Most articles that report on the entity of Sr. Mary Joseph's nodule are those usually of a singular experience published as a case report. However, If one is fortunate enough that the discovery of the surgical anomaly occurred sufficiently far in the past that there develops the advantage of longitudinal viewing of the issue that takes on almost a historical perspective.1-13 Such is the case for the Sr. Mary Joseph Nodule in that not only does history exist concerning the surgical condition, but also the history of its various describers exists. As the surgical entity begins to appear in the surgical literature over time, one can see the various changes that occur in the viewing of its differential diagnosis, method of pathologic diagnosis,14-16 imaging experience,17 mechanism of occurrence, changes in surgical and medical therapy, and survival statistics. Once the surgical literature of the reported entity has had some time to mature, the compilation of individual experiences (case reports) into literature review begins. To illustrate this phase of development, in a letter to the editor of the Annals of Internal Medicine in 1998, V. G. Galvan, MD18 conducted a Medline literature search that extended from 1966 to 1997, and revealed a total of 407 reports of Sr. Mary Joseph's Nodule published. He noted the most common primary sites are Gastrointestinal (52%), Gynecologic (28%), Stomach (23%), and Ovarian (16%) cancer. Unknown primaries accounted for in 15% of the cases. In these literature reports, between 14% and 33% of umbilical metastasis was the first diagnostic sign of a previously occult neoplasm. In 40% of the patients in the literature review who had a known primary, the appearance of Sr. Mary Joseph Nodule was an early sign of relapse. In spite of the average survival time of 10 months, some authors in the review demonstrated survival beyond 1 year. This depended on the primary site, the patient's performance status, and the combining of medical and surgical therapy. In the best of these situations, survival increased to 17.6 months. These findings, in the review of literature, led the author to make many interesting conclusions, 2 of which may change the paradigm concerning the Sr. Mary Joseph Nodule: (1) It should be remembered that indeed if the umbilical metastasis is the only metastatic site at the time of diagnosis that in some situations "aggressively active and not palliative treatment regimen could be undertaken." (2) Therefore, in addition to its historical view, perhaps the Sr. Mary Joseph Nodule should be "considered a method for easy, early diagnosis of unknown primary or a relapse of previously known primary rather than always just a sign of poor prognosis." It is interesting to note that "contemplating the umbilicus" may indeed have some further historical significance. As the story goes, in a private conversation between William Halstead and Thomas Cullen, it was overheard that Cullen gently criticized his chief, Halstead, for concentrating on surgical minutiae and was heard to comment, "I believe sir that you could write a book about the belly button." Halstead supposedly replied that he would not, but that he expected Cullen to do so. In fact, Cullen did produce an original book devoted to the umbilicus19 and further in a book entitled, Contributions to Medical and Biologic Research, dedicated to Sir William Osler in honor of his 70th birthday in 1919, Cullen contributed a 2-page article, including a color plate. The title of the article was, "Bluish Discoloration of the Umbilicus as a Diagnostic Sign Where Ruptured Extra-uterine Pregnancy Exists".
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