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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 XXXIII. Abscesses in the Anterior Abdominal Wall between the Umbilicus and Symphysis due to Infection of Urachal Remains or of Urachal Cysts

Report of a personal observation. Clinical course. Treatment.

Cases of abscess of the abdominal wall due to infection of remains of the urachus, and not communicating with the bladder.

My attention was particularly drawn to this group of cases in 1910 when Dr. L. Gibbons Smart, of Lutherville, Md., askecl me to see a boy, aged fifteen, who was complaining of a hard mass extending from the symphysis to the umbilicus in the mid-line. There was no history of abdominal injury.

Seven weeks before, the patient had begun to suffer with severe pain in the lower abdomen. On making an examination he had noted that it was very hard to the touch, but not tender. His pain had been constant during one day, and then had disappeared, only to recur every few days and last a day or two at a time. Sometimes the pain in the mid-line had disappeared; on other occasions it had been referred to the right or left side. He did not remember having had chills or fever until two weeks before entering the hospital, when he had had a chill, followed by an elevation of temperature. After this there had been several chills.

He had had no increased pain when voiding and had never passed any urine from the umbilicus, nor had he any umbilical discharge. He said he remembered having had a few night-sweats.

His appetite for the last eight weeks had been very poor, following a period of several months when he seemed unable to satisfy his craving for food.

The patient was a well-developed and healthy looking youth. He said that at the time he first noticed the condition his abdomen was just as hard as it was on the day that he entered the hospital, seven weeks later. His bowels were usually constipated ; his urine was normal.

Operation. — Church Home and Infirmary, June 11, 1910. Under anesthesia it was noted that the umbilicus was more prominent than usual, and that it welled out on both sides (Fig. 241) . The hardness in the abdominal wall also became much more evident when the patient was asleep. I made an incision commencing just below the umbilicus and extending to the symphysis. After separating the recti we found that the tumor lay extraperitoneally. It was exceedingly hard, and almost as dense as cartilage. An incision having been carefully made through this hard tissue, we encountered a sac, somewhat irregular in form, and filled with brownish, grumous contents amounting to about 50 c.c. The cavity was carefully scraped out. A portion of the thickened wall was removed for examination, and the cavity packed with iodoform gauze. The patient made a complete recovery.

Histologic examination of the tissue showed newly formed connective tissue, but without any evidence of an epithelial lining.

567


568


THE UMBILICUS AND ITS DISEASES.


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Fig. 241. — Infected Urachal Remains. The umbilicus is prominent and wells out. The recti muscles have been retracted, exposing a hard, indurated mass. Its walls were exceedingly dense, in places fully 2 cm. thick, and as hard as gristle. The cavity was irregular i r. i. iii line and contained about 50 c.c. of brownish, grumous contents. On histologic examination the walls of the mass were found to be composed of dense fibrous tissue and the cavity was lined with granulation tissue. No attempt was made to remove the mass. The cavity was wiped out and packed, and in a few weeks the mass had literally melted away, leaving a perfectly soft abdominal wall. The patient at the present time (March 1, 1916) is perfectly well.


URACHAL INFECTIONS. 569

The patient has since remained absolutely well. In this case the situation of the tumor left little or no doubt that we were dealing with remains of the urachus which had undergone a low grade of infection. The rapidity with which the inflammatory tissue literally melted away after drainage was established was remarkable.

CLINICAL COURSE.

One of the first symptoms is a feeling of pain or discomfort in the lower abdomen. As the process advances, the pain may be intermittent in character, as noted in my case, or sudden and violent, as experienced in Page's case. Arrou's patient, a soldier, had such abdominal discomfort that, when on the march, he walked with his body bent forward. Vaussy's patient experienced great abdominal pain, which was intensified on inspiration.

A moderate degree of fever was noted in Arrou's, Page's, Vaussy's cases, and in Weiser's Case I. My patient also had some fever and also night-sweats.

As often happens when pus is forming, some patients had a loss of appetite. Page's patient -was nauseated, and Baldwin's suffered a good deal from vomiting. Page's patient had diarrhea, and in Hornig's case there was loss of weight. Vaussy's . patient was markedly depressed. In those cases in which the posterior surface of the abscess causes an inflammation of the peritoneum the constitutional symptoms will be more marked.

From Weiser's Case II we get a graphic picture of the alarming symptoms that may develop: "On admission her temperature was 101.2° F., pulse 172, respirations, 30. The child was pale and emaciated, and had a dry tongue and an anxious expression. She complained bitterly of abdominal pain, and the entire abdomen was tender, especially so about the umbilicus, and the entire abdomen was greatly distended and board-like. A positive diagnosis was not made prior to operation, but tubercular peritonitis and suppurative urachal cyst were both considered."

There are, as a rule, no bladder symptoms. In Van Hook's sixmonths-old patient, however, the urine was quite turbid. In Weiser's seventyfive-year-old woman there had been frequent micturition for a month prior to operation. This absence of vesical symptoms stands out in sharp contrast to what occurs in those cases in which the urachal enlargements have a direct connection with the bladder. In the latter, vesical symptoms are the rule.

On examination of the abdomen it is often possible to detect a board -like induration between the umbilicus and symphysis. If the abdominal walls are particularly lax, one may be able to grasp the tumor in the hand and move it from side to side. As a rule, however, this is possible only when the patient is asleep and the recti muscles are relaxed.

As a rule, the abdominal skin looks perfectly normal. In Van Hook's case, however, the umbilicus had a red, inflamed appearance, and thin pus trickled from a small opening in the lower umbilical fold when pressure was made on the tumor. The right inguinal glands were enlarged.

In Weiser's Case II the umbilicus was surrounded by a zone of redness, where the abscess was ulcerating toward the surface. In Weiser's seventy-five-year-old woman there was a copious discharge of pus from the umbilicus, which had existed for fifteen years.


570


THE UMBILICUS AND ITS DISEASES.


Although the abscess usually opens at the weakest point, viz., the umbilicus, nevertheless, in rare instances, a fistulous opening may develop in the mid-line between the umbilicus and bladder, as indicated in Fig. 242.

The Abscess Sac. — The abscess walls are usually densely adherent to the recti in front and to the peritoneum behind. They vary much in thickness, some reaching in places almost 2 cm. The inner surface of the sac is usually smooth and velvety, resembling an ordinary abscess sac. The contents of the sac vary considerably. Sometimes they consist of ordinary pus; this, in Vaussy's case and also in Weiser's seventy-five-year-old woman, was very fetid. The fluid

may, however, be yellowish red, yellowish brown, or brownish in color, and be grumous or ropy in character and contain necrotic material, which Baldwin and Doran said reminded them of "disintegrating omentum."

From a careful consideration of these cases it seems to me that yellowish or brownish contents are found in those in which a very low and slumbering grade of infection has existed, the typical pus being found in the more acute inflammations.

In Arrou's case a calculus the size of an olive was found in the sac. It looked like a piece of incompletely dried mortar.

Weiser's seventy - five - year - old woman had in the abscess sac a calculus that weighed 70 grains. As noted from his personal communication to me, it was hard, had a dark-brown surface, and on section resembled a bladderstone in color and appearance.

On histologic examination the walls of the sac are found composed in a large measure of dense inflammatory tissue. In places some non-striped muscle may still be detected; all trace of transitional epithelium is usually lost, but it may occasionally be recognized in the contents of the abscess. For abscesses developing in the subumbilical space the reader is referred to the investigations of Fischer, given in detail on p. 263.



Fig. 242. — A>r Infected Urachus Opening Between the Umbilicus and Bladder. (Schematic.) When a urachal infection opens, it is usually either at the umbilicus or bladder; occasionally, however, it perforates the abdominal wall below the umbilicus, as indicated here.


TREATMENT. After the median abdominal incision has been made and the recti have been separated, the abscess wall is at once encountered. If the walls are thin, the cavity is readily reached, but at times it is necessary to cut deliberately through from 1 to


URACHAL INFECTIONS. 571

2 cm. of very dense tissue before the fluid is readied. The cavity should be wiped out, and, if it has thick walls, it should be curetted. It is then packed with gauze and allowed to close by granulation. Great care should be taken to avoid opening the peritoneal cavity. It is astonishing to see the rapidity with which the scar tissue disappears as the result of adequate drainage. In those cases in which the urachus is enlarged and adherent to the sac, and where this tube can be readily reached, it is advisable to ligate and cut it, as there is a possibility of urine escaping later from the abscess sac.

CASES OF ABSCESS OF THE ABDOMINAL WALL DUE TO INFECTION OF REMAINS OF THE URACHUS, AND NOT COMMUNICATING WITH THE BLADDER.

I have not cited all the recorded cases, but have included only those that are especially convincing.

Suppurating Cyst of the Urachus. — Arrou* reported the case of a patient operated upon by Tricot. A soldier, who gave absolutely no history of bladder trouble, complained of vague pain in the umbilical region. The pain became acute, and during his march he had to bend forward. He had no nausea or intestinal disturbances; urination was normal, the temperature unaltered.

Examination revealed a plaque as large as a hand a little below the umbilicus. This was painful, but there was neither edema nor reddening. Gradually a little swelling was noted. The patient had some pain and fever.

Operation. — An exploratory operation under local anesthesia was determined upon, the condition being thought to be due to an abscess of the abdominal wall. But almost as soon as the patient reached the operating room an escape of a small amount of pus was noted coming from the lower margin of the umbilicus. A probe introduced into the small orifice descended downward and backward into the cavity, which was 6 cm. long in its vertical direction. The patient was at once anesthetized, and a cavity was opened; this proved to be as large as a mandarin orange, and contained a calculus the size of an olive, like a piece of mortar incompletely dried. The cyst lining resembled an inflamed mucosa. Unfortunately, both sac and calculus were lost. The upper end of the sac ended at the bottom of the umbilicus; the lower extremity terminated in the closed cul-de-sac. Attached to the lower end of the sac was a cord the size of the little finger; this cord gradually became smaller and terminated in the fundus of the bladder. There is no doubt that it was the urachus.

The peritoneum was opened above and laterally, the intestine projected. The urachus was cut across with a cautery at a point several millimeters above the bladder. The sac was completely removed and the wound closed. The patient made a good recovery.

Abscess Between Umbilicus and Pubes.f- "Mrs. C. L. R., aged thirty-three, Shenandoah, Ohio. Physician, Dr. J. M. Fry. Married twelve years; one child, aged eleven years; labor normal; no miscarriages; appetite fair, but much vomiting; kidneys normal; menstruation normal. Patient had suffered from her present trouble for about a year, but no diagnosis had been

  • Arrou: Kyste suppure de l'ouraque. ' Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi,

832.

t Baldwin, J. F.: Large Cysts of the Urachus. Surg., Gyn., and Obst., June, 1912, xiv, 636.


572 THE UMBILICUS AND ITS DISEASES.

made until about three weeks before I saw her, which was March 29, 1901. In the previous July she had had a feeling of fulness and was as large as though pregnant six months. In September much of this fulness disappeared, but it again increased. When I saw her, the uterus was pushed forward and to the right by a tumor, which did not seem to involve the uterus but which extended from the pubes to the umbilicus. This tumor was cystic, and apparently about the size of an adult head. It could not be said to be movable, but did not seem to be very firmly fixed. Dr. Hunter Robb, of Cleveland, and myself saw the patient together in consultation, and assumed that the tumor was ovarian.

"She came to Columbus and was operated on April 24, 1901, Dr. Fry being present. When under the anesthetic the uterus was found, as before, pushed forward against the bladder, and the cyst could be very distinctly mapped out. On opening the abdomen we found the transversalis fascia to be much thickened. It was dissected through with great care. On getting through there was a gush of pus. With the fingers on the inside the incision was enlarged sufficiently for thorough examination. A large quantity of pus was evacuated, together with a considerable amount of more or less necrotic material, resembling somewhat disintegrated omentum (as in one of the cases mentioned by Doran). The cavity having been entirely cleaned out, the sac was found to be a smooth and rather thick membrane. The peritoneal cavity itself had not been entered. In the pelvis the uterus was found standing up, as it were, distinctly in the cavity, though covered by the membrane, as were also its appendages. The connection of the membrane with the surrounding parts seemed to be so firm as to render any attempt at its enucleation undesirable. The cavity was therefore drained, the incision being only in part closed.

"Patient stood the operation well, made an excellent operative recovery, and returned home in due time. Dr. Fry reported, under date of March 15, 1904, that the fistula which followed the drainage had closed only about four months before. Patient had been warned as to the probability of a hernia. Under date of September 17, 1911, the patient, in response to a letter of inquiry, reported that her health was as good as ever. From her letter it is evident that there is a small hernia at the point of drainage which perhaps should be operated upon, but seems to be making no special trouble. Menstruation perfectly regular." Baldwin said that the patient has had no further pregnancies.

Infection of the Urachus. — In Bryant's* Case 2 the patient was a man about thirty years of age who had a slight epispadias. He had had for many years a tumor the size of a small cocoanut lying between the umbilicus and the symphysis. He came under observation on account of great swelling and tenderness between the pubes and the umbilicus. The condition was thought to be due to an abscess. The urine was normal. After incision, very fetid material came out, bu1 there was no urinary smell. The cavity was packed with terebene, and some days later urine was discharged from the wound.

Abscess F o r m a t i o n in the Patent Urachus. f — A female child, apparently normal at birth, had abdominal pain and diarrhea and vomiting when three weeks old. When five months old she was sick again, and the mother noticed a protrusion of the abdominal wall below the umbilicus. The swelling

  • Bryant, T.: Brit. Med. Jour., 1898, i, 1390.

t Van Hook: Amer. Jour. Obst., New York, 1894, xxix, 624.


"URACHAL INFECTIONS. 573

reached the size of an orange. Hot applications resulted in an opening at the umbilicus, with the discharge of a large quantity of pus. Later on cystitis developed and pus continued to be discharged through the umbilicus.

Van Hook examined the child when it was six months old. She urinated repeatedly during the examination. The urine was quite turbid. The umbilicus projected slightly upward and forward and was apparently pushed in this direction by a tumefaction the size of a small apple, which also pushed forward the abdominal wall between the umbilicus and the pubes. The umbilicus had a red, inflamed appearance. A thin pus trickled from the small opening in the lower umbilical fold when pressure was made on the tumor. There was swelling of the right inguinal glands.

Under chloroform a probe was passed down almost to the pubes, but did not enter the bladder. The opening was dilated and a drainage-tube put in. Recovery followed in a week.

An Infected Urachal Cyst.' — Hornig* reviews the literature and reports a case from Trendelenburg's clinic.

The patient was a girl, three years and nine months old. For several weeks she had complained of painful urination. For eight days the mother had noticed swelling of the abdomen. The child had lost weight. The father said that she had often felt sick, and in the spring had remained in bed for two days.

Operation (December 4, 1902).- — The umbilicus bulged out, forming a nodule the size of a cherry. It was bluish red and covered with thin skin. From the umbilicus to the symphysis the abdomen was half-ball-shaped from tension. Palpation met with a tense resistance. The umbilical swelling collapsed while the child was being bathed, and yellowish-red, thick, fluid masses escaped. On catheterization the urine was perfectly clear and transparent; it contained no albumin nor sediment. The umbilical fluid contained staphylococci, and microscopically many flat cells. After the bladder had been emptied the half-ball-shaped swelling between the umbilicus and the symphysis became less prominent, and by rectal examination, with one hand on the abdomen, the surgeon could make out very clearly a cystic tumor.

The fistulous opening was closed to prevent infection. The incision encircled the umbilicus and extended to 2 cm. above the symphysis. The anterior wall of the cyst was exposed. On account of the danger of peritonitis total extirpation of the cyst was not attempted, but the anterior cyst-wall and the umbilicus were removed. A finger in the cyst showed that it extended downward behind the symphysis, and that it ended blindly in the pelvis. A catheter introduced into the bladder could be felt behind and to the left. The cyst-wall was curetted with a sharp curette to remove any epithelial lining. A drain was laid and the opening closed. By January 13, 1903, only a small, granulating strip, 5 mm. wide, remained.

On microscopic examination no epithelial lining of the cyst could be found. The walls were composed of connective tissue, showing marked round-cell infiltration. They also contained smooth muscle-fibers. Although the epithelium was missing, Hornig felt that the smooth muscle was all that was necessary for diagnosis.

A Case of Hardening of the Linea Alba and Umbilicus. — In some healthy persons Leggf says there may be felt in the linea alba,

  • Hornig, Paul: Zur Kasuistik der Urachuscysten. Inaug. Diss., Leipzig, 1905.

t Legg, J. W.: Saint Bartholomew's Hospital Reports, 1880, xvi, 251.


574 THE UMBILICUS AND ITS DISEASES.

between the pubes and the umbilicus, a certain thickness or firmness which is not, however, very marked. He cites an interesting case in which the linea alba between the pubes and the umbilicus was one inch thick, a new growth having its seat apparently in the subperitoneal tissue. This growth was white, dense, tough, and much thicker on the left than on the right of the mid-line. The omentum was thickened. The stomach was small, constricted, and adherent to the omentum. No microscopic examination was made. [The possibility of a malignant abdominal growth in this case cannot be excluded. — T. S. C]

A Partially Patent and Infected Urachus. — Lexer* reports a case coming under the observation of Delageniere. The patient was a boy, five and a half years old, who had a fistula dating from early childhood. At the sixth month a small tumor at the umbilicus opened. Delageniere cut around and then entered, behind the umbilicus, a pocket filled with granulation tissue. Its lower portion communicated with the urachus. In dissecting this out he opened the peritoneum and could feel a string of the urachus passing downward to the bladder. It was isolated for 3 cm. and cut across. The lumen was turned in and closed with sutures. The fistula healed as the result of this procedure, which Delageniere spoke of as partial resection of the urachus. The child remained healthy.

An Infected Cyst of the Urachus. — Page's t patient was a man thirty-six years of age, married, and previously in good health. In March, 1899, he had dull pain about the fundus of the bladder. The pain was intermittent, ceased, and reappeared the second year. In July, 1901, he had sudden violent cramps in the abdomen, followed by diarrhea. The diarrhea ceased in two weeks, but the pain continued. Page suspected appendicitis.

On admission the patient walked bent over. He had great pain in the hypogastric region. His temperature was 102.5° F., pulse 100. He was nauseated. Examination disclosed a circumscribed mass, the size of an average orange, which lay between the umbilicus and pubes, and seemed to be in the abdominal wall. The patient had had a chill the night before. Dr. F. L. Taylor suggested a suppurating cyst of the urachus.

Operation. — Incision three inches long over the mass. In cutting through the fascia the tissues were found to be dense and hard. The operator entered a cavity containing four ounces of thick, flaky fluid, yellowish-brown in color. The abscess cavity was large; the walls were smooth and very thick. In lengthening the incision the peritoneum was accidentally opened. It was at once closed.

The recovery was slow. The cavity gradually became obliterated. The sinus had to be curetted several times, but it healed permanently. The man had formerly weighed 115 pounds; he then weighed 145.

Subperitoneal Phlegmon of the Anterior Abdominal Wall Without Appreciable Cause, Opening Below the Umbilicus; Rapid Healing.! — On p. 5 Vaussy gives the history of phlegmonous subperitoneal inflammation of the anterior abdominal wall, and on p. 6 says that Velpeau, Boyer, Nelaton and Vidal, had cited in their publications

  • Lexer, K.: I'eber die Behundlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73.

f Pago, Charles C: The Post-Graduate, New York, 1902, xvii, 1094.

{Vaussy: Des phlegmons sous-periton<£aux de la paroi abdominale anterieure. These de Paris, 1875, No. 445, Obs. 2.


URACHAL INFECTIONS. 575

several examples of vast purulent accumulations developing between the peritoneum and the anterior abdominal wall. On p. 25 he gives Observation 2. A boy, aged eleven, had at first complained of malaise, fever, and lack of appetite, and later of extreme pain in the hypogastric region. This was increased on inspiration. For a time the pain became general throughout the entire abdomen. The parents soon noticed a swelling in the abdomen below the umbilicus. When admitted (October 26, 1875) to the hospital, the boy showed a great deal of depression, had fever, no appetite, but gave no history of chills or vomiting.

On inspection a tumor was found extending from the umbilicus to the pubes. It was in the median line, and extended over to the left 5 cm. and to the right as far as the crest of the ilium. The tumor was hard, possibly fluctuating, but this could not be determined on account of the patient's pain. It suggested in contour a markedly distended bladder. The skin was of normal color; there was no redness nor edema. Rectal examination was negative. It was decided that the condition was due to a subperitoneal phlegmon of the anterior abdominal wall. It was impossible to determine the cause of the phlegmon, as the child had never been injured, nor had he had typhoid fever. The hypogastric region remained painful, the tumor became fluctuating, and a small red point the size of a 50-centime piece appeared immediately below the umbilicus in the median line. Poultices were applied. The pain and redness persisted, and there developed a small tumor the size of a cherry. Fluctuation being evident, a small incision was made with a bistoury and an enormous quantity of pus escaped. This had a very fetid odor, but did not in any way suggest stercoraceous material. By the eleventh of November the fistula had closed and the child left the hospital. The cause of the inflammation in this case was not clear.

[The history, which is characteristic of such cases, suggests remains of the urachus which had become inflamed. — T. S. C]

Suppuration of a Urachal Cyst. — In Weiser's Case 2 the patient was a girl, eleven years old, who was admitted to the Mercy Hospital on April 11, 1905. The child had complained for several days of headache and vomiting and had gradually developed slight tenderness and some pain in the abdomen. At first there had been no localized tenderness and very little distention. One week prior to admission general flatness had been noted with fluctuation. The abdomen had become more and more distended. On admission her temperature was 101.2° F.; pulse, 172; respirations, 30. The child was pale and emaciated and had a dry tongue and an anxious expression. She complained bitterly of abdominal pain, and the entire abdomen was tender, especially about the umbilicus, greatly distended and board-like. The flatness extended from the umbilicus to the symphysis, and from a point two inches to the right of the median line almost completely into the loin on the left. Surrounding the umbilicus was a zone of redness l^g inches in diameter, which represented an area through which the abscess was ulcerating toward the surface. A positive diagnosis was not made prior to operation, but tubercular peritonitis and a suppurative urachal cyst were both considered.

Under anesthesia the abdomen was opened in the mid-line between the umbilicus and symphysis. Absence of the peritoneum made a diagnosis quickly possible. The abdominal cavity was divided into two compartments by the sac-wall, which

  • Weiser, W. R.: Annals of Surgery, 1906, xliv, 529.


576


THE UMBILICUS AND ITS DISEASES.


had displaced the intestines almost entirely to the right side of the cavity and walled them off. Almost the entire left side below the umbilicus was filled with the cyst, which had ruptured, as shown in Fig. 243. Except at the point of rupture, the cyst contents were entirely extraperitoneal, although occupying so large a part of the abdominal cavity. Free pus to the amount of several pints was confined to the left side, and was not in contact with the intestines. The position occupied by the mass is fairly well shown in Fig. 243. The urachus was patulous down to within three-eighths of an inch of the bladder, and was ligated at this point. So much of the sac as could be dissected out without tearing up the limiting wall was taken

away, and the abscess cavity washed out and drained with a coffer-dam drain of iodoform gauze. An area 2 x 4j/2 inches was bare of peritoneum at the site of the wound, but there was no trouble from this source.

A Small Urachal Cyst Showing Inflammation.* — ■ Case 23. Autopsy No. 260, 1881. — The body was that of a man, sixty-three years old, dead of arteriosclerosis, hypertrophy and dilatation of the heart, emboli of the lungs, general edema, hypertrophy of the prostate, catarrhal cystitis. The bladder was pear-shaped, and its vertex appeared to reach to within 4 cm. of the umbilicus. When it was opened at the upper end, tenacious and slimy pus escaped. An abscess lay above and behind the top of the bladder. The bladder itself was 11.5 cm. long, and the distance from the vertex to the umbilicus was 8.4 cm. The bladder appeared to be independent of the first abscess (a) . Above the surface of the larger abscess (a) was a smaller one (6), the size of a bean. The cavities of both of these were reddish. Above this point the urachus appeared as a cord, accompanied by the umbilical arteries. The mucosa of the bladder was pale, not ulcerated. On the mucosa of the vertex of the bladder was an extravasation the size of a pin-head, and in the middle of this was a punctiform depression through which a bristle could be passed into abscess (a). The cavity of abscess (a) was 1 cm. long, 0.6 cm. broad. From this abscess cavity a bristle could be passed into abscess h l so that the connection between the two was easily followed. From abscess (b) the urachus could be traced 0.5 cm. toward the umbilicus. Microscopic examination of the walls of the abscesses (a) and (6) showed that they were inflammatory urachal cysts. In some places the characteristic several layers of epithelium were in evidence; at other points the inner surface of the cyst was ulcerated and the connective tissue showed small-round-cell infiltration. The entire length of the urachus in this case was 4 cm.

  • Wutz, J. 15.: Tiber (Jrachus and I'raehuscysten. Virchows Arch., 1883. xcii, 387.



Fig. 243. — Urachal Cyst. 'After W. R. Weiser, Case 2, Fig. 2.) The urachus was patulous down to within three-eighths of an inch of the bladder. Above that it had dilated into a large cyst. The urachus was ligated and severed and as much as possible of the suppurating cyst-wall was cut away. The abscess cavity was washed out and drained.


URACHAL INFECTIONS. 577


LITERATURE CONSULTED ON ABSCESS IN THE ANTERIOR ABDOMINAL WALL,

BETWEEN THE UMBILICUS AND THE SYMPHYSIS, DUE TO INFECTION OF

URACHAL REMAINS AND OF URACHAL CYSTS.

Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832.

Baldwin, J. F.: Large Cysts of the Urachus. Surg., Gyn., and Obst., June, 1912, xiv, 636.

Bryant, T.: Brit. Med. Jour., 1898, i, 1390.

Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, n. F., Xo. 89 (Chir. No. 2-1), Leipzig, 189-1, 519.

Heinrich: Ueber beschriinkte, sogenannte aussere oder tuberculose Peritonitis bei Kindern, oder iiber Entziindung der subkutanen Sehicht der Bauchwand und iiber die Bildung von Abszessen und Verhartungen daselbst. Jour. f. Kinderkrankheiten, 1849, xii, 6.

Van Hook, W. : Abscess Formation in the Patent Urachus. Amer. Jour. Obst., New York, 1894, xxix, 624.

Hornig, P.: Zur Kasuistik der Urachuscysten. Inaug. Diss., Leipzig, 1905.

Legg, J. AY. : Cases of Hardening of the Linea Alba and Umbilicus. Saint Bartholomew's Hospital Reports, 1880, xvi, 251.

Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 189S, lvii, 73.

Nicaise: Ombib'c. Dictionnaire encycloped. des sciences medicales, Paris, 1881, 2. ser., xv, 140.

Page, C. C. : Cyst of the Urachus. The Post-Graduate, New York, 1902, xvii, 1094.

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

Weiser, W. R.: Cysts of the Urachus. Annals of Surg., 1906, xliv, 529.

Wutz, J. B.: Ueber Urachus and Urachuscysten. Virchows Arch., 1883, xcii, 387.



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

Reference

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

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