Book - Umbilicus (1916) 35
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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 XXXV. Acquired Urinary Fistula at the Umbilicus
Acquired umbilical urinary fistula, when no urethral obstruction exists.
Umbilical urinary fistula following partial or complete blockage of the urethra.
Urinary fistula at the umbilicus, with absence of the urethra.
Congenital phimosis, with a urinary umbilical fistula.
Umbilical urinary fistula following stricture of the urethra.
Umbilical urinary fistula associated with a growth in the bladder.
Vesical calculi obstructing the urethra and associated with escape of urine from the umbilicus; report of cases.
Umbilical urinary fistula associated with an enlarged prostate; report of cases.
Apparent escape of urine from the umbilicus, the breasts, and other parts of the body.
We have already considered (p. 487) congenital umbilical urinary fistulse due to a patent urachus, and also fistulse resulting from the opening of a urachal sac (p. 578). We shall now discuss acquired umbilical urinary fistulse, occurring apparently independently of urachal cyst formation.
These cases naturally fall into two classes :
1. Umbilical urinary fistulse when no urethral obstruction exists.
2. Umbilical urinary fistulse associated with partial or complete blockage of the urethra.
Monod, in his splendid thesis on Umbilical Urinary Fistulse Due to Persistence of the Urachus, mentions a case recorded by Laurentius in 1600. A young woman had retention of urine for several days; this was followed by an escape of urine from the umbilicus. He also refers to an observation published by Fernel in 1638. A man, thirty years old, developed an umbilical urinary fistula following an obstruction at the neck of the bladder. In the same thesis reference is made to a case recorded by Peyer in 1721, in which, following retention of urine, a calculus escaped from the umbilicus. Scattered throughout the literature are isolated cases of acquired urinary umbilical fistulse.
We have seen (p. 515) that remnants of the urachus are by no means rare. The urachus may remain as a small, patent filament connected with the bladder. In other cases the urachus at the bladder has been obliterated, but here and there along its course are small, spindle-like dilatations. In after-life these small bays or lakes may become connected up so that finally there is produced a fistulous tract between the bladder and umbilicus. Where there is obstruction of the urethra, it is only natural that the old channel through the urachus should open, but in those cases in which the urethra is of normal caliber, the reason for the reestablishment of the urachal channel is more difficult to explain, unless the urachus has always been patent or unless there has been an inflammatory reaction in the urachal region.
ACQUIRED UMBILICAL URINARY FISTULA WHEN NO URETHRAL OBSTRUCTION EXISTS.
In none of the cases here recorded was any abnormality noted at the umbilicus at birth. Five of the patients were males and one was a female. The youngest was a small boy; the oldest, eighty. In all the cases the urine escaped from both the umbilicus and the urethra. The recognition of the condition was eas3 r on account of the escape of urine from the umbilicus. In Binnie's case there was a line of induration between the symphysis and umbilicus. In Leveque-Lasource's case the eightyyear-old patient had been passing his urine at intervals from the umbilicus for twenty-five years. In this case the possibility of an enlarged prostate cannot be excluded.
Florentin thought his patient had a urinary fistula at the umbilicus. The history, however, is not very conclusive.
A Partially Patent Urachus That Finally Opened at the Umbilicus, Causing a Urinary Fistula. — Binnie,* in 1905, saw a woman twenty-nine years of age who for six years was supposed to have had cystitis of unknown origin. All her life she had complained of pain and tenderness in the hypogastrium, and Binnie found a line of induration between the bladder and umbilicus. Pus was escaping from the umbilicus. A little mass of granulation tissue was present at the umbilicus, and through this Binnie could pass a probe into the bladder. He excised the fistula, which was so closely attached to the peritoneum that the abdomen had to be opened. The fistula led into a small diverticulum at the fundus of the bladder.
On histologic examination the walls were found to consist of very vascular granulation tissue, together with sclerosed tissue. The lumen was lined with necrotic material. No epithelium was observed.
A Urinary Umbilical Fistula.! — ■ The man was thirty years old. The urine escaped in jets from the umbilicus, but some of it was passed through the urethra.
Possibly a Urinary Fistula at the Umbilicus. — Florentine reports a case narrated to him by Professor Froelich. A small boy, two years of age, was examined at the hospital of Nancy in January, 1906. At the umbilicus was a tumor the size of a gooseberry or currant. It had not increased in size. In the beginning there had been no discharge, but after several months a purulent fluid had commenced to escape in moderate amount from a small ulceration situated at the margin of the elevation, and still persisted. On examination there was seen at the base of the umbilical cicatrix a small, reddish tumor attached to the skin by a broad, short pedicle, from the base of which a little drop of pus was being discharged. The tumor was irreducible. There was a small ulceration with violet margins. In the center was a small depression, into which a probe could be introduced for 3 cm.
Operation. — The tumor was continuous with a fibrous cord, which extended down the median line. It was dissected out and tied off, the outer portion being removed. Healing took place. No microscopic examination was made. Floren
- Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc., 1908, ii, 109.
t Civiale, Jean: Traite de 1' affect ion calculeuse, Paris, 1838, 261.
t Florentin, P. : Fongus de l'ombilic chez le nouveau-ne et chez l'enfant. These de Nancy, 1908-09, No. 22 (obs. 8), 108.
ACQUIRED URINARY FISTULA AT THE UMBILICUS. 609
tin diagnosed the condition as a urinary fistula, but the case would seem to be doubtful.
Escape of Urine From the Umbilicus in an Old Man, * — The patient was a farmer, eighty years of age, of stout build. He had a double inguinal hernia. He had also had for a long period an umbilical hernia, which was not larger than a chestnut. For twenty-five years at times the urine had passed from the umbilicus, and sometimes from the urethra. It did not escape as a jet, as the opening was too small, but there was enough urine to keep the clothes wet. Xo method of control had thus far been discovered. Leveque-Lasource said that the condition was due to the reopening of the urachus.
A Case of Fistula of the Urachus. f — The patient was a soldier in active service, and had always been free from discomfort except that the pressure of the belt of his sword on the full bladder caused urine to escape from the umbilicus. At the umbilicus the opening was no larger than a hair in caliber, and even with a full bladder only a small amount of urine escaped. He was given a small quantity of potassium iodid and the urine soon contained an appreciable amount of iodin. The reaction was obtained from the umbilical urine by adding calomel, which at once gave it an intense yellow color.
A Vesico-umbilical Fistula. ± — -A boy, aged nine, had had incontinence of urine, and from time to time had complained of pain in the lower abdomen. For about six weeks urination had been frequent, and, three weeks before Trogneux saw him, moisture had been noted at the umbilicus, and later a few drops of urine had passed from the navel. The urine escaped both by the urethra and the umbilicus. Sometimes a large quantity came away from the navel, especially when the patient moved. The umbilical orifice was oval, elongated transversely, and the urine escaped from the bottom. The urethra was permeable. The bladder held 20 c.c. of fluid, and when more was introduced, it at once escaped by the umbilicus. The same result was obtained in the reverse direction. The urine contained pus.
Operation. — The tract was dissected out for 2 cm. and tied off. The upper part of the wound was closed. The canal was lined with what seemed to be macerated skin. On the tenth day the urine infiltrated the abdominal wall and escaped. The boy had tuberculosis in the apices of both lungs and was supposed to have tuberculosis of the bladder.
In this case the urachus did not open until the ninth year. The presence of the cystitis naturally hindered efforts at rectifying the condition.
UMBILICAL URINARY FISTULA FOLLOWING PARTIAL OR COMPLETE BLOCKAGE OF
Although in the majority of the cases the definite type of obstruction to the escape of urine from the urethra has been stated, in a few cases it is merely recorded that an obstruction existed.
Monod refers to an observation made b} T Fernel in 1638. A man, aged thirty,
- Leveque-Lasource: D'un cas particulier ou les urines sortaient par l'ombilic. Jour, de
med., Paris, 1811, xxi, 121.
t Starcke: Deutsche militararztliche Zeitschr., 1883, xii, 211.
% Trogneux, Albert: Contribution a l'etude des fistules ombilico-vesicales. These de Paris, 1897, No. 129. 40
610 THE UMBILICUS AND ITS DISEASES.
developed an umbilical urinary fistula following an obstruction at the neck of the bladder.
Littre* reported the case of a boy twelve years of age who had passed nearly all his urine by the umbilicus. At autopsy an obstruction was found at the neck of the bladder and the urachus had remained as a patent canal. Littre, in the same article, says that he knew a man thirty years old from whom the urine escaped forcibly from the umbilicus, no doubt as the result of an obstruction at the neck of the bladder.
Simon (obs. 14) records a case reported by Chopart.f I have attempted to find the original article, but was unable to locate it. It is, however, probably correct, as Chopart has many cases scattered throughout his excellent book.
The patient was a woman, thirty-seven years of age. Shortly after the beginning of pregnancy she suffered from retention of urine, and twelve days later several drops of puriform urine escaped. The abdomen increased in size day by day, and when she entered the hospital on September 7, 1781, she complained of abdominal tenderness. The skin was inflamed, and there was marked fluctuation around the umbilicus; the patient voided only in small quantities. She had high fever. Anthelme, surgeon-in-chief of the hospital, made an incision in the linea alba between the umbilicus and the muscle on the right, and a good deal of pus and a large quantity of fetid urine escaped. On the following day the symptoms were less acute. The clothes and the body were inundated with urine, and a large quantity of pus also escaped. On the next day the clothes were soaked with urine. The fever and other symptoms had disappeared, and the surgeon attempted to establish the return of the urine by the urethra. He was unable to introduce a sound into the bladder on account of some obstruction. Later on he was able to pass an elastic catheter into the bladder. The amount of urine escaping from the umbilicus diminished, and the pus in the urine gradually decreased. The pregnancy continued, and the patient left the hospital perfectly well. Normal labor took place in February, 1782.
Simon J says that at the meeting of the Medical Society in Florence, July 13, 1828, Betti reported a case seen by Falaschi, in which, as a result of a complete occlusion of the urethra at its vesical orifice, there was an escape of urine from the umbilicus in a patient very advanced in years. This phenomenon was observed for several months before death.
The various causes of blockage of the urethra have been:
1. A congeni tally closed urethra.
2. A congenital phimosis.
3. A stricture following gonorrhea.
4. New-growths of the bladder.
5. A vesical calculus.
6. An enlarged prostate.
URINARY FISTULA AT THE UMBILICUS, WITH ABSENCE OF THE URETHRA. The only case of congenital absence of the urethra with the escape of urine from the umbilicus with which I am familiar is that reported by Petit in 1837.
- Littre: Histoire de l'Academie Royale des Sciences de Paris, Amsterdam, 1701, 27.
t Chopart: Maladies des voies urinaires, Paris, 1792. X Simon: Obs. 17, p. 33.
ACQUIRED URINARY FISTULA AT THE UMBILICUS. 611
Urinary Fistula at the Umbilicus, With Absence of the Urethra.* — The child was born with a closed urethra. At the umbilical cicatrix was a tumor the size of a cherry, from which urine escaped. A bandage was applied. The bandage retained the urine very well, but she was often obliged to remove it in order to relieve herself. The bladder was sensitive and did not hold more than half a glass of urine. As soon as it reached this degree of dilatation the child suffered from pain in the abdomen, particularly in the region of the bladder and the kidneys.
CONGENITAL PHIMOSIS WITH A URINARY UMBILICAL FISTULA. Freer, in his article on Abnormalities of the Urachus, refers to an article appearing in the Medical Record of August 18, 1871. A boy, a year old, commenced to pass his urine through a vesico-umbilical fistula. A few drops only passed by the urethra. An examination revealed a congenital phimosis with an orifice so small that the vis a tergo required to force the urine through it had exerted itself in an upward direction and had opened up the urachus, rendering that structure patent throughout. After this fistula had persisted for some time the cause was discovered, • circumcision was performed, and the urachus closed spontaneously.
Freer says this case emphasizes the importance of examining carefully the urethra before proceeding to operate for the closure of the fistula.
UMBILICAL URINARY FISTULA FOLLOWING STRICTURE OF THE URETHRA.
This is a very rare condition, considering the enormous number of patients who suffer from urethral stricture. Jacoby reported a case in 1877, and Guisy two cases in 1903. One of Guisy's patients also had an enlarged prostate which was probably a contributory factor to the urethral obstruction.
Umbilical Fistula Following a Urethral Stricture. f — The patient was a boy, eighteen years of age, who had contracted gonorrhea a year before and had developed a stricture. Later there was a perineal fistula. After taking balsam of copaiba he improved somewhat, but three months later the urine stopped completely for twenty-four hours. He suffered great pain and the umbilicus opened. Pus escaped, and then large quantities of urine, the continuous flow confining him to bed. When Jacoby saw him he had tuberculosis and syphilis. All the urine came from the umbilical fistula and none from the urethra. The fistula in the perineum was dry.
The umbilicus was flat. There was a very narrow fistula. Once the fistula closed and a small amount of urine escaped from the urethra. At the end of thirty hours, when the patient bore down heavily, the fistula reopened, and fully a quart of urine came away. This was mixed with pus and blood. The boy soon died. No autopsy is recorded.
An Umbilical Urinary Fistula Developing in a Man with Urethral Stricture and Enlarged Prostate. — • Guisy'sJ
- Petit, J. L.: Traite des mal. chirurg., Chap, xi, 3. Oeuvres completes, 8°. Limoges,
1837. (Quoted by Simon, obs. 8.)
t Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, 202.
J Guisy, B.: Deux cas de permeabilite congenitale de l'ouraque. Ann. d. mal. d. org. genito-urin., Paris, 1903, xxi, 986.
612 THE UMBILICUS AND ITS DISEASES.
patient was a man sixty years of age, who, for five years, had been passing urine from the umbilicus. His previous history showed that he had suffered many years before with gonorrhea, and later with severe attacks of renal colic, accompanied by the passage of gravel from the urethra. He also had a urethral stricture. He developed pain and swelling about the navel. A physician opened the swelling and evacuated urine and pus, and thereafter the urine continued to flow by this route, as well as through the urethra. External urethrotomy was performed, and two large stones were removed from behind the stricture. The prostate was large. The urine ceased completely to flow from the umbilicus and recovery took place.
Escape of Urine from the Umbilicus Following Stricture of the Urethra. — Guisy's* second patient was a man aged thirtytwo years, who, on account of stricture following gonorrhea, had had great difficulty in passing urine and for two years had suffered pain at the umbilicus. Later a swelling appeared, and one day, during complete retention, the tumor ruptured and urine and bloody mucus escaped. Thereafter for several months there was constant leakage from the navel. A small sound could be passed through the navel into the bladder. The urethral stricture was treated by internal urethrotomy and dilatation, and the escape of urine through the navel diminished materially.
UMBILICAL URINARY FISTULA ASSOCIATED WITH A GROWTH IN THE BLADDER.
The only case of this character with which I am familiar is the one reported by Cadell in 1878.
Marked Cystitis in a Young Girl Followed by Escape of Urine from the Umbilicus. f — The patient was a delicate girl eight years of age. From her earliest childhood she had difficulty in making water. Micturition was frequent, and only a small amount of urine was passed. When she was six months old the lower abdomen and genitals became black and blue. The child went to school at four, but was taken home on account of pain and frequent urination. After an attack of typhoid fever at six years of age the other symptoms became more marked. Eight months before admission blood was noted in the urine. After a few days of great pain and swelling and hardness of the abdomen, the urine was observed to come in a small stream from the umbilicus. Nothing abnormal was noted in the appearance of the umbilicus or of the genitals. In the center of the umbilical depression was a fistulous opening into which a probe could be easily introduced and passed toward the bladder. A No. 2 elastic catheter introduced through the urethra was blocked by tenacious, mucopurulent masses in the bladder. The urethra was normal. No urine escaped by the urethra for several days. Later the urethra was dilated under anesthesia, and the procedure was followed by incontinence of urine.
The child died a few months later. At autopsy the bladder was found contracted and showed great thickening of the mucous and submucous coats. Protruding into the cavity were rounded nodules the size of peas. At the upper end of the bladder was the unobliterated urachus. It admitted the point of the little finger, gradually became narrower, and at the umbilicus admitted a No. 5 or No. 6 catheter. The
- Guisy, B.: Loc. eit.
t Cadell, F.: Notes on a Case of Umbilical Urinary Fistula. Edinburgh Med. Jour., 1878, xxiv, Part i, 221.
ACQUIRED URINARY FISTULA AT THE UMBILICUS. 613
mucous membrane of the urachus was thin and pale. Between the umbilicus and the bladder were evidences of an old peritonitis, and the omentum was adherent to the anterior abdominal wall along the course of the urachus. There were dense adhesions binding the uterus to the posterior surface of the bladder.
The right kidney was twice the natural size, cystic, and filled with putrid and ammoniacal pus. There was complete atrophy of the kidney substance. The left kidney was one and a half times the natural size. The calices were distended with putrid pus, but the kidney substance had been only partially destroyed. Both ureters were dilated. Cadell says the urachus must have been partly open at birth.
VESICAL CALCULI OBSTRUCTING THE URETHRA AND ASSOCIATED WITH ESCAPE OF URINE FROM THE UMBILICUS.
Cases of this nature have been reported by Littre (1701), Raussin (1752), d'Auxiron (1766), Eustache (1789), Civiale (1838), Simon (1843), and Lexer (1898). In seven cases in which the sex was mentioned, five were in males and two in females. The ages varied from two and a half to seventy years. The age at which the patient came under observation is, however, no index as to when the symptoms first developed. For example, d'Auxiron's patient came under observation when he was seventy years old, but from the history it will be seen that he had had vesical symptoms since childhood. Eustache's patient, a boy six years old, had vesical symptoms shortly after birth.
The symptoms were usually those referable to a vesical calculus, and after various periods of time urine commenced to escape from the umbilicus. In some cases the umbilical fistula was preceded by an inflammatory reaction in the umbilical region; in other cases this phenomenon was apparently lacking.
Some of the patients were relieved by lateral lithotomy, and in Simon's case the stone was successfully removed suprapubically. After removal of the stone the umbilical fistula usually closed.
With our present mode of treatment these patients would naturally be operated upon soon after symptoms develop. If there be little or no infection, the fistulous tract should be dissected out and excised, and the stone removed suprapubically at the same time. When the inflammatory reaction is marked, the stone may be removed and the tract dissected out after the inflammation has subsided.
CASES OF VESICAL CALCULUS WITH ESCAPE OF URINE AT THE UMBILICUS. Vesical Calculi Followed by Escape of Urine at the Umbilicus.* — The patient was a priest, seventy years of age, who had suffered with vesical stone since childhood. He had piercing pains in the lower abdomen at times, and suffered from retention of urine, which sometimes lasted for several days.
For four or five years stones had blocked the urethra, and the urine had at times escaped from the umbilicus. There was a small opening with reddish margins at the umbilicus, out of which the urine oozed. Sometimes it came as a stream and could be caught in a vessel. When the urine escaped by the ordinary channel, the umbilical opening would close.
- d'Auxiron: Une observation sur un homme qui rend ses urines par le nombril. Jour, de
m£d., Paris, 1766, xxiv, 58.
614 THE UMBILICUS AND ITS DISEASES.
Escape of Urine from the Umbilicus Due to a Vesical Calculus.* — In a patient seventy years old the urine escaped from the umbilicus in jets, in spite of the fact that the bladder was not extremely full. Each time it was found that a stone was obstructing the neck of the bladder.
Escape of Urine from the Umbilicus, Due to the Presence of a Vesical Calculus. — Civiale f says that Fourquet, of Toulouse, narrated to him the history of a child, thirty-one months of age, who was relieved by lithotomy. The vesical stone was voluminous, weighing 5.5 "gros," and enveloped in a covering of mucus and calcareous material. After about two months, as a result of considerable effort, the child expelled urine. It developed a urinary fistula at the umbilicus, from which three quarts or less of urine escaped. This closed after the operation.
Umbilical Urinary Fistula Associated With Stone Situated in the Neck of the Bladder. — Civiale also reports a case related by Covillard. The patient, a girl fifteen years of age, passed her urine from the umbilicus, and a stone was detected in the neck of the bladder. A lateral lithotomy effected an entire cure.
Urachal Fistula at the Umbilicus Associated With a Stone in the Bladder. — Lexer J reported a case that came under Goldschmidt's care. Goldschmidt operated on a ten-year-old boy on account of the gradual appearance of a fistula without signs of inflammation. This case was looked upon as one of urachal fistula of the abdominal wall, although no microscopic examination could be made. The boy had a large stone in the bladder. The fistula had produced an abscess-like dilatation below the umbilicus, and had been previously opened. At another time, when the cystitis had disappeared, the umbilical opening closed.
[This case is not particularly clear. — T. S. C]
Blockage of the Neck of the Bladder by a Stone; Partially Patent Urachus. — ■ Littre § demonstrated before the Paris Academy the body of a young man of eighteen. The neck of the bladder was occupied by a stone, and the urachus at the neck of the bladder was open for five fingerbreadths. He says that when the urine finds great difficulty in passing along its ordinary route, it commences to travel through its ancient channel.
A Renal Calculus Associated with Escape of Urine b y the Umbilicus. — Raussin|| reported before the Academy the case of a man, aged thirty-two years, who had had a renal calculus. In making an effort to urinate, while an attendant held the vessel, expecting to see a small stone fall into the vessel, he was greatly surprised to see urine passing from the umbilicus and from the penis at the same time. The umbilical stream was well formed, and made an arch over the shoulder of the servant, who at the time was kneeling. The umbilicus of the patient was represented as a tumor the size of a medium-sized walnut, with an opening in it which discharged a little blood. The patient continued to urinate by the
- Civiale, Jean: Traitc de l'affection calculeuse, Paris, 1838, 257.
- ( Jiviale, Jean
- Op. cit.
% Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. § Littre: Sur un foetus extraordinaire. Histoire de l'Academie Royale des Sciences de Paris, Amsterdam, 1701, 27.
1 1 Raussin : L'urine rendue par le nombril. Mem. de l'Acad. de Chir., Paris, 1752, ih, 10.
ACQUIRED URINARY FISTULA OF THE UMBILICUS. 615
umbilicus more than by the urethra, and claimed to be able to urinate by one or the other, as he desired. After a time most of the urine passed by the urethra.
Escape of Urine by the Umbilicus Due to Blockage of the Urethra by a Vesical Calculus.* — Dr. Eustache, surgeonin-chief of the Hotel-Dieu of Beziers, reported before the Academy of Surgery, in 1789, the case of a new-born boy who developed severe abdominal pain a few days after his birth. He was thought to have colic, but the usual remedies were given without success. At the thirteenth month he was weaned. The manner in which he urinated led to the supposition that he had a stone. When he was three years of age he drank to excess, and one day he consumed a pint of wine and became unconscious. The difficulty in urination increased. Sometimes he would have incontinence of urine, sometimes a dozen hours would pass without there being the escape of a drop. When five years of age he had complete retention of urine, and his abdomen was tender and painful, especially in the hypogastric region. His pulse was small and rapid, and the respiration was embarrassed. He had continual nausea. Pistre saw him on the third day, and at that time he had around the umbilicus a tumor which was inflamed, tender, and painful. Poultices were applied, and on the fourth day the child had not passed a drop of urine and was unconscious. On the fifth day there formed in the center of the umbilical tumor an opening about half an inch in diameter, and from this urine with pus escaped. Little by little the symptoms disappeared. The stomach retained nourishment, and he returned to the condition that he was in before the retention. The umbilical opening remained as a fistula and was the only passage by which the urine escaped. On the twenty-fourth of April, 1787, Eustache saw this patient, who was then six and a half years old. He had a slight fever and marasmus. Eustache confirmed the opinion of Pistre of the existence of a stone in the neck of the bladder, because a sound was arrested at this place and came in contact with a hard body. On the seventh of May of the same year, in the presence of several surgeons, Eustache extracted the stone through an incision in the perineum. It was in the shape of a large horn, and the lower extremity was engaged in the urethra. It was a little less than three inches long and 13^ inches in diameter. It was slightly concave toward the pubes, convex toward the rectum. After the extraction of the stone the urine commenced to escape through the wound, and in a short time the fistulous opening, which had been present for a year, closed. The urine contained much mucus. On the thirty-second day after the operation the urine commenced to pass by the urethra, and ten days later it passed entirely through this channel. The child made a good recovery.
Escape of Urine From the Umbilicus Due to Blockage of the Urethra by a Vesical Calculus. — Simon f reports the case of Marguerite P., aged twelve years, who had urinated by the umbilicus for four years. During this time not a drop of urine had escaped by the urethra. She had an enlargement of the abdomen, due to the escape of urine into the cellular tissue of the skin and of the muscle. She was brought to the hospital in May, 1786. With a sound an obstruction was found in the canal, which was preventing the flow of urine. The opening in the umbilical region offered a channel which communicated with the bladder. By this means it was possible to detect a stone fixed in the inner orifice of the urethra. The surgeon decided to pass a sound into the bladder by way of the urachus. The child was laid upon the table, the head and the buttocks being a little
- Simon: These de Paris, 1843 (obs. 19), 34. f Simon: Op. cit. (obs. 25), 44.
616 THE UMBILICUS AND ITS DISEASES.
elevated. After the sound had been introduced into the bladder by way of the urachus an incision was made in the skin for about the length of three fingerbreadths in the linea alba, and ending at the pubes. The sound acted as a guide. The bladder was opened. The stone was the size of a pigeon's egg. After the extraction of the stone the child was promptly put to bed, and a sound was introduced through the urethra. At the end of four months the urine escaped regularly by the urethra.
UMBILICAL URINARY FISTULA ASSOCIATED WITH AN ENLARGED PROSTATE.
Levie, Lexer, and Monod have recorded cases in which a urinary fistula developed at the umbilicus in patients suffering from an enlarged prostate.
In this connection it may be mentioned that, according to Kirmisson, Horion observed an umbilical fistula that had developed after retention caused by a prostatic abscess.
A P a t e n t U r a c h u s A s s o c i a t e d W i t h an Enlarged Prostate.* — The patient was a man seventy-nine years of age. After several years of dysuria due to an enlarged prostate, the urine commenced to escape from the umbilicus. At autopsy the urachus. was found open. The opening into the bladder was tubular. The opening was from 1 to 1.5 mm. broad.
Markedly Enlarged Prostate, Followed by Cystitis and Escape of Urine From the Umbilicus. — Lexer f reports the case of a man, aged sixty-seven, who came to the clinic for three years on account of a prostatic hypertrophy and a resulting cystitis. He came whenever retention of urine developed. The urine was removed with a soft catheter, and the bladder washed out each time. The patient, on coming to the hospital later, said that, after there had been a stoppage of urine for twenty-four hours, it had commenced to come away by the umbilicus. He had noticed no unusual pain, and there was no inflammation in the region of the umbilicus. The entire flow of purulent, slimy urine escaped from the umbilicus.
On examination the patient was found to have a markedly enlarged prostate. A sound could be carried from the umbilicus for 6 cm. toward the bladder. From the umbilicus to the symphysis in the middle line a cord-like mass could be felt. [In such a case it would now be very easy to use bismuth paste and get a clear picture of the character of the fistulous tract by means of the x-ray. — T. S. C]
Lexer said that the almost complete lack of symptoms in the development of the fistula was a strong indication against perforation of the bladder with infiltration of the urine. He says that, in view of the slow development and the fact that the position of the fistulous tract was exactly in the mid-line, the whole picture tends to prove that the case was one of urachal fistula.
[With the present brilliant results obtained by prostatectomy, as carried out by Young and others in this country, the first thing would be to remove the prostate; this would materially improve matters, and later, if necessary, the fistulous tract could be closed.— T. S. C]
With a sound in the tract Lexer divided it. It was surrounded on all sides by very firm connective tissue, and about 5 cm. above the symphysis he found a cavity
- Levie, L. : Een geval van profluvium urinae per umbilicum ab uracho patente bij een
volwassen persoon. Nederlandsch. Tijdschrift voor Geneeskunde, 1878, xiv, 501. t Lexer, E.: Loc. cit.
ACQUIRED URINARY FISTULA AT THE UMBILICUS. 617
the size of a walnut lined with slimy granulations and filled with purulent urine. This lay behind the abdominal wall and reached to the symphysis. The sac communicated with the bladder by a fistulous opening, the size of a lead-pencil. The entire wound was packed with iodoform gauze and a retention catheter left in.
The patient died fourteen days later with signs of uremia and fever. At autopsy a marked pyonephrosis was found on both sides. The small, thick-walled, ulcerated bladder ended in a small funnel just in the mid-line. Here it communicated with the opening in the abscess-sac. On the inner side of the abdominal wall was the median vesical ligament, appearing as a prominent cord 2 cm. broad.
From the results of the operation and from the autopsy specimen, it is clear that the bladder and umbilical fistula lay in the mid-line, and in the very markedly thickened median vesical ligament. The opening in the bladder was situated exactly in the middle of the vertex and in front of the peritoneum. In the fistulous tract it was impossible to make out any epithelium.
Lexer comes to the conclusion that these fistulous tracts should be dealt with early, before there is much inflammation; that is, in childhood.
Umbilical Urinary Fistula Associated With Hypertrophy of the Prostate.* — This case is particularly interesting. In a man, sixty-two years of age, the umbilical fistula developed after a prostatic hypertrophy. On looking into the history it was found that the patient had urinated from the umbilicus from the time of birth until he was three weeks old. The fistula had then closed spontaneously after the application of appropriate bandages.
Enlargement of the prostate is relatively common, and notwithstanding the tension under which the bladder labors in some of these cases, the escape of urine from the umbilicus is exceptional. It really seems as if the umbilical fistula only develops in those cases in which the urachus has remained partially patent, or where its lumen has persisted almost to the umbilicus.
- Bardeleben and Chapin have also reported cases in which an enlarged prostate probably existed. Bardeleben's patient was ninety-two, Chapin's was sixty-six, years old.
A Urinary Fistula at the Umbilicus Developing in a Man Ninety-two Years of Age. — ■ Bardelebenf says that, in the Memoires de l'Academie des Sciences for 1769, there is a report of a man, ninetytwo years old, who had severe pain in the neck of the bladder for several days. After the pain had ceased, he noticed that he voided less urine than usual and that his umbilicus was wet. A clear fluid (urine) was found escaping from the umbilicus. In fourteen days the urine by the urethra ceased. He died in six months. The fistula persisted until his death.
Escape of Urine from the Umbilicus in a Man Sixtysix Years of Age. — Chapin's f patient was a man, sixty-six years of age, who was seen in June with retention of urine. He suffered a great deal of pain and passed no urine for forty hours. The urine then began to dribble, and finally the bladder was emptied with a catheter. He suffered agony beyond expression during
- Jaboulay: Reported by Monod, Obs. 53.
f Bardeleben: Lehrbuch der Chirurgie und Operationslehre, 1882, iv, 223. t Chapin, Edward: A Case of Open or Patent Urachus. North Amer. Jour, of Homoeopathy, New York, 1897, third series, xii, 286.
618 THE UMBILICUS AND ITS DISEASES.
the retention. The catheter was used for several days, after which he developed a great deal of soreness over the upper part of the bladder. Palpation over this region was painful. His pulse was slightly accelerated, but he had no fever. He voided small quantities of strongly ammoniacal urine containing mucus. Later excoriations were noted around the umbilicus, and some pus escaped from this opening. The discharge became more watery and had the odor of urine. The amount of urine escaping gradually increased, and by November 5th fully three-fourths of the urine was coming from the umbilicus. A small stream came from the urethra, a large one from the umbilicus.
APPARENT ESCAPE OF URINE FROM THE UMBILICUS, THE BREASTS, AND OTHER
PARTS OF THE BODY.
The accompanying remarkable case, recorded by Lynker in 1836, is difficult to interpret. I have found no similar case in the literature.
Lynker* reports the case of a woman, aged twenty-four, who in 1831 had a bad fall and became sick. In 1833 she had paralysis of the lower extremities. Later she had dysuria and passed hardly any urine. Her breasts swelled up, and she passed what looked like urine from them, then from the umbilicus, and later from the legs, the rest of the body skin meanwhile being dry. She had marked pain and swelling in the lower abdomen.
Up to the time of writing no clue as to the cause had been obtained. The patient was still alive.
- Lvnker: Retention d'urine suiviede 1' excretion de ce liquide par des voies inaccoutumees.
Gaz. mid. de Paris, 1836, vii, 602.
LITERATURE CONSULTED ON ACQUIRED URINARY FISTULA AT THE UMBILICUS. d'Auxiron: Une observation sur un homme qui rend ses urines par le nombril. Jour, de med.,
Paris, 1766, xxiv, 58. Bardeleben: Lehrbuch der Chirurgie und Operationslehre, 1882, iv, 223. Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc, 1906, ii, 109. Cadell, F.: Notes on a Case of Umbilical Urinary Fistula. Edinburgh Med. Jour., 1878, xxiv,
Part i. 221. Chapin, E.: A Case of Open or Patent Urachus. North Amer. Jour, of Homoeopathy, New York,
1897. third series, xii, 286. Civiale, J.: Traite de l'affection calculeuse, Paris, 1838, 261. Florentin, P.: Fongus de l'ombilic chez le nouveau-ne et chez l'enfant. These de Nancy, 1908-09,
No. 22. Freer, J. A.: Abnormalities of the Urachus. Annals of Surg., 1887, v, 107. Guisy, B.: Deux cas de permeabilite congenitale de l'ouraque. Ann. d. mal. d. org. genito-urin.,
1903, xxi, 986. Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, 202. Kirrnisson: Maladies congenitales de l'ombilic. Traite des mal. chirurg. d'origine cong6nitale,
Paris, 1898, 208.
' 1 ue-Lasouree : D'un cas particulier ou les urines sortaient par l'ombilic. Jour, de m6d.,
Paris, 1811, xxi, 124. Levie, L. : Een geval van profluvium urinaj per umbilicum abs uracho patente bij een volwassen
persoon. Nederlandsch. Tijdschrift voor Geneeskunde, 1878, xiv, 501. Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. Littre: Sur un fcetus extraordinaire. Histoire de l'Academie Royale des Sciences de Paris,
Amsterdam, 1701, 27.
ACQUIRED URINARY FISTULA AT THE UMBILICUS. 619
Lynker: Retention d 'urine suivie de l'excretion de ce liquide par des voies inaccoutumees. Gaz.
med. de Paris, 1836, vii, 602. Monod, J.: Desfistules urinaires ombilicalesdues a la persistance de l'ouraque. These de Paris,
1899, No. 69. Petit, J. L.: Traite des malad. chirurg., Chap, xi, 3. Oeuvres completes, 8°. Limoges, 1S37. Raussin: L'urine rendue par le nombril. Mem. de l'Acad. de Chir., Paris, 1752, iii, 10. Simon, C: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales. These
de Paris, 1843, No. 80. Starcke: Fall von Urachusfistel. Deutsche militararztliche Zeitschr., 1883, xii, 211. Trogneux, A.: Contribution a l'etude des fistules ombilico-vesicales. These de Paris, 1897, No. 129.
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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