Book - Umbilicus (1916) 28

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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.

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
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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.


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

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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.



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.

Historic Disclaimer - information about historic embryology pages 
Mark Hill.jpg
Pages where the terms "Historic Textbook" and "Historic Embryology" appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms and interpretations may not reflect our current scientific understanding.     (More? Embryology History | Historic Embryology Papers)

Cite this page: Hill, M.A. (2019, September 19) Embryology Book - Umbilicus (1916) 28. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_Umbilicus_(1916)_28

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