Book - Umbilicus (1916) 6

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

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Chapter 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

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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.

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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

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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.

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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