the cyst is lined
with intestinal mucosa, which may be somewhat
inflamed.
The character of the cyst contents will depend on whether or not there is a connection
with the intestinal cavity. In those cases in
which the cyst has been cut off before meconium
has had a chance to get into it, the contents will be glairy mucus mixed with ex
foliated epithelium and sometimes with a little pus and blood.
* A Linie varied from one-twelfth to one-tenth of an inch.
Adh
Fig. 106. — An Intestinal Ctst Attached
to the Umbilicus by a Pedicle but
not Connected with the Bowel.
(Schematic.)
On comparing the cyst with the bowel,
it is found to be several centimeters in diameter. It is attached to the umbilicus by a
well-developed and twisted pedicle. The
omentum is plastered over its surface, and
below it is adherent to the appendix and
cecum. The small bowel has a tag projecting from it, possibly at the point where the
omphalomesenteric duct formerly existed.
The picture is a schematic representation
of a condition very rarely noted.
INTESTINAL CYSTS.
177
Adh.
CoLo i
An Intestinal Cyst Developing from a Meckel's Diverticulum. — Tiedemann,* quoted by Roth,f in examining a male fetus
at term with a double-sided harelip and an accessory little finger on each hand,
observed an umbilical hernia the size of a large walnut. In this lay a portion of
intestine. It showed a pear-shaped, bladder-like formation, 14.5 LinienX long and
7 Linien in its transverse diameter. It had a pedicle 3.5 Linien long, and lay attached
to the convex surface of the intestine by a narrow canal which admitted a probe.
The bladder-like projection contained whitish-yellow fluid, and had originated
through a canal communicating with the cavity of the intestine.
Volvulus of Meckel's Diverticulum. § — The patient was
a child, two days old, who
had intestinal obstruction and
greenish vomiting. There was
no fecal matter passing by
the bowel and no discharge
from the umbilicus. The abdomen was much distended.
Rectal examination was negative. The child was watched
for six hours, but nothingpassed by the bowel.
When the abdomen was
opened, the small intestine
was found to be very much
distended and covered with
lymph. The colon was not
larger than a crow's quill,
whitish-yellow in color, and
non-sacculated. A mass could
be felt to the right of the umbilicus. Here the gut was
much distended, and there
were so many adhesions that
the bowel could not be brought
out. The source of the obstruction could not be determined, but at autopsy was found to be due to an
anomaly of Meckel's diverticulum.
An artificial anus was made, and several ounces of meconium escaped. The
cecum and ascending colon were found to be hard and small. The child died twentyfour hours later. The cyst was made up of a greatly distended Meckel's diverticulum with three twists (Fig. 107). Only a fine, impervious cord connected it with
the bowel. Carwardine noted the following as the points of interest in this case: (1)
An acute commencement of peritonitis before birth; (2) the occurrence of a volvulus
of Meckel's diverticulum in utero during late fetal life, so that a meconium-contain
* Tiedemann: Kopflose Missgeburten, 1813, S. 66, Taf. i.
t Roth: Virchows Arch., 1881, Ixxxvi, 371.
t A Linie varied from one-twelfth to one-tenth of an inch.
§ Carwardine, T.: Brit. Med. Jour., 1897, ii, 1637.
13
Cateroslom
Op
Fig. 107. — Volvulus of Meckel's Diverticulum. (Redrawn after
Carwardine.)
The child was two days old and had passed nothing by the bowel.
There was no discharge from the umbilicus. The abdomen was markedly distended. At operation a large sac was detected and opened,
but the child died twenty-four hours later. The cyst was a greatly
distended Meckel's diverticulum. This had twisted three times, and
an impervious cord connected it with the bowel. The lower end of
the small bowel was empty and tortuous. The colon was small and
sacculated. No meconium had ever reached the rectum.
178
THE UMBILICUS AND ITS DISEASES.
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ing cyst was segmented off from the ileum, and consequently the obstruction was not
relieved by an opening into the distended diverticulum; (3) the lower 12 inches of
small bowel were empty and tortuous. The colon was small and non-sacculated. No
meconium had ever passed into them; yet the cecum and appendix were well formed.
A Solid Tumor* Probably Developing from Remnants of the Omphalomesenteric Duct.f — In an inguinal
hernia there was a small
cylindric tumor. This communicated with a second
mass, which lay in a chronically inflamed omentum and
was connected by a cord the
size of a penholder. The median portion of the last-named
tumor was attached to the
small intestine on its convex
side, 32 cm. above the ileocecal valve. This could be
traced to the submucosa of
the bowel. Both tumors and
the cord were completely
solid, and consisted of connective tissue with numerous
deposits of chalk. Colmers
said that Hendee's case affords a good example of the
difficulty of making an anatomic diagnosis of the remains
of the omphalomesenteric
duct.
An Intestinal
Cyst Due to Dilatation of Meckel's
Diverticulum. — In
Rimbach'sJ case there was
a cyst the size of a man's
head. This was wrapped
up in omentum and attached to the small bowel by
a short, completely solid pedicle. The cyst was not lined with mucosa, but in its
walls were two definite layers of muscle.
An Intestinal Cyst Developing from a Diverticulum
of the Ileum and Continuing with the Bowel; Beginning
Peritonitis Due to Torsion of the Pedicle. § — A boy,
* This tumor, although solid, was at first probably cystic, and is accordingly included here.
t Hendee, cited by Colmers: Arch. f. klin. Chir., 1906, lxxix, 132.
% Rimbach, quoted by Colmers: Loc. cit.
§ Roth, M.: Qeber Missbildungen im Bereich des Ductus omphalomesentericus. Virchows
Arch., 1881, lxxxvi, 371.
Fig. 108. — An Intestinal Cyst Developing from Meckel's Diverticulum. (After Roth.)
The cyst in front and above has omentum adherent to it. From
the ileum a sound has been carried into the hollow pedicle; the latter
is crossed by a small mesentery.
INTESTINAL CYSTS. 179
sixteen months old, up to a month and a half before admission, had always
been healthy. His stools became irregular, constipation and diarrhea alternating.
About three weeks before admission the child had to remain in bed for two weeks,
and for three days had marked vomiting. He died with definite signs of intestinal
obstruction. At autopsy the abdomen was found distended above the umbilicus,
where the intestinal loops were prominent. Below the umbilicus, in front of the
mesentery, was a transverse, oval, reddish, moderately distended tumor (Fig. 108).
This tumor was 6.2 cm. in its transverse diameter, 5.3 cm. in its vertical, and 3.6
cm. in its anteroposterior diameter. It was for the most part smooth, but above
and to the left it was firmly adherent. Above the anterior surface and to the right
were delicate adhesions to the greater omentum. In the omentum large vessels
were seen. On the under and right margin of the tumor was a pedicle 11 mm. long.
This passed to the concave surface of the ileum, close to the insertion of the mesentery. The cyst was situated 66 cm. above the ileocecal valve. The pedicle consisted of two portions, one of which was conic in shape and measured 11 mm. in
breadth at the ileum, whereas at the tumor it was only 4 mm. broad. Along the
base the intestine had become twisted from right to left. The second portion of the
pedicle, which was connected with the first, passed upward and to the left and
extended to the base of the tumor. The pedicle ended in the mesentery, and was
covered with peritoneum. It consisted of fatty tissue and of several vessels which
passed to the wall of the tumor; in other words, this was the mesentery of the
tumor. When the tumor, which was otherwise free, was turned from the left forward and to the right for 90 degrees, the torsion of the conic portion of the intestine
at its crossing with the mesentery was released. The lower portion of the abdominal
cavity contained a few drops of turbid yellow fluid. When the cyst was opened,
air and 32 c.c. of thick, brownish-red fluid mixed with mucus and reddish flocculi
escaped. The fluid consisted almost entirely of pus-cells intermingled with red
blood-corpuscles and cylindric cells.
The reddish threads proved to be hemorrhagic infiltration. The wall of the
cyst was 2 mm. thick, and at every point was as well developed as that of the ileum.
The inner surface was partly ulcerated, but for the most part had a lining of a soft,
velvety, dark-red membrane. The latter showed, on microscopic examination, a
lining of cylindric cells and Lieberkuhn's glands. Beneath the mucosa came the sub_
mucosa, then the ring muscle, and then the outer longitudinal muscle. In the subserous connective tissue were large vessels and an abundance of fat-cells, and then,
covering the cyst, was peritoneum. In the lower part of the cyst, in the swollen,
dark-red mucosa, was a minute opening not larger than a linseed, through which a
sound could be passed into the ileum. The conic-shaped portion of the pedicle
was not larger than a bean. This lay parallel with the long axis of the intestine
near the mesenteric border, but on the concave side of the intestine.
From the above it is seen that the abdominal cyst corresponded to the end of the
diverticulum, which still communicated with the intestine and which had a mesentery. This diverticulum showed a distinct intestinal structure. It was covered
over with an inflammatory deposit and adherent omentum. The peritonitis was,
without doubt, due to torsion of the pedicle.
A Cyst of Meckel's Diverticulum. — ■ Fitz,* in the Warren
Museum, found the following record in the manuscript catalogue (under No. 4903) :
*Fitz, R. H.: Amer. Jour. Med. Sci., 1884, lxxxviii, 30.
180 THE UMBILICUS AND ITS DISEASES.
Diverticulum from the Small Intestine. — The specimen
was obtained at autopsy from a patient dead of chronic pleurisy. There were no
symptoms during life to call attention to its existence. It was given off from the
small intestine about 1 meter above the ileocecal valve. It was 3 cm. in length
and about 1 cm. in diameter. There was no apparent communication with the
lumen of the intestine. This specimen was a cyst of the diverticulum, the origin
of which was near the mesenteric attachment. Its walls consisted of a peritoneal
envelope with loose subperitoneal connective tissue, both continued directly from
the intestine. There was a dense middle coat, resembling in appearance the muscular layer of the intestine, although elongated nuclei were not to be made out;
finally, an inner membranous lining, upon the free surface of which occasional clubshaped stunted villi were found to project. Pouch-like depressions with circular
openings upon the free surface were found scattered throughout this membrane.
Epithelium was not present. The middle and internal coats were in the closest
proximity to the corresponding layers of the ileum.
Fitz speaks of cysts noted in the region of the duodenum, and cites a case of a
cyst of the esophagus observed by Wyss. He mentions cases reported by Roth
and Hennig in which there were cysts in the vicinity of the esophagus.
INTESTINAL CYSTS LYING BETWEEN THE LAYERS OF THE MESENTERY.
Cases of this character have been recorded by Buchwald, Hennig, Kulenkampff ,
and others. The cysts are situated in the mesentery of the bowel, usually a short
distance from the ileocecal valve . They may be round or pipe-shaped. They show
a peculiar tendency to form sickle-like contractions on their inner surface. The
cyst is, accordingly, partially divided into separate chambers. These partial divisions may completely block off a portion of the cyst, giving rise to an isolated and
walled-off secondary cyst. The cysts may or may not communicate with the
lumen of the bowel. They are lined with intestinal mucosa. Where they are
completely shut off from the bowel, they may be filled with clear fluid, as was
noted in Hennig's case, in which the tumor reached large proportions, measuring
22 x 14 x 10 cm.
A Large Intramesenteric Enterocystoma.* — ■ The patient had a large intramesenteric double cyst. This at one point showed an epithelial lining. It communicated with the bowel.
Intestinal Cyst and an Esophageal Cyst in a Newborn I n f a n t . f — In this case the labor was a very difficult one, and the
child died before delivery. A hook was introduced into the chest and then a perforation was found advisable. Pressure on the abdomen caused a discharge of about 3000
c.c. of clear fluid from the child. The mother made a good recovery. The length
of the child's body was 45 cm. In the abdomen was a sac which had not been
injured, and reminded one of a partially filled stomach of a grown person. Passing
to it were numerous large blood-vessels, which behind and in front of it went to
the ileum.
The ileum lay peripherally to the sac, near the point where it passed over into
* Buchwald: (Colmers, Loc. cit.).
t Hennig, C: Cystis intestinalis, Cystis citra cesophagum bei einem Neugeborenen. Centralbl. f. Gyn., 1880, iv, 39S.
INTESTINAL CYSTS. 181
the cecum. There was no communication between the ileum and the sac. The
sac was 22 cm. long, 14 cm. broad, and 10 cm. thick. It contained about 100 c.c.
of almost clear, slightly reddish, somewhat sticky fluid, which was suggestive of
intestinal fluid. The large bowel was empty and much contracted. (We have
purposely omitted a description of the esophageal cyst.)
Microscopic examination showed that the intestinal cyst was lined with cylindric epithelium; in its walls intestinal glands were demonstrable. The sac was a
large intestinal cyst which lay in the mesentery. This specimen was examined by
Weigert.
An Intestinal Cyst; Death From Intestinal Obstruction.* — The patient, a poorly developed boy three years old, had died with
signs of intestinal obstruction. At autopsy a cyst was found in the mesentery of
the small bowel, 40 cm. from the ileocecal valve. It was the size of a man's fist,
had very thin walls, and was almost translucent. It had several sickle-like constrictions, partially dividing it into semi-spheroid sacs. There was no communication with the bowel. The cyst was filled with very thin, chocolate-colored fluid.
Kulenkampff refers to Roth's article. In this case no microscopic examination
was made.
In the following case, recorded by Roth,f there was not only a cyst attached to
the bowel, but also one in the mesentery and another in the thorax :
A Congenital Intestinal Cyst Separated From a
Diverticulum Situated in the Mesentery; In Addition,
Intestinal Cysts of the Abdominal and Thoracic Cavities; Compression of the Air-passages.- — ■ The specimen and
the history came from Roth's colleague, J. J. Bischoff. Elsie B., aged nineteen
years, was delivered easily. Immediately after there was an escape of 3000 c.c.
of amniotic fluid. The child, a male, was small. Movement of its extremities
was noted, and an attempt to breathe was detected. The abdomen was markedly
distended. Notwithstanding artificial respiration, the child died in ten minutes.
The body was 42 cm. long. There was marked edema of the umbilical cord; on
the left side was a hydrocele. When the greatly enlarged abdomen was opened, a
large, thin-walled cystic tumor with numerous vessels covering it was found beneath the liver. This tumor covered the stomach and the duodenum. A few loops
of small bowel lay over the tumor; others lay to the left, and through the walls of
the latter a small quantity of meconium could be seen.
A more careful examination of the tumor showed that it consisted of two parts :
the one on the left and in front was the size of a hen's egg (Fig. 109, 6); the
other (&') was only a third as large. The latter lay in the cecal region, and the
cecum was pushed over to the median fine. The stomach was in the normal position, and contained a little tenacious, yellowish mucus. The spleen, adrenals, kidneys, and bladder showed nothing unusual. The thymus gland was the size of a
hazel-nut. The lungs were atelectatic. The pleurae showed ecchymotic spots. The
foramen ovale was the size of a pea. Near the right lung, and covered by it, was
* Kulenkampff, D.: Ein Fall von Enterokystom. Tod durch Darraverschlingung. Centralbl. f. Chir., 1883, x, 679.
f Roth, M.: Ueber Missbildungen im Bereich des Ductus omphalomesentericus. Virchows
Arch., 1881, lxxxvi, 371.
182
THE UMBILICUS AND ITS DISEASES.
a fluctuating tumor which sprang from the vertebral column and was covered by
the costal pleurae. The esophagus passed obliquely above the left half of the
tumor, and was easily dissected from it (Fig. 109, c).
Fig. 109. — Intestinal Cysts in the Abdominal Cavity. (After Roth.)
The heart, lungs, and liver have been removed. The ascending colon has been thrown to the left, and the pedicle
of the cysts (b and b') has been freed. On the upper surface of the cyst (b) are several lymph-glands. The spleen,
stomach, duodenum, and the right kidney are visible; also remnants of the diaphragm. To the left of the cyst (c),
which lay in the thoracic cavity, are the esophagus and the doubly cut aorta.
There was a marked swelling over the left temporal vein, and numerous ecchymoses wore encountered in the dura. The pia mater was edematous, and the vessels
INTESTINAL CYSTS.
183
> > J&& »
were engorged and tortuous. The ventricles were dilated and contained bloody
fluid.
In the abdominal cavity, in addition to the above-mentioned tumors (Fig. 109,
b and b'), there was still another which lay between the layers of the mesentery
and close to the lower portion of the ileum. This was a sausage-shaped cyst (Fig.
110, a), which lay close to the concave wall of a loop of the ileum. The mesenteric
vessels passed on the top of, over, and beneath the tumor to the intestinal canal,
and from these vessels numerous small branches went into the cyst. This mass
itself resembled a sausage and was somewhat club-shaped. Its upper end was
directed toward the jejunum, and it had a knob-like end, 13 mm. broad. Here
the tumor had a greater diameter than the small intestine. The smaller, lower
end terminated in an extremity having a diameter of over 5 mm.
When the ileum was opened, it was seen that the lower end of the mesenteric
tumor projected into the intestine and then opened into it
through a roundish aperture
(Fig. 110, x). The opening followed the direction of a very
acute angle. In the picture the
edges of the opening have been
spread with a glass rod, and in
this way the original prominence
has been much exaggerated.
The opening was situated at a
point 14.5 cm. above the ileocecal valve. The length of the
club-shaped tumor was 10 cm.
A sound introduced into the intramesenteric diverticulum encountered several ring-like narrowings through which only a
bristle could be passed. The
swollen end of the diverticulum
(Fig. 110, a) did not admit the
sound. On being opened, it was seen that in this portion was a cyst the size of a bean
that had been completely cut off from the remaining portion of the diverticulum.
The diverticulum contained no yellowish material, but in the lower portion was
mucus. The small cyst contained thick masses which, on microscopic examination, showed numerous glistening round-cells without nuclei.
The walls of the diverticulum were similar to those of the intestinal canal, and
the inner surface was lined with a single row of cylindric goblet-cells with Lieberkuhn's glands beneath. The small cyst was different in structure. The outer
coats were similar to those of other portions of the diverticulum. The septum between the cyst and the diverticulum did not contain longitudinal muscle in the
subserous layers. The mucosa was very thin. The upper surface was partly flat.
Lieberkiihn's glands were entirely wanting. The inner surface was lined with
ciliated epithelium.
The abdominal cyst, which consisted of two apparently separate sacs (Fig. 109,
Fig. 110. — An Intramesenteric Ctst. (After Roth.)
The specimen shows the lower portion of the ileum, with the
mesentery, vermiform appendix, and ascending colon. The anterior
fold of the mesentery has been removed. The branching of the superior mesenteric vein and the larger portion of the diverticulum lie
on the concave side of the intestine and have been dissected free.
a is the outer cyst, which has been but incompletely developed
from the diverticulum, x indicates the ostium, which has been
made visible through the splitting open of the intestine.
184 THE UMBILICUS AND ITS DISEASES.
b and 6'), anteriorly, above, and below was covered with a glistening peritoneum,
and occupied a large portion of the middle of the right abdominal cavity. Both
sacs were easily moved on one another in various directions. Only in the region
of the pancreas and on the lower portion of the duodenum were they fixed. On
dissection it was found that there was a short pedicle, 1 cm. long, between the anterior round and the lower sausage-like mass. The pedicle was 2 mm. broad, and
had a canal 0.5 mm. in diameter, which joined the two cavities. There was no
open connection between the intestinal canal and the cysts. The whole tumor, on
its posterior and left side, was attached by a rather firm connective tissue to the
superior mesenteric artery from its point of origin beneath the pancreas. There
was no direct connection with the vertebral column.
The superior mesenteric artery was 1.6 mm. thick, and formed in its middle
course three ring-shaped anastomoses. It gave off from its right side, 9 mm. below
the art. colica dextra, the art. ileo-colica, which was 1 mm. in diameter. The
largest branch of this supplied the cyst (6). Eleven millimeters further on, it gave
off a branch which supplied the small cyst (&')•
On the upper surface of the cyst these vessels formed an extensive network which,
on the one side, anastomosed with the arteriae intestinales, and on the other side
with the arteria colica dextra. The veins had relations similar to those of the
arteries. There were numerous nerves and also veins over the surface of the cyst (6) .
Lymph-glands were also present under the serosa.
Thus the large abdominal cyst was retroperitoneal in the right portion of the
mesentery, and had pushed the mesentery in a pouch-like manner before it. It was
supplied by two branches of the superior mesenteric artery. The portion (6) contained 34 c.c. of tenacious, somewhat flocculent fluid. The fluid gave a reaction
for mucin. The inner surface of the cyst was smooth. The thickness of
the wall varied: near the vertebral column it reached a maximum of 1.5 to
2 mm. On microscopic examination all the layers of the intestinal wall could
be identified. The mucosa, however, was very thin, and only where the
inner surface was rough were there villus-like elevations. The inner surface was
lined with cylindric epithelium, but the mucosa was hardly sufficiently developed
to form glands. The portion (&') corresponded in the main with (6) and only
differed in that the walls were thinner and there were more folds. The surface was
lined with cylindric cells and goblet-cells, and here and there in the depth were real
gland-like spaces. The sac contained 7.5 c.c. of fluid. Lining the canal between
the two sacs were cylindric cells. In all three portions there was a lack of perfect
development of the mucosa, whereas the muscular layers were hypertrophied.
The cyst in the mediastinum (Fig. 109, c) extended from the third to the tenth
dorsal vertebra. It was 5.5 cm. long, 3.7 cm. in its transverse diameter, and 4 cm.
in thickness. It had thick walls, was opaque, distended, and elastic. The tumor
was firmly connected with the vertebral column. From above downward it was
only slightly movable; from side to side, somewhat more so. It lay to the right of
the esophagus.
The tumor, as shown in the hardened specimen, had produced much pressure
on the thoracic organs. The left lung, just behind and below the hilum, presented
a fiat surface. The right lung had a deep groove, 4.3 cm. long and 1.5 cm. broad,
which extended over the entire lower lobe.
The cyst contained 12 c.c. of tenacious, mucilaginous fluid, in which cylindric
INTESTINAL CYSTS. 185
cells and goblet-cells were found. It was divided into three chambers, which were
entirely separated from one another. The walls showed an intestinal structure,
but with more marked development of the muscular layers, while the mucosa was
everywhere thin and in most places devoid of folds or glands. Here and there,
however, were irregular folds between which small glands opened.
In summing up the findings Roth says: "In the first place, the intramesenteric
position of the diverticulum is perhaps unique. Usually the diverticulum springs
from the convex surface of the intestinal canal; not infrequently, however, it is
situated near the mesenteric attachment. Interest is also attached to the small
intestinal cyst, which is separated from the diverticulum at the matrix; it has the
same longitudinal muscular layers and the same serosa." He refers to the cyst as a
diverticulum.
Roth said he knew of only one similar case in the literature, that of Raesfeld,
in which the entire diverticulum had been transformed into a cyst, but in that case
the cyst was seated on the free circumference of the intestinal tract.
A CYST OF THE CENTRAL PORTION OF THE OMPHALOMESENTERIC DUCT.
Most of the schematic pictures illustrating the various points at which remnants
of the omphalomesenteric duct may be found represent cysts developing midway
between the intestine and the umbilicus (Fig. 105, p. 176). Theoretically, one might
expect to find them in such a position, but the following case, recorded by Schaad,*
is the only example of such a condition that I have found in the literature.
An Abdominal Cyst Originating From a Remnant
of the Omphalomesenteric Duct. — The patient was a married
woman, thirty-two years of age. Nothing is known of the appearance of the umbilicus at birth. She gave a history of two normal labors. At the last labor a
tumor was noted below the umbilicus. This patient was supposed to have had a
severe inflammation of the bowels seven years previously.
Several fingerbreadths below the umbilicus one could feel an elastic tumor
which was sharply outlined and was the size of a child's head. This could be pushed
in all directions.
Operation. — A cyst the size of a five-franc piece was found about two fingerbreadths below the umbilicus, and attached to the abdominal wall in the median
line. It had been separated from the peritoneum and drawn out of the abdomen.
Omental adhesions were tied off and cut. The cyst was adherent to the appendix.
The left ovary was hard and atrophic; the right ovary was normal. The patient
made a good recovery.
The cyst was oval in form, 7.5 cm. long, 6 cm. broad, and 4.5 cm. in thickness.
Its walls varied from 2 to 4 mm. in thickness. Its inner surface resembled mucosa
and was light yellow in color, with dark spots. On the right side of the cyst was a
secondary cyst, which communicated with the larger one by an opening the size of a
pin-head. The inner surface of the cyst was smooth, and its walls were in places
0.5 mm. thick.
The large cyst contained about 200 c.c. of a chocolate-colored, tenacious fluid,
with an abundance of cholesterin detritus and fat-droplets. The smaller cyst had
* Schaad, T.: Ueber die Exstirpation einer Cyste des Dotterganges. Corr.-Bl. f. Schweizer
Aerzte, 1886, xvi, 345.
186 THE UMBILICUS AND ITS DISEASES.
similar but thicker contents. The wall of the large cyst consisted of connective
tissue and of a large quantity of smooth muscle arranged in bundles, which ran in
all directions. The inner surface was lined with high cylindric epithelium. Glands
also opened on the surface. The epithelium and glands were in places missing.
The small cyst was lined with granulation tissue, in which were found giantcells, some containing 20 to 30 nuclei, arranged at the margin or irregularly scattered
in the center. [This rinding reminds one of foreign-body giant-cells.]
Schaad says there is no doubt that the cyst represented a remnant of the
omphalomesenteric duct. A portion of the duct had remained open and caused
a retention cyst.
SYMPTOMS OF INTESTINAL CYSTS.
Some of the children were born dead. Carwardine's patient lived two days,
Roth's patient lived a year and four months, and Kulenkampff's patient, three
years. In each of these cases the death was apparently due to intestinal obstruction.
Schaad's patient, a woman of thirty-two, recovered. In this case the tumor
apparently had no connection with either the bowel or the mesentery. It was
removed.
Fitz says: "The clinical importance of these intestinal cysts obviously depends
upon their size arid situation. Large abdominal cysts may interfere with the birth
of the child, as in Hennig's case and in that reported by Sanger and Klopp. Although the actual cyst or cysts in each instance were not the sole cause of obstructed
labor, for an associated ascites was present, they were an important element.
"In Hennig's case, puncture of the abdominal cavity was necessary before the
child could be delivered, and some three liters of a relatively clear fluid escaped.
The cyst was not injured. Even if the child is born, the cyst may remain as a
constant source of danger, and, as in the case reported by Roth, may prove fatal
by a twisting of its pedicle. The possible effect of an intrathoracic cyst is shown
by this observer, who found evidence of marked pressure upon the lungs and bronchi.
The possibility that cysts of the abdominal wall may become of considerable size
is suggested by the history of the urachus cysts sometimes found between the
muscle and peritoneum and extending from the navel to the symphysis pubes."
TREATMENT.
If these cysts were recognized early and before the obstruction was marked,
it would, of course, be possible to remove those arising from the free margins of
the bowel. Where the cyst is located in the mesentery, the danger of injuring
the blood-supply of the intestine would naturally materially increase the risk.
LITERATURE CONSULTED ON INTESTINAL CYSTS.
Buchwald: (Colmers, Loc. cib.).
Carwardine, T.: Volvulus of Meckel's Diverticulum. Brit. Med. Jour., 1897, ii, 1637.
Cazin, H.: Etude anatomiquc et pathologique sur les diverticules de l'intestin. These de Paris,
1862, No. 138.
Colmers, F.: Die Enterokystome und ihre chirurgische Bedeutung. Arch. f. klin. Chir., 1906,
Ixxix, 132.
INTESTINAL CYSTS. 187
Dittrich: (Runkel, Op. cit.)
Fitz, R. H.: Persistent Omphalomesenteric Remains; their Importance in the Causation of Intestinal Duplication, Cyst Formation, and Obstruction. Amer. Jour. Med. Sci., 1884, lxxxviii,
30.
Hendee: (Colmers, Loc. cit.)
Hennig, C: Cystis intestinalis, Cystis citra oesophagum bei einem Neugeborenen. Centralbl.
f. Gyn., 1S80, iv, 398.
Huter: (Runkel, Op. cit.)
Kulenkampff, D.: Ein Fall von Enterokystom. Tod durch Darmverschlingung. Centralbl.
f . Chir., 1883, x, 679.
Lohlein: (Runkel, Op. cit.)
Nasse: (Runkel, Loc. cit.)
Rimbach: (Colmers, Loc. cit.)
Roth, M.: Ueber Missbildungen im Bereich des Ductus Omphalomesentericus. Virchows Arch.,
1881, Lxxxvi, 371.
Runkel, A.: Ueber cystische Dottergangsgeschwulste. Inaug. Diss., Marburg, 1897.
Tiedemann: (Roth, Loc. cit.)
Tscherning: (Runkel, Op. cit.)
Schaad, L. : Ueber die Exstirpation einer Cyste des Dotterganges. Corr.-Bl. f. Schweizer Aerzte,
1886, xvi, 345.
==Chapter X. A Patent Omphalomesenteric Duct==
Historic sketch.
Appearance of the umbilicus.
Condition of the child.
Treatment.
Cases of patent omphalomesenteric duct.
In 1817 Poussin reported the case of a child three years old. On the fifth day
after birth the nurse made traction on the cord, as it had not yet come away.
"Inflammation" followed, and a small opening developed at the umbilicus. Sometimes this would close for three weeks or more, but never for a much longer period ;
from time to time the child passed round worms through it. At the umbilicus was
a projection the size of a hazelnut, which showed at its center an opening from
which feces escaped. The fistula was due to a patent omphalomesenteric duct.
Brun, in 1834, published a remarkably clear article on this subject, and
described several cases that had been observed by Dupuytren.
King, in 1843, reported a case observed by Parsons and Gunthorpe. In this
case a portion of the small bowel had turned inside out through the fistula, and lay
as a sausage-like mass on the abdomen. This case is reported in detail on page 233.
Eves, in 1845, reported the case of a child, one month old, who had a red, funguslike tumor, about the size and shape of a raspberry, attached to the umbilicus. At
its apex was a small opening, from which occasionally feculent liquid would issue
in jets and through which a probe could be passed directly backward for two inches.
On investigation it was found that the cord had separated at the end of a week,
and fecal matter had then commenced to come from the umbilicus.
Schroeder, in his inaugural dissertation on the formation of intestinal diverticula, published in 1854, said that in the Pathological Museum of Prague is the record
of a six-months-old child who showed an embryonic omphalomesenteric duct which
passed from the umbilicus to the ileum as a canal of gradually increasing size.
Lannelongue and Fremont, in their treatise on the varieties of congenital
tumors, said that umbilical fistulae of this origin had been observed by Sandifort,
F. Schulze, Tiedemann, Ludwig, and Tilling.
A patent omphalomesenteric duct is by no means common, but Brun was able
to publish three cases from Dupuytren's clinic, and Quaet-Faslem five cases from
Petersen's clinic. A fairly complete summary of the cases scattered throughout
the literature will be found toward the end of this chapter.
Sex. — In 13 of the cases here recorded we have no data as to the sex, but of
the remaining 35, 31 were in males and only 4 in females, showing conclusively that
the patent omphalomesenteric duct occurs almost exclusively in the male.
Age. — For the 35 cases in which we have data as to the age at which the
patient came under observation we have the following figures:
Under one year old 22
Between one and ten years old 8
From ten years of age and over 5
188
A PATENT OMPHALOMESENTERIC DUCT. 189
Holmes' patient and the one observed by Leisrink and Alsberg were ten years
old. Fitz's patient was twenty-one years of age, and Kehr's, twenty-eight years
old. Park's patient was an athlete, his exact age not being given.
The Umbilical C o r d . — In many cases no mention is made of the
condition of the cord at birth, but in quite a number the records show that the cord
was very large at its base, in some cases being fully twice as thick as usual near the
abdomen. Pratt, for instance, said that for an inch and a half from the abdomen
the cord was double its usual thickness. Many of the cases were handled by midwives and no definite records made. I feel sure that future reports will demonstrate that the cord near the umbilicus is invariably thicker than usual, when a
patent omphalomesenteric duct is present.
In Hansen's case the cord was very large, bluish green, and abnormally broad.
It came away on the eighth day.
In the cases in which the cord has been very thick, as a rule, the ligature has
been applied farther away from the abdomen than usual.
APPEARANCE OF THE UMBILICUS.
When the cord comes away, an abnormal condition at the umbilicus is generally
detected at once. The umbilical depression is occupied by a bright-red nodule.
This may not be larger than a pea, but is frequently the size of a hazelnut (Fig.
121, p. 206) or of a cherry. In some instances it is much larger. In Ardouin's
case, for example, its diameter was as large as that of the little finger, and the growth
was 2.5 cm. long (Fig. 115, p. 192). In Hansen's case it was cylindric, snout-like,
and curved. On its convex surface it was 3 cm., and on its under and concave
surface 2 cm., in length. In Battle's case it was l 1 ^ inches long. In Shepherd's
case it looked like a penis and was 1}4, inches long. In Roth's case it formed a
cylindric tumor 2 cm. in length (Fig. 120, p. 205). In Morian's case, when the cord
came away, a red, sausage-like mass was left (Fig. 119, p. 202); in Deschin's case
a mushroom-shaped mass the size of a walnut was found. Figs. Ill, 112, 113,
and 1 14 give a very good schematic representation of the various forms of a patent
omphalomesenteric duct.
In Jacoby's case, when the cord dropped off, the umbilicus was occupied by a
raw area the size of a silver dollar. In Quaet-Faslem's case of a boy, nine days old,
there was a long, pear-shaped tumor, 8 to 10 cm. in length. These tumors, whether
large or small, are bright or dark red in color, and are covered over with typical
intestinal mucosa. This occasionally, as was noted in one of Weiss's cases, may
be covered over with brownish crusts. On examination of the summit of the
tumor, an opening will be found. This may be exceedingly fine, or several millimeters in diameter. A probe introduced into the fistula can be passed directly into
the small bowel.
On microscopic examination the surface of the projection or of the fistulous
tract will be found to be covered with mucosa similar to that of the small bowel
(Fig. 75, p. 134; Fig. 123, p. 207; Fig. 125, p. 209).
In these cases the omphalomesenteric duct has remained open, as it was in the
early months of fetal life (Fig. 3, p. 3; Fig. 5, p. 5). Consequently, the appearance of the umbilical growth after the cord has come away will depend on how far
away from the abdomen the cord has been ligated. The greater the amount of
190
THE UMBILICUS AND ITS DISEASES.
omphalomesenteric duct left behind, naturally, the longer will be the protrusion.
In those cases in which a large, relatively flat area of mucosa is found, the duct has
probably been present as a cystic dilatation, and this has flattened out when the
cord ligature has cut through.
In this connection the case observed by Prestat and cited by Ledderhose is of
interest. In an autopsy on a male infant at term, Prestat demonstrated an intact
Fig. 111. — A Patent Omphalomesenteric Duct.
(Schematic.)
The lumen is of rather small diameter, and yet occasionally the bowel may prolapse through a lumen even
smaller than this.
Polyp
Fig. 112. — A Patent Omphalomesenteric Duct
with a Polypoid Formation at the Umbilicus.
(Schematic.)
The lumen of the duct diminishes markedly in size
a short distance from the small bowel. Its outer end
projects more than a centimeter beyond the surface of
the abdomen. The outer surface of this polypoid projection is covered over with mucosa, which is directly
continuous with that lining the omphalomesenteric duct
and the small bowel.
Fig. 113. — A Very Short Omphalomesenteric Duct.
(Schematic.)
Usually the convex loop of small bowel is several
centimeters away from the umbilicus, but occasionally,
when the duct is very short, it may be almost directly
attached to it. In the sketch here shown the greater
part of the duct lies in the abdominal wall, and in the
center of the polypoid nodule which projects outward
from the umbilical depression.
Fig. 114. — A Patent Omphalomesenteric Duct with
a Polyp-like Formation at the Umbilicus.
(Schematic.)
The omphalomesenteric duct is relatively short,
and at its intestinal end is a sort of valve. Just above
the umbilical opening of the duct is a polyp covered over
with intestinal mucosa which, on the one side, is continuous with the skin, and on the inner side with the
mucosa lining the omphalomesenteric duct.
umbilical cicatrix. On opening the abdomen he found a cord the size of a goosequill. This was 2J^ inches long, and communicated with the small bowel. On
pressure fecal matter passed into the fistula, and at the umbilicus a small tumor
projected from the cicatrix. This opened, and on moderate pressure fecal matter
escaped. In this case there was nearly a fistula. If the patent omphalomesenteric duct had extended just a little farther out, it would have been constricted by
the ligature and left open when the cord dropped off.
A PATENT OMPHALOMESENTERIC DUCT. 191
The Discharge From the Fistula. — ■ This varies greatly.
When the opening is very small, a little mucus may come away. In some cases
this has a fecal odor; in other cases, as in Salzer's case, this is lacking.
Where the fistula is a little larger, liquid feces may escape every day, or, as
noted in Pratt's case, every three or four days. In some cases the escape of feces
was detected only when the child cried or when pressure was made upon the abdomen. In other cases the bowel contents escaped in large quantities from the
umbilicus. The amount of the umbilical discharge will depend almost entirely
on the size of the fistulous opening.
Skin.- — ■ The skin around the fistula often shows irritation. This again will
depend on the amount of feces escaping, and on the irritating or non-irritating
qualities of the contents of the particular intestine. Furthermore, the nearer the
diverticulum is to the cecum, the less irritation one would expect.
CONDITION OF THE CHILD.
In many cases the children were in good physical condition, but others were
weak and frail.
Billroth's patient was very weak; Broadbent's had congenital syphilis; Morian's child cried a great deal and lost weight; Leisrink and Alsberg's patient frequently had abdominal pain; Nicaise's patient was pale and emaciated, as was also
one of those observed by Quaet-Faslem; Weiss's patient had had abdominal pain,
diarrhea, and vomiting; Roth's patient died suddenly when six months old.
TREATMENT.
Various methods have been adopted to effect a closure of the umbilical opening.
The most satisfactory results have been obtained from the use of caustics or the
actual cautery, or from the application of a ligature to the umbilical growth.
Many of the fistulse closed permanently; others opened up again as a result of
coughing, as in Weiss's case. Leisrink and Alsberg's patient was operated upon
and died of intestinal obstruction. King's patient underwent a plastic operation, which successfully closed the umbilical end of the fistula, but the child died
later of intestinal obstruction.
Removal of the umbilicus and the fistulous tract has given the best permanent
results. This is the only method to be considered at the present day. An incision
should be made encircling the umbilicus down to and through the peritoneum;
if traction is then made, the fistula and the loop of small bowel can be readily brought
out of the abdomen. The fistula should then be removed in precisely the same
manner as in dealing with an appendix.
CASES OF PATENT OMPHALOMESENTERIC DUCT.
Other cases of patent omphalomesenteric duct are referred to in Chapter XI
(p. 214), on Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct; and
"in Chapter XXI (p. 328), on Worms.
Radical Operation in a Case of Persistent Omphalomesenteric Duct. — Alsberg's * patient was eighteen weeks old. When
* Alsberg, A. : Ueber einen Fall von Radicaloperation eines persist irenden Ductus omphalomeseraicus. Deutsche med. Wochenschr., 1892, xviii, 1040.
192
THE UMBILICUS AND ITS DISEASES.
the cord came away, healing did not occur, a red, moist area remaining. This
became more prominent, and a small, horn-like projection, 1 cm. long, developed.
This projection was red in color and had an opening from which, yellow fluid
escaped.
On admission the child was found to be well developed. At the umbilicus was a
flat tumor, the size of a bean, with an abundance of fluid escaping from an opening
in it. The line of junction between the skin and mucosa was sharp. A bougie
could be passed for 20 cm. into the opening.
Operation. — -The omphalomesenteric duct was cut off near the small bowel and
the stump turned in. The child died on the twelfth day from peritonitis.
Patent Omphalomesenteric Duct. Extirpation. Recovery.* — The child was born September 14, 1906, and was seen on October
5th. He was then twenty-one days old, and presented a fecal fistula at the umbilicus. The parents
thought that the woman, who had had charge of the
tying of the cord, had applied this ligature to an intestinal loop, but the history shows that there was
no room for criticism of the midwife. The boy was
well nourished.
At birth the person who tied the cord, 5 or 6 cm.
from the umbilicus, noted that it was large at its base.
In the course of three days the cord came away, and
in its place was a tumor the size of a little finger in
diameter, and 2.5 cm. in length. It was red in color,
and from it a few days later there was a considerable
amount of hemorrhage.
On October 1st, the sixteenth day, the family
noticed for the first time an escape of intestinal material and gas. At the same time the bowels moved
regularly.
Ardouin saw the child five days later, and the
tumor presented the picture seen in Fig. 115. It was
red, like a cherry, and resembled intestinal mucosa
which had been irritated. The tumor was limited at
its base by a cutaneous elevation at the umbilicus. The surrounding skin was reddened and ulcerated at some points. At the summit of the tumor was a depression,
from which fecal material and gas escaped. Ardouin recognized the condition as
one of persistent omphalomesenteric duct. There were no other malformations.
Operation. — A lozenge-shaped incision encircling the umbilicus was made and
the peritoneum opened. The tract was clamped off at the point of junction with
the intestine, and cut across with the thermocautery, just as in the removal of an
appendix. The opening in the bowel was closed, and the child made a perfect
recovery.
Extroversion of Meckel's Diverticulum. — Battle's f
patient was a girl eighteen months old. She was fairly well nourished, but had
* Ardouin, P.: Persistance du Diverticule de Meckel ouvert a l'ombilic. Fistule stercorale.
Omphalectomie. Extirpation du diverticule, guerison. Arch. prov. de chir., Paris, 1908, xvii, 1.
t Battle, W. H.: Clin. Soc. Trans., London, 1893, xxvi, 237.
Fig. 115. — A Patext Omphalomesenteric Duct. (After Ardouin.)
A probe has been introduced into
the tract in order to show its permeability. 1, the diverticulum; 2, the
umbilicus; 3, the surrounding collar
of skin; 4, the point of attachment of
the diverticulum to the intestine; 5,
the probe passing through the length
of the fistulous tract.
A PATENT OMPHALOMESENTERIC DUCT.
193
a pear-shaped tumor at the umbilicus. This was noted shortly after birth, and
had been increasing in size.
It was one and a half inches long, and covered with red, smooth mucosa, which
bled on manipulation. There was a sharp line of demarcation between the tumor
and the skin. At the free end the diameter equaled that of a cherry, and at its
narrowest point was reduced by one-half. At its extremity was a hole through
which a probe could be passed inward for two inches. There was a thin, rather
feculent discharge, and the tissues surrounding the tumor were eczematous. The
stools were normal. The protrusion could be reduced only very slightly by
pressure. It increased in size when the patient cried or stood erect.
Operation. — The abdomen was opened; the diverticulum was cut through
transversely, and the stump invaginated. The next day scarlet fever
developed, and the child died on the
eleventh day.
At autopsy the abdominal condition was found to be perfectly normal. The death was due to scarletfever. The distance of the diverticulum from the ileocecal valve was
ten inches.
A Patent Omphalomesenteric Duct.* — The
boy, fourteen weeks old, had had a
fecal umbilical fistula since birth.
Projecting from the umbilicus was
a growth half an inch in length from
which a small amount of fecal matter
escaped from time to time. Billroth
thought that this represented an
omphalomesenteric duct that had
remained open (Fig. 116).
The growth was tied off with the
hope that the fistula might close, but when the suture came away, it remained
open. Billroth thought of closing the fistula later with sutures, but the child was
very weak, and was taken home by its parents. It soon died.
A Patent Vitelline Duct. — Broadbent f showed the specimen.
The child had occasionally passed fecal matter from the umbilicus, but as it was a
subject of congenital syphilis, no surgical procedure was undertaken. At autopsy
a coil of intestine was found in contact with the umbilicus, and there was a slender
tube passing from the intestine to it.
A Patent Meckel's Diverticulum. J — A boy, six months old,
was brought to the hospital June 3, 1894. He had a pear-shaped tumor 4 cm.
long, with a pedicle about 1 cm. in diameter, at the umbilicus. Its surface was
Fig. 116. — A Patent Omphalomesenteric Duct. (After
Billroth.)
The patient was a boy, fourteen weeks old, who had had
an umbilical fecal fistula since birth. Projecting from the umbilicus was a growth, half an inch in length, from which a
small amount of fecal matter escaped from time to time.
* Billroth: Chirurgische Klinik, Berlin, 1869, 294.
f Broadbent: Med. Times and Gaz., 1866, ii, 45.
JBroca: Persistance du diverticule de Meckel ouvert a l'ombilic et invagine au dehors.
Revue d'orthopedie, 1895, vi, 47.
14
194 THE UMBILICUS AND ITS DISEASES.
covered with a bright-red mucosa, resembling that of a prolapsed rectum. In
the center was an orifice from which there escaped a mucous liquid. Nothing resembling fecal matter had ever been noted. A probe was easily introduced into
the center of the orifice, and passed into the abdomen.
Operation, June 9, 1894. — Broca made a circular incision around the umbilicus,
going down to the peritoneum. The growth communicated with the intestine by
an opening that would admit a probe. The opening in the ileum was closed, and
the child made a good recovery.
Patent Omphalomesenteric Duct. — Bureau records another
observation made by Broca.* A boy, aged ten months, was admitted to the
hospital on October 21, 1897. In the center of the umbilicus was a small red tumor,
about 2 cm. long, consisting of the everted diverticular mucosa. At its summit
was an orifice into which a probe could be passed. There was a serous discharge
from the fistula. On October 21st the fistulous tract was resected. The child
made a good recovery.
Prolapsus of the Omphalomesenteric Duct. — Bureau f
says that diverticular entero-umbilical fistulse are always due to the persistence
of Meckel's diverticulum or to remains of the omphalomesenteric duct. Open
diverticula at the umbilicus are rare, and prolapsus of the diverticulum complicating
the fistula is still rarer. Broca observed one case in 12,000 patients examined at
the Hopital Trousseau during two years. J The danger is from intestinal occlusion.
The modes of treatment are compression, ligation, cauterization; laparotomy
followed by resection of the diverticulum and closure of the bowel should be
employed.
Patent Omphalomesenteric Ducts. — Brun's § article, published in 1834, is a remarkably clear one. He records three cases coming under the
care of Dupuytren and a fourth observed by Poussin. In three of the four cases
there was an umbilical fecal fistula, and in the other there was no fistula. Brun
said that Dupuytren had never seen a case before 1833, and then in short succession
the three patients were admitted.
C a s e 1 came under Dupuytren's care. The child was twenty-eight days old.
At the umbilicus was a tumor the size of a cherry, red, and covered over with
mucosa. The tumor was irreducible; it was narrowed at its base and had a perforation in its center from which fecal matter escaped. In this case the cord had
dropped off on the fifth or sixth day, and shortly afterward the condition had been
noted. The child's general health was good. A sound could be carried one and a
half inches into the fistula. Finally the growth was tied off with a silk ligature. It
sloughed off after fifty-four hours and the wound healed.
C a s e 3. A boy, who came under Dupuytren's care, had a large cord at birth.
This was tied at a point five fingerbreadths from the umbilicus. At the end
of the fifth day the cord had not yet come away, and a new ligature was
applied nearer to the abdomen. On the ninth day, when the cord sloughed
off, there were two small red tumors at the umbilicus. These were about
* Broca (Quoted by Bureau): These de Paris, 1898, No. 257, 32.
t Bureau, J. : Prolapsus ombilical du diverticule de Meckel. These de Paris, 1898, No. 257,
14.
% Broca: Rev. d'orthopeYlie, 1895.
§ Brun, L. A.: Sur une espece particuliere de tumeur fistuleuse stercorale de l'ombilic.
These de Paris, 1834, No. 238.
A PATENT OMPHALOMESENTERIC DUCT. 195
the size of a finger-tip, and projected half an inch. They were roundish and
covered over with mucosa. The one was opposite the other, and both were in the
same horizontal plane. The right was smaller than the left. The left one was
perforated in its center, having an opening one ligne (2.25 mm.) in diameter. A
probe could be carried for more than an inch into this opening, and fecal matter
escaped from it. The child also had normal stools. Neither of the tumors was
reducible on pressure. Both were tied with silk and dropped off on the third
day, with perfectly satisfactory results, the fistula remaining closed.
A Patent Omphalomesenteric Duct.* — Deschin's patient
was a boy five months old. A tumor was noted at the umbilicus when the cord
came away. To the left of the umbilicus was a walnut-sized, mushroom-like tumor,
bright red in color, and reminding one of the mucosa of the large bowel. In the
middle was an opening which led into the bowel. Feces escaped from it. The
surface of the growth was alkaline in reaction.
The abdomen was opened, and the fistulous tract found to be 3 to 4 cm. long.
It passed to the small bowel. The tract, together with the umbilicus, was removed.
The child took the anesthetic badly and died several hours later. At autopsy it
was found that the fistula was 49 cm. above the cecum. It was lined with intestinal
mucosa.
A Case of Diverticulum Ilei Communicating with
the Umbilicus. f — W. D., aged one month and four days, had a red,
fungus-like tumor, about the size and shape of a raspberry, attached at the umbilicus.
At its apex was a small opening from which occasionally feculent liquid would issue
in jets and through which a probe passed directly backward for two inches. The
child was in good health and the bowels moved in a natural way.
On investigation it was found that the cord had separated at the end of a week,
and fecal matter had then commenced to come from the umbilicus.
A ligature was tied firmly around the base of the umbilical projection. This
sloughed off in a few days. The canal became obliterated, and the discharge ceased
completely. Eves refers to his case as one particularly favorable for palliative
treatment.
Intestinal Obstruction Due to a Patent Omphalomesenteric Duct. — Fitz J refers to a case observed by Dr. John Homans,
of Boston. A man, twenty-one years of age, met with a severe fall February 8,
1884. He had always been healthy, with the exception of a congenital umbilical
sinus, which was vaguely supposed to communicate with the intestine. His
mother was confident that portions of food (seeds and the like), after being swallowed, had escaped at times from the sinus, and that the latter had been closed
since October, 1882.
"Four days after the fall he was seen by Dr. John 0. Dow, of Reading, Mass.,
who found him suffering from absolute intestinal obstruction, tympanites, tenderness, and pain. Three days later — a week after the accident — frequent vomiting
of an offensive, so-called fecal, material took place. Dr. Homans was summoned
* Deschin: Zur Frage der chirurgischen Behandlung bei dem Vorfall des Dotterganges.
Centralbl. f. Chir., 1895, xxii, 1154.
t Eves, A: The Lancet, London, 1845, i, 101.
t Fitz, R.: Persistent Omphalomesenteric Remains, their Importance in the Causation of Intestinal Duplication, Cyst-formation and Obstruction. Amer. Jour. Med. Sci., 1884, lxxxviii, 30.
196 THE UMBILICUS AND ITS DISEASES.
in consultation, after another interval of three days, and found the patient vomiting, every few minutes, an exceedingly offensive brown fluid. The abdomen was
distended, tympanitic, and tender. The eyes were bright, and the countenance
intelligent. Pulse feeble, about 130.
"A dark-colored urine was drawn from the bladder and a director introduced
into the sinus. A little fecal matter seemed to escape. The opening was enlarged
laterally, especially to the left, sufficiently to admit the finger. The incision may
have been an inch and a half long, and the finger entered the peritoneal cavity.
No obstruction was felt near the umbilicus within reach of the finger. A loop of
intestine was seized, sewn to the skin, and an opening, about half an inch in length,
was made through its wall. No fecal or intestinal contents escaped until after the
junction was completed, when an offensive, brownish fluid material and gas were
freely discharged.
"On the day following the operation the temperature was 100.4° F.; the pulse,
108. The vomiting had ceased, and there was some relish for food. Occasional
twinges of pain in the right groin were complained of. There was but little abdominal distention, and Dr. Dow was able to detect a circumscribed enlargement
in the vicinity of the ileocecal valve. Two days later the temperature was normal;
pulse, 108. The swelling and tenderness in the groin were much diminished, and
there were no twinges of pain. Solid food was desired. On the next day the temperature was 96.2° F., pulse, 120. Restlessness, distress in the back, and ringing
in the ears were the prominent symptoms, and were attributed to insufficient nourishment. Injections of beef-tea were given, and were followed by marked relief,
the pulse falling to 108 and the temperature rising to normal. His strength
gradually failed, however, notwithstanding that food was given by the mouth and
rectum. The temperature became persistently lower, and the pulse weaker, with
increasing frequency. His death took place one week after the operation. On
the day preceding a passage from the bowels occurred, although Dr. Dow was of
the opinion that the contents of the stomach never passed beyond the intestinal
fistula.
"An autopsy was made twenty-six hours after death by Dr. G. E. Putney, of
Reading, who has furnished the following interesting report :
"He found the body considerably emaciated and the abdomen flat. A probe
inserted into the congenital opening passed downward, forward, and to the right,
at an angle of 40 degrees with the median line.
"The parietal peritoneum was glistening, of a dark, reddish-slate color. Its
blood-vessels were prominent, especially around the umbilicus, within a radius of
four inches. There was no lymph. The small intestine was of a very dark, drabred color. The large intestine and the colon were of about two-thirds the normal
size. The artificial opening into the intestine was 52 inches below the pylorus.
Its edges were thickened, ragged, and sloughing, and had failed to unite with those
of the abdominal wound.
"A diverticulum four inches long and half an inch in diameter arose from the ileum
four feet above the ileocecal valve, and extended to the umbilicus. The ileum
below its origin was three-quarters of an inch in diameter. The tissues of the
diverticulum appeared normal, with the exception of the muscular coat of the distal
three-quarters of an inch, which was thrice the normal thickness. A tendinous
cord the size of a darning needle and 4 inches long proceeded from the mesentery
A PATENT OMPHALOMESENTERIC DUCT.
197
along the diverticulum and became lost in the tissue surrounding the umbilical
opening. In its course along the diverticulum it appeared as if ensheathed.
"The contents of the small intestine resembled dark pea-soup; those of the
large intestine were pultaceous, resembling yeast. There was no evidence of any
existing constriction at the time of autopsy.
"There seems to be no reasonable doubt that the above case is one of intestinal
obstruction from persistent omphalomesenteric remains. The autopsy gives no
evidence of the manner in which the obstruction occurred."
Fitz's article is one of the most readable in the English language.
A Patent Omphalomesenteric Duct.* — ■ The boy was five
years old. When the cord came away, an
enlargement the size of a hazelnut was
noted at the umbilicus. This nodule was
red and discharged a clear liquid, which at
times was blood-tinged. Up to the fifth
year the tumor had occasioned no serious
Fig. 117. — A Patent Omphalomesenteric Duct.
(After Froelich.)
The umbilicus was particularly prominent, owing to a definite projection. This had existed since
the cord came away. For its relative size and position see Fig. 118.
Fig. 118. — A Patent Omphalomesenteric Duct. (After
Froelich.)
The umbilical growth seen in Fig. 117. S, S, is the sound,
which passed down a certain distance and then directly into
the abdomen, as indicated by the dotted line. The entire
growth was removed. Its inner portion was continuous with
a pervious cord which opened into a loop of small bowel.
trouble. When the child came under observation, an elongated projection was
noted at the umbilicus (Fig. 117). At its center was an opening from which a clear
liquid escaped. The tumor was bright red and resembled intestinal mucosa. It
was soft in consistence, but on pressure could not be reduced in size. The patient's
movements did not cause any alteration in its size. A probe introduced into this
fistula could be carried downward and came in contact with the lower part of the
mass, but a curved probe directed toward the umbilicus passed into the abdomen.
The fluid escaping was alkaline. The condition was one of patent omphalomesenteric duct with partial eversion of the outer portion.
* Froelich, R. : Du fungus ombilical du nouveau-ne, a l'occasion cl'une operation de prolapsus ombilical du diverticule de Meckel. Rev. mens, des maladies de l'enfance, Paris, 1902, xx, 517.
198 THE UMBILICUS AND ITS DISEASES.
The omphalomesenteric duct was excised from a point about 0.5 cm. from the
intestine, and the stump turned into the bowel. Microscopic examination showed
that the surface of the umbilical nodule was covered with intestinal mucosa.
A Patent Omphalomesenteric Duct.* — The patient was a
boy two and one-half years old. From the time that the cord had come away fecal
matter had been noted at the umbilicus. In time a granular tumor the size of a
cherry developed at this point. There was some prolapse of the mucosa of the fistulous tract.
The fistulous tract was dissected free as far as the bowel and then removed.
The patient made a good recovery.
A Patent Omphalomesenteric Duct.f — At birth the cord
was very large near the umbilicus. It was bluish-green in color, and fell off on the
eighth day. There remained a red, snout-like mass, 2 cm. in length. This
secreted much pus, and, when the child cried, there was some bleeding. Later
on gas-bubbles and feces escaped.
At examination there was noted at the umbilicus a cylindric, somewhat conic,
snout-like mass, which hung downward and to the left. The left, which was the
under side, was 2 cm. long. The right, the upper side, was 3 cm. long. At the
bottom the growth was 2 cm. in diameter.
The skin was drawn upward upon the surface of the tumor on the right side for
a distance of 1.5 cm.; on the left for a distance of 0.75 cm. The remainder of the
tumor was covered with bright-red mucosa. In the center was a funnel-shaped
opening. A sound passed upward and to the right 7 cm.
Operation. — Two threads having been passed through its base to prevent
its giving way, the tumor was excised. Three small vessels were caught. On
account of the friable mucosa it was impossible to suture it, and the stitches were
taken at some distance away. The peritoneum was not seen. The skin ring of
the umbilicus was removed, and this area was drawn over the stump and closed.
The child made a good recovery. The wound healed perfectly, and the umbilical
ring, which was previously 2.5 cm. in diameter, contracted down until it was very
small.
The microscopic picture showed typical intestinal mucosa. The condition was
due to a patent omphalomesenteric duct.
A Fecal Concretion Discharged at the Umbilicus. J —
Heaton presented a patient in whom, after a short illness, a large fecal concretion
had been discharged from the umbilicus. This patient, before his illness and since
he left the hospital, had been in perfect health. There was no history nor any
evidence of tuberculosis. Heaton suggested that perhaps a concretion had become
impacted in Meckel's diverticulum, had set up an ulceration there, and, fortunately for the patient, had been discharged from the umbilicus.
Probable Persistence of the Omphalomesenteric
Duct.f — The patient was a female child, four months old, who had a red,
velvety, cylindric projection at the umbilicus. This was three-quarters of an inch
* Gevaert, G.: Fistule ombilicale diverticulaire chez un enfant. Ann. de med. et de chir.,
- iv, 1.
f Hansen, J. A. : Ein Beitrag zur Persistenz des Ductus omphalo-entericus. Inaug. Diss.,
Kiel I "
% Heaton, G.: Brit, Med. Jour., 1898, i, 627.
§ Hickman: Persistent Vitelline Duct, Trans. Path. Soc. London, 1869, xx, 418.
A PATENT OMPHALOMESENTERIC DUCT. 199
long, stiff and tense, and constricted at its base. Its end was covered with a thin
slough. It bled readily, but no aperture could be detected. It had existed since
the cord had come away. The mother said she had noticed a little moisture having
the odor of feces, but no fecal matter could be detected.
Hickman says that usually, in these cases, eversion of the mucous membrane
leaves a canal extending into the bowel through which the feces occasionally pass.
In this case no canal could be found.
[The fact that there was a fecal odor here seems to indicate clearly that an opening existed, although Hickman did not find it. A reference to other cases will show
that, although no definite connection with the bowel was detected, at operation
the canal was found to be patent.]
Patent Omphalomesenteric Duct. — Holmes* had a patient
who gave a history of having had a warty growth at the umbilicus during his first
year. This was ligated. Holmes saw him when he was ten years old, and at that
time he had a constant but not copious discharge from the umbilicus. This fluid,
macroscopically and chemically, resembled bile. Later vegetable matter escaped,
showing that a definite fecal fistula existed.
A Patent Omphalomesenteric Duct, f — The patient was
a poorly developed male. The midwife, when tying the cord, noticed its unusual
breadth, but nevertheless put the ligature at the usual point. When the cord
dropped off on the third day there was left a raw area, the size of a thaler, which
was prominent and moist and from which fluid escaped. Within a few days the
surrounding parts became erythematous, and on the sixth day the mother observed
feces coming from the umbilicus. The greater part of the intestinal contents,
however, still passed by the rectum. The child had no pain in the lower abdomen,
but the parents were greatly distressed.
After several physicians had treated the child without success, an old nurse
put on an occlusion apparatus and then applied pressure. As a result the feces
were held back and the ring closed rapidly and became flatter. By the sixth week
the child had improved greatly and soon only a small amount of feces escaped
from the umbilicus. Three or four weeks later the umbilicus had healed completely and the child was strong and healthy.
A Patent Omphalomesenteric Duct.J — The patient was a
man, twenty-eight years old, who had a patent omphalomesenteric duct. At the
umbilicus was a reddish mass, the size of a cherry, showing at its top a depression
from which a mucous secretion escaped; no feces, however, were noted. The patient
had suffered from obstipation, and felt as if there were something in the umbilical
region which prevented the feces from passing. He had had severe colic. On
account of the foul odor his comrades avoided him, and his condition had rendered
him melancholic.
Operation. — The duct was removed at the bowel and the opening in the ileum
closed with two rows of sutures. The patient made a good recovery, but three
weeks after operation he committed suicide at his home.
* Holmes, T. : Surgical Treatment of Diseases of Children, London, 1868, 181.
t Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, xiv, 202.
Jacoby also reported this case in Jahrb. f. Kinderheilk. u. phys. Erzieh., 1878, xii, 144.
X Kehr, H. : Ueber einen Fall von Radicaloperation eines persistirenden Ductus Omphalomeseraicus. Deutsche med. Wochenschr., 1892, xviii, 1166.
200 THE UMBILICUS AXD ITS DISEASES.
A Patent Omphalomesenteric Duet.* — The child was six
months old. At the umbilicus was a red, smooth, moist tumor, the size of a hazelnut. When the child cried or when pressure was made on the abdomen, the tumor
increased in size. At its most prominent part was an opening, hardly the size of a
linseed, into which a sound could be introduced for from 5 to 8 cm. There escaped
from the fistula a clear green fluid, with a slightly yellowish tint. Under light narcosis the surface was seared with the cautery and a bandage was applied. At the
end of eight days nothing but a small opening remained. It was suggested that
the child be taken home for a time. When Kern reported the case, the child was
more than one year old and had improved, but a fistula remained.
Operation.- — Professor Kraske later excised the diverticulum and the child made
a good recovery.
A Patent Omphalomesenteric Duct . — -Kirmisson f says that
persistence of Meckel's diverticulum with an opening at the umbilicus is a rarity.
His patient was five and one-half months old. The father was not a strong man.
When the cord came away on the third day the mother noticed a whitish swelling,
which, eight days later, became reddish in color. The swelling was the size of a
strawberry. Its mucosa was smooth, and on its surface were two small, teat-like
projections, and in its upper portion a small orifice into which a probe could be
carried 3.5 to -i cm. The mucosa of the nodule merged directly into the skin surrounding the umbilicus. When the child cried or moved, the tumor became larger
and larger. Feces were not detected.
The tract was dissected out and removed. It communicated with the small
bowel. The fistula was about 5 cm. long and tapered off; its larger end was at the
bowel, the smaller, at the umbilicus. The child made a good recovery.
Microscopic Examination. — The mucosa at the umbilicus resembled that of the
intestine. Its surface was covered with cylindric epithelium and the glands were
tubular.
A Patent Omphalomesenteric Duct. — Kortet quoted Deschin
as saying that 1.8 per cent, of autopsies in children have shown remains of the
omphalomesenteric duct. He then reports the case of a boy, fifteen months old,
who had at the umbilicus a tumor resembling a penis. When the child cried, this
became larger than a finger. Its reduction was difficult. Usually the nodule was
the size of the tip of a finger.
The child suffered with intestinal catarrh. Attributing this to the open umbilicus,
Korte inserted an iodoform drain into the fistula. Later he resected it down
to the bowel. The child made a good recovery.
Patent Omphalomesenteric Duct. — Lannelongue and Fremont! refer to the cases of fistulse observed by Sandifort, Schulze, Tiedemann,
Ludwig, and Tilling, all of which were analyzed by Cazin.
They also say that Bruce reported several instances in which a small hernia of
* Kern: Leber das offene Meckel'sche Divertikel. Beitrage z. klin. Chir., 1S97, xix, 353.
t Kirmisson, E.: Persistence du diverticule de Meckel ouvert a rombilic avec prolapsus
de la rnuqueuse intestinale. Revue d'orthopedie, 1901, xii, 321.
{ Korte: Ein Fall von Extirpation des persistirenden Ductus omphalo-mesentericus.
Deutsche med. Wochenschr., 1898, xxiv, 103.
§ Lannelongue et Fremont : De quelques varietes de tumeurs congenitales de l'ombilic et
plus specialement des tumeurs adeno'ides diverticulaires. Arch. gen. de med., 1884, 7. ser., xiii,
36.
A PATENT OMPHALOMESENTERIC DUCT. 201
the umbilicus was included in the cord, and when the cord dropped off, a small
orifice was left from which feces and gas escaped; later, granulation developed at
the umbilicus, and after a variable time these openings closed. After considering
all the facts Duplay (they say) came to the conclusion that these were hernial
diverticula.
Intestinal Obstruction Due to a Patent Omphalomesenteric Duct.* — The patient was a boy, ten years of age, who was
said to have had an open umbilicus. The physician who saw the boy first when he
was three years old said it was nearly closed at that time. Nevertheless, it would
become prominent, finally flatten, and discharge a few drops of yellowish fluid
(odor not given). The child had good health, but frequently complained of
abdominal pain.
After eating three apples he was suddenly seized with abdominal pain, signs of
obstruction developed, and an operation was performed fourteen days later.
Operation. — When the abdomen was opened, a cord was found passing from the
umbilicus back into the abdominal cavity. It resembled intestine, and was the
size of a finger. Near the umbilicus it looked fibrous, but in the deeper portion
resembled bowel. It had encircled a loop of distended bowel and completely
occluded it. Peritonitis followed, and the patient died. The cord was found -to
be the omphalomesenteric duct, which was adherent to the umbilicus.
Case of Perforate Umbilicus. f — The patient was a male child.
Projecting from the umbilicus was a tumor the size of a hazel-nut. It was bright
red in color, and was perforated at its apex by an orifice from which there was a
continuous mucous discharge. This opening led into a long canal. There was no
escape of urine. The fluid looked like and smelled like fecal contents. The mucous
membrane was dissected away and the wound closed.
Marshall said that, although the outer opening could be closed, there would
always be a risk of some of the contents of the intestine passing into the canal and
setting up irritation and suppuration in the region of the umbilicus.
A Patent Omphalomesenteric Duct.J — The boy was born
with an umbilical hernia. On the fourth day, when the cord came away, a red,
sausage-like tumor was seen, from which feces and air escaped in small quantities.
The boy also passed stools by the rectum. He cried and lost weight. The tumor
was covered with mucosa, was the thickness of a thumb, and projected, somewhat
like a twisted horn, 3 cm. from the distended umbilicus (Fig. 119). A sound could
be introduced into it for 6 to 7 cm. and passed obliquely upward.
When the child was five weeks old, the abdomen was opened and the diverticulum removed. The child made a good recovery. Morian gives a table of the cases
of patent omphalomesenteric duct.
A Patent Omphalomesenteric Duct. — Nicaise § reports an
observation made by Patry. After ligation of the cord the child cried, was greatly
* Leisrink und Alsberg: Einklemmung seit 14 Tagen, Laparotomie. Einschniirung durch
einen off en gebliebenen Ductus omphalo-mesaraicus; Resection des eingeschniirten Darmstuckes
mit dem schnlirenden Strang ; Darmnaht. Tod nach 6 Stunden. Langenbeck's Arch. f. klin. Chir.,
1882, xxviii, 768.
t Marshall: Med. Times and Gaz., 1868, ii, 640.
t Morian: Ueber das offene Meckel'sche Divertikel. Langenbeck's Arch. f. klin. Chir.,
1899, lviii, 306.
§ Nicaise: Ombilic. Dictionnaire encyclopedique des sciences medicales, Paris, 1881, 2. ser.,
xv, 159.
202 THE UMBILICUS AND ITS DISEASES.
agitated, vomited, and suffered from constipation and abdominal distention.
These symptoms persisted for four or five days and did not cease until the ligature
of the cord came away, leaving a large aperture through which an abundance of
greenish liquid escaped. The child seemed to be very much relieved. Patry saw
the infant for the first time at the eighth month. He was then much emaciated.
The umbilical opening easily admitted a probe. It was surrounded by a collar
of mucosa the margins of which were raised, round, and reddish in color. From
the opening there escaped a quantity of fecal material almost equal to that passed
by the rectum. After feeling assured that the fecal material could all escape by
the intestine, Patry closed the umbilical orifice. He was able to obtain healing of
the fistula by cauterization and compression after a term of two months.
A Patent Omphalomesenteric Duct.* — ■ The patient was a
child thirteen days old. At birth an unusually thick cord was noted. When it
came away on the ninth day a red, moist surface was left behind. This rolled out
,J8fefc~
Fig. 119. — A Patent Omphalomesenteric Duct. (After Morian.)
The boy was born with an umbilical hernia. On the fourth day, when the cord came away, a red, sausage-like
tumor was seen. It projected 3 cm. from the umbilicus, and was covered with mucosa. It was a patent omphalomesenteric duct, with some prolapsus of its mucosa.
during the next two days. Projecting from the umbilicus, which was prominent,
was a red growth 1 cm. long, and covered with mucosa. At the tip of the projection was a small opening the size of a pin-head, into which a probe could be introduced for 8 cm. A mucoserous fluid escaped, but no feces.
The condition was diagnosed as a persistent omphalomesenteric duct with slight
prolapsus of the everted intestinal wall. It was not thought to open into the bowel.
Operation. — The abdomen was opened and the duct was found attached to the
convex surface of the small bowel. It was severed, and, with the umbilicus,
removed intact. The child made a good recovery.
A Patent Omphalomesenteric Duct. — Park's f patient (Case
2) was a college athlete who gave a history of always having had some discharge
from the navel. A probe could be passed downward through a small opening for
* Xeurath, Rudolf: Zur Casuistik des persist irenden Ductus omphalomesaraicus. Wien.
klin. Wochenschr., 1896, ix, 1158.
+ Park, Roswell: Clinical Lecture on Congenital Fistula? and Sinuses at the Umbilicus.
Med. Fortnightly, 1896, ix, 9.
A PATENT OMPHALOMESENTERIC DUCT. 203
a distance of three inches. A median abdominal incision was made, and the operator found a tubular communication with a loop of small bowel. The fistula was
exsected and the opening in the bowel closed. The patient made a good recovery.
A Patent Omphalomesenteric Duct. — In Pernice's Case
142* it was noted at birth that there was an abnormal thickening of the umbilicus.
The cord came away on the ninth day. The umbilicus did not contract down and
close as usual, but a greenish, thick discharge from it was noted; this gradually
became yellow and then whitish and turbid. "When seen at seven months of age,
the boy had at the umbilicus a growth suggesting " proud flesh," which was open
in its center. The umbilicus swelled out markedly whenever the child cried. The
skin in the vicinity was reddened and excoriated, and the skin papillae were somewhat enlarged. In the middle of the umbilicus was a broad-based, reddish, mucuslike excrescence, and in the vicinity a funnel-like depression which also had a reddish wall. A probe could be passed down this funnel for 6 cm. toward the pelvis.
The canal was broad and easily admitted a No. 12 bougie. When the child cried,
the funnel filled with a secretion resembling mucus, which was turbid, alkaline in
reaction, and contained particles of fecal matter.
The inner surface of the canal was lined with cylindric cells. The canal was
curetted with a sharp spoon several times, and after five weeks it remained
closed.
A Patent Omphalomesenteric Duct.f — The patient was a
male child, three years old. His parents were in good health. On the fifth day
after birth the nurse made traction on the cord, as it had not come away. "Inflammation" followed, and a small opening developed. Sometimes this opening
would close for three weeks or more, but never for a much longer period.
On examination the mother was surprised to see a worm, half an inch long,
crawling along the child's abdomen. The child, who had been ill, rapidly recovered.
Several weeks later two worms similar in character were extracted from the
umbilical fistula.
Between intervals of abdominal pain the child enjoyed good health, except for
occasional pain due to the worms. At the umbilicus was a slight projection the
size of a hazelnut, with an opening in the center which discharged contents resembling feces.
On several occasions a physician was called to see the child when in great pain
and removed lumbricoid worms from the fistula.
A Patent Omphalomesenteric Duct.* — The umbilical cord
was unusually thick, for an inch and a half from the abdomen, being more than
double the caliber of the rest of the cord. The ligature was applied distally to this
thickening, the resultant stump being unusually tense and hard. On the ninth
day the covering at the top sloughed, revealing a red, granular projection. At
the end of a month the outer covering had disappeared, and a firm, smooth, red
tumor remained. This was one and a half inches long, pyriform in shape, and
attached to the umbilicus by a short but thick pedicle. Its outer extremity pre
* Pemice, L.: Die Nabelgeschwiilste, Halle, 1892.
f Poussin: Observation sur l'expulsion de l'abdomen, par une ouverture a l'ombilic, de
plusieurs vers ascarides-lombricoides. Jour, de med., 1817, xl, 81.
t Pratt, J. W. : A Remarkable Case of Umbilical Tumor. The Lancet, London, 18SL ii,
1142.
204 THE UMBILICUS AND ITS DISEASES.
seated a central orifice from which a watery fluid exuded more or less constantly.
There was no evidence of hernia. The growth was not painful, but bled when
handled, unless treated gently with oiled fingers. It became vascular when the
child cried. Toward the end of the third week after birth fecal matter commenced
to escape. This phenomenon was noted every three or four days during the
following month. The child's general health was good.
"When the child was seven weeks old, a strong silk ligature was tied around the
pedicle of the growth. Three days later, on removal of the. dressing, the growth
was found detached. The raw area was dressed with zinc ointment and a pad
applied. In a few days nothing but an induration was noted around the umbilicus.
The child was well a few days later. There was no return of the fistula.
An Omphalomesenteric Duct so Nearly Patent that
Moderate Pressure was Sufficient to Force Intestinal
Contents Through the Umbilicus. — In a male infant at term
Prestat* demonstrated an intact umbilical cicatrix. On opening the abdomen
he found a cord the size of a goose-quill, 2^ inches long, and communicating with
the small intestine. This opening was oblique and passed from the convex side of
the bowel. When pressure was exerted on the small bowel, fecal matter passed
along the fistula and caused a pouting out of the umbilical cicatrix. This readily
yielded, allowing feces to escape, thus demonstrating conclusively that the omphalomesenteric duct was practically patent along its entire course and merely sealed
over at the umbilicus.
A Series of Patent Omphalomesenteric Ducts. —
Quaet-Faslem f gives a very good resume of the literature on the origin of the
omphalomesenteric duct, and then reports five cases of persistent patency. The
first case had been already recorded by Hansen in his inaugural dissertation (Kiel,
1885).
In Case 2 of his series a boy, nine days old, was admitted to the hospital, on
January 4, 1888, because feces were escaping at the umbilicus. At the navel was
a long, pear-shaped tumor, 8 to 10 cm. long, with an opening in the center. A
sound could be passed through it into the abdomen.
The tumor was cut off with scissors and the opening closed with catgut. The boy
made a satisfactory recovery. The fistula was a patent omphalomesenteric duct.
Case 3 (1892). A ten-months-old male child presented a prominent umbilicus
with a small opening from which mucus escaped. The tumor was removed and
the wound successfully closed.
Case 4 (1885) was that of a boy two days old in whom a blackish-green cord still
remained. There was also a conic, red umbilical tumor, showing at its summit
a small opening from which mucus escaped. When the child coughed or moved,
small fecal masses came away. The tumor was removed and the lumen closed,
with good results.
Case 5 (1895). A girl, five years old, was admitted because the umbilicus had
never healed and secreted fluid. Around the umbilical opening was a reddening,
and at the umbilicus was a hernia the size of a nut, from the center of which a
* Prestat (quoted by Ledderhose) : Chirurgische Erkrankungen des Nabels. Deutsche
Chirurgie, 1890, Lief. 45 b.
t Quaet-Faslem : Das Offenbleiben des Ductus omphalo-mesentericus. Inaug. Diss., Kiel,
1899.
A PATENT OMPHALOMESENTERIC DUCT.
205
yellowish secretion escaped. The child was very thin and pale. A diagnosis of
persistence of the omphalomesenteric duct was made.
Operation. — The tract was dissected out, cut off, and the hole in the bowel
closed. The results were satisfactory. It is unusual to find so many cases reported
from the same clinic (Petersen's). The cases, though perfectly clear, are fragmentary.
A Patent Omphalomesenteric Duct with the Central
Portion Partially Closed, Preventing the Further
Escape of Feces.* — The patient (L. P.), eleven months old, had a small,
smooth projection half an inch long and oneeighth of an inch in diameter at the umbilicus.
This was red, cylindric, and covered with mucosa.
There was no aperture leading to the abdominal
cavity. The mother stated that for some months
after the birth of the child there had been a very
foul discharge from the navel. This was fecal in
character. Xow there was no escape of feces,
and only occasionally moisture.
The projection was ligated and nipped off,
and the child left the hospital three days later in
good condition.
On microscopic examination the umbilical
polyp was found covered with intestinal mucosa.
In some places the covering had been rubbed off.
Railton comments on the closure of part of the
fistulous tract, thereby shutting off the escape of
feces. The closure was probably caused by new
connective-tissue formation.
A Patent Omphalomesenteric
Duct. — Roth (p. 383), f in the description
of Case 3, refers, to a boy, nearly a month old,
who exhibited an unusual outgrowth at the umbilicus after the cord came away. The tumor
was cylindric, red in color, and about the size of
the last phalanx of a small finger. The cord was
unusually large and came away on the eighth clay.
When the child was brought to the hospital,
this projection was 2 cm. long, and a sound could
be introduced 4 cm. downward. The surface of the tumor was velvety. From the
fistula bile, yellow grumous masses, and vegetable matter escaped, showing conclusively that it was a fecal fistula. The child died suddenly when six months old.
From a loop of small bowel the diverticulum extended to the umbilicus. From
the mesentery a delicate fold passed over the intestine and was adherent to the
umbilical ring (Fig. 120, b). In this fold several vessels were seen. The diver
Fig. 120. — A Patext Omphalomesenteric
Duct. (After Roth.)
A longitudinal section through the patent duct and the surrounding tissues, a is
the valve-like flap of mucosa where the omphalomesenteric duct opened into the small
bowel, b indicates the point of attachment
of the duct to the peritoneum of the anterior
abdominal wall. Just beneath it is the omphalomesenteric artery, c is the edge of the
peritoneal fold just above the diverticulum.
It will be noted that the outer portion of the
duct really formed a penile projection extending downward from the surface of the
abdomen.
* Railton, T. C: Prolapse of Meckel's Diverticulum (Omphalo-mesenteric Duct). Brit.
Med. Jour., 1893, i, 795.
t Roth, M.: ITeber Missbildungen im Bereich des Ductus omphalo-mesentericus. Virchows
Arch , 1881, Lxxxvi, 371.
206
THE UMBILICUS AXD ITS DISEASES.
ticulum was 58 cm. above the ileocecal valve. It gradually became smaller as it
passed from the small bowel to the umbilicus. There was a definite valve (Fig.
120, a) where the diverticulum passed from the intestine outward.
A Patent Omphalomesenteric Duct.* — In May, 1903, a
strong five-months-old girl was brought to the clinic with a history that, soon after
the dropping off of the cord on the sixth da} r , there had been observed a small red
tumor at the umbilicus. An odor had been detected only a little while before admission. The tumor had an opening at its tip, and from this now and then drops
of clear mucus were discharged.
It had not increased in size, but
wheu the child cried or when
pressure was exercised, it became a little more prominent .
The umbilical nodule was
about the size of a pea. It was
reddish and velvet -like, with a
fistulous opening in the middle
through which a sound could be
easily passed for 2 cm. into the
abdominal cavity (Fig. 121).
The tumor was somewhat pedunculated. The mother said
that there had never been any
discharge of fecal matter from
the fistula, and that the child's
Fig. 121. — A Patent Omphalomesenteric
Duct. (After Salzer.)
/' is the tumor: .V, the attachment to
the abdominal wall; D, the opening into the
bowel. For the low-power picture see Fig.
122. For the high-power see Fig. 123.
Fig. 122. — Paht of a Patent Omphalomesenteric Duct. (After
Salzer.)
Fig. 122 shows a longitudinal section of Fig. 121, on one side of
the fistulous tract. The entire outer surface of the tumor is covered
over with typical intestinal mucosa. MD indicates a point where
the glands show some branching. E shows the squamous epithelium. The line of junction between the skin and the mucosa is
sharply defined. For the high-power picture see Fig. 123.
stools had always been regular. From the history there was no doubt that the
condition was due to persistence of the omphalomesenteric duct. The only question was as to whether the fistula was complete or partial.
Operation, June 26, 1903. — An elliptic incision was made, encircling the
umbilicus, and a cord was found passing from the navel to the convex side of the
small bowel. This cord was 2 cm. long and 0.5 cm. thick. It was covered with
* Sulzr;r, H.: Ueber das offene MeckePsche Divertikel. Wien. klin. Wochenschr., 1904, xvii,
614.
A PATENT OMPHALOMESENTERIC DUCT.
207
peritoneum on all sides. Blood-vessels passed from the mesentery over the bowel
to this cord.
The diverticulum was cut off at the bowel; the bowel was closed, and the child
made a perfect recovery.
The tumor was hardened in Muller formalin solution and then in alcohol of
different strengths and embedded in paraffin. Serial sections were cut in such a
manner that they ran parallel with the course of the diverticulum throughout.
In some sections it was possible to see that the lumen of the intestine was open and
A.D.
v-ay - /-
Fig. 123. — Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Omphalomesenteric
Duct. (After Salzer.)
Fig. 123 shows a small portion of Fig. 121. At M.D. is a large gland. On being followed downward, its branches
are clearly seen. D.D. indicates goblet-cells. The surface of the mucosa shows some degeneration, evidently on
account of coming in contact with the clothing.
communicated with the umbilical fistula. Some of the sections were stained with
hemalum-eosin and some by the van Gieson method. The peritoneal covering
of the diverticulum was seen to be directly continuous with that of the intestine as
far as the abdominal wall.
The nerve elements of Meissner's and of Auerbach's plexus were found in their
normal positions in all portions of the diverticulum. The mucosa of the diverticulum presented points of much interest. In its free abdominal portion, as well as
in the region of the abdominal wall, it was identical with the normal mucosa of the
small intestine. But where it lay free on the surface of the prolapsus on the
208 THE UMBILICUS AND ITS DISEASES.
abdomen, the character of the glands was markedly changed. The gland tubules
were smaller than Lieberkiihn's crypts. They often showed bifurcation or
numerous branches and were tortuous (Fig. 123). The gland-cells were clear, finely
granular, polygonal in shape, and showed a nucleus resting on the base. They took
the eosin weakly, and the glands themselves did not pass as deeply as those of
Lieberkiihn.
Professor v. Ebner and Professor Schaff er, who examined the specimens, said that
all these glands bore some resemblance to those of the cardiac end of the stomach.
At the point where the mucosa passed into the skin, the Lieberkiihn glands with
numerous goblet-cells were again visible (Fig. 122). A portion of the duct resembled, as Professor Ebner said, the mucosa of the large bowel.
Salzer says that, to epitomize the findings, we have a case of a patent omphalomesenteric duct.
A Patent Omphalomesenteric Duct.* — J. W., about ten
months old, was brought to the clinic on February 27, 1896. On the fifth day after
the cord had come away a granulation was noted at the umbilicus. This had an
opening the size of a darning-needle. It was surrounded by reddish walls, and by
making pressure the midwife could bring away sausage-like masses of fecal matter
from the umbilicus. The reddish walls became higher and thicker, and as the fecal
discharge did not cease, the child was brought to Dr. Noder, July 31, 1895.
Noder was able to introduce a sound fully 10 cm. into the abdominal cavity, and
at once greenish, soft fecal matter and greenish-colored fluid escaped. By gradually pressing inward, as one would do with a prolapsed anus, he could diminish the
size of the tumor. As a result of four applications of the cautery, the fistula
became so constricted that only mucus and watery fluid escaped from it.
As the child was not in very good physical condition, he was brought to the
hospital. Projecting from the umbilicus was a sausage-like body, 4.5 cm. long,
which spread out over the abdomen (Fig. 124). From its form and also its color
it was easily seen that it was divided into two portions. The first was in intimate
connection with the abdominal wall (Fig. 124, a). It was 2.5 cm. long, about
the thickness and roundness of a man's finger, and covered over with a prolongation
of the abdominal skin. Sitting on this like a cap was a second portion. It was
red, strawberry-shaped (Fig. 124, b), and covered over with a shiny red mucosa
which secreted an abundant quantity of mucus. Where the first mass joined the
second, there was a rather deep depression. No opening could be made out. There
was, however, at the top of the red tumor a slight depression (Fig. 124, c), but a
probe could not be introduced.
On pressure the two portions of the tumor were found to differ in consistence;
the first was hard and cord-like; the second was softer and could be pressed together
somewhat, but, nevertheless, was firm and uniform. On pressure both developed
some gurgling and could be reduced in size. When the child took a long breath
the entire mass was pushed outward and then receded again.
The abdominal walls were excoriated. Digestion and defecation were normal.
The fluid was alkaline in reaction and contained mucin. There was no evidence
whatever of urine at the umbilicus. The case was diagnosed as one of a Meckel's
* Sauer, Felix: Ein Fall von Prolaps eines offenen Meckel'schen Diver tikels am Nabel.
Deutsche Zeitschr. f. Chir., 1896-97, xliv, 316.
A PATENT OMPHALOMESENTERIC DUCT.
209
diverticulum reaching to the umbilicus and originally communicating with the
surface.
Operation. — When the peritoneum was opened, it was found that the tract had
communicated with a loop of the small bowel. The diverticulum was cut off, the
end turned in,, and the growth removed. The diverticulum was 3 cm. in length.
The child developed peritonitis
and died on the third day.
Sauer then goes on to give a
careful description of the microscopic findings. He sums up as
follows: At a point 53 cm. d
above the ileocecal valve is the
Meckel diverticulum which extends through the umbilical ring. g
After the dropping off of the um
Fig. 124. — An Umbilical Polyp and a Fibrous
Nodule at the Umbilicus. There was
Originally a Patent Omphalomesenteric Duct. (After Sauer.)
a is a portion of the prolapsus covered with
skin; 6, the outer end of the omphalomesenteric
duct, covered over with mucosa and formerly
opening into the bowel; c indicates the depression whence the fecal matter had at one time
escaped. The opening was closed by means of
the thermocautery. For the microscopic picture
see Fig. 125.
Fig. 125. — Longitudinal Section through the Entire Center of a Partially Closed Omphalomesenteric Duct.
(After Sauer.)
For the general appearance of the umbilical tumor see Fig.
124.
a, a portion of the tumor lying on the abdominal wall. The
tumor, b, is covered over with skin and consists of tissue of the
abdominal wall; c, the tumor covered over with mucosa; d, the
prominent hypertrophied mucosa of the diverticulum; e, the depression where communication with the diverticulum opening into
the bowel had formerly taken place; /, line of junction between
the skin and the mucosa; g, blood-vessels; h, the portion of
Meckel's diverticulum communicating with the bowel; i, a portion of Meckel's diverticulum has been nipped off and scar tissue
has formed as a result of cauterization; k, marked thickening of
the mucosa; I, scar tissue where the lumen formerly existed.
bilical cord the diverticulum becomes adherent to the abdominal ring. Through
mechanical pressure feces escape, then prolapsus of the diverticulum takes
place.
By means of the thermocautery the outer portion of the opening was closed.
Fortunately, there was no prolapse of the intestine. The opening was still closed
at the end of about three months. The solid portion of the tumor is shown in
15
210 THE UMBILICUS AND ITS DISEASES.
Figs. 124 and 125, and consists of fibrous tissue. The reddish tumor is covered
with typical intestinal mucosa.
A Patent Omphalomesenteric Duct. — Schroeder * says that
in the Prag. Path.-anat. Museum (Protocol 479, 1849) is the record of a child six
months old. The embryonic omphalomesenteric duct was present. It passed
from the umbilicus to the ileum as a canal increasing in size until it joined the bowel.
A Patent Omphalomesenteric Duct. | — The patient was a
strong, healthy boy three months old. He was admitted to the hospital with a
fecal fistula at the umbilicus. At birth the cord was thicker than usual. The
ligature came away on the fifth day, and on the following day the nurse noticed
flatus escaping from the umbilicus; later, feces were discharged in large or small
quantities. A few days after the cord came away the umbilical growth protruded
more markedly.
At the site of the umbilicus was a protrusion which was the size of, and had the
appearance of, a child's penis. This projection was V/^ inches long and had at its
extremity an opening which looked very much like a preputial orifice. The growth
was covered over with mucosa and bled easily. For three or four inches around
the umbilicus the skin was raw, red, and eczematous. A probe could be introduced
into the projection, and feces escaped. The fistulous tract was large enough to
admit easily a pair of artery forceps.
Operation. — The abdomen was opened; the diverticulum was cut off, and the
hole in the bowel closed. The child made a good recovery.
A Patent Omphalomesenteric Duct. J — A boy, aged seven,
was brought to the hospital on account of a lumbricoid worm which was protruding
from the umbilicus. MacSwiney says: "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 tract or sinus through which it was slowly making its
way out."
The father said that since birth there had been a fistula at the umbilicus and
that it constantly discharged. There was never, however, any sign of blood, bile,
or feces. The discharge was clear yellow matter with no fecal odor. MacSwiney,
and his friend, Dr. Kelly, thought the case to be one of an unclosed vitelline duct.
A Patent Omphalomesenteric Duct.§ — A male child, two
months old, was admitted June 1, 1896. The labor had been normal. The old
midwife said that in her long experience she had never seen so large an umbilicus
in the new-born.
When the cord came away, the mother had noticed at the umbilicus a reddish
tumor from the point of which intestinal contents were discharged. Since birth
the tumor had grown but very little. The child was well developed and healthy.
At the umbilicus was a tumor the size of a hazel-nut. In form it resembled a penile
* Schroeder, G.: Ueber die Diverlikel-Bildungen am Darmkanale. Inaug. Diss. (Erlangen),
Augsburg, 1854.
t Shepherd, F.: Umbilical Fecal Fistula in an Infant Cured by Radical Operation. Arch.
of Pediatrics, L892, ix, 55.
% MacSwinev, S. M.: Ascaris Lumbricoides extracted from an Umbilical Fistula. Proc.
Path. Soc. of Dublin, 1873-75, vi, 251.
\ Stierlin, R. : Zur Casuistik angeborener Nabelfisteln. Deutsche med. Wochenschr., 1897,
xxiii, 188.
A PATENT OMPHALOMESENTERIC DUCT.
211
gland. It was dark red in color, velvety, glistening, and reminded one of intestinal
mucosa. At the point of the tumor was an opening which admitted a sound; at
the base was a ring of indurated tissue, 4.5 mm. broad, which surrounded the
tumor as a cuff. When the child cried, the tumor was a little more prominent.
If pressure was made on the abdomen, there escaped a small quantity of
gas and fluid fecal matter from the umbilicus. A metallic sound passed 6 to
8 cm. downward; an elastic catheter, 25 cm. and farther, without any difficulty.
Defecation and urination were normal. Stierlin came to the conclusion that
he had to deal with a diverticulum.
The skin ring at the umbilicus was split upward and downward. It was then
easy to separate the tumor from the surrounding structures. On making traction
and continuing the dissection Stierlin found that the fistula passed to the convex
side of the small bowel. The diverticulum was 6 cm. long (Fig. 126).
While the dissection was being made, it was noted that an artery had been
injured. This was isolated, tied, and dropped back
into the abdomen. It was a persistent omphalomesenteric artery. The base of the diverticulum
was now clamped, and the diverticulum removed.
The opening in the bowel was closed with two continuous silk sutures. The child made a good recovery.
Strangulation of Intestine by
Diverticulum Ilei. — Wilks* reported a
case of obstruction caused by Meckel's diverticulum. The child had previously undergone a
successful plastic operation for fecal fistula at the
umbilicus.
A Patent Omphalomesenteric
D u c t . f — ■ Peter M., three weeks old, had an
umbilical fistula which had been noted soon after
the cord came away. A great deal of fecal matter
escaped. Surrounding the opening was a small fungous wall. Caustics were applied to the fistulous
tract, and a bandage was put on, but without success. Several years later the child was brought back.
The fistula had become smaller, but fecal matter still escaped
tried, this time with success.
A Patent Omphalomesenteric Duct. J — Frederick W., seen
by Wernher, was a twin child eleven weeks old, and well formed. The parents
said that the child had had intestinal obstruction. At other times there would be
abdominal pain and diarrhea. He cried a good deal and vomited. On examination the umbilicus was found to be prominent. Surrounding the margin of the
fistula was a fleshy wall which bled readily and was covered with brownish crusts.
Wernher lost track of the child, but it was brought back three months later. The
Fig. 126. — A Patent Omphalomesenteric Duct. (After Stierlin.)
A diverticulum, springing from
the convex surface of a loop of small
bowel. It was 6 cm. long, and ended
in a mushroom-like extremity. It was
cut off at the line indicated by a-a
and inverted just as one would do
with an appendix.
Caustics were again
* Wilks, Samuel: Trans. Path. Soc. London, 1865, xvi, 126.
f Weiss, Eduard : Ueber diverticulare Nabelhernien und die aus ihnen hervorgehenden Nabelfisteln. Inaug. Diss., Giessen, 1868.
X Weiss, Eduard : Op. cit.
212 THE UMBILICUS AND ITS DISEASES.
projection at the umbilicus was hard, and when the child cried, a few drops of brownish fecal matter escaped. Cauterization was tried and the amount of fecal discharge
diminished. Eight days later the opening was closed and the bowels were regular.
Six months later the child was again admitted. A week before admission it
had coughed a great deal, and as a result of the coughing a prominence was noticed
at the umbilicus. The digestion had been disturbed for some time, and there were
diarrhea and colic. As a result of severe coughing the umbilical scar broke and
yellowish fecal matter and some blood escaped. The child soon died.
Autopsy. — A Meckel's diverticulum was found extending from the convex side
of the bowel; it had a mesentery of its own. The mucosa of the diverticulum of
the ileum was much injected. It opened at the umbilicus by a small passage.
LITERATURE CONSULTED ON PATENT OMPHALOMESENTERIC DUCT.
Alsberg, A. : Ueber einen Fall von Radicaloperation eines persistirenden Ductus omphalo-meserai
cus. Deutsche med. Wochenschr., 1892, xviii, 1040.
Ardouin, P.: Persistance du diverticule de Meckel ouvert a l'ombilic, fistule stercorale, omphal
ectomie, extirpation du diverticule, guerison. Arch. prov. de Chir., 1908, xvii.
Barth, A. : Ueber die Inversion des offenen Meckel'schen Divertikels und ihre Complication mit
Darmprolaps. Deutsche Zeitschr. f. Chir., 1887, xxvi, 193.
Battle, W. H.: Extroversion of Meckel's Diverticulum. Clin. Soc. Trans., London, 1893, xxvi,
237.
Billroth: Chir. Klinik, Berlin, 1869, 294.
Broadbent: Patent Vitelline Duct. Med. Times and Gaz., 1866, ii, 45.
Broca, A. : Persistance du diverticule de Meckel ouvert a l'ombilic et invagine au dehors. Revue
d'orthopedie, 1895, vi, 47.
Bureau, J.: Prolapsus ombilical du diverticule de Meckel. These de Paris, 1898, No. 257.
Brun, L. A. : Sur une espece particuliere de tumeur fistuleuse stercorale de l'ombilic. These de
Paris, 1834, No. 238.
Deschin: Zur Frage der chirurgischen Behandlung bei dem Vorfall des Dotterganges. Centralbl.
f. Chir., 1895, xxii, 1154.
Eves: A Case of Diverticulum Ilei Communicating with the Umbilicus. The Lancet, London,
1845, i, 101.
Fitz, R.: Persistent Omphalomesenteric Remains, their Importance in the Causation of Intestinal
Duplication, Cyst-formation, and Obstruction. Amer. Jour. Med. Sci., 1884, lxxxviii, 30.
Froelich, R.: Fongus ombilical du nouveau-ne, prolapsus ombilical du diverticule de Meckel.
Etude de chir. infantile, Paris, 1905, 85. Du Fongus ombilical du nouveau-ne, a l'occasion
d'une operation de prolapsus ombilical du diverticule de Meckel. Rev. mens, des mal. de
l'enfance, Paris, 1902, xx, 517.
Gevaert, G.: Fistule ombilicale diverticulaire chez un enfant. Ann. de med. et de chir., 1892,
iv, 1.
Hansen, J. A.: Ein Beitrag zur Persistenz des Ductus omphalo-entericus. Inaug. Diss., Kiel,
1885.
Heaton, G.: Fecal Concretion discharged at the Umbilicus. Brit. Med. Jour., 1898, i, 627.
Hickman: Persistent Vitelline Duct. Trans. Path. Soc. London, 1869, xx, 418.
Holmes, T.: Surgical Treatment of Diseases of Children, London, 1868, 181.
Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, xiv, 202; Jahrbuch
fur Kinderheilkunde und phys. Erzieh., 1878, xii, 144.
Kehr, II.: Leber einen Fall von Radicaloperation eines persistirenden Ductus omphalomese
raicus. Deutsche med. Wochenschr., 1892, xviii, 1166.
King, T. W.: Fajculent Discharge at the Umbilicus from Communication with the Diverticulum
Ilei. Guy's Hospital Reports, 1843, i, 2. series, 467.
Kern: Ueber das offene Meckel'sche Divertikel. Beitrage z. klin. Chir., 1897, xix, 353.
Kirmisson, E.: Persistance du diverticule de Meckel ouvert a l'ombilic avec prolapsus de la
muqueuse intestinale. Revue d'orthopedie, 1901, xii, 321.
A PATENT OMPHALOMESENTERIC DUCT. 213
Korte: Ein Fall von Extirpation des persist irenden Ductus omphalomesentericus. Deutsche
med. Wochenschr., 1S9S, xxiv, 103.
Lannelongue et Fremont: De quelques varietes de tumeurs congenitales de l'ombilic et plus
specialement des tumeurs adenoides divert iculaires. Arch. gen. de med., 1884, 7. ser., xiii, 36.
Leisrink und Alsberg: Einklemmung seit 14 Tagen, Laparotomie. Einschntirung durch einen
offen gebliebenen Ductus omphalo-mesaraicus; Resection des eingeschniirten Darmstiickes
mit dem schniirenden Strang; Darmnaht. Todnach 6 Stunden. Langenbeck's Arch. f. klin.
Chir., 1S82, xxviii, 768.
Marshall: Case of Perforate Umbilicus. Med. Times and Gaz., 1868, ii, 640.
Morian: Ueber das offene Meckel'sche Divertikel. Langenbeck's Arch. f. klin. Chir., 1899, lviii,
306.
Xicaise: Ornbilic. Dictionnaire encyclopedique des sciences medicales, Paris, 1881, 2. ser.,
xv 5 159.
Xeurath,. R. : Zur Casuistik des persist irenden Ductus omphalo-mesaraicus. Wien. klin. Wochenschr., 1896, ix, 1158.
Park, Roswell: Clinical Lecture on Congenital Fistula? and Sinuses at the Umbilicus. Med.
Fortnightly, 1896, ix, 9.
Pernice. L.: Die Xabelgeschwiilste, Halle, 1892.
Poussin: Observation sur l'expulsion de l'abdomen, par une ouverture a l'ombihc, de plusieurs
vers ascarides-lombricoides. Jour, de med., 1817, xl, 81.
Pratt, J. W.: A Remarkable Case of Umbilical Tumor. The Lancet, London, 1884, ii, 1142.
Prestat: Ledderhose, Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lieferung 45 b.
Quaet-Faslem: Das Offenbleiben des Ductus omphalo-mesentericus. Inaug. Diss., Kiel, 1899.
Railton, T. C: Prolapse of Meckel's Diverticulum (Omphalo-mesenteric Duct). Brit. Med.
Jour., 1893, i, 795.
Roth, M.: Ueber Missbildungen im Bereich des Ductus omphalo-mesentericus. Virchows
Arch., 1881, Lxxxvi, 371.
Salzer, H.: Ueber das offene Meckel'sche Divertikel. Wien. klin. Wochenschr., 1904, xvii, 614.
Sauer, F.: Ein Fall von Prolaps eines offenen Meckel'schen Divertikels am Nabel. Deutsche
Zeitschr. f. Chir., 1S96-97, xhv, 316.
Schroeder, G.: Ueber die Divert ikel-Bildungen am Darmkanale. Inaug. Diss. (Erlangen), Augsburg, 1854.
Shepherd, F. : Umbilical Faecal Fistula in an Infant Cured by Radical Operation. Arch, of Pediatrics, 1892, ix, 55.
MacSwiney, S. M.: Ascaris Lumbricoides extracted from an Umbilical Fistula. Proc. Path.
Soc. of Dublin, 1S73-75, iv, 251.
Stierlin, R.: Zur Casuistik angeborener Xabelfisteln. Deutsche med. Wochenschr., 1S97, xxiii,
188.
Wilks, S.: Strangulation of Intestine by Diverticulum Ilei. Trans. Path. Soc. London, 1S65,
xvi, 126.
Weiss, Eduard: Ueber diverticulare Xabelhernien und die aus ihnen hervorgehenden Xabelfisteln.
Inaug. Diss., Giessen, 186S.
==Chapter XI. A Patent Omphalomesenteric Duct — Continued==
The opening of a patent omphalomesenteric duct on the side of the umbilical cord before the cord
drops off: Report of cases.
Prolapsus of the bowel through a patent omphalomesenteric duct opening on the side of the
umbilical cord.
Escape of meconium into the liquor amnii through the umbilicus.
An omphalomesenteric duct opening into the abdomen and discharging feces into the abdominal
cavity.
A patent omphalomesenteric duct associated with defective development of the rectum or anus.
In this chapter are considered several cases of patent omphalomesenteric duct
that presented some rather unusual features.
THE OPENING OF A PATENT OMPHALOMESENTERIC DUCT ON THE SIDE OF THE
UMBILICAL CORD BEFORE THE CORD DROPS OFF.
A glance at Fig. 10, p. 10, Fig. 11, p. 11, Fig. 12, p. 12, in the chapter on
Embryology, will show that in the early months of fetal life a large part of the intestine lies in the exoccelomic cavity of the cord. As the embryo develops nearly all
the intestine is found in the sac, but finally the bowel recedes into the abdomen and
this sac becomes obliterated.
That the sac occasionally remains open, and contains a patent omphalomesenteric
duct, is clearly demonstrated by the following cases:
Peake, in 1811, in a new-born child observed a tumor at the umbilicus. It was
larger than a walnut, and the skin grew over it for a quarter of an inch. The tumor
had the appearance of intestine protruding into the umbilical cord. The cord was
ligated at a point three or four inches from the umbilicus. At the lower part of
the tumor Peake noticed a fissure, and soon a thin, dark material escaped from the
opening. The child died on the third day, and at autopsy the ileum was found
protruding at the umbilicus.
Auvard, in 1889, observed a tumor at the umbilicus in a newly born child,
Accordingly the cord was tied at a point 8 cm. from the umbilicus. The tumor
measured 3x4 cm. In the anterior portion of the cord, 3 cm. from the umbilicus.
was an opening which had everted margins and measured 3 to 4 mm. It was reddish
in color, and meconium escaped from it. Both the mother and the midwife said
this opening existed when the child was born (Fig. 127, p. 216, Fig. 128, p. 216).
The child's bowels moved regularly, but it sometimes vomited fecal matter.
When the cord came away, a red tumor the size of a walnut remained, which
was continuous with the opening. At autopsy a patent omphalomesenteric duct
was found (Fig. 129).
(iampert, in 1893, reported a case in which the cord was larger than usual. It
was accordingly tied at a point 9 cm. from the umbilicus. Five days later, although
the cord was still attached, yellowish material began to escape from its base. The
214
A PATENT OMPHALOMESENTERIC DUCT. 215
cutaneous umbilical orifice was prominent, and formed a collar around the tumor
occupying its center. This tumor was 1 cm. in diameter and irreducible, and in
its center was an orifice from which gas and feces escaped. A sound could be carried for 3 or 4 cm. into the fistula. The surrounding skin was slightly irritated.
On the tenth day a slight prolapse of the mucosa occurred. Fearing prolapsus of
the bowel, Gampert cauterized the canal, applied a ligature to the tumor, cut off
the excess, and applied pressure. In this way the fistula was successfully closed.
Guthrie, in 1896, recorded the case of a child that had had no movement for
three days after birth. Feces then began to escape from an opening in a colorless,
bladder-like projection, which had existed at the umbilicus since birth. This protrusion was attached to the cord. It became red and inflamed, ulcerated, and then
disappeared.
For a month after birth some feces were passed by the rectum, and then all escaped through the umbilicus. Later there occurred a prolapse of the bowel through
the opening, which, however, finally disappeared spontaneously. At autopsy the
patent omphalomesenteric duct was found at a point 12 inches above the ileocecal
valve.
CASES IN WHICH THE OMPHALOMESENTERIC DUCT OPENED ON THE SIDE OF
THE UMBILICAL CORD.
A Patent Omphalomesenteric Duct Opening to the
Side of the Umbilical Cord.* — In this case the midwife noticed a
tumor at the umbilicus. The cord was tied distally to this, at a point 8 cm. from
the insertion at the umbilicus. When the child was seen by Auvard, there was a
cylindric tumor, measuring 3x4 cm., at the umbilicus. This was included in the
membranes of the cord and covered with amnion. The cord was free for about 6
cm. from the umbilicus. In the anterior portion of the cord, at a point 3 cm. from
the umbilicus, was an opening, the margins showing an eversion. This opening was
reddish in color; it measured 3x4 mm., and from it there escaped a greenish liquid,
rather thick, and of the character of meconium. The midwife and the mother said
that this opening had existed at the time of the child's birth (Figs. 127 and 128).
The bowels moved regularly. All the generative organs were normal.
This boy was transferred on the fourth of January to La Charit?. By January
8th the cord had not yet come away, but a small quantity of greenish liquid was escaping from the opening. The discharge was sometimes yellowish. The patient
vomited frequently, and the fecal matter was sometimes green. On January 10th
the cord came away, leaving a red tumor, the size of a walnut, continuous with
the opening above described. A sound introduced could be passed into the cavity
without difficulty, and carried inward 6 cm. The child's weight continually
diminished.
On January 12th the child was presented at the Obstetrical and Gynecological
Society of Paris. The members present, particularly Lucas-Championniere, were
of the opinion that the tumor represented a hernia of the diverticulum of the intestine. The child's weight continued to diminish, and he died on February 3d,
apparently from weakness. The umbilical tumor had diminished in size. At
autopsy it was not larger than a pea. When the abdomen was opened, a loop of
* Auvard: Travaux d'obstetrique, 1889, Paris, i, 331.
216
THE UMBILICUS AND ITS DISEASES.
small bowel was found extending toward the umbilicus, and a diverticulum opened
from the loop through the umbilicus (Fig. 129). The diverticulum entered the
small bowel at a point 42 cm. from the cecum.
A Patent Omphalomesenteric Duct Opening on the
Side of the Umbilical Cord.* — • The cord at the umbilicus was
larger than usual. The ligature was applied at a point 9 cm. from the umbilicus.
On February loth, five days after birth, the midwife called Gampert, because the
cord did not come away and because at its base a yellowish material was escaping.
This discharge resembled fecal matter. The stools passed normally by the rectum.
Fig. 127. — A Patent Omphalomesenteric Duct Opening at the
Base or the Umbilical Cobd.
(After Auvard.)
This sketch was made four days
after the birth of the child. The
cord was ligated at a point about 8
cm. from the umbilicus. In the anterior part of the cord, 3 cm. from
the umbilicus, was an opening admitting the little finger. The margins were raised, and there was some
eversion, the everted portion being
reddish in color. From the orifice a
greenish material, having the characteristics of meconium, escaped.
There was frequent vomiting.
Fig. 128. — A Patent Omphalomesenteric Duct.
(After Auvard.)
This picture was obtained
eleven days after birth. The
cord came away on the seventh
day, and left a pinkish tumor
the size of a walnut, with the
opening as shown. The child
became weaker, and died after
a month. For the appearance
four days after birth see Fig.
127. For the intra-abdominal
picture see Fig. 129.
Fig. 129. — A Patent Omphalomesenteric Duct as Seen fbom the
Abdominal Cavity. (After Auvard.)
This picture was obtained at autopsy. A loop of small bowel lies near
the inner umbilical opening, and from
it a diverticulum passes directly to the
umbilicus. It opened on the surface.
Passing from the mesentery over loops
of small bowel to the umbilicus was a
fine fibrous cord, evidently a remnant
of an omphalomesenteric vessel.
When seen, the child was large and well developed, and the cord was still adherent to one-half of the circumference of the umbilicus. The cutaneous umbilical
orifice was prominent, and formed a large collar around the tumor which occupied
the center. This tumor was about the size of the little finger, and cylindric in form
and shape. It was 1 cm. in diameter and irreducible. It had in its center an orifice from which yellowish material and gas escaped. A sound could be carried in
to a depth of 3 or 4 cm. The skin around the umbilicus was slightly irritated.
On the tenth day, when the child cried, a slight prolongation of the mucosa
showed at the orifice. Fearing prolapsus of the bowel, Gampert cauterized the
* Gampert: Fistule entcTo-ombilicale diverticulaire chez un nouveau-ne. Rev. med. de la
Suisse romande, 1893, xiii, 356.
A PATENT OMPHALOMESENTERIC DUCT. 217
canal and used pressure. The tumor diminished, and tannic acid powder and
vaselin were used. A silk ligature was applied, and the excess of tissue was cauterized. When the ligature came away, the opening was closed and remained so.
A Case of Patent Meckel's Diverticulum into which
the Posterior or Distal Wall of the Ileum Became Intussu seep ted, Forming an Umbilical Tumor; Death.* — A
male infant, six weeks old, was admitted to the Paddington Green Hospital on
April 25, 1892. At birth it weighed seven pounds and three ounces. After three
days, during which there was no stool, the child began to defecate through an opening in a colorless, bladder-like projection, which had existed from birth at the
umbilicus and to which the cord was attached. The cord separated on the ninth
day.
The colorless protrusion subsequently became red and inflamed and finally
ulcerated; it disappeared a few days before admission. For about a month after
birth some portion of the feces came from the rectum, but later all passed through
the umbilicus. Micturition was normal.
On admission the child was puny and emaciated. Protruding from the umbilicus
was an elongated mass, V/2 inches long by 1 inch in breadth. It was of
a dull red color, and had the appearance of intestinal mucosa. Near its superior
extremity there was an opening through which feces were discharged, and a
catheter could be passed upward and to the right. There was also a small dimple
on the inferior end of the protrusion. This would not admit a probe.
On April 29th the protrusion increased to the length of six inches. It became
somewhat tightly constricted at the umbilicus. It was much congested, and
resembled an intussusception. Taxis failed.
As the patient was too weak, the hernia was let alone. Two days later it
disappeared spontaneously, but the child died of exhaustion May 2d.
Autopsy. — The fistula was 12 inches above the ileocecal valve. The upper
opening led to the somewhat dilated ileum; the lower opening to the collapsed
small and large bowel. The entire large bowel was not bigger than a lead-pencil.
The cecum was reduced to the size of the first joint of the little finger. The large
bowel apparently had never contained feces. There had been a prolapsus of the
bowel through the patent omphalomesenteric duct.
Case of Preternatural Anus Found in a Portion of
Ileum Protruded at the Umbilicus. — J. Peake,f a member of
the Royal College of Surgeons, London, found, on delivering a woman of a healthylooking boy, that the child had a tumor at the umbilicus. This was larger than a
walnut, and the skin grew over it for a quarter of an inch. At the upper part the
umbilical vessels passed over the tumor but seemed altogether distinct from it.
A ligature was tied around the cord where it appeared normal, that is, at a point
three or four inches from the umbilicus.
Peake goes on to say that the tumor had the appearance of a protruding portion
of the intestine within the umbilical cord, and at its lower part he could observe a
fissure. Soon a thin, dark material escaped from this opening; it was probably
meconium.
Shortly after birth the child vomited frequently, and was evidently ill. It
* Guthrie, L. G.: Pediatrics, 1896, ii, 1.
t Peake, J.: Edinb. Med. and Surg. Jour., 1811, vii, 52.
218 THE UMBILICUS AND ITS DISEASES.
had many convulsions, and died on the third day. The food that was given it was
either directly brought up again or afterward passed through the aperture at the
navel. Nothing seemed to pass along the regular course of the intestine. Just
before death a little mucus and meconium escaped by the rectum.
Autopsy. — The passage from the stomach to the umbilicus was normal. A
portion of the ileum protruded at the umbilicus. The bowel below was much
smaller than normal.
PROLAPSUS OF THE BOWEL THROUGH A PATENT OMPHALOMESENTERIC DUCT
OPENING ON THE SIDE OF THE UMBILICAL CORD.
Prolapsus of the bowel through a patent omphalomesenteric duct is discussed
at length in Chapter XII. The case recorded by Gibb is the only example known
to me in which prolapsus of the bowel occurred on the side of the cord during the
first few hours of life. In Guthrie's case the omphalomesenteric duct opened on
the side of the cord, but prolapsus did not occur until several weeks after the cord
came away.
Unique Congenital Malformation, Associated with
Umbilical Hernia and a Pendulous Artificial Anus.—
Gibb * reports a rather unusual condition noted a few hours after the child's birth.
The upper part of the cord had dilated, forming an umbilical hernia containing
intestine. Attached to the side of the sac was a blood-red body with villous surfaces, looking like intestinal mucous membrane. Meconium passed from both
ends of this body. From the anus feces passed on the third day. At autopsy the
large bowel was found to be diminished in size. Gibb thought that the mass was
a portion of the cecum and the ileum. [This picture (Fig. 130) presents the appearances typical of a prolapse or inversion of the small bowel through the patent
omphalomesenteric duct in association with an umbilical hernia.]
ESCAPE OF MECONIUM INTO THE LIQUOR AMNII THROUGH THE UMBILICUS.
If Auvard had been present when the child, whose case he reported, was born,
he would probably have found meconium in the liquor amnii, as the omphalomesenteric duct lay open on the side of the cord. In other words, at birth there
was a direct connection between the lumen of the small bowel and the amniotic
cavity.
The only case in which it is definitely stated that meconium escaped through
the cord into the liquor amnii is the one mentioned by Brindeau.
A Patent Omphalomesenteric Duct, with Fecal Matter Escaping into the Liquor Amnii. f — The patient, an eight
months child, died on the fifth day after birth. Its weight was two pounds and
three ounces. Meckel's diverticulum was 22 cm. above the cecum. The omphalomesenteric duct was open, and traction had drawn the gut outward at a sharp
angle. The portions of the intestine immediately above and below the duct were
thus easily drawn together, like the barrel of a fowling-piece.
Meconium before birth had passed into the liquor amnii. The intestine above
the diverticulum was dilated; below, it was very small.
* Gibb: Trans. Path. Soc. London, 1856, vii, 216.
t Brindeau: Nouv. arch, d'obstet. et de gyn., Fevrier 25, 1895, 45.
A PATENT OMPHALOMESENTERIC DUCT.
219
AN OMPHALOMESENTERIC DUCT OPENING INTO THE ABDOMEN AND DISCHARGING FECES INTO THE ABDOMINAL CAVITY.
Weiss* said: "Notwithstanding the fact that in dead-born children diverticula
are found in the umbilical cord, there has been no example of death due to an out
Fig. 130. — Inversion of the Bowel Through a Patent Omphalomesenteric Duct Opening on the Side or the
Umbilical Cord. (Redrawn after Gibb.)
At a is a hernial dilatation of the cord. This sac was filled with intestines. At 6 is the opening of a patent omphalomesenteric duct. Through this the small bowel had prolapsed, turning inside out. At c and d are the bowel openings. As the bowel had turned inside out, its mucosa was, of course, congested and dark red.
pouring of fecal matter into the abdominal cavity." This was probably true at
that date, but Orthf says: "I recently made an autopsy on a new-born child and
found a diverticulum split longitudinally below the umbilicus and adherent to the
* Weiss: Inaug. Diss., Giessen, 1868.
t Orth: Lehrbuch der spec. path. Anatomie, Berlin, 1887, i, 765.
220 THE UMBILICUS AND ITS DISEASES.
anterior abdominal wall in such a manner that meconium could escape into the
abdominal cavity. A large quantity of meconium lay between the abdominal wall
and the thickened omentum."
LITERATURE CONSULTED ON THE OPENING OF THE PATENT OMPHALOMESENTERIC DUCT ON THE SIDE OF THE UMBILICAL CORD OR IN THE
ABDOMINAL CAVITY.
Auvard: Travaux d'obstetrique, 1889, Paris, i, 331.
Brindeau: Nouv. arch, d'obstet. et de gyn., Fevrier 25, 1895, 45.
Gampert: Fistule entero-ombilicale divert iculaire chez un nouveau-ne. Rev. med. de la Suisse
romande, 1893, xiii, 356.
Gibb: Unique Congenital Malformation Associated with Umbilical Hernia and a Pendulous Artificial Anus. Trans. Path. Soc. London, 1856, vii, 216.
Guthrie, L. G. : A Case of Patent Meckel's Diverticulum into which the Posterior or Distal Wall
of the Ileum became Intussuscepted, forming an Umbilical Tumor. Death. Pediatrics,
1896, ii, 1.
Peake, J.: Case of Preternatural Anus found in a Portion of Ileum protruded at the Umbilicus.
Edinburgh Med. and Surg. Jour., 1811, vii, 52.
Weiss, E.: Ueber diverticulare Nabelhernien und die aus ihnen hervorgehenden Nabelfisteln.
Inaug. Diss., Giessen, 1868.
A PATENT OMPHALOMESENTERIC DUCT ASSOCIATED WITH DEFECTIVE DEVELOPMENT OF THE RECTUM OR ANUS.
Anderson's patient was a child born at the seventh month. There was no anus,
and the rectum and sigmoid were lacking. The omphalomesenteric duct was
patent.
Cheyne's patient was a three-weeks -old child. The omphalomesenteric duct
was patent. The anus ended in a blind pouch, one inch within the sphincter. The
child was still alive when the case was reported to the medical society.
Nicolas's patient was a child six days old. The omphalomesenteric duct was
patent. The anus was open, but an obstruction was found several inches above it.
A Case of Fecal Fistula at the Umbilicus with Nondevelopment of the Sigmoid Flexure and Rectum.* —
The patient was a male child delivered at the seventh month. After tying and
cutting the cord, the physician noticed a red tumor of nevoid aspect at the line of
section, and perceived that the proximal end of the cord was considerably enlarged.
On the following day meconium escaped from the umbilical stump. There was no
trace of an anal orifice. The edges of the umbilical orifice became red and everted.
The child lost flesh, and died on the twenty-third day after birth.
At autopsy prolapsus of the ileum through the umbilicus was found. This was
134 inches from the cecum. The short portion of the ileum extending to the cecum
was empty. The sigmoid and rectum were wanting.
[The opening undoubtedly represented a patent omphalomesenteric duct.]
A Patent Omphalomesenteric Duct Associated with
an Imperforate Rectum. — • Mr. Cheyne f showed an infant, aged three
weeks, with congenital umbilical fecal fistula, and asked for suggestions as to treatment. The child was rapidly losing weight. The anus was present, and a sound
* Anderson, William: Trans. Path. Soc. London, 1891, xlii, 128.
f Cheyne, Watson: Umbilical Fecal Fistula. Brit. Med. Jour., 1892, i, 815.
A PATENT OMPHALOMESENTERIC DUCT. 221
passed in about an inch. The umbilical aperture seemed to lead into a canal.
The general impression seemed to be that operative intervention was undesirable.
Patent Omphalomesenteric Duct Associated with
an Imperforate Sigmoid. — -Nicolas* (Obs. 12) refers to a boy six
days old who was observed in Marjolin's clinic. At birth there was a purulent
discharge from the umbilicus, and nothing had passed by bowel. The child had
vomited fecal matter several times. On rectal examination the anus was found to
be patent, but there was an obstruction at a point several centimeters higher up,
so that not even gas could be expelled by the rectum. Two days later an artificial
anus was made, but the child died forty-eight hours later.
Autopsy. — -The small bowel was large for so young a child. At a point 80 cm.
from the pylorus it was 23^ times the normal in diameter. It suddenly dilated and
became 4 to 5 cm. in diameter. Meckel's diverticulum was 3 cm. long.
Had it not been for the open omphalomesenteric duct these children would have
succumbed a few days after birth. The open duct was in reality a safety valve.
For those desiring a more extended knowledge of the subject of patent omphalomesenteric duct associated with faulty development of the bowel, a careful perusal
of Ahlfeld's splendid monograph is to be recommended.
In these cases it would be necessary to establish the continuity of the bowel
before attempting to remove the omphalomesenteric duct.
* Nicolas, P. : Sur deux varietes de fistules ombilicales, Paris, 1883.
LITERATURE CONSULTED
ON PATENT OMPHALOMESENTERIC DUCT ASSOCIATED WITH DEFECTIVE DEVELOPMENT OF THE
RECTUM OR ANUS.
Anderson, Wm.: A Case of Fecal Fistula at the Umbilicus with Non-development of the Sigmoid
Flexure and Rectum. Trans. Path. Soc. London, 1891, xlii, 128.
Cheyne, Watson: Umbilical Fecal Fistula. Brit, Med. Jour., 1892, i, 815.
Nicolas, P.: Sur deux varietes de fistules ombilicales, Paris, 1883.
Ahlfeld: Zur yEtiologie der Darmdefecte und der. Atresia ani. Arch. f. Gyn., 1873, v, 230.
==Chapter XII. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct==
Historic sketch.
Prolapsus of the bowel.
Results.
Findings at autopsy.
Cases of prolapsus of the bowel through a patent omphalomesenteric duct.
In 1843 King reported an observation made by Parsons and Gunthorpe in
which the small bowel had prolapsed through a patent omphalomesenteric duct
and was recognized as a sausage-like mass lying on the abdomen in the umbilical
region. From time to time since then an isolated case has been observed. We
shall now refer briefly to certain conditions which may be found associated with
this abnormality.
The Cord. — In some of these cases, when the child is born, the cord near
the umbilicus is unusually thick. In one case, reported by Gesenius, this thickened
area gave a crackling sensation when it was grasped between the fingers.
Age. — The condition has been noted as early as the third day and as late
as six months after birth. In nearly half of the cases it occurred within the first
two weeks. In Lowenstein's case the child was three months old; in Helweg's,
four months; in Kolbing's, nineteen weeks; in Huttenbrenner's and in Weinlechner's case, five months, and in Blin's case, six months.
Development of the Umbilical Fistula. — In considering
these cases we must remember that the omphalomesenteric duct has remained
patent from the intestine through the umbilicus, and out for a variable distance
into the cord. If it has remained open to the point where the cord has been tied
off, of course, a fecal fistula will be present just as soon as the cord drops off. When
the fistulous tract is very small, it may be impossible for feces to escape for
some days. Should the duct be patent just to the umbilicus, a small umbilical
polyp may present itself in the umbilical depression and no fistula will for the time
being be noted.
It may be interesting to trace the development of the fistula in the individual
cases.
In Barth's case, when the cord came away, there was a red nodule 1 cm. in
diameter at the umbilicus, and in the center of this a fistula, into which a probe could
be introduced for 4 cm.
In Gesenius's case a small polyp was noted when the cord came away. Next day
this showed an opening in its center, and two days later the projection had increased
in size and looked like a raspberry. The opening now admitted a catheter for six
or seven inches, and feces escaped from it .
In Gevaert's and in Golding-Bird's cases the fistula was noted when the cord
came away.
222
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 223
In Basevi's case, when the cord dropped off, it was apparent that the umbilicus
had not healed, a reddish, moist wound remaining. Feces did not escape until
later.
In Lowenstein's case, after the cord came away, an "inflammation" was noted at
the umbilicus. On the fourteenth day a fistula developed. Lowenstein urged
operation, which was refused. Later the opening became as large as a 50-pfennig
piece, and three weeks after this as large as a plum.
In Arndt's and in Ophuls's case a small umbilical polyp was found in addition to
the fistula, and in Blin's case there were two small polyps as well as a minute fistulous
opening.
In Theremin's Case 1 the cord came away on the eleventh day. In the center
of the umbilical ring was a reddish tumor, conic in form, and resembling an umbilical polyp. There were small ulcers on the surface of the tumor, and on the
twenty-third day a superficial hemorrhage occurred.
In Theremin's Case 2 the cord came away on the eighth day, leaving at the umbilicus a conic red polyp, 1.5 cm. long and 1 cm. broad. There was no vestige of an
opening. Twelve days later the polyp had receded; it was not over 5 mm. long,
but had an ulcer in its center, from which a few drops of blood escaped. On the
following day the polyp showed a small central opening.
In Holmes' patient, who was born prematurely, the umbilical cord bifurcated
three inches from the abdomen. It was tied off below the bifurcation. A fecal
fistula was noted after two weeks.
In the following cases a small reddish tumor had been noted at the umbilicus,
but the fistula did not develop until this umbilical polyp had been tied off.
Helweg's patient, a boy four months old, had a penis-like tumor at the umbilicus.
This was not present at his birth. It was covered with mucosa, and had in its
center a canal into which a sound could be introduced, but no feces escaped from
it. The tumor was tied off with silk. It became necrotic in four days; shortly
after prolapsus of the bowel was noted.
In King's case an umbilical polyp was removed by means of caustics. When
it came away feces escaped.
In Robbing's case a polyp existed at the umbilicus. This was tied off and
removed. Later there was prolapsus of the bowel through the patent duct.
From the evidence here adduced it is perfectly clear that in some cases the fecal
fistula develops just as soon as the cord comes away. If the opening be of sufficient
caliber, feces escape readily, but if very small, only mucus may be discharged for
a time. In other cases the outer end of the omphalomesenteric duct has not extended to the point at which the cord has been ligated, but as a result of ulceration
or gangrene the intervening barrier may be broken down and the fistula established.
In a few cases the removal of the umbilical polyp has been sufficient to establish
a patent vitelline duct.
PROLAPSUS OF THE BOWEL.
Inversion of the bowel does not necessarily follow when a patent omphalomesenteric duct exists. This will be clearly seen if the reader refers to Chapter X
on Patent Omphalomesenteric Duct (p. 188). In that chapter are recorded a large
number of cases in which the bowel manifested no tendency to prolapse.
Several factors are probably necessary to bring about prolapsus: (1) a duct
224
THE UMBILICUS AND ITS DISEASES.
that is of good caliber throughout, or at least at its intestinal attachment; (2) an
excessive amount of abdominal pressure, such as is produced by crying or by the
paroxysms of whooping-cough, as was noted in Hiittenbrenner's case, or by the
cough of a bronchitis, as was noted in the case recorded by King. Whether a
Fig. 131. — Patent Omphalomesenteric Duct of
Large Diameter
The lumen of this duct is directly continuous with
that of the small bowel, and at the umbilicus its intestinal lining extends out a short distance upon the surface of the umbilicus. When the lumen of the omphalomesenteric duct is wide, there is always great danger of
the bowel prolapsing and turning inside out through the
duct, following the direction indicated by the arrows.
For the subsequent stages of such a prolapsus see Figs.
132, 133, 134, and 135.
Fig. 133. — Partial Prolapsus of the Small Bowel
through the omphalomesenteric duct.
The wedge of small bowel has extended partly
through the abdominal wall. The loop is now divided
into two definite portions, the dilated and proximal, and
the contracted and distal portion. The proximal portion is naturally dilated, because there is already a barrier to the adequate escape of the fecal contents. The
distal portion is, of course, contracted, because nothing
is passing into it. For the subsequent steps of the prolapsus see Figs. 134 and 135.
Fig. 132. — Commencing Prolapsus of Small Bowel
through Patent Omphalomesenteric Duct.
The lumen of the duct is large, and the small bowel,
on its mesenteric side, is forming a wedge, as indicated
by the arrow. This wedge will gradually pass out
through the duct, as shown in Figs. 133, 134, and 135.
Fig. 134. — Prolapsus of the Small Bowel through
the Patent Omphalomesenteric Duct.
The small bowel has prolapsed still farther through
the omphalomesenteric duct. The proximal loop has
become more distended, and the distal loop has become
contracted still more. The lumina of both loops can
be traced out to the surface of the abdomen. The mucosa of the bowel has now extended out so far that it
forms a definite, roundish projection, elevated above
the surface of the abdomen, and naturally covered over
with intestinal mucosa, because it is the inner surface of
the small bowel. Between the proximal and distal contracted loops of bowel the peritoneum is carried outward beyond the level of the abdomen, as indicated by
x. At this stage only a small amount of fecal matter
can escape from the umbilicus, and signs of obstruction
will soon develop. For complete prolapsus see Fig. 135.
weakly and emaciated child is more prone to the prolapsus is problematic, as some
of the patients were strong, others very frail.
Just prior to the prolapsus some of the children have had stoppage of the bowel
for several days. In other cases the first intimation of alarming trouble was the
presence of the inverted bowel on the abdomen. A careful study of Figs. 131,
132, 133, 134, 135, and 136 will clearly show the reader the various stages in the
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 225
development of the prolapsus of the bowel through the patent omphalomesenteric
duet.
A glance at Fig. 137, p. 227, Fig. 138, p. 228, Fig. 140. p. 230, and Fig. 141, p.
232, will give a very good idea of the prolapsed bowel. Lying on the surface of the
abdomen is a red or dark-red, sausage-like mass. This may lie transversely on the
abdomen; it may be S-shaped, or appear as two horns forming a semicircle, as in
Theremin's Case 1. The mass varies in length from a few inches to one and a half
feet, as noted in Violbing's case. As the tumor is nothing more than a portion of
the small bowel that has turned inside out through the fistula, its surface consists
of intestinal mucosa. At each end is an opening; these represent the upper and
^ /
sfcai
Fig. 135. — Complete Prolapsus of the
Bowel through the Patent Omphalomesenteric Duct.
For the early stages of the prolapsus see
Figs. 131, 132, 133, and 134. The proximal loop
of bowel is now markedly distended, and the distal loop is correspondingly small. Lying on the
surface of the abdomen is a sausage-shaped
mass. This is naturally reddish or dark red in
color, because it is covered over with the mucosa
of the small bowel. It has an upper opening corresponding to the lumen of the proximal loop of
small bowel, and a lower opening — the lumen of
the distal loop of bowel. A loop of small bowel
is trying to pass outward in the chink between
the proximal and distal loops, as indicated by
the arrow. That this can take place is shown
in Fig. 136.
Fig. 136. — Prolapsus of the Small Bowel through the
Patent Omphalomesenteric Duct, and ajn- Umbilical
Hernia Between the Loops of Prolapsed Bowel.
In order that the reader may satisfactorily unravel this picture, he should consult Figs. 131, 132, 133, 134, and especially
135. The loop of small bowel that in Fig. 135 was near the
chink between the distal and proximal loops has now succeeded
in passing between them and occupies the cavity (x) noted in
that picture. The lumina of the distended and contracted loops
are visible, and the now enlarged and rounded mass would give
a note of tympany. The interloping loop of bowel, as a result
of its constriction, now has a distended and contracted portion.
lower ends of the lumen of the bowel. Usually the openings are very small, but
in Weinlechner's case they were large enough to admit the tip of the finger. Where
the prolapsus is small, the picture reminds one very much of a prolapsus of the
rectum or of an intussusception. The tumor is usually elastic to the touch and
tends to bleed on manipulation.
If the child lives long enough, the mucosa covering the prolapsed bowel may
become necrotic. The children, however, usually soon go into a state of collapse,
and die in from a few hours to two or three days. After the prolapsus has developed,
nothing but mucus escapes by the rectum. There is in reality complete obstruction of the bowel, as practically nothing can escape through the constricted abdominal tumor.
16
226 THE UMBILICUS AND ITS DISEASES.
RESULTS.
Some of the children were so ill that no operation could be undertaken. Others
were operated upon, the abdomen being opened, the bowel drawn back, and the
fistula closed. All these died. In only one case have we any record of a success.
This was in King's case, in which no operation was undertaken. The bowel was
reduced, and the fistula cauterized. Finally it closed. The child died later, probably of pulmonary tuberculosis.
FINDINGS AT AUTOPSY.
In Basevi's case Chiari found a fibrinopurulent exudate at the umbilicus, and
a small abscess between intestinal loops.
In Gesenius's case, in which no operation had been performed, the omentum and
intestine were adherent near the umbilicus. The intestinal loops were adherent
and covered with a reddish exudate.
In Theremin's Case 1, no inflammation existed in the abdomen, but the prolapsed bowel was markedly infiltrated.
The variability in the location of the omphalomesenteric duct was very clearly
brought out. In Lowenstein's case it was just above the ileocecal valve; in
Gesenius's case the diverticulum was 1 cm. long and 9 inches above the valve; in
King's case, 5 inches long and 18 inches above the valve; in Blin's case, 3 to 4 cm.
long and 25 cm. above the valve; in Ophiils's case, 35 cm. above the valve, and in
Theremin's Case 2, 60 cm. above the ileocecal valve.
TREATMENT.
A careful study of these cases clearly demonstrates that when the omphalomesenteric duct is patent, the wisest plan is at once to make an incision encircling
the umbilicus, draw out the loop of bowel, and treat the fistulous tract as one would
an appendix.
Newly born children are only fair risks, yet, on the other hand, if one waits
until prolapsus has occurred, death is almost certain, as the child has so little
reserve force.
In those cases in which prolapsus has already occurred the same procedure may
be adopted, but in such a case, after the fistula has been closed, a loop of bowel just
above the attachment of the diverticulum should be drawn out and opened, even
if there be a remote possibility of prolapsus occurring through this enterostomy
wound. We are all familiar with cases of strangulated hernia in which the
bowel has been obstructed for several days. In these, even if the obstruction is
relieved, death is liable to follow from the absorption of products of decomposition
that have been accumulating in the bowel. The same principle also applies here,
and we must allow free drainage of the bowel contents.
CASES OF PROLAPSUS OF THE BOWEL THROUGH A PATENT OMPHALOMESENTERIC DUCT.
Three other cases of prolapsus of the bowel through the vitelline duct, those of
Gibb, Guthrie, and Peake, are recorded in Chapter XL
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 227
A Case of Prolapsus of the Small Bowel Through the
Patent Omphalomesenteric Duct. — Arndt * reports the case of
a boy sixteen days old. The midwife was struck by the thickness of the umbilical
cord at the time of labor. The father said that, shortly before admission, when the
child vomited, "pus" escaped in a stream from the umbilical region. The child was
poorly nourished, and at the umbilicus was a tumor the size of a walnut, reddish in
color, which on manipulation bled slightly. It was apparently covered over with
mucosa. On the right and also on the left upper portion of the umbilical projection was an opening, into which a sound could be passed for a long distance. From
both openings intestinal contents escaped when pressure was made, or if the child cried. Because of the
prolapsus a diagnosis of patent omphalomesenteric
duct was made. Three days later there was stool
by bowel. Five days after admission two tumors
could be seen — one was sausage-shaped, the other
round. The former was 9 cm. long (Fig. 137). It
doubled in length in four days, became S-shaped,
and both ends had openings. The opening in the
upper end was about the size of a pea; the lower
opening was half as large. Pressure on the child's
abdomen increased the size of the tumor. The
second tumor was situated in the upper margin
of the umbilical ring. It was solid and as large as
a hazelnut.
At operation Professor Runge found that the
tumor with the two openings was an inverted portion of the small bowel that had passed through the
patent omphalomesenteric duct. When the bowel
was replaced in its normal position, a hollow channel
was found passing from the small bowel to the umbilicus. This opening was about the size of a pea.
The fistulous tract was removed. The child unfortunately died of peritonitis, as the sutures did not
hold properly.
Arndt says: "In this case we have to do with
prolapsus of the small bowel through the omphalomesenteric duct." Microscopic examination of
the solid umbilical tumor showed that it was an enteroteratoma (an umbilical
polyp).
This case was also reported by Ophlils in his monograph.
Prolapsus of the Small Intestine Through a Patent
Omphalomesenteric Duct. — Barth'sf patient was a child, nine days
old, who was brought to the clinic on account of a tumor at the umbilicus. The
mother said that this tumor was noted immediately after the cord came away: The
cord itself did not present anything unusual, so far as the mother or midwife could
Fig. 137. — Prolapse op the Small
Bowel through an Open Omphalomesenteric Duct. (After
Arndt.)
The sausage-like mass ivas 9 cm.
long. It had doubled its length in four
days. At both ends were openings.
These represented the lumen of the
bowel. The smaller, polyp-like mass,
seen in the upper part of the picture,
was covered with mucosa and attached
to the upper part of the umbilical ring.
Histologic examination showed that it
was covered over with intestinal mucosa. It was a so-called adenoma or
umbilical polyp.
* Arndt, C: Ein Fall von Dunndarmprolaps durch den offen gebliebenen Ductus omphaloentericus. Arch. f. Gyn., 1896, lii, 71.
fBarth, A.: Ueber die Inversion des offenen Meekel'schen Divertikels und ihre Complication mit Darmprolaps. Deutsche Zeitschr. f . Chir., 1887, xxvi, 193.
228 THE UMBILICUS AND ITS DISEASES.
tell, but through the opening at the umbilicus fecal matter had been discharging
for several days. The bowels in the meantime had moved regularly, and the urination was normal.
The child was a well-formed boy, and apart from the umbilical trouble was
apparently normal. At the umbilicus was a tumor about 1 cm. long. This was
of a blood-red color, and was covered with injected mucosa. On its surface was an
opening. The tumor was 1.5 cm. in breadth and firmly fixed at the umbilicus. A
sound could be passed into the canal without difficulty for 4 cm. There was no
change noted in the tumor when the child cried. Barth, having seen a similar
case in Danzig, came to the conclusion that this was an inversion and prolapsus
through a patent Meckel's diverticulum. The small tumor was covered with
iodoform gauze, a compression band was applied, and the child was brought to the
polyclinic daily. For the next few days there was no change. The child digested
well, and there was very little discharge from the umbilicus.
Fig. 13S. — Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct. (After Barth's Fig. 1.
Redrawn by August Horn.)
a is the point at which the bowel has prolapsed and turned inside out through the umbilicus; c and 6 are the points at
which probes could be introduced into the bowel lumen.
Five days later Barth was surprised to see that the small tumor had been transformed into a reddish, sausage-like tumor, as shown in Fig. 138. At the umbilical ring there was now a tumor 2.5 cm. long and 1.75 cm. thick. This was continuous with the sausage-shaped cylindric tumor b-c, which was 7 cm. long and
varied from 1 to 1.5 cm. in thickness. The entire tumor, pedicle, and sausagelike mass were dark red and covered over with a slightly hemorrhagic mucosa.
At b and c the mucosa was continuous in the openings. The opening (6) led through
a canal into the pedicle (a), and through the umbilical ring into the abdominal
cavity. From the opening (6) fecal matter escaped. The opening (c) led into a canal
toward (b), but nothing came out of it. When a sound was introduced, a wall could
be made out between the two openings.
From this description it is seen that there was a prolapsus of the inverted
intestine. The child was at once brought to the hospital. His general condition
was good. There was no pain, and the child's digestion was good. From the open
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 229
ing yellowish fecal matter escaped. From the rectum nothing but mucus came.
Dr. Schmid, who saw the patient, thought of reducing the prolapsus. Just as
soon, however, as this was attempted, the child commenced to cry and more loops
of the intestine came out at the umbilicus. These were seen to be covered with
peritoneum. Other loops now presented themselves (Fig. 139).
Operation. — One of the intestinal loops passed directly into the prolapsed and
inverted bowel. When traction was made on
it, it could be drawn back. The intestine was
supported only by a small pedicle. This was
cut and the bowel was reduced. When reduction had been effected, the intestine showed an
oval opening 1.5 cm. long. One of the assistants who was holding the intestine tore it, and
fecal matter came out. The wound was at
once closed with catgut. The diverticulum
was removed, and the intestine closed. The
child died on the third day after operation.
The autopsy showed a small abscess in the
upper portion of the abdominal wall and a circumscribed adhesive peritonitis. A short convolution of small intestine had become attached to the abdominal wall.
Prolapsus of the Bowel
Through a Patent Omphalomesenteric Duct.* — -A well-nourished child, twelve days old, came under observation on account of non-healing of the umbilicus. At the umbilicus was a reddish, moist
wound. The surrounding tissue was normal.
In this case the cord was thicker than usual
and had come away on the tenth day. On
the nineteenth day, when the child cried, a
reddish cone, 4 cm. high, appeared. This
showed no opening, and there was stool by
the bowel daily. A few nights later the child
suffered from discomfort ; the tumor increased
in size, gradually became necrotic, and the
child died. In this case there were prolapsus
and inversion of the small bowel through a
patent omphalomesenteric duct (Fig. 140).
On opening the abdomen Dr. Chiari, who
made the autopsy, found the small bowel attached to the umbilicus by a fibrmopurulent exudate, and there was an abscess the size of a walnut between intestinal loops.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct, f — A child six months old was brought to the Hotel
Fig. 139. — Prolapsus of the Bowel through
a Patent Omphalomesenteric Duct,
with Secondary Complications. (After
Barth's Fig. 3. Redrawn by August Horn.)
This illustration by Barth is a diagrammatic representation of a hernial protrusion that
may be associated with the prolapsed omphalomesenteric duct. & is a proximal portion of the
bowel that has prolapsed; c, the distal portion
of the loop. The portion lying on the abdomen
has turned inside out, and is naturally covered
with mucosa. A probe can be readily introduced into the extra-abdominal portion, either
from above or from below. At x-y the bowel
has been markedly constricted by the abdominal wall. The loop of bowel (d) has prolapsed
to a certain extent through a small hernial
opening above the omphalomesenteric duct.
* Basevi, Settimio: Jahrb. f. Kinderheilk. u. physische Erziehung, 1878, xii, 275.
fBlin: Diverticulum de l'intestin ileum chez tin enfant de 6 mois; anus contre nature a
rombilic, issue d'une anse intestinale par rorifice ombilical; etranglement ; debridement; mort;
autopsie. Mem. de la Soc. de biol., Paris, 1853, 1. ser., iv, 131.
230
THE UMBILICUS AND ITS DISEASES.
- : V
Dieu (Jobert's clinic). At the umbilicus was a cylindric tumor lying transversely
on the abdomen. This tumor was reddish brown and was evidently an intestinal
loop. Below this were two small elevations, the size of peas. These were not so
red as the large tumor; they were resistant on pressure and adherent to the skin.
The mother said that these two small nodules had been noticed since the cord
came away, and that below one of the small nodules was a minute opening from
which a little fecal matter escaped at first, but later only mucus. Suddenly, on the
day of admission, during straining, the tumor noted escaped from the abdomen.
Reduction was impossible. An incision was made in the ring, but the
child died in two days.
At autopsy a diverticulum, 3 to
/ 4 cm. long and of the diameter of a
penholder, was found. This was 25
cm. above the cecum.
Inversion of the Small
Bowel Through a Patent
Omphalomesenteric
Duct.* — The patient was a
well-nourished boy. The umbilical
cord near the abdomen was thicker
than usual, and on pressure a rumbling, crackling sound was heard. The
abdominal wall below the cord presented a furrow, as if the muscles had
not come together properly. The
cord was tied about four inches from
the umbilicus, and came away on
the ninth day; the umbilicus then
appeared to be normal. On separation of the folds, however, a small,
red, fleshy wart, resembling an umbilical polyp, was seen. On the following day, instead of the elevation,
there was an opening with reddish
walls, and two days later, after the
child had cried a good deal, a projection the size of a raspberry was noted.
This had at its summit an opening which admitted a catheter for from six to
seven inches. From this opening a little yellow fluid escaped. The child took
the breast well. The urine passed normally, and the stools were regular. About
eight days later the child was brought back, but the condition was greatly changed.
It was very fretful, and cried continuously. For three days it had had no stool.
At the umbilicus was a brownish-red, glistening tumor, which was distended like a
sausage. It was three inches long, with blunt ends, and attached to the umbilicus
by a sort of pedicle. Its covering was undoubtedly intestinal mucosa, and at either
end was an opening into which a sound could be introduced for nearly an inch.
1 i ii ins: Inversion des Dlinndarmes durch ein am Nabcl off en gebliebenes Divertikel.
Jonr. f. Kinderkrankh., 1858, xxx, 56.
Fig. 140. — Prolapsus and Inversion op the Intestine
through a Patent Omphalomesenteric Duct. (After
Basevi.)
A square piece of the anterior abdominal wall, with the
umbilical ring in its middle, has been removed. Above and to
the left is the cecum, with the valve-like opening passing into
the small bowel. On the right is the ileum. The bowel has
become inverted through the patent omphalomesenteric duct,
forming a somewhat sausage-like mass on the surface of the
abdomen. At either end is an intestinal opening. The one
on the left shows up clearly.
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 231
Around the so-called pedicle was a reddish ring, firmly fixed and preventing the
introduction of a sound at this point. There was evidently a diverticulum with
an inversion through it.
The child became more restless, collapsed, and died after forty-eight hours.
At autopsy, after the omentum and intestine near the umbilicus had been loosened
up, the intestine could be pulled back and there remained a diverticulum, 1 cm.
long, 9 inches above the cecum. The intestines around it were stuck together by
a reddish exudate. In this case there was a patent omphalomesenteric duct,
through which the intestine had prolapsed.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.* — This child was six weeks old. At the umbilicus
was an elongated cylindric tumor, tense and reddish purple in color. It was 12 cm.
in length, soft and elastic. In this case, when the cord came away, a fecal
fistula existed at the umbilicus. There was an inversion of the intestine through
the fistula, like an inversion of the uterus or prolapsus of the bowel through the
anus.
Operation. — The bowel was reduced and the fistula closed, but the child died
ten hours after operation.
A Case of Intussusception Through a Patent Meckel 's
Diverticulum, f — -A male infant, four weeks old, when seen, was almost
in collapse. When the cord had separated four days after birth, the stools had
begun to pass through the navel. During all this time there was a red lump or
projection at the umbilicus, and it was through the end of this that the discharge
took place. Twenty-four hours before admission a more pronounced protrusion
was observed, and the bowels ceased to move by the rectum, discharging only at
the umbilicus, and not through the apex of the projection, but at its base, where it
seemed to emerge from the original swelling.
The tumor was elongated and about the size and length of a little finger. It
depended from the umbilicus, and was inclined toward the left groin. It was
covered with bleeding mucosa. It was firm, and looked like an intussusception.
Around its base was a rolled collar or cuff of mucous membrane, out of which
emerged the protrusion described. The protrusion was separated from the collar
by a sulcus, from one part of which yellow fecal matter exuded. A probe inserted
into the apical opening passed in three inches and met with an obstruction. A
probe, inserted into the basal groove, whence yellow fecal contents were coming out,
passed without obstruction for several inches. There was in this case a prolapsus
or intussusception of some of the small bowel through a patent omphalomesenteric
duct. The child was too ill for operation and died.
Prolapse of the Bowel Through an Originally Partially Patent Omphalomesenteric Duct.} — A boy, four
months old, had a penis-like tumor at the umbilicus. This projection was not
present at the time of his birth. It was covered over with mucosa, sharply differentiated from the umbilical skin, and at its end was a canal, into which a sound
* Gevaert, G.: Inversion intestinale a travers 1'onibilic. Chirurgie infantile, Charon et Gevaert, deuxieme edition, Bruxelles, 1895, 251.
t Golding-Bird, C. H.: Clin. Soc. Trans., London, 1896, xxix, 32.
t Hehveg, Kr.: Aabent Diverticulum ilei, Invagination, Prolaps, Inkarceration. Hosp.
Tidende, 1884, ii, 705.
232
THE UMBILICUS AND ITS DISEASES.
could be introduced for one inch beyond the abdominal wall; nothing escaped from
the opening. The stools were normal.
The tumor, which was hard at its base, was tied off with a silk ligature. It
became necrotic in four days. As a result of violent coughing, prolapse of an
S-shaped piece of intestine with a dark-red mucous lining took place (Fig. 141).
It was attached to the umbilicus by a short pedicle. The portion of intestine
lying on the abdomen was eight to nine inches
long, and as thick as the small intestine of an adult.
At both free ends was a canal. After loosening up
the tumor at the umbilicus the operator found that
two pieces of small bowel had passed out of the umbilical ring into the horns of the prolapsus. After
making traction on the intestine he was able to draw
back both horns, but there remained an opening in
the bowel the size of a mark. This communicated
with the umbilicus and was the patent omphalomesenteric duct. The bowel was closed. The child
died a few hours later.
At autopsy a beginning peritonitis was found
around the umbilical region. The omphalomesenteric duct was 18 inches above the ileocecal valve.
Prolapse of the Bowel Through
a Patent Omphalomesenteric Duct. —
Holmes* described a specimen that had been sent
to him by Dr. H. Whiteman. It was from a male
infant which had been born prematurely with a bifurcated cord. The bifurcation began three inches from
the abdomen. The cord was tied below it. At the
end of two weeks feces were coming from the umbilicus, and the surrounding tissues were inflamed. The
intestine rolled out, and, when Holmes saw the patient, a loop was hanging out of the abdomen and
feces were coming from it. There was evidently some
defect in the closure of the umbilical opening, probably due to a fissured cord, and Holmes thought that
the nurse had probably retied the cord after Dr.
Whiteman had tied it well away from the abdomen,
and that she had tied off the end of the bowel.
Attempts were made to push the bowel back in
order to use Dupuytren's clamp method. The
child did well for several days, but the bowel came out again and death occurred. In this case, until prolapse of the bowel took place, the feces passed
by the rectum.
[The history of the case leaves no doubt that a patent omphalomesenteric duct
existed and that the nurse was in no way responsible for the injury.]
Fig. 141. — Prolapsus of the Bowel
THROUGH THE PaTEXT OMPHALOMESENTERIC Duct. (After Helweg.)
A boy, four months old, had a
definite projection at the umbilicus.
This was covered over with mucosa
and was sharply differentiated from
the abdominal skin. A sound could
be passed for a certain distance into
the abdomen. The tumor was tied
off at its base with a silk ligature. It
became necrotic in four days.
As a result of violent coughing an
S-shaped piece of intestine with a
dark-red mucosa escaped through the
umbilical opening. It was attached
to the umbilicus by a short pedicle.
At each end was a canal. After the
tumor had been loosened at the umbilicus, it was found that two pieces
of small bowel had passed out of
the umbilical ring and terminated in
each horn of the prolapsus. In other
words, the bowel had turned inside
out through the patent omphalomesenteric duct. The child died a few
hours after operation.
182.
Holmes, T.: Surgical Treatment of the Diseases of Infancy and Childhood, London, 1868,
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 233
Prolapsus of the Small Bowel Through a Patent
Omphalomesenteric Duct.* — A boy, twelve days old, was supposed
to have a persistence of Meckel's diverticulum. The midwife had tied off the cord
well away from the body. When Hue saw the child, there was a sausage-like projection, about the size of an adult's thumb, and about 10 cm. long, lying on the
abdomen. It was evidently covered with mucosa, and bore some resemblance to
a prolapsed rectum in a child. It was deep red in color, livid, and had two orifices on its surface. The first was situated near the middle of the tumor, and from
it gas and partly digested intestinal contents escaped. The second was situated
at the end of the tumor, and from this neither gas nor feces came.
For the first three days stools were passed by the rectum. After that nothing
escaped by the normal route. An enema of water and milk returned without
escaping through either of the abdominal openings.
At autopsy it looked as if there had been a prolapse of Meckel's diverticulum.
There was a persistence of the left omphalomesenteric artery. Deve, in the
discussion of Hue's case, reported a case in which this also had persisted.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.- — ■ Hiittenbrennerf saw a child who, as a result of an
attack of whooping-cough in the fifth month, had a prolapse of nine inches of bowel
from the umbilicus. .The prolapsed portion lay as a transverse tumor on the
abdomen, and on each side had an opening. The condition was diagnosed as an
invagination of the bowel through a patent omphalomesenteric duct. After removal of the prolapsus death followed as result of pneumonia.
A Patent Omphalomesenteric Duct with Prolapse
of the Intestine Through i t . t — A male child was seen on the eighth
day. Occupying the umbilicus was a fungoid growth supposed to have been caused
by the nurse pulling on the cord and cutting it off too short. The fungus was
removed by means of caustics. When it came away, feces escaped. The child
was greatly emaciated; it developed a bronchitis, and a piece of bowel four
inches long protruded through the umbilicus. During a fit of coughing feces
were seen escaping from its open extremity. At the same time feces passed by the
bowel. The wound was closed by cicatrization in about a year, but the child died
a little later on, probably of tuberculosis.
Autopsy. — The diverticulum, which was five inches long, was found 18 inches
above the cecum, and extended from the convexity of the ileum to the umbilicus,
to which it was firmly attached. The umbilicus itself appeared to be fairly normal.
There was in its center an area of granulation the size of a pea.
A Patent Omphalomesenteric Duct with Prolapse of
the Bowel Through it.§ — ■ The patient was a boy who had at the umbilicus a reddish tumor the size of a strawberry. This was thought to be telangiectatic,
and was accordingly tied off and removed. Kolbing saw the child when nineteen
weeks old. Projecting through the umbilicus was a piece of red and distended
intestine. The child was operated on at once, but died in thirteen hours. The
* Hue, Francois: Prolapsus ombilical diverticulaire. La Normandie med., 1906, xxi, 162.
t Huttenbrenner, A.: Allgem. Wien. med. Zeitung, 1878, Nr. 23, 225, 235.
t King, T. W.: Guy's Hospital Reports, 1843, 2. ser., i, 467.
§ Kolbing, A. : Beschreibung einer auf dem Nabel eines neugebornen Kindes befindlichen
rothlichen Geschwulst, besonders wegen ihrer Folgen merkwiirdig. Neue Zeitschr. f. Geburtsk.,
1843, xiv, 443.
234 THE UMBILICUS AND ITS DISEASES.
small intestine had grown to the lower end of the umbilical opening, and through
the opening the intestine had inverted.
[Tillmanns said the ease was one of prolapsus in the usual sense, namely,
through inversion of the bowel.]
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.* — A personal communication from Karewski. The
patient was a three-months-old boy who was in good health. On the fourteenth
day there was "inflammation" of the umbilicus, and a spontaneous opening
appeared from which a thin yellow fluid escaped. Dermatitis developed, and on
the surface of the prominence of the umbilicus a pea-sized opening was seen. This
was lined with a very red mucosa, and from it there escaped a feces-like discharge.
Operation was refused. In consequence of ulceration the opening soon became the
size of a 50-pfennig piece, and the child grew very weak. In three weeks the opening had increased to the size of a plum. The child cried a good deal and had stoppage of the bowels for several days. Strong pressure was applied to the umbilicus.
Finally a prolapsus took place at the umbilicus, and a small piece of bowel, 5 cm.
long, came down through the open omphalomesenteric duct. An abdominal
incision was made, and the prolapsus was easily reduced. The open omphalomesenteric duct was situated just above the ileocecal valve. It was tied off and
removed. The child, however, died twenty-four hours later.
At the present time in such a case an immediate laparotomy would be indicated;
the diverticulum should be tied off, the umbilicus" removed, and probably a
temporary enterostomy made.
Prolapsus of the Bowel Through an Open Omphalomesenteric Duct. — Ophuls | gives the autopsy report on a three-weeksold boy. The clinical diagnosis was peritonitis following a laparotomy. This
operation had been performed on account of prolapsus of the bowel through an
open Meckel's diverticulum, 10 to 15 cm. of the bowel having prolapsed. In this
case the bowel had been reduced and the diverticulum removed. In the vicinity
of the umbilical fistula was a small tumor the size of a hazelnut. It was roundish
and firm in consistence, and covered over with mucosa. It was entirely independent of the bowel.
Autopsy showed that the intestinal suture had not held, and that fecal matter
had escaped into the general abdominal cavity. The closure in the bowel was
found to be 35 cm. above the ileocecal valve, and on the side opposite the mesentery.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct. | — A recently born child showed moisture at the umbilicus, which was found to be unusually prominent and firm. There was a groove
in the middle where cicatrization had not occurred. Here there was still moisture,
and yellow fluid and gas-bubbles escaped. Siebold thought the condition was due
to lack of closure of the vitelline duct. At the end of the third week a small, black,
gangrenous area was noted. When the child cried, the small bowel was forced out
* Lowenstein, L.: Der Darmprolaps bei Persistenz des Ductus omphalo-mesentericus mit
Mittheilung eines operativ geheilten Falles. Langenbeck's Arch. f. klin. Chir., 1894-95, xlix,
541.
t Ophuls, W.: Beitrage zur Kenntnis der Divert ikel-Bildungen am Darmkanal. Inaug.
Diss., Gottingen, 189."., 36.
i Siebold, quoted by G. Schroder: Uber die Divertikel-Bildungen am Darm-Kanale. Inaug.
Diss. (Erlangen), Augsburg, 1854.
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 235
from right to left from the gangrenous opening, forming two horns, like sausageskins filled with air; and when the child cried, both ends lengthened. A small
opening was made at the umbilicus, and the intestine reduced. The child died in a
few hours. Autopsy revealed a diverticulum three-quarters of an inch in length,
which had opened at the umbilicus.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct.* — The patient was a well-developed boy. At birth
it was noted that the umbilical cord was remarkably large at its base. It came
away on the eleventh day. In the center of the cutaneous umbilical ring was a
reddijsh tumor, conic in form, and resembling a fungus of the umbilicus. There
were small ulcers on the surface of the tumor, and on the twenty-third day superficial hemorrhage occurred. The small intestine prolapsed through a fistula in the
form of two horns, each 5 to 6 cm. in length, which were curved, forming a semicircle. They were covered over with mucous membrane. Attempts at reduction
were made, without result. Two days later the child died.
The autopsy showed a true diverticulum of the small intestine adherent to the
umbilical ring, and a prolapse of the bowel through it. There was no trace of
inflammation of the peritoneum or of the intestine that had remained in the
abdomen, but there was marked infiltration of the prolapsed portion of the
bowel.
Prolapsus of the Bowel Through a Patent Omphalomesenteric Duct. f — A boy was born on February 26, 1884, and admitted
to the hospital on February 29th. The cord came away on the eighth day, and at
the umbilical orifice was a small tumor which resembled a fungus. This was conic,
red, and measured 1.5 cm. x 1 cm. At its base there was no vestige of an opening.
By March 16th, twelve days after the cord had come away, the fungus had receded
somewhat and was not over 5 mm. high, but there was a small ulcer in its center,
from which a few drops of clear blood escaped. On the following day, while the
bandage was being changed, the child cried, and there emerged from the summit of
the tumor a mass resembling granulation. This was covered with mucosa and had
a small central opening. On March 21st there was an intestinal prolapsus for a
length of 10 cm. The mucosa was red and a yellow mucus escaped from the central
opening. Gas and fecal matter also came away when the child cried. The general
condition was not satisfactory, and it was impossible to reduce the prolapsus.
Later the prolapsus receded in part, leaving a prominence measuring only 5 mm.
The child died of gastro-intestinal catarrh on April 29th.
At autopsy there were signs of an acute enteritis with engorgement. The mesenteric glands were tumefied, reddish, and softened. The intestinal prolapsus had
been reduced completely. The diverticulum was 60 cm. above the cecum. It
was inserted into the umbilical ring. The mucosa reached the umbilical opening.
There was atelectasis in the posterior part of both lungs.
Prolapse of the Bowel Through a Patent Omphalomesenteric Duct. J — The patient was a well-formed boy. After the
dropping off of the umbilical cord a small, rather prominent, tumor, resembling a
wild strawberry, was noted at the umbilicus. The physician raised it and tied it
* Theremin, E.: Sur les fistules entero-ombilicales diverticulaires. Rev. mens. d. mal. de
l'enfance, 1885, 558.
f Theremin: Loc. cit., Case 2. J Violbing: (Quoted by Bureau, op. cit.).
236 THE LTMBILICUS AND ITS DISEASES.
off at its base. When the child was nineteen weeks old there occurred a prolapsus
of the intestine 1 % feet in length through the umbilicus. It came out as two cornua ;
these were covered with mucosa. Death soon followed. At autopsy a diverticulum was found opening into the bowel.
Prolapse of Intestine Through a Patent Omphalomesenteric Duct.* — J. G., five months old, was admitted to the
hospital on March 23, 1873. The umbilicus had been open since birth, and
occasionally mucus had escaped, but no feces. During a severe coughing spell the
day before his admission a bright-red, two-horned tumor had appeared at the
umbilicus. The left horn was 4 cm. long, the right 11 cm. long, with several furrows
on its concave side. At the end of each horn was an opening which admitted the
tip of a finger. No feces escaped from these openings. The prolapsed tumor was
constricted at the umbilicus.
The tumor was dark red, and undoubtedly covered with mucosa. The surface
was covered with mucus and bled readily.
The abdomen was markedly distended; the child was very pale and breathed
with difficulty. There was no vomiting.
The growth was cut off, a short stump and two lumina being left. The child
died thirty hours later.
* Weinlechner: Vorfall des Dtinndarms durch den off en gebliebenen Ductus omphalomesaraicus. Jahr. f . Kinderheilk. u. physische Erziehung, N. F., 1874-75, viii, 55.
LITERATURE CONSULTED ON PROLAPSUS OF THE BOWEL THROUGH A PATENT
OMPHALOMESENTERIC DUCT.
Amdt, C: Ein Fall von Dunndarmprolaps durch den off en gebliebenen Ductus omphalo
entericus. Arch. f. Gyn., 1896, lii, 71.
Barth, A.: Ueber die Inversion des offenen Meckel'schen Divertikels und ihre Complication
mit Darmprolaps. Deutsche Zeitschr. f . Chir., 1887, xxvi, 193.
Basevi, Settimio: Jahrb. f. Kinderheilk. u. physische Erziehung, 1878, xii, 275.
Blin: Diverticulum de l'intestin ileum chez un enfant de 6 mois; anus contre nature a l'ombilic,
issue d'une anse intestinale par l'orifice ombilical; etranglement; debridement; mort;
autopsie. Mem. de la Soc. de biol., Paris, 1853, 1. ser., iv, 131.
Bureau, J. : Prolapsus ombilical du diverticule de Meckel. These de Paris, 1898, No. 257.
Gesenius: Inversion des Diinndarmes durch ein am Nabel off en gebliebenes Divertikel. Jour. f.
Kinderkrankh., 1858, xxx, 56.
Gevaert, G.: Inversion intestinale a travers l'ombilic. Chirurgie infantile. Charon et Gevaert,
deuxieme edition, Bruxelles, 1895, 251.
Golding-Bird, C. H.: A Case of Intussusception through a Patent Meckel's Diverticulum. Clin.
Soc. Trans., London, 1896, xxix, 32.
Helweg: Aabent Diverticulum ilei. Invagination, Prolaps, Inkarceration. Hosp. Tidende,
1884, ii, 705.
Holmes, T. : Surgical Treatment of the Diseases of Infancy and Childhood, London, 1868, 182.
Hue, P>ancois: Prolapsus ombilical diverticulaire. La Normandie med., 1903, xxi, 162.
Huttenbrenner, A.: Allgem. Wiener med. Zeitung, 1878, xxiii, 225, 235.
King, T. W.: Fseculent Discharge at the Umbilicus From Communication with the Diverticulum
Ilei. Guy's Hospital Reports, 1843, 2. ser., i, 467.
Kolbing, A. : Beschreibung einer auf dem Nabel eines neugebornen Kindes befmdlichen rothlichen
( reschwulst, besonders wegen ihrer Folgen merkwurdig. Neue Zeitschr. f. Geburtsk., 1843,
xiv, 443.
Lowenstein: Der Darmprolaps bei Persistenz des Ductus omphalo-mesentericus, mit Mittheilung
cine- open-it iv jrr-lieilten Falles. Langenbeck's Arch. f. klin. Chir., 1894-95, xlix, 541.
PROLAPSUS OF BOWEL THROUGH PATENT OMPHALOMESENTERIC DUCT. 237
Ophuls, W.: Beitrage zur Kenntnis der Divertikelbildungen am Darmkanal. Inaug. Diss.,
Gottingen, 1895, S. 36.
Siebold : (Quoted by G. Schroder, tJber die Divertikel-Bildungen am Darm-Kanale. Inaug. Diss.
(Erlangen), Augsburg, 1854.)
Theremin: Sur les fistules entero-ombilicales diverticulaircs. Rev. mens. mal. de l'enfance,
1885, 558.
Violbing: (Described in Bureau's article, Op. cit.)
Weinlechner: Vorfall des Dtinndarms durch den off en gebliebenen Ductus omphalo-mesaraicus.
Jahrb. f . Kinderheilk. u. physische Erziehung, N. F., 1874-75, viii, 55.
==Chapter XIII. Cysts In The Abdominal Wall Due To Remnants Of The Omphalomesenteric Duct==
Historic sketch.
Cysts developing between the peritoneum and muscles.
Subcutaneous cysts.
Report of cases.
Wtss and Colmers have each reported a case in which a small cyst was found
lying between the peritoneum and the abdominal muscles. Zumwinkel observed
a cyst lying external to the abdominal muscle.
Wyss's cyst was the size of a bean; Colmers' was as large as a hen's egg and
divided into two cavities; Zumwinkel's was the size of a cherry-stone.
As will be noted from the histories, in each case the inner surface of the cyst at
some point was lined with cylindric epithelium, and in Colmers' and Zumwinkel's
Fig. 142. — A Small Cyst of the Umbilicus Due to a
Remnant of the Omphalomesenteric Duct.
This is a schematic representation of a small cystic
remnant of the omphalomesenteric duct lying just external to the peritoneum and communicating with the
umbilicus. Passing from it to the bowel is a fibrous
remnant of an omphalomesenteric vessel.
Fig. 143. — Small Cyst of the Abdominal Wall due
to a Remnant of the Omphalomesenteric Duct.
In rare instances a small cyst may be found in the
abdominal wall in the umbilical region. This cyst is
lined with a mucosa resembling to a more or less marked
degree intestinal mucosa. This is a schematic representation of such a cyst.
cases Lieberkiihn's glands were demonstrable. In these two cases the walls of the
cyst also contained non-striped muscle.
In Zumwinkel's case the cyst was connected with the umbilicus by a fine opening, and in Colmers' case the patent omphalomesenteric vessels were still present
in the cord passing from the cyst to the umbilicus. These cysts, without a doubt,
were due to remnants of the omphalomesenteric duct.
In Figs. 142 and 143 we have schematic representations of cysts developing just
externally to the peritoneum and in the umbilicus itself.
A Small Cyst Between the Peritoneum and Muscle,
Probably Remains of the Omphalomesenteric Duct.* —
At autopsy, about an inch above the umbilicus and a little to the side of the linea
* Wyss, Hans v.: Zur Kenntnis der heterologen Flimmercysten. Virchows Arch., 1870,
li, 143.
238
CYSTS IN THE ABDOMINAL WALL. 239
alba, Wyss found a cyst, the size of a bean, between the muscle and peritoneum.
This contained turbid and tenacious mucus, which was grayish yellow in color.
The cyst was lined with cylindric, ciliated epithelium, an epithelium that had
undergone colloid change. Wyss thought the cyst might represent embryonic
remains. The findings strongly suggest remains of the omphalomesenteric duct.
An Enterocystoma Developing Between the Peritoneum and the Recti Muscles. — Colmers* considers enterocystoma
of the abdominal wall, but before giving his own case, mentions those reported by
v. Wyss, Roser, and Schaad.
Colmers, in 1903, saw Frau K. 0., aged forty-six. She had always been healthy
and was the mother of 12 children. Her illness commenced in the summer of 1903.
In August she noticed that every movement of the body excited pain in the abdomen.
No further trouble was noted until October, when there were digestive disturbances. When admitted to the hospital (November 17th) the woman was fairly
well nourished, but the skin was pale. The abdomen was firm. On careful palpation an indefinite resistance could be felt around the umbilicus. The mass was
the size of an egg, firm in consistence, and very movable.
Operation. — When the abdomen was opened, a fluctuating tumor, the size of
a small hen's egg, was found in the umbilical region. It was attached to the abdominal peritoneum and partly nipped off from a small one about the size of a hazel-nut.
This was also in the abdominal wall. Passing from the tumor to the umbilicus
was a short, thick cord. The tumor was dissected out of the abdominal wall without difficulty. The stomach, intestine, and mesentery, as well as the uterus and
adnexa, were normal. A somewhat enlarged gland from the greater curvature of
the stomach was removed. This, on histologic examination, showed a simple
hyperplasia. The extirpated tumor lay between the peritoneum and the sheath
of the rectus. With the latter it had formed a broad adhesion.
The tumor contained a thick yellowish fluid, which had colorless masses,
resembling mucus, scattered through it. The fluid contained numerous fat-droplets, many cholesterin crystals and fatty acid needles, as well as cells closely resembling fatty epithelium. The walls of the large cyst had on the inner surface
numerous calcareous particles. These were attached to the wall or lay free in the
cyst cavity. The wall of the portion of the cyst lying beneath the peritoneum was
not over 0.2 mm. in thickness, and in places only 0.1 mm. thick. Near it were little
bays or depressions running out in various directions. Here the walls reached a
thickness of 0.5 mm.
These cysts communicated with each other by a small opening through which
a sound could pass. The cord extending from the small cyst to the umbilicus
appeared to be solid. The free walls of the cyst, that is, the portion lying beneath
the peritoneum, contained connective tissue, in the inner layers of which calcareous
deposits were found. No epithelial lining could be detected.
The small cyst was similar to the larger one. Here, however, the calcareous
deposit was not marked. At one point at the base of the cyst were two small
bays. These communicated with the main cyst by a small opening. The two
small cysts, as indicated in Fig. 144, a, b, were lined with a beautiful, very high
cylindric epithelium. This contained definite Lieberkuhn's glands, although
* Colmers, F. : Die Enterokystome und ihre chirurgische Bedeutung. Arch. f. klin. Chir.,
1906, lxxix, 132.
240 THE UMBILICUS AND ITS DISEASES.
these were low and often irregular. Sometimes papillae were found projecting into
the lumen of the cyst. This glandular layer covered a definite muscularis mucosae
in which bands of smooth muscle-fiber were seen. The glands were not regular.
but in some places they were arranged at right angles to one another. At a few
points there were evidences of Auerbach's plexus.
The cord passing from the small cyst contained the omphalomesenteric vessels.
Two of them had remained open and were surrounded by smooth muscle-fibers.
The diagnosis was not difficult. The cysts had developed from remains of the
omphalomesenteric duct.
A Subcutaneous Cyst Originating From the Omphalomesenteric Duct.*- — ■ The patient was a child seven years old. Since
birth there had been a small opening at the umbilicus, which secreted a slimy fluid.
In the right abdominal wall in the umbilical region was a roundish, ulcerated, hard
'-^i--' ^A
Fig. 144. — A Small Intestinal Ctst Lying Between the Peritoneum and the Recti. (After Colmers.)
This picture represents one of the small bays running off from the large cyst, and communicating with it by a fine
opening. At a we have Lieberkuhn's glands, some with well-developed papillary folds. The cyst space (6) in some
places is lined with mucosa. At other places the epithelium is somewhat flattened or has disappeared completely.
Surrounding the glands is non-striped muscle cut longitudinally and transversely.
nodule, 1.25 cm. in diameter. In the middle was a fine opening through which a
sound could be passed 1 cm. into a cavity.
At operation a cyst the size of a cherry-stone was found. This was round,
bluish in color, and easily loosened by blunt dissection from the underlying
tissue.
The inner surface of the cyst was lined with cylindric epithelium, intestinal
folds, and Lieberkuhn's glands. Outside of this was a muscular zone. In some
places this was cut lengthwise; at others, transversely. It consisted of two layers.
The mucosa was not normal. The folds or papillae were high and broad, and sometimes had several projections, suggesting a papilloma. The glands were more
abundant. The muscle was especially thick. At only one point did the sac show
normal mucosa.
The squamous epithelium in the vicinity of the cyst was increased in thicknessIn some places it was ten times as thick as normal. The papillae of the skin were
also much lengthened.
* Zumwinkel: Subcutane Dottergangscyste des Xabels. Langenbeek's Arch. f. klin. Chir.,
1890, xl, 838.
CYSTS IN THE ABDOMINAL WALL. 241
Zumwinkel says that in Roser's case the cyst lay behind the navel, just extraperitoneally, whereas his cyst lay in front of the closed navel.
In Zumwinkel's case the skin surrounding the umbilicus was greatly thickened,
the squamous epithelium in places being fully ten times as thick as normal.
In a case seen by Fox and MacLeod, and cited on page 268, there was a definite
Paget's disease, due undoubtedly to the irritating discharge from skin remnants of
the omphalomesenteric duct. Fox and MacLeod's patient was a sailor, sixty-five
years of age, who came under the care of Mr. W. Turner, surgeon to the Dreadnought Hospital at Greenwich. In the umbilical region was a rounded, eczematoid
patch, two inches in diameter, which had been forming gradually for eleven years.
On microscopic examination the outlying portion of the umbilicus showed the
typical picture of Paget's disease. The central portion showed a covering of cylindric epithelium, and contained glands resembling those of Lieberkuhn. In this case
there evidently had been remains of the omphalomesenteric duct at the umbilicus,
and the continued discharge had set up a proliferation of the squamous epithelium.
This case is reported in detail in Chapter XVII.
LITERATURE CONSULTED ON CYSTS IN THE ABDOMINAL WALL DUE TO REMNANTS OF THE OMPHALOMESENTERIC DUCT.
Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 1905, xxi, 729.
Colmers, F.: Die Enterokystome und ihre chirurgische Bedeutung. Arch. f. klin. Chir., 1906,
lxxix, 132.
Fox and MacLeod: A Case of Paget's Disease of the Umbilicus. Brit. Jour. Dermatol, 1904, xvi,
41.
Wyss, Hans v. : Zur Kenntniss der heterologen Flimmercysten. Virchows Arch., 1870, li, 143.
Zumwinkel: Subcutane Dottergangscyste des Nabels. Langenbeck's Arch, f . klin. Chir., 1890,
xl, 838.
==Chapter XIV. Persistence of the Omphalomesenteric Vessels==
Historic sketch.
Remnants of the omphalomesenteric vessels at the mesentery.
Omphalomesenteric vessels accompanying Meckel's diverticulum or a patent omphalomesenteric
duct.
Persistence of the omphalomesenteric artery in the bases of umbilical polyps.
An omphalomesenteric vessel lying perfectly free in the abdomen.
Fatal obstruction due to remnants of the omphalomesenteric vessels.
In the earliest stages of the embryo the omphalomesenteric arteries are two in
number. They arise from a plexus of from two to four small vessels, coming directly
from the aorta, and pass out one on each side of the yolk-sac.
The left artery disappears, the right persists and follows the omphalomesenteric
duct, to terminate in a network which covers the entire yolk-sac. The proximal
portion of the right omphalomesenteric artery later becomes the superior mesenteric artery.
The omphalomesenteric veins, in the beginning, are two in number. The right
disappears, but the left collects the blood from the entire yolk-sac and from the
omphalomesenteric duct, and in the liver anastomoses with the left umbilical vein.
Before entering the liver it receives tributaries from the intestine — from the superior
mesenteric vein (Fig. 7).
A reference to Fig. 6, p. 6, Fig. 7, p. 7, Fig. 8, p. 8, Fig. 10, p. 10, Fig. 11, p. 11,
Fig. 12, p. 12, Fig. 13, p. 13, Fig. 14, p. 14, Fig. 15, p. 15, and Fig. 33, p. 32, will
serve to give a very clear idea of the origin and course of the omphalomesenteric
vessels during the various months of fetal life.
The omphalomesenteric vessels, as a rule, totally disappear, but occasionally
persist, sometimes independently, sometimes associated with remnants of the
omphalomesenteric duct (Fig. 145). When one realizes that in every human being
these structures were at one time present, it is remarkable that remnants of them
are not more frequently found.
According to Fitz, Meckel was familiar with remnants of the omphalomesenteric
vessels.
An observation made by Ruge in 1877 is of interest. He rejDorts the discovery,
in the body of a new-born child, of a cord the thickness of a linen thread for 2 cm.,
and then of hair-like thinness for 1.5 cm. ; it ran between the mesentery of the small
bowel and the tissue around the right umbilical artery, just before its entrance
into the abdominal wall. Ruge further described the projection of a delicate,
thread-like process with a knobbed end, from the mesentery near the intestine, and
a short distance above the cecum. He then makes the statement that floating
threads with rounded ends may often be found on the mesentery or near the navel,
and are derived from the omphalomesenteric vessels or the duct.
Tillmanns, in 1882, said that occasionally remains of the fetal omphalomesenteric
242
PERSISTENCE OF THE OMPHALOMESENTERIC VESSELS.
243
vessels are seen as strings of various forms — threads or canals extending from the
inner surface of the umbilicus, not to the point of the diverticulum, but directly to the
mesentery. Thus, Schroeder had relatively often observed such pictures in new-born
cats, dogs, and rabbits, although he acknowledged that they are more rare in man.
Fitz, writing in 1884, said that the vitelline duct is not only composed of layers
of tissue equivalent to those forming the coats of the intestine, but is also accompanied by blood-vessels. These are the omphalomesenteric or vitelline arteries
and veins, which course along its surface and ramify over the walls of the umbilical
vesicle. Coincidently with the atrophy of the vitelline duct these vessels also
become atrophied and eventually disappear, with the elimination of the former.
The progressive shrinkage and eventual disappearance of the vitelline duct, however, do not necessitate the atrophy of these vessels.
In Fig. 21, p. 20, from a human embryo 12 cm. long, is seen a small filament
attached at one end to the umbilicus, and at the
other end lying perfectly free. It is a remnant
of the omphalomesenteric vessels.
Remnants of the Omphalomesenteric Vessels at the Mesentery. — Fitz says that soon after his
attention had been drawn to persistence of the
omphalomesenteric vessels he examined the body
of a man who had died of chronic tuberculosis
at the Massachusetts General Hospital. There
were two tuft-like projections from the upper
surface of the mesentery, each half an inch long
and about half an inch apart. They were about
two inches distant from the portion of the ileum
lying some three feet above the ileocecal valve.
The peritoneum, covering them was normal in
appearance, and the mesentery elsewhere was
free from all abnormal changes. The peritoneum in the vicinity of the navel was examined,
but with negative results. Fitz says that since
then repeated examinations have been made
with reference to what might be regarded as vitelline remains, but with indifferent
success.
Omphalomesenteric Vessels Accompanying Meckel's
Diverticulum or a Patent Omphalomesenteric Duct.
— Fig. 25, p. 24, and Fig. 26, p. 24, show very clearly the relation of the
omphalomesenteric vessels to Meckel's diverticulum. Fig. 27, p. 24, represents
the same vessels passing from their point of origin to the umbilicus, when no trace
of the vitelline duct remains.
Fitz says that the existence of the omphalomesenteric vessels, their relation
to the omphalomesenteric duct, and their occasional persistence, entire or in part,
were well known to Meckel. Their transformation into fibrous cords was likewise
familiar to this author. He quotes Meckel* as saying: " Quite recently I found
them in a child of three months, arising, as usual, from the superior mesenteric
* Meckel: Arch. f. d. Physiologie, 1809, ix, 439.
Fig. 145. — An Omphalomesenteric Duct
Originating from the Concave Side
of the Bowel and Attached to
the Umbilicus by a Fibrous Cord.
(Schematic.)
This picture illustrates a condition that
occasionally exists. The diverticulum, as a
rule, springs from the outer or convex surface of the bowel. The origin of the omphalomesenteric vessels from those of the mesentery is clearly seen. Where the omphalomesenteric duct is attached to the umbilicus
by a fibrous cord, this usually represents the
obliterated portion of one of the omphalomesenteric vessels.
244 THE UMBILICUS AND ITS DISEASES.
artery and vein, running along the entire length of the diverticulum, and converted
at its end into a solid thread several inches long and hanging free. "
Hue, when making an autopsy on a child dead of prolapsus of the bowel through
a patent omphalomesenteric duct, found a persistence of the omphalomesenteric
artery. Deve, who took part in the discussion on Hue's case, mentioned a case
in which the artery also persisted. Stierlin, while removing a patent omphalomesenteric duct, noted that an artery was injured. It was isolated, tied off, and
dropped back into the abdomen. It was a patent omphalomesenteric artery.
PERSISTENCE OF THE OMPHALOMESENTERIC ARTERY IN THE BASES OF
UMBILICAL POLYPS.
Quite frequently, when these small growths are being cut off, a vessel spurts,
which is undoubtedly a patent omphalomesenteric artery. In Case 2, recorded by
Lannelongue and Fremont, when the polyp was cut off, there was hemorrhage from
a small artery. Pestalozza, in 1889, reported a case in which the omphalomesenteric
vein in the cord of a child at term was still patent.
AN OMPHALOMESENTERIC VESSEL LYING PERFECTLY FREE IN THE ABDOMEN.
One of the most interesting cases of this character was reported by Spangenberg*
in 1819. In the body of a young man, twenty years old, he found what he regarded
as an open omphalomesenteric vessel. It could be followed to within half an inch
of the navel, where it became a delicate ligament and was lost in the umbilical ring.
It descended from the navel between the epigastric veins, on the posterior surface of
the peritoneum, to which it was united by fibrous tissue, to nearly midway between
the umbilicus and pubes; then, leaving the wall of the abdomen as a thin round
cord, it crossed the abdominal cavity between the coils of small intestine, passed
beneath the intestines toward the spine, somewhat to the left, and emptied into a bifurcation of the main trunk of the superior mesenteric vein. The vessel was wholly
free throughout its entire course, nowhere adhering to the intestine, and was enveloped in a fibrous sheath. It was open to within two inches of the navel, and a
small quantity of thin blood from the mesenteric vein was admitted as far as its
middle. Its walls for three inches from its origin from the mesentery were collapsed, like those of any other vein, but from this point onward the vessel was of
denser structure and very smooth externally. It had no branches, and in texture
it resembled in all respects the umbilical vein, which later was found open through
half its course. The appearance of the navel as seen from without did not vary
from that of other normally formed umbilical depressions.
From the cases just cited it is perfectly clear that one or both of the omphalomesenteric vessels may persist in part or as a whole.
FATAL OBSTRUCTION DUE TO REMNANTS OF OMPHALOMESENTERIC VESSELS.
Falk, King, and Mahomed have each recorded a case in which the remnant of
an omphalomesenteric vessel appeared to be the cause of intestinal obstruction.
Fitz referred to the case reported by Falkf in 1835. The patient was a man,
* Spangenberg: Deutsches Arch. f. d. Physiologie, 1819, v, 87.
t Falk: De Ileo e Diverticulis, adieeta Morbi Historia, 1835, 18.
PERSISTENCE OF THE OMPHALOMESENTERIC VESSELS.
245
twenty years of age, who had a diverticulum 43^ inches long. Two feet above the
ileocecal valve a solid, pseudomembranous ligament, V/^ inches long, ran from its
apex to the abdominal wall, an inch from the umbilicus. Uniting the diverticulum
and the mesentery was a band, and this apparently had caused an intestinal obstruction. Falk states that diverticula in themselves are not of much importance in
producing disturbances of the intestine. But where the umbilical vessels are still
adherent and hang off as threads in the abdominal cavity, they may become agglutinated to the organs of the abdomen and thus cause volvulus.
In 1843, King described a case of fatal intestinal obstruction in which an adventitious cord was found passing from the mesentery to Meckel's diverticulum. The
patient was a boy fourteen months old. After the cord came away on the eleventh
day there was a thin, yellow, slightly odorous discharge from the umbilicus. Poultices were used for three months, and caustics were applied to destroy the surface.
The edges of the fistula were pared and
strapped. The opening communicated with
a deep sinus into which a probe passed two
inches, evidently into the small bowel.
About seventeen days later there was an
escape of feces.
An ovoid incision was made, and the
parts were brought together with pins and
plaster. The child was well in a little over
two weeks. He died later of intestinal obstruction. At autopsy the diverticulum
was found to be three inches long and adherent to the umbilicus. An adventitious
cord had apparently compressed the ileum
just below its connection with the diverticulum.
Fig. 146 is from another case recorded
by King. This patient also died from intestinal obstruction apparently due to a
remnant of an omphalomesenteric vessel.
Mahomed's case, published in 1875,
leaves absolutely no doubt that the omphalomesenteric artery was responsible for
the fatal obstruction.
The patient was a boy eighteen years old who was admitted to the hospital with
signs of obstruction, after having eaten a meal of badly cooked potatoes. He died
with typical signs of intestinal obstruction eleven days after the illness began.
Autopsy. — A fibrous band was found extending from the middle of the abdominal wall, midway between the pubes and the umbilicus, backward toward the right
iliac fossa. It had carried out with it from the abdominal wall a triangular fold of
peritoneum. The cord was found passing amid the distended coils of small intestine
to the lower part of the ileum, where it formed a noose encircling a loop of ileum
33 inches in length. It had passed one and a half times around the gut at the point
of constriction, and was then found to extend to the mesentery of the ileum, about
Fig. 146. — A Remnant of an Omphalomesenteric
Duct Causing Fatal Intestinal Obstruction. (After King.)
The figure represents a Meckel's diverticulum
attached to the convex surface of a loop of small
bowel. An adventitious cord extends from the
mesentery over the small bowel to the side of the
diverticulum. It represents what remained of one
of the omphalomesenteric vessels. It was the cause
of fatal intestinal obstruction.
246 THE UMBILICUS AND ITS DISEASES.
three feet from the ileocecal valve. On being traced between the layers of peritoneum forming the mesentery, the cord was discovered terminating in the large
branch of the ileocolic artery.
In its course forward the fibrous cord was found to bifurcate at the apex of the
triangular fold of peritoneum, which it had carried out from the abdominal wall.
One branch ascended to the umbilicus, accompanying the obliterated hypogastric
artery of the right side ; the other branch descended toward the bladder and terminated in the left superior vesical artery.
The "committee" were of the opinion that the case was one of persistence of
the fetal omphalomesenteric artery, which sends off branches of communication
with the left superior vesical or hypogastric artery, the latter having been probably smaller than normal, and having its distribution supplemented by the former.
On page 169 is a very interesting account of a case of fatal intestinal obstruction
coming under the care of Sheen. A large quantity of small bowel had passed
through a hole in the mesentery of a Meckel's diverticulum, and become strangulated (Fig. 102, p. 170). A note was made that the strength of the constricting
cord of mesentery was largely due to the presence of a vessel that crossed it. This,
of course, was one of the omphalomesenteric vessels.
From the preceding cases it is clearly evident that remnants of the omphalomesenteric vessels are from time to time found, and that these may lead to fatal
intestinal obstruction.
LITERATURE CONSULTED ON PERSISTENCE OF THE OMPHALOMESENTERIC
VESSELS.
Fitz, R. H.: Persistent Omphalomesenteric Remains. Their Importance in the Causation of
Intestinal Duplication, Cyst-formation, and Obstruction. Amer. Jour. Med. Sci., 1884,
lxxxviii, 30.
Falk, J.: De Ileo e Diverticulis, adiecta Morbi Historia, 1835, 18.
Hue, F. : Prolapsus ombilical diverticulaire. La Normandie medicale, 1906, xxi, 162.
King: Feculent Discharge at the Umbilicus from Communication with the Diverticulum Ilei.
Guy's Hospital Reports, 1843, 2. series, i, 467.
Mahomed, F. A.: Case of Intestinal Obstruction Produced by the Abnormal Remains of a Fetal
Vessel. Trans. Path. Soc. London, 1875, xxvi, 117.
Pestalozza, E.: Persistenza di un vaso onfalomesenterico nel cordone ombelicale di un feto
a termine. Bull, della soc. medico-chir. di Pavia, 1889, 11.
Ruge, C. : Ueber die Gebilde im Nabelstrang. Zeitschr. f . Geb. u. Gyn., 1877, i, 7.
Spangenberg, G.: Beitrag zur Entwicklungsgeschichte des Darmkanals. Deutsches Arch. f.
d. Physiologie, 1819, v, 87.
Tillmanns, H. : Ueber angeborenen Prolaps von Magenschleimhaut durch den Nabelring (Ectopia ventriculi), und liber sonstige Geschwlilste und Fisteln des Nabels. Deutsche Zeitschr.
f. Chir., 1882-83, xviii, 161.
==Chapter XV. Umbilical Concretions Associated with Inflammatory Changes in the Abdominal Wall==
Historic sketch.
Symptoms.
Cause.
Treatment.
Cases with umbilical concretions.
Umbilical concretions frequently diagnosed as dermoids.
Cases of umbilical horn.
Other foreign substances in the umbilical depression.
This subject has been very carefully considered by Blum, Nicaise, Villar,
Foulerton, Ledderhose, and Pernice. Umbilical concretions seem to be much more
frequent in men than in women, and usually occur during the period of life in which
the patient is most actively engaged in work, namely, between the twentieth and
sixtieth year. They are exceptional in children and not common in the aged.
As a rule, the patient is unaware of any trouble until abdominal pain is felt.
This is usually referred to the umbilical region, and may be increased on muscular
exertion, on defecation, or on pressure upon the abdomen. On visual examination
sometimes nothing is detected. Later induration is noted in the umbilical region,
the umbilical opening becomes very small, and the surrounding tissue feels hard.
The overlying skin may or may not be reddened. At this stage the patient may
have excruciating abdominal pain, followed by the escape of a foreign body, together with some blood and pus. A speedy disappearance of the symptoms usually
follows.
In the majority of cases the umbilical depression is the center of the trouble,
but occasionally the swelling and induration are situated a short distance from
it. This was noted in Williams's case. The tumor, the size of an egg, was
situated one inch above the umbilicus, whereas the discharge came from the
umbilicus itself.
The umbilical opening, as a rule, is very small, and suggests the mouth of a
fistula. Its margins are usually flat, but occasionally the opening is surrounded by
a zone of granulation tissue, as noted in cases reported by Foulerton, Nicaise,
Polaillon, Richelot, Roques, Shattock, and Tremontani.
On examination the umbilical cavity is invariably found distended and filled
with pus and a concretion or cheesy material. The cavity itself may be several
centimeters in diameter. In Nicaise's case the umbilical depression opened through
a very narrow aperture into a second cavity, which contained the concretion.
In Taylor's case, when opened up, the umbilical cavity was found to contain an
ounce of foul-smelling pus, and this cavity communicated with a second filled with
a softened, cheesy material and some hair.
Walters, under the title "An Umbilical Pocket," reports a very instructive
247
248 THE UMBILICUS AND ITS DISEASES.
case. A man, aged thirty-four, had complained of mild periodic attacks of abdominal pain. The umbilical depression led to a second pocket, containing a yellowish
mass, which the patient said had been there for years. The mass consisted of
sebaceous material and felted hair. The pocket was two inches in diameter and
three-quarters of an inch deep.
Probably one of the most interesting and instructive cases is that reported by
Foulerton. Protruding from the umbilical site was a smooth, solid, round, reddish
growth, the size of a cherry, from which there was a slight discharge. Surrounding
this was a zone of induration. Cancer was suspected. Under local freezing the
growth was cut off flush with the abdominal wall, opening up an abscess sac
which contained pus and a concretion the size of a cherry-stone. The red nodule
proved to be granulation tissue around the mouth of a small fistulous opening, and
the abscess sac was nothing more than the occluded umbilical depression. Healing was complete in two weeks.
Although the induration in the abdominal wall is usually uniform, there may be
marked local elevation. In one instance the swelling was as large as a hen's egg,
and in the one described by Gueterbock it reached the dimensions of a child's head,
a large collection of pus being present. The umbilical discharge may be small
in amount or very free. Sometimes it is seropurulent, but usually most offensive,
and of an odor suggesting decomposing smegma.
The umbilical concretions are variously recorded as being the size of a pea,
bean, almond, sparrow's egg, or pigeon's egg. They have reached 1.5 to 2.5 cm. or
more in diameter. They may be whitish yellow, brown, or pearly in color. Sometimes they appear to consist almost entirely of sebaceous material, and are exceedingly friable. Other concretions are much firmer, have a laminated structure, present a pearly appearance, and constitute what Coenen has termed cholesteatomata.
The surface of these concretions may be perfectly smooth, or small hairs may be
seen projecting from their surfaces. These hairs may be colorless or correspond
in color to those of the patient. The cheesy material sometimes contains, in addition, other foreign material, such as wool or cotton fibers from the patient's clothing
and particles of such matter as clay, coal, or stone, according to the occupation of
the individual. On histologic examination the cheesy material is seen to consist
of fatty desquamated epithelium, and in some cases keratin, fatty debris, and
cholesterin crystals are also found.
The cause of these umbilical inflammations is easy to explain. Owing to lack
of cleanliness or to an unusually deep umbilicus, particles of hair or wool accumulate
deep m the umbilical depression. These form a small ball, which in turn, by its
irritation, causes exfoliation of the squamous epithelium. This adheres to the
mass and gradually increases its size. Finally, as a result of the constant irritation,
there ensues a mild inflammation of the tissue surrounding the umbilicus, which
gradually narrows the umbilical opening until it becomes but little larger in diameter than a fistulous tract. Pus accumulates and dilates the umbilical depression,
and an abscess cavity containing a concretion results.
This condition rarely leads to serious consequences. In one of Volkmann's*
cases, however, it would seem that the long-continued irritation of the concretion
had induced a primary carcinoma of the umbilicus.
The history of these cases is characteristic, and there should be little difficulty
* Volkmann (Cited by Pernice) : Die Nabelgeschwtilste, Halle, 1892.
UMBILICAL CONCRETIONS.
249
A./i.
Fig. 147. — A Small Umbilical Concretion.
From a woman, ninety-seven years of age,
seen at the Church Home June 4, 1910. The
umbilical opening was small; completely filling it was a small black mass, which on pressure was partly forced out. It consisted of
cheesy material. The superficial portion had
become black as a result of exposure to the
light, air, and dust.
in establishing the diagnosis. In Foulerton's case, however, the condition was supposed to be one of carcinoma of the umbilicus.
Treatment. — This consists in widely dilating the fistulous tract with the
full knowledge that in the depth a concretion
or caseous material or both will be found.
Thorough removal of the foreign substance is
invariably followed by prompt recovery, but as
long as portions remain there will be a discharge.
Occasionally an umbilical concretion may be
present without producing any inflammatory
reaction. On June 4, 1910, I saw a patient
ninety-seven years of age at the Church Home,
Baltimore. The umbilicus was exceedingly
small; projecting from it, and completely filling
the opening, was a small black mass (Fig. 147) .
The house officer suspected a malignant growth.
On making pressure I forced the mass farther
out. The deeper portions presented the characteristic cheesy character of a concretion.
The superficial portion had become hard and
black on account of exposure to the light, air,
and dust.
While analyzing this group of cases the following case came under my care:
Mr. S. W., aged thirty-two, was seen on March 31, 1913. This patient had been
ill for two weeks; previous to this time he had been perfectly well. On examination I found the umbilicus pouting out like a snout. It projected
out about 1 cm., and from its
center there was a discharge of
creamy pus. The opening from
which this pus escaped was about
2 mm. in diameter. The abdominal wall on each side was indurated over an area of about 3 cm.,
and there was a distinct flush.
Fig. 148 is a water-color sketch
of the condition. On pressure the
parts were found to be indurated
and there was a good deal of discomfort. I felt sure that we were
dealing with an accumulation of
sebaceous material, and that this
had caused an acute inflammation.
Bichlorid compresses were applied for forty-eight hours. The patient was then brought to the operating-room,
and with a pair of Kelly forceps the opening at the umbilicus was stretched. We
then used a sharp curet and brought away quantities of sebaceous material. The
Fig. 148. — Acute Inflammation op the Umbilicus due to an
Accumulation of Sebaceous Material.
The umbilical depression is raised and tense. Near its center pus is seen escaping from a small orifice. The surrounding
abdominal wall is swollen, red, and indurated. The small opening was stretched considerably, and the cavity evacuated. A
large quantity of cheesy material was cureted away. The cavity
was packed with gauze. The inflammation speedily subsided, and
in a few weeks the umbilicus presented the normal appearance.
250 THE UMBILICUS AND ITS DISEASES.
cavity was packed with iodoform gauze. From clay to day the wound was washed
out with hydrogen dioxid. The patient was discharged on April 5, 1913. On April
21st the umbilicus presented the normal appearance, and there was not the slightest
trace of inflammation or of discharge.
CASES WITH UMBILICAL CONCRETIONS.
In some cases I have given an exact translation of the original title, although on
careful examination of the description of the case it is evident that the patient was
suffering from an umbilical concretion and not from a dermoid cyst, as diagnosed by
the individual author.
Tuberculosis o f t h e Umbilicusf?].* — Ten days before the
patient had had cramp-like pains in the abdomen, followed in three days by a discharge from the umbilicus, accompanied by tenderness and soreness in that region.
His sisters had died of tuberculosis. There was a purulent discharge from the umbilicus and slight swelling to the right and below it, apparently in the deeper portion of the abdominal wall.
At operation the umbilical opening was enlarged, and over an ounce of "typical
tuberculous " granulation tissue removed. The cavity, the size of a walnut, internal
to the abdominal wall was exposed and packed with iodoform gauze.
Smears of this showed numerous "tubercle bacilli" in some specimens, none in
others. Bouffleur questioned whether he was dealing with a primary tuberculosis
of the blind urachus or- Meckel's diverticulum or with a primary umbilical tuberculosis.
[The history of the case and the findings at operation would rather suggest
an accumulation of sebaceous material at the umbilicus than any tuberculous
process. The acid-fast organisms found were possibly smegma bacilli.- — T. S. C]
Umbilical Concretions. f — In two cases of phlegmonous inflammation of the umbilical region with fistula, Bufalini found at the bottom of the
abscess stony concretions which consisted of fatty and gritty particles, of carbonic
acid chalk, exfoliated epithelium, and threads from clothing.
Cholesteatomata of the Umbilicus. — Coeneni said that in
the last two years two cases of "pearl tumor" of the umbilicus had been seen in
Kiittner's clinic. The first had already been reported in Brun's Beitrage, Bd.
lviii, Hft. 3.
Case 1. — The patient, forty-nine years old, had a purulent discharge and a
general phlegmonous condition in the region of the umbilicus. Slight jaundice
developed and the umbilicus became very prominent. An incision was made, and
an abscess cavity the size of a hen's egg was found at the umbilicus. This contained
a tumor the size of a pigeon's egg (Fig. 149). It was made up of concentric layers
of glistening mother-of-pearl tissue. These layers were arranged just as the various
layers of an onion, and consisted of hornified epithelium. The process was complicated by suppuration.
Case 2. — A man of strong build, aged twenty-five, a few days before admission
* Bouffleur: Clinical Review, Chicago, 1898, ix, 329.
t Bufalini, G.: Jahresbericht der gesammt. Med., 1887, ii, 497.
i Coenen, H.: Ueber das Cholesteatom des Nabels. Beitrage zur klin. Chir., 1908, lviii,
718; Munch, med. Wochenschr., 1909, lvi, II, 1583.
UMBILICAL CONCEETIONS.
251
Fig. 149. — Cholesteatoma from the Umbilicus in Case 1.
(After Coenen.)
From the description,
this is apparently the natural size. It was described
as being the size of a pigeon's egg.
to the hospital had noticed at the umbilicus a swelling from which purulent fluid
escaped. At the umbilicus was a smooth, pea-sized elevation, reddish in color,
soft in consistence. When slight pressure was made on the umbilical funnel, there
escaped a body the size of an acorn (Fig. 150). It had a mother-of-pearl, glistening
appearance, was composed of horny layers, and at once brought to mind the previous case of cholesteatoma of the umbilicus. With the
patient anesthetized, the posterior surface of the umbilical
ring was found adherent to the gastrocolic ligament. These
adhesions, together with the ligamentum teres and the obliterated urachus, were cut through. The umbilicus, which contained a small tumor the size of a hazel-nut, was removed. The
abdomen was closed, and healing took place without difficulty.
Histologically, the tissue lying in the umbilical funnel
consisted of markedly proliferating fibrous tissue with abundant small-round-cell infiltration and cells around the bloodvessels. Covering the surface of the fibrous tissue was a
very thick layer of epithelium. This had exfoliated quantities of horny epithelium, so that in the space between this
projection and the wall of the umbilical ring there was a
large amount of horny epithelium. The connective tissue
itself showed marked subepithelial cell proliferation, just as is
seen in the vicinity of carcinomatous prolongations. Nevertheless, no carcinomatous infiltration by the epithelium could
be definitely made out.
Sections from the cholesteatoma stained with Gram were intensely blue. The
cells shewed keratin bodies. In the umbilical funnel there was a knob-like fibroma
(Figs. 151 and 152). There was marked proliferation of its epithelial covering,
and there had been a continual throwing off of layers of epithelium into the umbilical depression. This desquamated epithelium was held in the umbilicus, the
fibroma acting as a cork to the umbilical opening. In layer after
layer the exfoliated epithelial cells had accumulated into a large
plaque, forming the cholesteatomatous mass. Probably this process had existed for years, but was only noted by the patient when
an abundant purulent discharge took place.
According to Coenen, the primary cause in this second case
of cholesteatoma of the umbilicus was without doubt the presence
of the fibrous tumor in the umbilical depression. The continuous
irritation of the products of the cholesteatoma in the umbilical
ring could now easily lead to an eczematous inflammation of the
skin of the umbilicus, to abscess formation, and to phlegmon.
Cholesteatoma of the Umbilicus. — Coenen *
described a case from Kuttner's clinic. A woman, sixty-two years
old, had a pendulous abdomen and lax abdominal walls. When the various folds
were drawn away from one another, there was seen in the umbilicus the characteristic
pearly, glistening epithelial exfoliation noted in a cholesteatoma. The growth could
be lifted out with a spoon and appeared as small balls the size of a pea or of a bean.
If the material had remained longer, it would have developed into a cholestea
* Coenen, H.: Loc. cit.
Fig. 1.50. — Cholesteatoma FROM
Case 2. (After
Coenen.)
It was the size of an
acorn.
252
THE UMBILICUS AND ITS DISEASES.
toma. In this case there was a desquamative omphalitis with an accumulation of
cholesteatomatous masses in the umbilical ring. Coenen calls attention to the
analogy between cholesteatoma of the umbilicus and cholesteatoma of the ear.
Fig. 151. — The Coxxective-tissue Projection" Really Represexts a Small Fibroma in the Floor of the
Umbilicus. (After Coenen.)
It consists of fibrous tissue showing marked small-round-cell infiltration. The covering consists of many layers of
squamous epithelium, superficial portions of which are horny.
' .
Fig. 152. — Exlargemext of Fig. 151. (After Coenen.)
The excessive thickening of the squamous epithelium in the umbilical depression is shown. The center of the
epithelial areas shows hornification. The underlying tissue shows small-round-cell infiltration, particularly well seen
around the capillaries.
Fistulous Abscess of the Umbilicus.* — A digger, forty-six
years of age, had always been healthy except for a pleurisy at four years of age. He
said that fifteen days before coming under observation he had had pain in the
* Derville, L. : Abces fistuleux do I'ombilic. Jour. d. sci. med. de Lille, 1894, ii, 320.
UMBILICAL CONCRETIONS. 253
umbilical region, and at the same time a serous discharge from the umbilicus. The
pain increased greatly, and after the application of poultices a grayish piece of
stone the size of a pea came away. A probe was passed to a depth of 2 cm.
A Sebaceous Umbilical Tumor.* — At autopsy on a stout
woman, seventy-five years of age, a small, elongate tumor at the umbilicus, with a
little opening, was found. A probe introduced into this opening was arrested by
a yellow, very hard body. An incision showed that the cavity was continuous with
the skin. The body in this cavity was ovoid in form, the size of an almond, whitish
yellow, and sticky. It had the odor of infected smegma.
On microscopic examination it was found to consist of cholesterin and an accumulation of exfoliated epithelium.
Growths from the Umbilicus. f — A dockyard laborer, aged
forty-nine, had protruding from the site of the umbilicus a smooth, solid, round
growth the size of a cherry. This had a covering resembling mucous membrane,
and from it there was slight discharge. Its base was somewhat constricted, but
there was no definite pedicle, and no sulcus could be detected between the growth
and the surrounding skin. Around the growth was a zone of uniform induration
extending for an inch and a quarter in every direction, involving the skin and subcutaneous tissue. The skin over the indurated region was of the natural appearance, adherent to the subcutaneous tissue, and extremely tender. The patient
thought that his umbilicus had always been smaller than usual, but had noticed
nothing else until three weeks previously, when a very painful lump had suddenly
appeared there. The lump was considerably smaller when he first saw it than on
admission. The pain had been extreme and continuous. The surgeon who sent
him to Foulerton had diagnosed cancer, and, as a matter of fact, the growth had
every appearance of epithelioma. The pain had been, however, too acute in its
commencement and in its intensity. The growth was removed at the level of the
skin under the ether spray, and a cavity was exposed. This contained some thin,
purulent fluid, and a hard mass of inspissated sebaceous material the size of a
cherry-stone. The cavity admitted the tip of the finger; it was laid open, scraped
out, and a poultice was applied.' Four days later the induration was gone and
the wound healed up in two weeks. Foulerton draws attention to his article in
the Lancet of July 7, 1888, in which he described four intractable umbilical sinuses
due to concretions. No microscopic examination was made in this case.
Dermoid Cysts of t heUmbilicus [?].j — -A man, thirty-five years
of age, entered the hospital for umbilical suppuration. About five months before
a small tumor had been noted at the umbilicus. This had reached the size of a
walnut and was slightly painful. It had been incised a month before admission,
and a caseous mass and a tuft of hair had escaped. Gonard found the umbilicus
indurated and red; the orifice was very small, and from it drops of pus escaped.
A probe was passed 2 cm. into the depth, and the sac dissected out. Gonard
thought it was a dermoid cyst on account of the hair and the inner lining.
[Probably the case was one of inflammation due to the presence of a foreign
body.— T. S. C]
* Fere, C. : Tumeur sebacee ombilical. Bull. Soc. anat. de Paris, 1875, 1, 622.
t Foulerton, A. G. R.: Illustrated Med. News, 1889, iv, 161.
t Gonard, G. : Des kystes dermoides. These de Alontpellier, 1906, No. 31.
254 THE UMBILICUS AND ITS DISEASES.
A Dermoid Tumor of the Umbilicus [?]. * — -A girl of sixteen
had noticed a swelling in the abdomen fourteen days before coming under observation. During the last eight days this had rapidly increased in size. On admission
it was the size of a child's head, round, and at several points markedly nodular.
It was situated in the mid-line, was easily grasped, was firm, not very elastic, somewhat movable, and slightly painful on pressure. Three days later fever developed,
and after two days more redness and fluctuation were noted. On the following
day there was an abundant quantity of thin pus coming from an irregular hole in
the tumor. Sebaceous masses and portions of a thin membrane were then removed.
The tumor, after its contents had escaped, became markedly smaller and gradually
disappeared. Microscopic examination showed free nuclei, granules, cholesterin
crystals, and fat.
[If it had been a dermoid, why had it appeared so suddenly and why did it
disappear completely, although all the wall was certainly not removed? Was it
not more probably an abscess? — T. S. C]
An Umbilical Concretion the Size of a Pigeon's Egg.
— Hahnf says concretions of the umbilicus occurring as a result of lack of cleanliness are not rare. His patient, a joiner, forty-three years old, fourteen days before
he came under observation had noticed a painful swelling at the umbilicus. The
skin was unchanged. For four days before Hahn saw him pus had been escaping
from the umbilicus. On examination a swelling on the right side of the umbilical
depression was found, and a tumor the size of a walnut, circumscribed, smooth,
firm, and painful on manipulation. There was an escape of thick, greenish, foul
pus in small quantities. The sound passed 2 cm. downward and to the right.
After a few days there was edema of the skin and a slight elevation of temperature.
A transverse incision was made to the right. Pus with whitish, friable particles
escaped. In the depth was a roundish, whitish, glistening tumor, the size of a
pigeon's egg, which was easily removed. It was 3 cm. long and 2 cm. broad. It
was yellowish white, rather firm, and friable. It had an outer covering 3 to 4 mm.
thick, with a blackish central portion. On histologic examination it was found to
be composed of horny epithelium, fat, sebaceous masses, dirt, and particles of coal.
The dark center had the same constituents and also contained wool fibers. Hahn
draws attention to the fact that such concretions are often confused with suppurating dermoids.
An Umbilical Concretion. — - According to Ledderhose,t Gilbert
described a concretion which was composed of lamellae. It showed amorphous
and crystalline fat, leukocytes, and fragments of chalk.
An Umbilical Concretion. § — Duplay's patient was a stout,
elderly woman. At autopsy, at the umbilical level there could be felt a small,
elongate tumor directed obliquely downward and then backward. This occupied
a fatty pocket. The upper portion of the umbilical wall was intact. When the
- 1 Gueterbock, P.: Ueber einen Fall von Dermoidgeschwulst cles Nabels. Deut. Zeitschr.
f. Chir., 1891, xxxii, 319; Deutsche med. Wochenschr., 1891, xvii, 1079.
t Halm, Otto: Ein Nabelkonkrement von Taubeneigrosse. Beitrage z. klin. Chir., 1900,
xxvi, 80.
i Ledderho.se, G.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief.
45 b.
§ Nicaise: Ombilic. Dictiormaire encyclopedique des sci. med., Paris, 2. ser., xv, 1881,
140.
UMBILICAL CONCRETIONS. 255
margins of the cutaneous depression were separated, at the bottom could be seen
a small opening a little over 1 mm. in diameter. A probe introduced impinged
upon a foreign body which was yellowish in color. An incision was made, and at
the umbilical cicatrix was found a sac-like formation containing a hard, homogeneous body the size of an almond and consisting of sebaceous material.
An Umbilical Concretion. — Nicaise * r eports the following case,
seen by Notta, in which an accumulation of sebaceous material had given rise to
an inflammation of the umbilicus. A shoemaker, aged fifty-six, had previously
had excellent health. Two years before he had noticed at the umbilicus a hardness
without any change in color of the skin and without any discharge. This hardness
had increased in volume very slowly, and only later had become painful. At last he
could not bear the clothes to come in contact with the part, and his work naturally
augmented the pain. He was not able to hold the shoe against his umbilicus, as
is the custom with shoemakers, but was obliged to work with it applied to another
part of the abdomen. About June 10, 1878, the pain had become more severe,
the skin had reddened, ulceration had occurred in the center of the umbilicus, and
a small amount of pus had escaped until a fragment of a sebaceous calculus, the
size of a filbert, had come away spontaneously, and the pain had ceased. His
physician later had extracted several fragments. When called in consultation,
Notta found the umbilicus tumefied and the skin red and indurated for a distance
of from 12 to 15 cm. around it. In the center was an area of ulceration 15 mm. in
diameter, at the bottom of which, bathed in pus, was a whitish mass. After enlarging the opening Notta extracted the whitish mass, the size of a walnut, which consisted of hard sebaceous material. Linseed poultices were applied for twenty-four
hours, and later lint steeped in aromatic wine. The umbilicus healed rapidly.
The cause of this affection, according to Notta, was very simple. Sebaceous material had accumulated in the deep folds of the umbilicus, and little by little had condensed to form a mass having the appearance of a calculus. This had produced
an inflammation which had caused the elimination.
Inflammation in the Umbilical Depression. — Park'sf
patient was thirty years old, and for two or three years had had a slight but constant discharge from a small opening at the umbilicus. At no time had this had a
fecal or urinary odor. It was seropurulent in character, and excoriated the parts.
The cavity was slit open with a probe as a guide. It had the diameter of an
almond, and had glistening walls; it contained no hair or epithelial products. Park
thought it was a dermoid. The cavity was scraped out, packed, and partly closed.
Healing took place.
[In this case there had evidently been a simple inflammatory condition. —
T. S. C]
Umbilical Concretion. — Pernice J reports a case of Longuet's.§
A young woman had a swelling at the umbilicus for three weeks. At first there
was no pain. Later it began to suppurate. Three days after the patient's entrance
* Nicaise: Op. cit.
f Park, Roswell: Clinical Lecture on Congenital Fistulae and Sinuses at the Umbilicus.
Med. Fortnightly, 1896, ix, 9.
t Pernice, L. : Die Nabelgeschwulste, Halle, 1892.
§ Longuet: Bull. Soc. anat. de Paris, 1875.
256 THE UMBILICUS AND ITS DISEASES.
to the hospital, as a result of the introduction of a sound, a foreign body was expelled.
It was the size of an almond, hard, made up of epithelial masses and fatty crystals.
Umbilical Concretions.* — A man, forty years of age, after
muscular exercise had felt something give way in the region of the umbilicus, and
after that had had pain there. The umbilicus was red, swollen, and projected 3 cm.
from the abdomen. From it there escaped a foul-smelling discharge. On pressure
two bodies the size of beans were forced out. They consisted entirely of matted
hair.
Suppurating Dermoid Cyst of the Umbilical Region [ ? ] . f — A woman, thirty years of age, presented a tumor in the umbilical
region. When one year old, she had had a blow on the umbilicus. For several days,
during the six weeks before she was admitted, her abdomen had continually come in
contact with the wash-tub. For about three days she had had pain in the umbilical
region. A few days later she had noticed a discharge from the umbilicus and a
swelling for a distance of 2 cm. around the umbilical region. Squeezing caused a
moderate amount of pus to escape from the umbilicus. On admission there was
an elevated area of proud flesh the size of a pigeon's egg. The umbilicus was red
and thickened; fluctuation was evident. An incision evacuated pus and grumous
material. A probe passed 4 cm. downward. The cavity was irrigated. About
two weeks later a sebaceous-like mass, the size of a walnut, escaped.
[The condition suggests a foreign body or a concretion rather than a dermoid.
— T. S. C]
Subumbilical Tuberculous Abscesses [?].| — ■ Case 1 . A
man, thirty-five years old, had complained of swelling in the umbilical region for
about a month. He had vomiting, and pain at the umbilicus. Following this there
had developed a painful swelling, but when his physician, thinking it was a hernia,
had attempted to reduce the mass by taxis, pus had escaped from the umbilicus.
Since then there had been a fistulous opening and a phlegmonous induration of the
region. The patient's general condition was good. The tumefaction was exactly
in the median line and symmetric. A probe could be introduced only with difficulty, except when curved. A sound passed 7 or 8 cm. below the umbilicus, both to
the right and left.
The tumor opened toward the right side, and one day a large mass of caseous
material came away. The opening closed, and the patient left the hospital. Six
months later there was pain in the abdomen, but nothing was noted at the umbilicus.
Ten years before the patient had had inflammation of the left lung and a pleuropneumonia on the right side five years later, but never a hemorrhage. Auscultation was negative.
[The history of the case and the character of the discharge strongly indicate
an accumulation of sebaceous material in the umbilicus. Had tuberculosis existed,
one would hardly have expected the cavity to have closed so satisfactorily. — T. S. C]
Case 2. — Richelot reports a personal communication from Verneuil. A Sister
of Charity, who had had scrofula as a child and also an old coxalgia, received a contusion beneath the umbilicus when using a good deal of force in closing a drawer.
* Pernice, L.: Op. cit. Labalbary: Gaz. des hop., 1862, 443.
t Polaillon: Kyste dermoi'de suppure de la region ombilicale. Gaz. med. de Paris, 1886,
lvii, 43.5.
% Richelot, L. G.: Abces tuberculeux sous-ombilical. L'union med., 1883, xxxv, 61.
UMBILICAL CONCRETIONS. 257
Several weeks later a fluctuating tumor was noted at the umbilicus. It was incised,
and a large quantity of milk-like fluid escaped. A fistula developed several months
later; she began to cough, and finally died of tuberculosis.
An Umbilical Concretion.* — The patient, fifty years old, had
been previously in good health. The umbilicus formed a deep cul-de-sac surrounded
by a red and tumefied zone. It was painful on pressure. The pain was increased
on movement or on defecation. Applications were made, and later there was
a discharge of seromucous fluid and a small body came away. The symptoms
rapidly subsided. This nodule was spheric, the size of a hazelnut, and hard. On
section it showed black and white areas. The black particles occupied the center;
the whitish areas were soluble in ether.
[There were evidently foreign bodies associated with an accumulation of epithelium.— T. S. C]
An Umbilical Concretion, f — A soldier, thirty-two years of age,
complained of pain at the umbilicus for fifteen days. The pain was extreme and
there was a certain amount of heat in the depth of the tissue. Surrounding the umbilicus was a tumefied and red area. When a probe was introduced, a sensation of
a hard body in the depth could be made out and an abundant amount of sebaceous
material escaped. At the end of five days a probe could be introduced 7 cm. On the
twentieth day there were violent contractions, accompanied by severe pain, and
a foreign body escaped with half a glass of pus and blood.
This body was the size of a sparrow's egg, pearly in color, and had a sebaceous
odor. Its center was hard and consisted of a piece of clay containing several
particles of grit and several hairs of the same color as those of the patient. He was
a stone-cutter, and particles had evidently dropped into the umbilical cavity.
Two Specimens of Umbilical Calculi.! — -Case 1 . — A man,
twenty-three years of age, had noticed a discharge from the umbilicus for eight weeks.
The surrounding abdominal wall was indurated and tender. Later a calculus was
extracted. The sinus and a granuloma which had formed around its margins
rapidly disappeared. The concretion was 1.5 cm. long, oval in form, and consisted
of closely packed squamous epithelial cells with a certain number of hairs.
Case 2 . — A man, thirty years old, had had a discharge from the umbilicus
for five years, associated with a granuloma. Around the sinus was granular tissue
which formed a tumor the size of a cherry. The sinus was opened and found to be
burrowing in various directions. An oval concretion, 2.5 cm. long, was found.
Over certain areas this was smooth and had a silvery exterior. From the surface
projected the ends of fine hairs, and a section presented traces of laminations. In
the center was a small piece of flocculent material — cotton fiber. The concretion
consisted of closely packed, flattened, and wrinkled epithelial cells.
Dermoid Cyst in the Abdominal Wall of a Man [ ? ] . § —
A man, twenty-two years of age, four weeks before coming under observation had
noticed a small mass in the median line of the abdomen directly below the umbilicus.
It had gradually increased in size until it was as large as an egg, hard and tender.
* Rouget: Gaz. des hop., 1862, 259.
t Roques: Kyste occasionne par la presence d'un fragment de terre dans l'ombilic. Gaz.
des hop., 1862, 314.
t Shattock, S. G.: Trans. Path. Soc. London, 1900, li, 282.
§ Taylor, Wm. J.: Annals of Surgery, 1896, xxiii, 296.
18
258 THE UMBILICUS AND ITS DISEASES.
He had had some purulent discharge from the umbilicus before entering the hospital. This had increased in quantity.
An incision was made over the swelling, and about an ounce of foul-smelling
pus was evacuated. The probe passed from the umbilicus into the abscess cavity.
At the bottom of the cavity, and communicating with it, was a depression containing soft, cheesy material and a small amount of hair. Taylor considered the nodule
as a small dermoid that had become infected. It was limited strictly to the abdominal wall. The abscess cavity and cyst were cureted freely; the umbilicus was
dissected away. The cavity was filled with iodoform gauze. Prompt recovery
ensued.
[In all probability this was an abscess due to retained material. Had a dermoid
existed, it would have been almost impossible to curet and completely remove the
cyst-wall.— T. S. C]
Dermoid Cyst of the Umbilicus [?].*■ — -A man, twenty-nine
years of age, had a tumor the size of a walnut at the umbilical cicatrix. This was
bright red in color, moist, and translucent. On the surface it was firm in consistence; it did not pulsate, was irreducible, and had a short pedicle. The pedicle was
smaller than the top of the umbilicus, and there was a discharge of seropurulent
fluid, yellowish in color and of an offensive odor. The tumor was dissected out,
but returned rapidly. Histologic examination showed a membrane of fibrous
tissue; the contents were cholesterin crystals, numerous epithelial cells, and colorless hairs. Tremontani thought the tumor was a dermoid.
[It strongly suggests an accumulation at the umbilicus. — T. S. C]
Umbilical Pocket. f — A man, thirty-four years old, complained of
periodic attacks of mild stomachache with a slight discharge from the umbilicus.
The umbilical depression led to a skin pocket containing a yellowish mass which
the patient said had been there for years. The mass was readily detached by careful probing, and proved to consist of felted hairs and sebaceous material. The
pocket was about two inches in diameter and three-quarters of an inch deep, with an
opening half an inch in diameter. No hernia was present. The man was of cleanly
habits, accustomed to take much exercise, and habitually wore a home-made belt
of flannel, from which the hairs were derived.
An Umbilical Concretion. J — One inch above the umbilicus
there was a tumor the size of a small egg. Pus escaped from the umbilicus. A
flaxseed poultice was applied. Suddenly a small amount of blood and a concretion
escaped. The wound healed up at once. The mass weighed only four grains,
and appeared to be felted together like a concretion of ear-wax.
The two cases which follow are also in all probability instances of abscess due
to an accumulation of foreign material at the umbilicus.
An Umbilical Sinus. § ■ — ■ The woman was twenty-five years of age,
married, and very stout. Two years before she had noticed some discharge from
the umbilicus. Eighteen months before admission there were signs of abscess,
* Tremontani, E.: Sopra un caso di granuloma ombellicale da cisti dermoide in un adulto.
II Morgagni ; Giornale Indirizzato Al Progresso Delia Medicina, 1903, xlv, Parte 1; Archivio, 387.
t Walters, F. R.: Brit, Med. Jour., 1893, i, 173.
1 Williams, F. H.: Amer. Med. Jour., St. Louis, 1907, xxxv, 295.
§ Chislett, H. R. : Umbilical Sinus. The Clinique, Chicago, 1905, xxvi, 167.
UMBILICAL CONCRETIONS. 259
with pain, swelling, and redness. An incision was made. The sinus was an inch
deep; the pocket extended to the peritoneum and contained thick pus. The abscess was evacuated, and the granulation tissue cureted away. Iodin was applied
and the cavity packed wit h iodoform. She made a good recovery.
A Sub umbilical Tumor. — Fischer* said he operated on a woman
who had a fistula to the right of and below the umbilicus, near the linea alba. This
fistula was deeply seated and led to a fixed tumor the size of an apple, which extended
from the umbilicus 8 cm. downward and was 5 cm. in breadth. On pressure there
escaped pus and cheesy, tenacious masses and hair. The patient had noticed the
tumor for only five weeks, and then, on account of the inflammation and swelling
that had developed. It had ruptured fourteen days before admission. As the
tumor was nowhere adherent to the peritoneum, it was removed without difficulty.
CASES OF UMBILICAL HORN.
This condition is evidently very rare, as I could find records of only two cases,
those of Hennig and Xagel. Unfortunately, the data relating to these are not very
clear.
In Hennig's case the horn was about 2 cm. long, 1 cm. in diameter, and slightly
bent, while in Nagel's case it was 1 cm. long. The consistence is not mentioned in
either case. Both dropped off spontaneously.
It is difficult to understand how a horny growth can appear in this situation.
In 1910 I saw a woman over ninety years of age with a small, dark mass protruding
from a very small umbilical depression. This mass was black and hard in consistence. When pressure was made around the umbilicus the mass protruded
fully 1 cm. from the level of the abdomen. Further pressure caused still more protrusion, and the mass dropped out. It was an umbilical concretion. On account
of the exposure to the air the superficial portion had become very hard and was
black, whereas the part lying more deeply in the umbilicus was whitish yellow and
cheesy (see Fig. 147, p. 249) . It will be noted that the superficial portion of Xagel's
specimen was also black. It is just possible that in both of these cases the horns
were in reality hardened umbilical concretions and not true umbilical horns.
A Case of Horn of the Umbilicus. — Pernicef says that Hennig
saw a healthy American who from her childhood had had a horn at the umbilicus.
It was about 2 cm. long, 1 cm. thick, cone-shaped, and slightly bent. In the eighth
month of her first pregnancy the horn dropped off, partly as result of the unfolding
of the umbilicus, "partly as a result of diminished nourishment."
A Small Horn at the Umbilicus. — In a letter to Dr. Kelly
Prof. F. W. Nagel mentions the case of Frau H., who was born in Berlin, December, 1878. On the eighth of June, 1907, she was delivered for the first time by
Nagel. About the middle of the pregnancy a little prominence, the thickness of
a match, was noticed at the umbilicus. This was more and more -visible toward
the end of pregnancy. It formed a horn 1 cm. long. At the beginning it was gray;
later on it dried up and became black. After labor the horn drew in and disap
* Fischer, H. : Die Eiterungen im subunibilicalen Raume. Volkmann's Samml. klin. Vortrage, Neue Folge, Nr. 89 (Chir. No. 24), Leipzig, 1890-94, 519.
f Pernice, L.: Die Nabelgeschwiilste, Halle, 1892.
260 THE UMBILICUS AND ITS DISEASES.
peared. Nagel examined the patient on December 10, 1910, and by separating the
umbilical folds was able to see the points of the now yellowish-white horn.
MAGGOTS IN THE UMBILICUS.
In a letter dated December 9, 1910, Dr. John S. Fulton gave me an account of
a rather unusual umbilical condition. Several years previously a baker had come
to his clinic at the University of Maryland complaining of some umbilical trouble.
Fulton watched the man undress, and at once recognized his occupation by three
rings of dough — "waist deep, midarm deep, and elbow deep." On examining the
umbilicus he found it inhabited by six maggots. Their removal was followed by
complete relief of the patient.
The only other case I know of in which a similar condition was noted was
furnished by E. L. M.* in 1899. He was called to see an infant eight days old. The
cord had come off on the fifth day. On examination the umbilicus was found filled
with maggots. A few drops of chloroform were dropped into the umbilicus, and
24 dead maggots were washed out with sterilized water. Boric acid was then
dusted in and there was no further trouble.
Escape of a Piece of Wild-oat Straw From an Umbilicus, t — The patient was one month old. The mother had noticed much
moisture at the umbilicus ever since the cord had come away. At the umbilicus
was a reddish, pedunculated tumor the size of a pea. This was cut away with
scissors and cauterized. It recurred, but on being again treated in a similar manner,
did not reappear. Some time later an abscess developed at the umbilicus. It was
opened, some pus and a piece of wild-oat straw escaping. The fact that there was
continual moisture at the umbilicus after the cord came away strongly suggested
a remnant of either the omphalomesenteric duct or the urachus.
* E. L. M. : Maggots in the Umbilicus. Med. Council, Philadelphia, 1899, iv, 364.
f Fabrege: Note sur les excroissances polypeuses de la fosse ombilicale chez les enfants
nouveau-nes. Rev. med. chir., 1848, iv, 353.
LITERATURE CONSULTED ON UMBILICAL CONCRETIONS ASSOCIATED WITH
INFLAMMATORY CHANGES IN THE ABDOMINAL WALL.
Blum, A.: Tumeurs de l'ombilic chez l'adulte. Arch. gen. de med., Paris, 1876, 6 e ser., xxxviii,
151.
Bouffleur: Tuberculosis of the Umbilicus. Clin. Review, Chicago, 1898, ix, 329.
Bufalini, G.: Jahresber. der gesammt. Med., 1887, ii, 497.
Coenen, H. : Ueber das Cholesteatom des Nabels. Beitrage z. klin. Chir., 1908, lviii, 71S.
Cbislett, H. R. : The Clinique, Chicago, 1905, xxvi, 167.
Derville, L. : Abces fistuleux de l'ombilic. Jour, des sci. med. de Lille, 1894, ii, 320.
Fere, G.: Tumeur sebacee ombilicale. Bull. Soc. anat. de Paris, 1875, 1, 622.
Fischer, H.: Volkmann's Sammlung klin. Vortrage, Neue Folge, Nr. 89 (Chirurg., Xo. 24),
Leipzig, 1890-94, 519.
Foulerton, A.'G. R. : Form of Umbilical Sinus Occurring in Adults. The Lancet, 1888, ii, 16.
Foulerton, A. G. R. : Growths From the Umbilicus. Illustrated Medical News, 1889, iv, 261.
Gonard, G.: Des kystes dermo'ides. These de Montpellier, 1906, No. 31.
Gueterbock, P. : Ueber einen Fall von Dermoidgeschwulst des Nabels. Deutsche Zeitschr. f.
Chir., 1891, xxxii, 319.
UMBILICAL CONCRETIONS. 261
Hahn, Otto: Ein Nabelkonkrement von Taubeneigros.se. Beitrage z. klin. Chir., Tubingen,
1900, xxvi, 80.
Ledderhose, G. : Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b.
Nicaise: Ombilic. Dictionnaire encyclopedique des sci. m6cl., Paris, 1881, 2. ser., xv, 140.
Park, Roswell: Clinical Lecture on Congenital Fistulso and Sinuses at the Umbilicus. Med.
Fortnightly, 1896, ix, 9.
Pernice, L. : Die Nabclgcschwulstc, Halle, 1892.
Polaillon: Kyste dcrmoide suppure de la region ombilicale. Gaz. med. de Paris, 1886, lvii, 435.
Richelot, L. G. : Abces tuberculeux sous-ombilical. L'union m6d., 1883, xxxv, 61.
Rouget: Gaz. des hop., 1862, 259.
Rouqes: Kyste occasionne par la presence d'un fragment de terre dans l'ombilic. Gaz. des hop.,
1862, 314.
Shattock, S. G. : Two Specimens of Umbilical Calculi. Trans. Path. Soc. London, 1900, li, 282.
Taylor, Wm. J. : Dermoid Cyst in the Abdominal Wall of a Man. Annals of Surgery, 1896, xxiii,
296.
Tremontani, E.: Spora un caso di granuloma ombellicale da cisti dermoide in un adulto. II Mor
gagni; Giornale Indirizzato al Progresso della Medicina, Parte 1, Archiv, 1903, 45, 387.
Villar, F.: Tumeurs de l'ombilic. These de Paris, 1886, No. 19.
Walters, F. R. : Umbilical Pocket. Brit. Med. Jour., 1893, i, 173.
Williams, F. H.: An Umbilical Concretion. Amer. Med. Jour., St. Louis, 1907, xxxv, 295.
==Chapter XVI. Abscess In The Subumbilical Space==
Description of Heurtaux's observations.
Fischer's injections of the subumbilical space.
An empyema opening into the subumbihcal space.
A liver abscess opening into the subumbilical space.
An appendix abscess opening into the subumbilical space.
An echinococcus cyst in the subumbilical space.
Actinomycosis in the subumbilical space.
Resume.
Heuktaux,* in 1877, described what he called a phlegmonous subumbilical
inflammation deep in the anterior abdominal wall. He said that, up to that time,
so far as he knew, this condition had never been reported. The affection is characterized by the presence of an inflammatory tumor, which is sharply circumscribed
and is in the median line. It is symmetric and oval inform; its base occupies the
umbilicus. The tumor is deep-seated. On examination it will be found to have
developed exactly at the umbilicus (Fig. 153) . It varies
from 6 to 10 cm. in diameter, is immobile, firm in consistence, and after a few days may give deep fluctuation.
When suppuration commences, the tumor becomes
prominent and the umbilicus may be reddened and perforate, the quantity of escaping pus varying from 120 to
150 c.c. In Heurtaux' cases there never was any escape
of gas. A sound sometimes entered toward the pubes
for 6 cm., and to the right or left for 3 cm. In three
acute cases, fluctuation was detected in from nine to
seventeen days after the onset ; in subacute cases, after
a period varying from four to five weeks.
In all of the six cases reported by Heurtaux the
phlegmon terminated in suppuration. In four it opened
spontaneously, the opening being in the umbilical cicatrix in two of these. According to Heurtaux, the lesion
is always found in the same situation and the prognosis
is good.
An analysis of Heurtaux' cases shows that the
youngest patient was six and one-half years, the oldest, fifty-five. Nearly all of
them had been ill before. Three were males and three females. In Case 2 a labor
had occurred three weeks before the abscess developed; in Case 3 it followed a
pleurisy; in Case 6 it developed in the course of measles, and a severe bronchopneumonia also complicated matters. In Case 1 the patient was in the second
* Heurtaux, A.: Phlegmon sous-ombilical. Bull, et Mem. de la Soc. de chir. de Paris,
n. s., 1877, iii, 641.
262
Fig. 153. — Subumbilical Phlegmon - . (After Heurtaux.)
According to Heurtaux, the
swelling is sometimes visible with
the naked eye, and appears as an
oval tumefaction, slightly prominent, and shading off into the surrounding tissue.
ABSCESS IN THE SUBUMBILICAL SPACE. 263
stages of syphilis, and in Case 4 the patient had recovered from a grave attack of
typhoid fever. In four of the cases the symptoms were acute; in two, subacute.
In the acute cases there were severe pain, sensitiveness in the umbilical region,
and a tendency toward constipation. In some cases there was vomiting.
The observations of Heurtaux seem in a large measure to have been overlooked,
and it was not until the work of Fischer* that we again hear much on this subject.
Fischer wrote a most extensive article in which he discussed acute subumbilical
phlegmon, chronic abscess in the subumbilical space, and the breaking through of
purulent collections into the subumbilical space. In the beginning he refers to the
work of Heurtaux, and says that Jolion and Heurtaux in 1877 studied the anatomy
and pathology of the subumbilical region and found on each side of the linea alba
a triangular space. He says that Charpy, in 1888, found that the subumbilical
space was in part retroperitoneal, in part prefascial.
Fischer tried to fill the subumbilical space by injecting colored gelatin with a
syringe introduced through an incision in the lateral wall of the rectus, the needle
being directed inward and between the sheath of the rectus and the peritoneum.
By this procedure he was able to produce a tumor, heart-shaped in form, with its
base at the umbilicus and the apex about 6 cm. below it (Fig. 154). It was most
prominent laterally, and diminished toward the linea alba, where it was represented by a fine furrow. At its base it was 14.6 cm. broad; at its apex, 1.6 cm.;
its greatest length was from 8 to 9 cm. In men and women, in young and old, in
fat and thin, the space was always the same size. Above it was closed partly by
the umbilical scar, partly by firm adhesions between the peritoneum and the sheath
of the rectus, at the outer side and below only by adhesions between the peritoneum
and the sheath of the rectus. Jouon said that there was no definite walling-off
below, but that a loose connective tissue existed through which the space communicated with the cavity of Retzius.
On page 523 Fischer says that suppurations which start in the subumbilical
space run either an acute or a chronic course, and whereas some develop in the
space, others wander in. He then goes on to describe briefly the clinical picture.
In speaking of acute subumbilical phlegmon, he says that he had five definite cases of subumbilical inflammation, such as were described by Heurtaux, and
that in all he found the same characteristic picture. Fischer's tumors developed
in men from seventeen to thirty-four years of age, who, apart from a gonococcal
infection, had always been well. None of them had had a definite trauma nor was
there any evidence of such a condition having existed.
The affection commences with a chill, and there is fever during the entire course
of the disease, the temperature varying from 38.5° to 39.5° C. There is marked
pain on attempting to straighten out the legs and on pressure on the abdomen.
The pain commences at the umbilicus and spreads in all directions. The patient
accordingly lies perfectly flat on the back, with the legs drawn up and the abdomen
tense. In addition there is constant vomiting of slimy, pale-stained masses, the
effort naturally increasing the amount of abdominal pain. The vomiting increases,
and there is a feeling of faintness. The patient becomes pale and shows signs of
collapse. The extremities, however, remain warm. The pulse is quick and the
expression anxious. These symptoms are so pronounced at times that peritonitis
* Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Samml. klin. Vortrage, n. F., No. 89 (Chir. No. 24), Leipzig, 1890-94, 519.
264
THE UMBILICUS AND ITS DISEASES.
is thought of and a bad prognosis is given. Nevertheless, after the distressing
symptoms have lasted two to four days the vomiting disappears. The bowels
move again and flatus is expelled. The pain becomes more marked in the
umbilical region, and a faint reddening and edema are noted in this situation. On
palpation one can now feel a dense but movable infiltration, triangular in form,
Fig. 154. — The Subumbilical Space. (Schematic.)
Heurtaux has described a series of cases in which abscesses have developed just below the umbilicus. He speaks
of these as subumbilical abscesses. Fischer has attempted to outline these spaces by using injections of gelatin. This
sketch has been drawn after the description and measurements of Fischer. The umbilicus is seen in the midline. On
each side of this the fascia and muscle have been removed. The space is situated just below the umbilicus, and lies
behind the rectus muscles. The base of the space is indicated by a line drawn between o and b. The apex of the
space is at c and d. The space is usually partially or completely divided by a septum which extends from the umbilicus
above to the apex below. The anterior wall of the space is composed of the sheath of the rectus, its posterior wall,
of peritoneum. The distance between a and b averages 14.6 cm. The distance between the umbilicus and c averages
8 or 9 cm. The distance between c and d averages 1.6 cm.
limited by the outer walls of the recti, and with its base directed upward. The
skin can be pushed over, but is not gathered up into folds. There is dulness on
percussion.
In the course of from nine to twelve days, with the gradual disappearance of
the general disturbances, there develops on both sides of the linea alba a firm, elastic
tumor below the umbilicus. This, as was pointed out by Heurtaux, is of the size
ABSCESS IN THE SUBUMBILICAL SPACE. 265
and form of the urinary bladder. Not infrequently a definite long furrow can be
traced downward from the umbilicus. This is the linea alba, which partially or
completely divides this space into two parts. Finally, this tumor rises 5 or 6 cm.
above the level of the abdominal wall. Under chloroform narcosis the recti
muscles can be pushed over the tumor. The fluctuation becomes more and more
evident. Fischer, contrary to the observations of others, has never noted spontaneous rupture either outward or into the peritoneal cavity.
Fischer says that in four of the cases, after making the incision, he found that
he was dealing with a single abscess cavity, although there are two subumbilical
spaces separated from each other by the linea alba. It could very readily happen
he decides, that in these cases one portion of the cavity might be infected and the
inflammation extend to the opposite side. Fischer, in one case, was able to carry
his finger from the first cavity over to the second through an opening, a dividing
partition still persisting.
Differential Diagnosis. — The differential diagnosis in this group
of cases is not always perfectly clear. Fischer mentions the fact that in two cases
he found flat epithelial cells in the pus contents. Their presence would be against
the existence of a subumbilical abscess. Where flat epithelial cells are found in
such an abscess the inflammatory process is usually of urachal origin. This group
is a very characteristic one, and is described on page 567.
ABSCESSES BREAKING THROUGH INTO THE SUBUMBILICAL SPACE.
Fischer, after describing the subumbilical space, records three cases in which a
purulent accumulation from distant points found its way into the subumbilical
space. One was an empyema, another a liver abscess, and the third an appendix
abscess. In each of these cases the subumbilical space was involved secondarily.
An Empyema Opening into the Subumbilical Space.
Fischer, on page 535, mentions the case of a Russian girl, eight years of age, who
had a left-sided empyema which reached as high as the scapula. In addition there
was a fluctuating, egg-shaped tumor below the umbilicus, and to the left of the linea
alba. When the patient coughed, this swelling increased in size at the subumbilical
space. Fischer resected several ribs and found that water would flow through the
entire space as far as the umbilicus. The child finally recovered. In this case
there was a fistulous opening from the pleural cavity downward to the subumbilical
space.
A Liver Abscess Opening into the Subumbilical Space.
Fischer and Biermer, in 1876, treated a patient suffering from liver abscess,
which, however, gave no characteristic symptoms. The patient was twenty-seven
years of age. There was a history of injury, followed some time later by an irregular
fever. The liver dulness was increased. Six months after the injury, when Fischer
saw the patient, there was an oval tumor to the right of and below the umbilicus,
with the base directed upward and the apex downward. The tumor was soft and
fluctuating and increased in size when the patient coughed. On pressure it could
be made smaller. It was 8 cm. in length and 9 cm. in its greatest breadth. It was
incised, and there escaped a yellowish-tinged, foul-smelling pus in which liver substance could be detected. The abscess cavity had the size and form of a subumbilical
266 THE UMBILICUS AND ITS DISEASES.
space. As the fever persisted Fischer made an incision parallel to the margins of
the ribs, and opened into a large retroperitoneal abscess which had been shut off on
all sides. From this an opening extended downward into the subumbilical space.
The patient improved slowly and gradually recovered.
An Appendix Abscess Opening into the Subumbilical Space.
Fischer says that an appendix abscess occasionally opens into the subumbilical
space. On page 536 he reports the case of a woman, twenty-seven years of age,
who came to the Breslau clinic on account of a fecal fistula below and to the right
of the umbilicus. Ten months previously she had had severe abdominal pain,
vomiting, and obstruction. After six weeks of much suffering an egg-shaped tumor
had developed and a fistula had followed. First there had escaped foul-smelling
pus and then fecal matter. On splitting the abdominal walls Fischer noticed a
cavity lined with granulations. The abscess in position, form, and size corresponded exactly with the subumbilical space. In its posterior wall in the lower and
outer angle was a fecal fistula which had arisen from an ulcerated vermiform appendix. In its lumen was a cherry-stone. After removal of the stone, resection of the
appendix, and cureting of the abscess cavity, healing took place.
AN ECHINOCOCCUS CYST IN THE SUBUMBILICAL SPACE.
This condition is evidently rare, as I have found but one case recorded. Fischer
said that he operated on a man, thirty-two years of age, in whom a fluctuating,
smooth, painless, immovable tumor, the size of a fist, had developed beneath and
to right of the umbilicus, near the median line. It had been noted for six years.
The patient during this time had often vomited, but otherwise had been healthy.
For three weeks the tumor had been painful and increasing in size. Fever had
been present, and the skin had become reddened and edematous. In size, form,
and position the tumor corresponded with the subumbilical space. Fischer made
an incision at the outer wall of the rectus and into the subumbilical space. There
was a densely adherent echinococcus sac, which could not be extirpated on account
of firm adhesions binding it to the peritoneum. It was split, scraped out, and
packed. The patient made a good recovery and remained apparently well.
ACTINOMYCOSIS IN THE SUBUMBILICAL SPACE.
Fischer furnishes the only record of such a case that I am familiar with. The
patient was a man in whom an actinomycotic infiltration was noted as a firm, circumscribed tumor the size of an apple in the subumbilical space. It gave the
patient little discomfort. The skin was movable over the tumor and was not
altered. At first there was no fever. Later, at intervals, there appeared an
inflammatory but painless swelling. Four months after the patient first noticed
his trouble, edema developed, and there were thickening and reddening over the
tumor, which broke through the skin at several points. The escaping pus contained
a few actinomycotic bodies. On the third day feces escaped. The fistulse lay below
the umbilicus, one on each side of the linea alba, and communicated with each
other. In attempting an extirpation and clearing-out of the sinuses, Fischer found a
ABSCESS IN THE SUBUMBILICAL SPACE. 267
sieve-like fistula representing the points at which the intestine had broken through.
The patient died fourteen days after the operation.
Resume. — ■ From the foregoing it is clearly evident that below the umbilicus
there is a definite, heart-shaped cavity — the subumbilical space — about 8 cm. in
length and 14 cm. broad. This is situated between the peritoneum and the sheaths
of the muscles. It is often divided longitudinally into two cavities by the linea alba,
which forms a septum between the muscle-sheath in front and the peritoneum
behind. This subperitoneal space can be definitely outlined by injection methods.
There is no doubt that subumbilical abscesses can develop. The symptoms in
the early stages strongly suggest a peritonitis; later the general abdominal symptoms subside, and a localized tumor can be detected just below the umbilicus.
When opened, the abscess is found to lie between the muscle-sheath and the peritoneum. Usually the septum between the two sacs disappears, leaving only one
abscess cavity.
Whether all the hitherto reported cases were really abscesses in the subumbilical
spaces or not is problematical. Those cases in which epithelial elements were
detected probably represented abscesses resulting from infection of remnants of the
urachus.
That the subumbilical space may be secondarily involved seems to be clearly
shown by the cases of empyema and liver abscess reported by Fischer. The possible presence of echinococcus cysts and actinomycosis in the subumbilical space
is proved by the cases above described.
Treatment.— As soon as these abscesses are diagnosed, they should be
opened and drained. Not much force should be used in the packing, as the posterior
wall of the abscess consists merely of the thickened peritoneum. Recovery
promptly follows evacuation of the pus.
==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.
==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
i
>N
*> V
j£>..
■<%
Is
\ \ \
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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^
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o
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i
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 j-L.
dark-staining zone. As noted in the history, the dilated thirty-eight years of age. Eleven lllOUths
gland cavities in the tumor contained exfoliated epithe- before, a myomatous uterUS had beeil relium, granular material, and in some instances blood. i xi i_ i i l • • •
moved through an abdominal incision.
Eight months later she noticed at the
umbilicus a tumor which increased in size for three months and then stopped growing.
During menstruation there was pain in the tumor. From the umbilicus to the symphysis there was an operation scar. At the umbilicus was a conic tumor with its base
high in the umbilicus. The tumor extended for 2 cm. above the surface of the abdomen, and was covered with pigmented skin. During the excision itwas noted that this
tumor was adherent to the omentum. With the naked eye one could see in it a cavity
containing several drops of brownish fluid. Microscopic examination showed that this
cavity was scantily lined with epithelium. There were tubular growths and cavities,
some more or less filled. By strong magnification one could see that the canals and
spaces were lined with cylindric epithelium. At other points the cavities contained exfoliated epithelium. Around the glands the connective-tissue cells, here and there,
were star-like and contained large quantities of collagen, suggesting the tissue of the
umbilical cord. At other points the connective tissue surrounding the gland cavities
showed inflammatory changes. The tubules were dilated, and here and there were
seen emigrated leukocytes. In some of the connective-tissue cells hemosiderin was
visible.
ADENOMYOMA OF THE UMBILICUS.
381
■
■
T ■ ■ ■
' /. "\
S£ : "'i
' .. :a *'~
iv'd
Fig. 173. — Dichotomous Branching of a
Gland in a Small Umbilical Tumor.
(Mintz, Case 3.)
The histologic picture might very readily be taken for that of an adenomyoma. In
the lower part the gland shows dichotomous
branching.
[In this case we are not so sure of the exact condition. It reminds us somewhat
of adenomyoma, but no mention is made of muscle. It is just possible that the cells
surrounding the glands were not inflammatory,
but represented ordinary stroma. This, however,
is doubtful. The chief points in favor of adenomyoma are that the tumor was painful during
menstruation, and that the cavities contained
blood or brownish fluid; furthermore, that the
patient had been operated upon for a fibroid
growth eleven months before, and that, on histologic examination, hemosiderin was noted in
the stroma.— T. S. C]
A Small Umbilical Tumor Containing Uterine Glands. — Case 3
(Mintz) . — The patient was a woman, forty-five
years of age. Nine months before, she had
noticed a hardening at the umbilicus. During
the first four months the tumor remained stationary in size, but later it grew and was painful.
Then the growth ceased and the pain disappeared. The skin was adherent to the tumor; it was brownish in color and traversing it were slightly dilated veins. The tumor
passed in a cone-shaped form into the umbilicus.
The tumor on section was found to consist of
firm scar tissue in which numerous small cysts filled
with brownish contents were noted.
Microscopic Examination. — The connectivetissue portion of the skin passes directly into the
connective tissue of the tumor. This consists of
parallel and irregular connective-tissue strands,
here and there showing small-round-cell infiltration. With the low power one sees cavities of
various sizes filled with a brownish, pigmented
fluid. The small, round and tubular cavities are
partly arranged in groups, partly separated from
one another by old scar tissue. The tubules here
and there show dichotomous branching (Fig. 173).
At several points the growth is seen passing in
various directions. At many points where one
group of unchanged tubules exists, it is surrounded
by young connective tissue, which toward the periphery passes off into the old fibrous tissue (Fig.
174). The cavities of more recent formation and
the tubules are lined with one layer of cylindric
epithelium. In the more widely dilated cavities
the epithelium assumes a flattened shape. On further dilatation the epithelium becomes still flatter and drops off into the cavities. These cavities are surrounded by connective tissue (Fig. 175) ; they contain detritus, swollen epithelium, and leukocytes.
Fig. 174. — Uterine Glands in an Umbilical Tumor. (Mintz, Case 3.)
The gland grouping in the picture is
similar to that seen in a typical adenomyoma of the uterus. In the colony of
glands near the center of the picture the
glands are regularly distributed and are
surrounded by a definite stroma which
separates them from the matrix of the
tumor. The chain of glands in the left
upper corner is in part surrounded by
stroma, but some of its glands lie in direct
contact with the dense surrounding tissue.
382 THE UMBILICUS AND ITS DISEASES.
[Mintz's various figures are very suggestive, and Fig. 174 could very readily be
used by us to demonstrate an adenomyoma of the uterus instead of adenomyoma
of the umbilicus. Here we have cross-sections of glands forming a definite colony.
This area is surrounded by the characteristic stroma of the mucosa. Fig. 175 could
be used to picture a mild grade of gland hypertrophy of the uterus. Here also the
gland is surrounded by the characteristic stroma of the mucosa. Although no
mention is made of muscle being found in this growth, the glands and the gland
branchings are absolutely identical with those of the uterus. In my case of adenomyoma of the round ligament* connective tissue predominated, and there is no
reason why in some of these cases also connective tissue should not take the upper
hand throughout. — T. S. C]
On p. 396 Mintz gives a resume of his three cases. They developed in women
in middle life in the umbilical tissue, and the tumors reached the size of hazelnuts.
The growth at first was slow, but suddenly increased after the lapse of several
months. Examination of the tumors showed
that they were painful. There was an exacerbation (congestion) at the menstrual
periods.
In all three cases the microscopic picture
showed the growth of tubular glands in the
. ;■: •"%„... scar tissue of the umbilicus, this glandular
, r ./ .: V growth being accompanied by granulation
tissue reaction. This young connective tis- y sue surrounded the tubular glands, sepa
rated them from one another, and transformed itself gradually into connective
- • --' tissue.
fig. 175.— Glaxd htpehtropht in a Small um- [This is the characteristic stroma which
bilical tumor. (Mint*, Case 3.) one norma n y fi n( is separating the uterine
Near the center of the field is a gland showing ■, _, « , •. rr\ q r^ "|
hypertrophy. Separating it from the surrounding glanOS IrOlTl Olie anotner. 1. b. U.J
stroma is a characteristic stroma which stains more The gland tubules showed One layer of
deeply and is rich in cell elements. This picture i- i ■ -n t i • i i ,1 , i
could be used very readily as an example of a uter- CylmdriC epithelium, which, when the tub
ine gland in the muscle. ules dilated into cavities under the influence
of the secretion, became flattened. Finally
this epithelium disintegrated and dropped into the cavities which contained the albuminous bodies and leukocytes. Mintz thought the tumors originated from remains
of the omphalomesenteric duct. He then describes an instance of a somewhat similar
growth reported by von Xoorden in the Deutsche Zeitschr. f. Chir., 1901. f
A Small Umbilical Tumor Containing Uterine M u cosa.i- — The patient was fifty-four years of age, and had had no children. She
had had an abdominal operation ten years before on account of some uterine trouble.
* Cullen, Thomas S.: Adenomyoma of the Round Ligament. Johns Hopkins Hosp. Bull.,
May, 1896, 112. Further Remarks on Adenomyoma of the Round Ligament. Johns Hopkins
Hosp. Bull.. 1898, 142.
t See also Herzenberg, R.: Ein Beitrag zum wahren Adenom des Xabels. Deutsche med.
V\ oc-henschr., 1909, i, 889. Herzenberg evidently describes the same cases as those reported by
Mintz.
i Ehrlich, H.: Primares doppeLseitiges Mammacarcinom und wahres Xabeladenom (Mintz).
Aus von EiseLsberg's Klinik, Arch, f . klin. Chir., 1909, lxxxix, 742.
ADENOMYOMA OF THE UMBILICUS.
383
Shortly after leaving the hospital she developed a tumor in each breast, which
gradually reached the size of an apple. They caused little difficulty, and in the
course of a year did not increase much in size. Simultaneously with the appearance
of the tumors in the breasts the umbilicus was pressed upward markedly by a
tumor the size of a hazelnut, developing at that point. This growth had remained
stationary. The umbilicus had been transformed into a small tumor with pigmented
skin. The tumor was hard, and was with difficulty pushed over the underlying
structures. The umbilical growth and the carcinomata of both breasts were removed. (We are here interested chiefly in the umbilical .-.-„•
tumor.) . s - £.y.?-) v v • H ; v: • '• •
The tumor of the umbilicus fV ,..- ■. ., : \, '■ '•• . > 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
¥ ' n
S ■-'/
UK
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
*lw
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]
" § •■
, ■ ■•■; ' "" * : -V ;
W-3
,-~ - > S** : '
" X - - ,-",
■' : .' i*
iff s ,^]i
— ■ J& i'
7~-' *' ; '- |
■■i .X\:'& ■ %
Fig. 179.
(After
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
Ste it"? '•••
"V
*seSE
M • ---'v. -? ■■,/- ? : j* . ?xgE£ji& ■■..-■;
' •
J 1 ?
*/ ; '' /'' ^
■r -
> v<
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
*3k ■
W-o'Wk
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
V:<
i ft*
' ,
X/5T7.
-4fj/jk,,,6
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
.'. '' *
LD jggji r>
=%
5i
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 (<S>) 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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i
1
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' ? '7
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1
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
■■■:■•■ H.V.?^. • •: .- -•• ■ »I ■..'■:■•• -. >-..••••.'.'• ■ ",/ .-. ■ <■«, '.. . . >? • • ■ '. .v. • • •
• ■■
•iJif "i? jfK-'-i '
bM
-.
- '•;■'¥. ,'■■
dr
W
-VV'-^v
c
Fig. 258. — Giant-cells in the Wall op an Adenocarcinomatous Cyst of the Urachus. (X 90 diam.)
Gyn.-Path. Nos. 10368 and 10488. Occupying the center of the field are slit-like spaces lined on one or both sides
with giant-colls. The most perfect picture is that seen at a. At 6 is a giant-cell lying in the stroma. From this picture
as a whole one gets the impression that these slit-like spaces may be due to the cracking of brittle giant-cells. At c
are the epithelial cells lining a gland-like space of the carcinomatous cyst. Scattered throughout the field are quantities
of small round-cells. Many of these have absorbed brown pigment, have swollen up, and at first sight look like vacuoles.
In the center of these pale round or oval spaces the small round, deeply staining nucleus is still clearly visible. At d
the stroma has undergone almost complete hyaline transformation.
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.
y\i
;
v.
mi
/**\ \
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.
•
>>
<a
a
mm ise*
ipm
d
C
J
c^
•
B
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a . <\. : 7 \
A
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/^ -->' , -" * ' ■.."".'-' ; I-- :'_ - 1^
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Fig. 260.
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
# [[:File:Cullen1916 plate01.jpg|Drawings of Normal Umbilici]]
he promptly did. An examination of them shows the following:
# [[:File:Cullen1916 plate02.jpg|Drawings of Normal Umbilici]]
# [[:File:Cullen1916 plate03.jpg|Drawings of Normal Umbilici]]
# [[:File:Cullen1916 plate04.jpg|Drawings of Normal Umbilici]]
# [[:File:Cullen1916 plate05.jpg|Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary]]
# [[:File:Cullen1916 plate06.jpg|Umbilical Hernia]]
# [[:File:Cullen1916 plate07.jpg|Exstrophy of the Bladder]]


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
{{Cullen1916 footer}}
of tuberculosis of the urachus.
[[Category:Draft]]

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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

Cullen1916 titlepage.jpg

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

Figures

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

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

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

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

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

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

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

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

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

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

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

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

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

14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm in Length as Viewed from within the Abdomen

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

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

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

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

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

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

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

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

25. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others

26. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others

27. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others

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

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

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

31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the Embryo 5.5 cm. Long

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

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

34. Normal Umbilicus according to Catteau

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

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

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

38. Classic Type of Umbilicus

39. Disposition of the Vascular Cords (Usual Type)

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

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

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

43. Vascular Cords, Noted 3 Times in 50 Cases

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

45. Umbilical Fascia. Peritoneum in Place

46. Umbilical Fascia and Umbilical Mesentery

47. Reduplication of the Linea Alba. Peritoneum Removed

48. Atrophy of the Umbilical Fascia, Posterior View

49. Formation of a Mesentery. Peritoneum in Place

50. Mesentery of the Urachus and of the Umbilical Arteries

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

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

53. Peritoneal Diverticula. Peritoneum in Place

54. Peri-umbilical Fossettes. Peritoneum in Place

55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Abdominal Wall

56. Extra-abdominal Multilocular Fibrocystoma of the Ovary

57. An Extra- abdominal Multilocular Fibrocystoma

58. Superficial Lymphatics of the Umbilical Region

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

60. The Umbilical Vessels about the Time of Birth

61. The Umbilical Vessels in the Adult

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

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

65. An Umbilical Granulation

66. The Gradual Atrophy of the Omphalomesenteric Duct

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

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

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

70. A Polypoid Outgrowth from the Umbilicus

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

72. A Diverticular Tumor at the Umbilicus

73. A Glandular Tumor from the Umbilicus

74. A Glandular Growth at the Umbilicus

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

76. Adenoma of the Umbilicus

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

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

79. An Umbilical Polyp

80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression

81. An Umbilical Polyp

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

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

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

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

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

87. Gastric Mucosa at the Umbilicus

88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in Fig. 87

89. Persistence of the Outer End of the Omphalomesenteric Duct

90. Atrophy of the Inner End of the Omphalomesenteric Duct

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

92. Meckel's Diverticulum

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

94. An Abnormally Large Meckel's Diverticulum

95. A Meckel's Diverticulum with a Lobulated Extremity

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

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

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

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

100. A Diverticulum Tying Off a Loop of Small Bowel

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

102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a Hole in the Mesentery of a Meckel's Diverticulum

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

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

105. An Intestinal Cyst

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

107. Volvulus of Meckel's Diverticulum

108. An Intestinal Cyst Developing from Meckel's Diverticulum

109. Intestinal Cysts in the Abdominal Cavity

1 10. An Intramesenteric Cyst

111. A Patent Omphalomesenteric Duct

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

113. A Very Short Omphalomesenteric Duct

114. A Patent Omphalomesenteric Duct with a Polyp-like Formation at the Umbilicus

1 15. A Patent Omphalomesenteric Duct

116. A Patent Omphalomesenteric Duct

117. A Patent Omphalomesenteric Duct

118. A Patent Omphalomesenteric Duct

119. A Patent Omphalomesenteric Duct

120. A Patent Omphalomesenteric Duct

121. A Patent Omphalomesenteric Duct

122. Part of a Patent Omphalomesenteric Duct

123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Omphalomesenteric Duct

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

125. Longitudinal Section through the Entire Center of a Partially Closed Omphalomesenteric Duct

126. A Patent Omphalomesenteric Duct

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

128. A Patent Omphalomesenteric Duct

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

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

131. A Patent Omphalomesenteric Duct of Large Diameter

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

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

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

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

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

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

138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct

139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Secondary Complications

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

141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct

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

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

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

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

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

147. A Small Umbilical Concretion

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

149. Cholesteatoma from the Umbilicus in Case 1

150. Cholesteatoma from Case 2

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

152. Enlargement of Fig. 151

153. Subumbilical Phlegmon

154. The Subumbilical Space

155. Paget's Disease of the Umbilicus

156. Paget's Disease of the U/mbilicus

157. Paget's Disease of the Umbilicus

158. Paget's Disease of the Umbilicus

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

160. Syphilis of the Umbilicus

161. Atrophic Tuberculid Starting at the Umbilicus

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

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

164. Escape of Pleural Fluid from the Umbilicus

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

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

167. Small Papilloma in the Umbilical Depression

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

169. Glands from a Small Umbilical Tumor

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

171. Glands in a Small Umbilical Tumor

172. Dilated Glands in a Small Umbilical Tumor

173. Dichotomous Branching of Glands in a Small Umbilical Tumor

174. Uterine Glands in an Umbilical Tumor

175. Gland Hypertrophy in a Small Umbilical Tumor

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

177. Uterine Mucosa in an Umbilical Tumor

178. A Small Umbilical Tumor Containing Numerous Glands

179. Glands in a Small Umbilical Tumor

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

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

182. Adenomyoma of the Umbilicus

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

184. Appearance of the Carcinomatous Umbilicus After Removal

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

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

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

188. Adenocarcinoma of the Umbilicus

189. A Section Showing Carcinoma of the Right Inguinal Glands

190. Secondary Carcinoma of the Umbilicus

191. Telangiectatic Myxosarcoma of the Umbilicus

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

193. Myxosarcoma of the Umbilicus

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

195. A Telangiectatic Myxosarcoma

196. A Case of Congenital Umbilical Hernia

197. An Amniotic Hernia

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

199. A Serous Umbilical Hernia

200. Freeing the Umbilical Hernial Sac from the Abdomen

201. Closure of the Hernial Opening at the Umbilicus

202. Closure of the Hernial Opening at the Umbilicus

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

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

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

206. An Umbilical Cyst

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

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

209. Exstrophy of the Bladder

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

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

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

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

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

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

216. A Patent Urachus

217. A Urachus Open from Bladder to Umbilicus

218. An Open Urachus

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

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

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

222. A Partially Patent Urachus

223. A Patent Urachus

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

225. Portion of a Urachus Ten Times Enlarged

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

227. Spindle-Shaped Dilatations of the Urachus

228. A Small Cyst of the Urachus

229. A Patent Urachus

230. A Multilocular Cyst of the Urachus

231. Section of a Patent Urachus

232. Transverse Section of a Patent Urachus

233. A Small Cyst of the Urachus

234. A Diffuse Neuroma of the Bladder

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

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

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

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

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

241. Infected Urachal Remains

242. An Infected Urachus Opening between the Umbilicus and Bladder

243. Urachal Cyst

244. A Dilated Urachus Communicating with the Bladder

245. Large Accumulation of Urine in a Partially Patent Urachus

246. An Infected Urachus Opening at the Umbilicus

247. A Patent Urachus Dilated in Its Middle Portion

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

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

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

251. A Dilated Urachus Communicating with the Bladder

252. Urachal Cyst

253. Urachal Cyst

254. Urachal Cyst

255. A Patent Urachus Containing a Vesical Calculus

256. Carcinoma of the Patent Urachus

257. A Multilocular and Malignant Cyst of the Urachus

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

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

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

261. Adenocarcinoma of the Urachus

262. A Papillary-like Area in an Adkxocarcinomatous Cystofthe Urachus

263. Metastasis from Adenocarcinoma of the Urachus

264. An Umbilical Cyst

265. \\ aj.i of an Umbilical Cyst

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

267. Tuberculosis of the Urachus

268. An Area Suggesting a Tubercle

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

List of Plates

List of Plates


  1. Drawings of Normal Umbilici
  2. Drawings of Normal Umbilici
  3. Drawings of Normal Umbilici
  4. Drawings of Normal Umbilici
  5. Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary
  6. Umbilical Hernia
  7. Exstrophy of the Bladder


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

Reference

Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.

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Cite this page: Hill, M.A. (2024, April 27) Embryology Book - Umbilicus (1916). Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_Umbilicus_(1916)

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