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| | [[File:Mark_Hill.jpg|90px|left]] This historic 1916 textbook by Cullen describes the umbilical region. | | | [[File:Mark_Hill.jpg|90px|left]] This historic 1916 textbook by Cullen describes the umbilical region. |
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| | '''Links:''' [[Media:Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus (1916).pdf|PDF version]] | [https://archive.org/details/embryologyanatom00cull/page/n5 Internet Archive] |
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| {{Historic Disclaimer}} | | {{Historic Disclaimer}} |
| =Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus= | | =Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus= |
| | | [[File:Cullen1916 titlepage.jpg|thumb|300px]] |
| By | | By |
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| ==Contents== | | ==Contents== |
| {{Cullen1916 TOC}} | | {{Cullen1916 TOC}} |
| | | <br><br> |
| # [[Book - Umbilicus (1916) 1|Embryology of the Umbilical Region]] | | # [[Book - Umbilicus (1916) 1|Embryology of the Umbilical Region]] |
| # [[Book - Umbilicus (1916) 2|Anatomy of the Umbilical Region]] | | # [[Book - Umbilicus (1916) 2|Anatomy of the Umbilical Region]] |
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| ==List of Illustrations== | | ==List of Illustrations== |
| 1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois 2
| | [[Book - Umbilicus (1916) Figures|Figures]] |
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| 2. A More Advanced Stage in the Formation of the Umbilical Region 2
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| 3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo 3
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| 4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Show
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| ing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk ... 4
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| 5. Sagittal View of a Human Embryo 5 mm. in Length 5
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| 6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing
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| the Umbilical Region 6
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| 7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length 7
| | 1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois |
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| 8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length 8
| | 2. A More Advanced Stage in the Formation of the Umbilical Region |
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| 9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in
| | 3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo |
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| Length 9
| | 4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Showing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk |
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| 10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length 10
| | 5. Sagittal View of a Human Embryo 5 mm. in Length |
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| 11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length .. 11
| | 6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing the Umbilical Region |
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| 12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm.
| | 7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length |
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| Long 12
| | 8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length |
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| 13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length .. 13
| | 9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in Length |
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| 14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm.
| | 10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length |
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| in Length as Viewed from within the Abdomen 14 | | 11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length |
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| 15. Sagittal View of a Graphic Reconstruction of the Umbilical Region of a Human
| | 12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm. Long |
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| Embryo 5.2 cm. in Length 15 | | 13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length |
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| 16. Intra-abdominal View of the Umbilical Region of a Human Embryo 6.5 cm. in
| | 14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm in Length as Viewed from within the Abdomen |
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| Length 17 | | 15. Sagittal View of a Graphic Reconstruction of the Umbilical Region of a Human Embryo 5.2 cm. in Length 15 |
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| 17. Intra-abdominal View of the Umbilical Region in a Human Embryo 7.5 cm. Long . . 18
| | 16. Intra-abdominal View of the Umbilical Region of a Human Embryo 6.5 cm. in Length |
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| 18. Intra-abdominal View of the Umbilical Region in a Human Embryo 9 cm. in
| | 17. Intra-abdominal View of the Umbilical Region in a Human Embryo 7.5 cm. Long |
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| Length 18 | | 18. Intra-abdominal View of the Umbilical Region in a Human Embryo 9 cm. in Length |
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| 19. Intra-abdominal View of the Umbilical Region in a Human Embryo 10 cm. in | | 19. Intra-abdominal View of the Umbilical Region in a Human Embryo 10 cm. in Length |
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| Length 19
| | 20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long |
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| 20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long . . 19
| | 21. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in Length |
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| 21. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in
| | 22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in Length |
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| Length 20 | | 23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm. in Length |
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| 22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in
| | 24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long |
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| Length 21
| | 25. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others |
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| 23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm.
| | 26. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others |
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| in Length 22
| | 27. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others |
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| 24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long 23
| | 28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left |
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| 25. A Composite Representation of Abnormal Umbilical Structures, Based on the
| | 29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven Months |
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| Work of Keibel, Lowy, and Others 24
| | 30. Three Diagrams of the Umbilical Ring and Its Significance in the Development of Ventral Hernia |
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| 26. A Composite Representation of Abnormal Umbilical Structures, Based on the
| | 31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the Embryo 5.5 cm. Long |
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| Work of Keibel, Lowy, and Others 24
| | 32. The Umbilical Region, the Cord, and the Placenta at Term |
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| 27. A Composite Representation of Abnormal Umbilical Structures, Based on the
| | 33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term |
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| Work of Keibel, Lowy, and Others 24
| | 34. Normal Umbilicus according to Catteau |
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| 28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left . . 25
| | 35. A Type of Umbilical Region in the Adult, Viewed from Within |
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| 29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven
| | 36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within |
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| Months 25
| | 37. The Umbilical Region of an Adult, Viewed from Within |
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| 30. Three Diagrams of the Umbilical Ring and Its Significance in the Development
| | 38. Classic Type of Umbilicus |
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| of Ventral Hernia 27 | | 39. Disposition of the Vascular Cords (Usual Type) |
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| XV
| | 40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases |
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| | 41. Vascular Cord Type, Noted 5 Times in 50 Cases |
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| | 42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical Ring |
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| XVI LIST OF ILLUSTRATIONS
| | 43. Vascular Cords, Noted 3 Times in 50 Cases |
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| Fig. Page
| | 44. Vascular Cords, Noted in 2 out of 50 Cases |
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| 31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the
| | 45. Umbilical Fascia. Peritoneum in Place |
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| Embryo 5.5 cm. Long 28
| | 46. Umbilical Fascia and Umbilical Mesentery |
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| 32. The Umbilical Region, the Cord, and the Placenta at Term 29
| | 47. Reduplication of the Linea Alba. Peritoneum Removed |
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| 33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term .... 32
| | 48. Atrophy of the Umbilical Fascia, Posterior View |
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| 34. Normal Umbilicus according to Catteau 35
| | 49. Formation of a Mesentery. Peritoneum in Place |
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| 35. A Type of Umbilical Region in the Adult, Viewed from Within 44
| | 50. Mesentery of the Urachus and of the Umbilical Arteries |
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| 36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within .... 44
| | 51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place |
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| 37. The Umbilical Region of an Adult, Viewed from Within 45
| | 52. Adipose Fringes in a Stout Subject. Peritoneum in Place |
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| 38. Classic Type of Umbilicus 47
| | 53. Peritoneal Diverticula. Peritoneum in Place |
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| 39. Disposition of the Vascular Cords (Usual Type) 48
| | 54. Peri-umbilical Fossettes. Peritoneum in Place |
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| 40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases 48
| | 55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Abdominal Wall |
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| 41. Vascular Cord Type, Noted 5 Times in 50 Cases 49
| | 56. Extra-abdominal Multilocular Fibrocystoma of the Ovary |
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| 42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical
| | 57. An Extra- abdominal Multilocular Fibrocystoma |
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| Ring 49
| | 58. Superficial Lymphatics of the Umbilical Region |
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| 43. Vascular Cords, Noted 3 Times in 50 Cases 49
| | 59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side |
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| 44. Vascular Cords, Noted in 2 out of 50 Cases 50
| | 60. The Umbilical Vessels about the Time of Birth |
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| 45. Umbilical Fascia. Peritoneum in Place 52
| | 61. The Umbilical Vessels in the Adult |
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| 46. Umbilical Fascia and Umbilical Mesentery 52
| | 62. 63. Method of Treating the Umbilical Stump at Birth |
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| 47. Reduplication of the Linea Alba. Peritoneum Removed 52
| | 64. Nature's Method of Checking Bleeding from the Umbilical Arteries |
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| 48. Atrophy of the Umbilical Fascia, Posterior View 53
| | 65. An Umbilical Granulation |
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| 49. Formation of a Mesentery. Peritoneum in Place 53
| | 66. The Gradual Atrophy of the Omphalomesenteric Duct |
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| 50. Mesentery of the Urachus and of the Umbilical Arteries 53
| | 67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord |
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| 51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place 54
| | 68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord |
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| 52. Adipose Fringes in a Stout Subject. Peritoneum in Place 54
| | 69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia |
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| 53. Peritoneal Diverticula. Peritoneum in Place 55
| | 70. A Polypoid Outgrowth from the Umbilicus |
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| 54. Peri-umbilical Fossettes. Peritoneum in Place 55
| | 71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70 |
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| 55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Ab
| | 72. A Diverticular Tumor at the Umbilicus |
| dominal Wall 57
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| 56. Extra-abdominal Multilocular Fibrocystoma of the Ovary 5S
| | 73. A Glandular Tumor from the Umbilicus |
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| 57. An Extra- abdominal Multilocular Fibrocystoma 59
| | 74. A Glandular Growth at the Umbilicus |
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| 58. Superficial Lymphatics of the Umbilical Region 64
| | 75. Section in the Long Axis of a Small Umbilical Growth |
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| 59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side 65
| | 76. Adenoma of the Umbilicus |
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| 60. The Umbilical Vessels about the Time of Birth 72
| | 77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord |
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| 61. The Umbilical Vessels in the Adult 72
| | 78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord |
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| 62. 63. Method of Treating the Umbilical Stump at Birth 98
| | 79. An Umbilical Polyp |
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| 64. Nature's Method of Checking Bleeding from the Umbilical Arteries 107
| | 80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression |
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| 65. An Umbilical Granulation 117
| | 81. An Umbilical Polyp |
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| 66. The Gradual Atrophy of the Omphalomesenteric Duct 121
| | 82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression |
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| 67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord . . 121
| | 83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus |
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| 68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord 121
| | 84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Resembling those of the Pylorus |
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| 69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia : . . 123
| | 85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach |
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| 70. A Polypoid Outgrowth from the Umbilicus 129
| | 86. Appearance of the Umbilical Depression in von Rosthorn's Case |
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| 71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70 129
| | 87. Gastric Mucosa at the Umbilicus |
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| 72. A Diverticular Tumor at the Umbilicus 132
| | 88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in Fig. 87 |
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| 73. A Glandular Tumor from the Umbilicus 132
| | 89. Persistence of the Outer End of the Omphalomesenteric Duct |
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| 74. A Glandular Growth at the Umbilicus 133
| | 90. Atrophy of the Inner End of the Omphalomesenteric Duct |
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| 75. Section in the Long Axis of a Small Umbilical Growth 134
| | 91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct |
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| 76. Adenoma of the Umbilicus 135
| | 92. Meckel's Diverticulum |
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| 77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord. 138
| | 93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus |
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| 78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord . . . 138
| | 94. An Abnormally Large Meckel's Diverticulum |
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| 79. An Umbilical Polyp 139
| | 95. A Meckel's Diverticulum with a Lobulated Extremity |
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| 80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression 139
| | 96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface |
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| 81. An Umbilical Polyp 140
| | 97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment |
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| 82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression .... 141
| | 98. An Accessory Pancreas in the Tip of Meckel's Diverticulum |
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| 83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus . . . . 149
| | 99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel |
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| | 100. A Diverticulum Tying Off a Loop of Small Bowel |
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| | 101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum |
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| LIST OF ILLUSTRATIONS XV11
| | 102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a Hole in the Mesentery of a Meckel's Diverticulum |
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| Fia. Fage
| | 103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel |
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| 84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Re
| | 104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary |
| sembling those of the Pylorus 150
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| 85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach 150
| | 105. An Intestinal Cyst |
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| 86. Appearance of the Umbilical Depression in von Rosthorn's Case 152
| | 106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected with the Bowel |
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| 87. Gastric Mucosa at the Umbilicus 153
| | 107. Volvulus of Meckel's Diverticulum |
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| 88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in
| | 108. An Intestinal Cyst Developing from Meckel's Diverticulum |
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| Fig. 87 154
| | 109. Intestinal Cysts in the Abdominal Cavity |
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| 89. Persistence of the Outer End of the Omphalomesenteric Duct 156
| | 1 10. An Intramesenteric Cyst |
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| 90. Atrophy of the Inner End of the Omphalomesenteric Duct 156
| | 111. A Patent Omphalomesenteric Duct |
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| 91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct 156
| | 112. A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus |
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| 92. Meckel's Diverticulum 159
| | 113. A Very Short Omphalomesenteric Duct |
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| 93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus. . 160
| | 114. A Patent Omphalomesenteric Duct with a Polyp-like Formation at the Umbilicus |
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| 94. An Abnormally Large Meckel's Diverticulum 161
| | 1 15. A Patent Omphalomesenteric Duct |
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| 95. A Meckel's Diverticulum with a Lobulated Extremity 161
| | 116. A Patent Omphalomesenteric Duct |
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| 96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface 162
| | 117. A Patent Omphalomesenteric Duct |
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| 97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment . . 163
| | 118. A Patent Omphalomesenteric Duct |
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| 98. An Accessory Pancreas in the Tip of Meckel's Diverticulum 163
| | 119. A Patent Omphalomesenteric Duct |
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| 99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel 164
| | 120. A Patent Omphalomesenteric Duct |
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| 100. A Diverticulum Tying Off a Loop of Small Bowel 165
| | 121. A Patent Omphalomesenteric Duct |
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| 101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum. . . . 166
| | 122. Part of a Patent Omphalomesenteric Duct |
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| 102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a
| | 123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Omphalomesenteric Duct |
|
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| Hole in the Mesentery of a Meckel's Diverticulum .170
| | 124. An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Originally a Patent Omphalomesenteric Duct |
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| 103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel 171
| | 125. Longitudinal Section through the Entire Center of a Partially Closed Omphalomesenteric Duct |
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| 104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary 175
| | 126. A Patent Omphalomesenteric Duct |
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| 105. An Intestinal Cyst 176
| | 127. A Patent Omphalomesenteric Duct Opening at the Base of the Umbilical Cord |
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| 106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected
| | 128. A Patent Omphalomesenteric Duct |
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| with the Bowel 176
| | 129. A Patent Omphalomesenteric Duct as Seen from the Abdominal Cavity |
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| 107. Volvulus of Meckel's Diverticulum 177
| | 130. Inversion of the Bowel through a Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord |
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| 108. An Intestinal Cyst Developing from Meckel's Diverticulum 178
| | 131. A Patent Omphalomesenteric Duct of Large Diameter |
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| 109. Intestinal Cysts in the Abdominal Cavity 182
| | 132. Commencing Prolapsus of Small Bowel through a Patent Omphalomesenteric Duct |
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| 1 10. An Intramesenteric Cyst 183
| | 133. Partial Prolapsus of the Small Bowel through the Omphalomesenteric Duct |
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| 111. A Patent Omphalomesenteric Duct 190
| | 134. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct |
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| 112. A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus . 190
| | 135. Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct |
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| 113. A Very Short Omphalomesenteric Duct 190
| | 136. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and an Umbilical Hernia between the Loops of Prolapsed Bowel |
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| |
|
| 114. A Patent Omphalomesenteric Duct with a Polyp- like Formation at the Umbil
| | 137. Prolapse of the Small Bowel through an Open Omphalomesenteric Duct |
| icus 190
| |
|
| |
|
| 1 15. A Patent Omphalomesenteric Duct 192
| | 138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct |
|
| |
|
| 116. A Patent Omphalomesenteric Duct 193
| | 139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Secondary Complications |
|
| |
|
| 1 17. A Patent Omphalomesenteric Duct 197
| | 140. Prolapsus and Inversion of the Intestine through a Patent Omphalomesenteric Duct |
|
| |
|
| 118. A Patent Omphalomesenteric Duct 197
| | 141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct |
|
| |
|
| 119. A Patent Omphalomesenteric Duct 202
| | 142. A Small Cyst of the Umbilicus Due to a Remnant of the Omphalomesenteric Duct |
|
| |
|
| 120. A Patent Omphalomesenteric Duct 205
| | 143. Small Cyst of the Abdominal Wall Due to a Remnant of the Omphalomesenteric Duct |
|
| |
|
| 121. A Patent Omphalomesenteric Duct 206
| | 144. A Small Intestinal Cyst Lying between the Peritoneum and the Recti |
|
| |
|
| 122. Part of a Patent Omphalomesenteric Duct 206
| | 145. An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord |
|
| |
|
| 123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Om
| | 146. A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction |
| phalomesenteric Duct 207
| |
|
| |
|
| 124. An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Origin
| | 147. A Small Umbilical Concretion |
| ally a Patent Omphalomesenteric Duct 209
| |
|
| |
|
| 125. Longitudinal Section through the Entire Center of a Partially Closed Om
| | 148. Acute Inflammation of the Umbilicus Due to an Accumulation of Sebaceous Material |
| phalomesenteric Duct 209
| |
|
| |
|
| 126. A Patent Omphalomesenteric Duct 211
| | 149. Cholesteatoma from the Umbilicus in Case 1 |
|
| |
|
| 127. A Patent Omphalomesenteric Duct Opening at the Base of the Umbilical Cord . . 216
| | 150. Cholesteatoma from Case 2 |
|
| |
|
| 128. A Patent Omphalomesenteric Duct 216
| | 151. A Connective-tissue Projection Really Representing a Small Fibroma in the Floor of the Umbilicus |
|
| |
|
| 129. A Patent Omphalomesenteric Duct as Seen from the Abdominal Cavity 216
| | 152. Enlargement of Fig. 151 |
|
| |
|
| 130. Inversion of the Bowel through a Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord 219
| | 153. Subumbilical Phlegmon |
|
| |
|
| 131. A Patent Omphalomesenteric Duct of Large Diameter 224
| | 154. The Subumbilical Space |
|
| |
|
| 132. Commencing Prolapsus of Small Bowel through a Patent Omphalomesenteric Duct 224
| | 155. Paget's Disease of the Umbilicus |
|
| |
|
| 133. Partial Prolapsus of the Small Bowel through the Omphalomesenteric Duct . . . 224
| | 156. Paget's Disease of the U/mbilicus |
|
| |
|
| 134. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct .... 224
| | 157. Paget's Disease of the Umbilicus |
|
| |
|
| 135. Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 225
| | 158. Paget's Disease of the Umbilicus |
|
| |
|
| 136. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and an Umbilical Hernia between the Loops of Prolapsed Bowel 225
| | 159. The Appearance in a Case of Paget's Disease of the Umbilicus After Treatment with Radium |
|
| |
|
| 137. Prolapse of the Small Bowel through an Open Omphalomesenteric Duct 227
| | 160. Syphilis of the Umbilicus |
|
| |
|
| 138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct 228
| | 161. Atrophic Tuberculid Starting at the Umbilicus |
|
| |
|
| 139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Sec
| | 162. Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket |
| ondary Complications 229
| |
|
| |
|
| 140. Prolapsus and Inversion of the Intestine through a Patent Omphalomesenteric Duct 230
| | 163. The Manner in Which a Periprostatic Abscess may Occasionally Rupture at the Umbilicus |
|
| |
|
| 141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 232
| | 164. Escape of Pleural Fluid from the Umbilicus |
|
| |
|
| 142. A Small Cyst of the Umbilicus Due to a Remnant of the Omphalomesenteric Duct 238
| | 165. The Opening of a Broad Ligament Abscess at the Umbilicus |
|
| |
|
| 143. Small Cyst of the Abdominal Wall Due to a Remnant of the Omphalomesenteric Duct 238
| | 166. Abdominal Pregnancy with Spontaneous Escape of Liquor Amnii from the Umbilicus |
|
| |
|
| 144. A Small Intestinal Cyst Lying between the Peritoneum and the Recti 240
| | 167. Small Papilloma in the Umbilical Depression |
|
| |
|
| 145. An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord 243
| | 168. A Shall Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine Mucosa |
|
| |
|
| 146. A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction 245
| | 169. Glands from a Small Umbilical Tumor |
|
| |
|
| 147. A Small Umbilical Concretion 249
| | 170. Typical Uterine Mucosa in a Small Umbilical Tumor. An Enlargement of Area B in Fig. 168 |
|
| |
|
| 148. Acute Inflammation of the Umbilicus Due to an Accumulation of Sebaceous Material 249
| | 171. Glands in a Small Umbilical Tumor |
|
| |
|
| 149. Cholesteatoma from the Umbilicus in Case 1 251
| | 172. Dilated Glands in a Small Umbilical Tumor |
|
| |
|
| 150. Cholesteatoma from Case 2 251
| | 173. Dichotomous Branching of Glands in a Small Umbilical Tumor |
|
| |
|
| 151. A Connective-tissue Projection Really Representing a Small Fibroma in the Floor of the Umbilicus 252
| | 174. Uterine Glands in an Umbilical Tumor |
|
| |
|
| 152. Enlargement of Fig. 151 252
| | 175. Gland Hypertrophy in a Small Umbilical Tumor |
|
| |
|
| 153. Subumbilical Phlegmon 262
| | 176. A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands |
|
| |
|
| 154. The Subumbilical Space 264
| | 177. Uterine Mucosa in an Umbilical Tumor |
|
| |
|
| 155. Paget's Disease of the Umbilicus 270
| | 178. A Small Umbilical Tumor Containing Numerous Glands |
|
| |
|
| 156. Paget's Disease of the U/mbilicus 270
| | 179. Glands in a Small Umbilical Tumor |
|
| |
|
| 157. Paget's Disease of the Umbilicus 271
| | 180. An Adenomyoma in the Abdominal Wall Near the Anterior Iliac Spine |
|
| |
|
| 158. Paget's Disease of the Umbilicus 274
| | 181. A Small Umbilical Tumor Containing Glands Similar to Those of the Body of the Uterus |
|
| |
|
| 159. The Appearance in a Case of Paget's Disease of the Umbilicus After Treatment with Radium 275
| | 182. Adenomyoma of the Umbilicus |
|
| |
|
| 160. Syphilis of the Umbilicus 284
| | 183. A Group of Sweat-glands in an Umbilical Tumor |
|
| |
|
| 161. Atrophic Tuberculid Starting at the Umbilicus 286
| | 184. Appearance of the Carcinomatous Umbilicus After Removal |
|
| |
|
| 162. Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket 288
| | 185. Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries |
|
| |
|
| 163. The Manner in Which a Periprostatic Abscess may Occasionally Rupture at the Umbilicus 289
| | 186. A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth |
|
| |
|
| 164. Escape of Pleural Fluid from the Umbilicus 289
| | 187. Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth |
|
| |
|
| 165. The Opening of a Broad Ligament Abscess at the Umbilicus 290
| | 188. Adenocarcinoma of the Umbilicus |
|
| |
|
| 166. Abdominal Pregnancy with Spontaneous Escape of Liquor Amnii from the Umbilicus 348
| | 189. A Section Showing Carcinoma of the Right Inguinal Glands |
|
| |
|
| 167. Small Papilloma in the Umbilical Depression 365
| | 190. Secondary Carcinoma of the Umbilicus |
|
| |
|
| 168. A Shall Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine Mucosa 376
| | 191. Telangiectatic Myxosarcoma of the Umbilicus |
|
| |
|
| 169. Glands from a Small U\iisiLirALTuMOR 377
| | 192. Appearance of the Umbilicus After Removal of the Tumor Shown in Fig. 191 |
|
| |
|
| 170. Typical Uterine Mucosa in a Small Umbilical Tumor. An Enlargement of Area B in Fig. 168 378
| | 193. Myxosarcoma of the Umbilicus |
|
| |
|
| 171. Glands in a Small Umbilical Tumor 379
| | 194. Telangiectatic Myxosarcoma Projecting from the Right Side of the Umbilicus |
|
| |
|
| 172. Dilated Glands in a Small Umbilical Tumor 380
| | 195. A Telangiectatic Myxosarcoma |
|
| |
|
| 173. Dichotomous Branching of Glands in a Small Umbilical Tumor 381
| | 196. A Case of Congenital Umbilical Hernia |
|
| |
|
| 174. Uterine Glands in an Umbilical Tumor 381
| | 197. An Amniotic Hernia |
|
| |
|
| 175. Gland Hypertrophy in a Small Umbilical Tumor 382
| | 198. Several Loops of Bowel Which Lay Outside the Umbilicus and were Nipped Off During Fetal Life. The Child Lived a Short Time After Birth |
|
| |
|
| 176. A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands 383
| | 199. A Serous Umbilical Hernia |
|
| |
|
| 177. Uterine Mucosa in an Umbilical Tumor 384
| | 200. Freeing the Umbilical Hernial Sac from the Abdomen |
|
| |
|
| 178. A Small Umbilical Tumor Containing Numerous Glands 388
| | 201. Closure of the Hernial Opening at the Umbilicus |
|
| |
|
| 179. Glands in a Small Umbilical Tumor 389
| | 202. Closure of the Hernial Opening at the Umbilicus |
|
| |
|
| 180. An Adenomyoma in the Abdominal Wall Near the Anterior Iliac Spine 394
| | 203. An Umbilical Hernia Associated with Marked Prolapsus of the Abdominal Wall |
|
| |
|
| 181. A Small Umbilical Tumor Containing Glands Similar to Those of the Body of the Uterus 396
| | 204. An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds |
|
| |
|
| 182. Adenomyoma of the Umbilicus 397
| | 205. The Abdominal Scar After the Removal of a Very Large Area of Fat |
|
| |
|
| 183. A Group of Sweat-glands in an Umbilical Tumor 398
| | 206. An Umbilical Cyst |
|
| |
|
| 184. Appearance of the Carcinomatous Umbilicus After Removal 424
| | 207. Exstrophy of the Bladder Opening at or Near the Umbilicus |
|
| |
|
| 185. Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries 432
| | 208. Exstrophy of the Bladder. A side View of the Case Depicted in Fig. 207, Showing the Relative Distance from the Symphysis to the Opening in the Abdominal Wall |
|
| |
|
| 186. A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth 439
| | 209. Exstrophy of the Bladder |
|
| |
|
| 187. Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth .... 440
| | 210. Escape of Urine from the Umbilicus When the Inner Urethral Orifice Is Blocked by a Membrane |
|
| |
|
| 188. Adenocarcinoma of the Umbilicus 441
| | 211. A Patent Urachus with a Mushroom-like Projection at the Umbilicus |
|
| |
|
| 189. A Section Showing Carcinoma of the Right Inguinal Glands 442
| | 212. A Patent Urachus with a Penile Projection at the Umbilicus |
|
| |
|
| 190. Secondary Carcinoma of the Umbilicus 443
| | 213. The Appearance of the Umbilicus in a Case in Which both a Patent Omphalomesenteric Duct and a Patent Urachus Existed |
|
| |
|
| 191. Telangiectatic Myxosarcoma of the Umbilicus 450
| | 214. Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same Child |
|
| |
|
| 192. Appearance of the Umbilicus After Removal of the Tumor Shown in Fig. 191. . 450
| | 215. A Picture of the Child Three Weeks After Removal of a Patent Omphalomesenteric Duct and a Patulous Urachus |
|
| |
|
| 193. Myxosarcoma of the Umbilicus 451
| | 216. A Patent Urachus |
|
| |
|
| 194. Telangiectatic Myxosarcoma Projecting from the Right Side of the Umbilicus . . 452
| | 217. A Urachus Open from Bladder to Umbilicus |
|
| |
|
| 195. A Telangiectatic Myxosarcoma 452
| | 218. An Open Urachus |
|
| |
|
| 196. A Case of Congenital Umbilical Hernia 460
| | 219. Escape of Urine from the Umbilicus Due to a Patent Urachus |
|
| |
|
| 197. An Amniotic Hernia 462
| | 220. A Patent Urachus with a Penile Projection at the Umbilicus |
|
| |
|
| 198. Several Loops of Bowel Which Lay Outside the Umbilicus and were Nipped Off During Fetal Life. The Child Lived a Short Time After Birth 464
| | 221. A Ring-shaped Vesical Calculus with a Fine Hair in Its Axis |
|
| |
|
| 199. A Serous Umbilical Hernia 469
| | 222. A Partially Patent Urachus |
|
| |
|
| 200. Freeing the Umbilical Hernial Sac from the Abdomen 472
| | 223. A Patent Urachus |
|
| |
|
| 201. Closure of the Hernial Opening at the Umbilicus 473
| | 224. A Portion of a Urachus Seven Times Enlarged, with Numerous Large and Small Dilatations |
|
| |
|
| 202. Closure of the Hernial Opening at the Umbilicus 474
| | 225. Portion of a Urachus Ten Times Enlarged |
|
| |
|
| 203. An Umbilical Hernia Associated with Marked Prolapsus of the Abdominal Wall 475
| | 226. Cysts of the Urachus Arranged Like a String of Pearls |
|
| |
|
| 204. An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds 476
| | 227. Spindle-Shaped Dilatations of the Urachus |
|
| |
|
| 205. The Abdominal Scar After the Removal of a Very Large Area of Fat 477
| | 228. A Small Cyst of the Urachus |
|
| |
|
| 206. An Umbilical Cyst 478
| | 229. A Patent Urachus |
|
| |
|
| 207. Exstrophy of the Bladder Opening at or Near the Umbilicus 482
| | 230. A Multilocular Cyst of the Urachus |
|
| |
|
| 208. Exstrophy of the Bladder. A side View of the Case Depicted in Fig. 207, Showing the Relative Distance from the Symphysis to the Opening in the Abdominal Wall : 483
| | 231. Section of a Patent Urachus |
|
| |
|
| 209. Exstrophy of the Bladder 483
| | 232. Transverse Section of a Patent Urachus |
|
| |
|
| 210. Escape of Urine from the Umbilicus When the Inner Urethral Orifice Is Blocked by a Membrane 488
| | 233. A Small Cyst of the Urachus |
|
| |
|
| 211. A Patent Urachus with a Mushroom-like Projection at the Umbilicus 489
| | 234. A Diffuse Neuroma of the Bladder |
|
| |
|
| 212. A Patent Urachus with a Penile Projection at the Umbilicus 489
| | 235. Cut Surface of the Bladder Showing a Diffuse Neuroma of Its Walls |
|
| |
|
| 213. The Appearance of the Umbilicus in a Case in Which both a Patent Omphalomesenteric Duct and a Patent Urachus Existed 493
| | 236. A Diffuse Neuroma Forming a Mantle Around the Cavity of the Bladder |
|
| |
|
| 214. Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same Child 493
| | 237. Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus |
| | |
| 215. A Picture of the Child Three Weeks After Removal of a Patent Omphalomesenteric Duct and a Patulous Urachus 494
| |
| | |
| 216. A Patent Urachus 497
| |
| | |
| 217. A Urachus Open from Bladder to Umbilicus 498
| |
| | |
| 218. An Open Urachus 499
| |
| | |
| 219. Escape of Urine from the Umbilicus Due to a Patent Urachus 502
| |
| | |
| 220. A Patent Urachus with a Penile Projection at the Umbilicus 505
| |
| | |
| 221. A Ring-shaped Vesical Calculus with a Fine Hair in Its Axis 507
| |
| | |
| 222. A Partially Patent Urachus 515
| |
| | |
| 223. A Patent Urachus 517
| |
| | |
| 224. A Portion of a Urachus Seven Times Enlarged, with Numerous Large and Small Dilatations 518
| |
| | |
| 225. Portion of a Urachus Ten Times Enlarged 518
| |
| | |
| 226. Cysts of the Urachus Arranged Like a String of Pearls .- 520
| |
| | |
| 227. Spindle-Shaped Dilatations of the Urachus 520
| |
| | |
| 228. A Small Cyst of the Urachus 532
| |
| | |
| 229. A Patent Urachus 534
| |
| | |
| 230. A Multilocular Cyst of the Urachus 535
| |
| | |
| 231. Section of a Patent Urachus .' 536
| |
| | |
| 232. Transverse Section of a Patent Urachus 537
| |
| | |
| 233. A Small Cyst of the Urachus 538
| |
| | |
| 234. A Diffuse Neuroma of the Bladder 542
| |
| | |
| 235. Cut Surface of the Bladder Showing a Diffuse Neuroma of Its Walls 543
| |
| | |
| 236. A Diffuse Neuroma Forming a Mantle Around the Cavity of the Bladder 544
| |
| | |
| 237. Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus 551 | |
|
| |
|
| 238. Section of the Segment of Urachus Which Passed between the Bladder and the Cyst- wall, as Seen under a Low Power 552 | | 238. Section of the Segment of Urachus Which Passed between the Bladder and the Cyst- wall, as Seen under a Low Power 552 |
|
| |
|
| 239. The Abdominal Contour in a Case of Very Large Urachal Cyst 558 | | 239. The Abdominal Contour in a Case of Very Large Urachal Cyst |
|
| |
|
| 240. A Urachal Cyst Turned Inside Out and Showing Papillary Masses, Particularly in the Lower Part of the Picture 559 | | 240. A Urachal Cyst Turned Inside Out and Showing Papillary Masses, Particularly in the Lower Part of the Picture 559 |
|
| |
|
| 241. Infected Urachal Remains 568 | | 241. Infected Urachal Remains |
| | |
| 242. An Infected Urachus Opening between the Umbilicus and Bladder 570
| |
| | |
| 243. Urachal Cyst 576
| |
|
| |
|
| 244. A Dilated Urachus Communicating with the Bladder 579
| | 242. An Infected Urachus Opening between the Umbilicus and Bladder |
|
| |
|
| 245. Large Accumulation of Urine in a Partially Patent Urachus 579
| | 243. Urachal Cyst |
|
| |
|
| 246. An Infected Urachus Opening at the Umbilicus 580
| | 244. A Dilated Urachus Communicating with the Bladder |
|
| |
|
| 247. A Patent Urachus Dilated in Its Middle Portion 580
| | 245. Large Accumulation of Urine in a Partially Patent Urachus |
|
| |
|
| 248. Accumulation of a Large Quantity of Urine in a Urachal Pouch 581
| | 246. An Infected Urachus Opening at the Umbilicus |
|
| |
|
| 249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac 584
| | 247. A Patent Urachus Dilated in Its Middle Portion |
|
| |
|
| 250. A Phosphatic Deposit on the End of a Long Bone 585
| | 248. Accumulation of a Large Quantity of Urine in a Urachal Pouch |
|
| |
|
| 251. A Dilated Urachus Communicating with the Bladder 598
| | 249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac |
|
| |
|
| 252. Urachal Cyst 599
| | 250. A Phosphatic Deposit on the End of a Long Bone |
|
| |
|
| 253. Urachal Cyst 603
| | 251. A Dilated Urachus Communicating with the Bladder |
|
| |
|
| 254. Urachal Cyst 603
| | 252. Urachal Cyst |
|
| |
|
| 255. A Patent Urachus Containing a Vesical Calculus 625
| | 253. Urachal Cyst |
|
| |
|
| 256. Carcinoma of the Patent Urachus 632
| | 254. Urachal Cyst |
|
| |
|
| 257. A Multilocular and Malignant Cyst of the Urachus 637
| | 255. A Patent Urachus Containing a Vesical Calculus |
|
| |
|
| 258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus 638
| | 256. Carcinoma of the Patent Urachus |
|
| |
|
| 259. Giant-cells in the Wall of an Adenocarcinoma of the Urachus 639
| | 257. A Multilocular and Malignant Cyst of the Urachus |
|
| |
|
| 260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus. . .640-641
| | 258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus |
|
| |
|
| 261. Adenocarcinoma of the Urachus 642
| | 259. Giant-cells in the Wall of an Adenocarcinoma of the Urachus |
|
| |
|
| 262. A Papillary-like Area i.\ an Adkxocarcinomatous Cystofthe Urachus 643
| | 260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus |
|
| |
|
| 263. Metastasis from Adenocarcinoma of the Urachus 644
| | 261. Adenocarcinoma of the Urachus |
|
| |
|
| 264. An Umbilical Cyst 645
| | 262. A Papillary-like Area in an Adkxocarcinomatous Cystofthe Urachus |
|
| |
|
| 265. \\ aj.i of an Umbilical Cyst 645
| | 263. Metastasis from Adenocarcinoma of the Urachus |
|
| |
|
| 266. Giant-cells in the Wall of an Umbilical Cyst 646
| | 264. An Umbilical Cyst |
|
| |
|
| 267. Tuberculosis of the Urachus 652
| | 265. \\ aj.i of an Umbilical Cyst |
|
| |
|
| 268. An Area Suggesting a Tubercle 653
| | 266. Giant-cells in the Wall of an Umbilical Cyst |
|
| |
|
| 269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus 654
| | 267. Tuberculosis of the Urachus |
|
| |
|
| | 268. An Area Suggesting a Tubercle |
|
| |
|
| | 269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus |
|
| |
|
| ==List of Plates== | | ==List of Plates== |
| | [[Book - Umbilicus (1916) Figures#List of Plates|List of Plates]] |
|
| |
|
| I. Drawings of Normal Umbilici 40
| |
|
| |
| II. Drawings of Normal Umbilici 41
| |
|
| |
| III. Drawings of Normal Umbilici 42
| |
|
| |
| IV. Drawings of Normal Umbilici 43
| |
|
| |
| V. Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary. .434-435
| |
|
| |
| VI. Umbilical Hernia 466-467
| |
|
| |
| VII. Exstrophy of the Bladder 484-485
| |
|
| |
|
| |
| ==Chapter XXXIV. Urachal Cavities between the Symphysis and Umbilicus Communicating with the Bladder or Umbilicus or with Both==
| |
|
| |
| General consideration.
| |
|
| |
| Symptoms.
| |
|
| |
| Differential diagnosis.
| |
|
| |
| Treatment.
| |
|
| |
| Instance of a urachal cavity between the symplrysis and umbilicus and communicating with the
| |
| bladder or umbilicus or both.
| |
|
| |
| Figs. 244 and 245 graphically illustrate urachal cavities communicating with
| |
| the bladder. Fig. 246 shows in a schematic manner the way in which a distended
| |
| urachus may open at the umbilicus. Dilatation of the urachus with the escape of
| |
| urine from both the bladder and umbilicus is indicated in Fig. 247, while in Fig. 248
| |
| we see the tremendous quantities of stagnant urine that niay be forced little by
| |
| little into the pervious urachus when the bladder contracts during micturition.
| |
| Finally, the valve-like opening is overcome and there is a sudden gush of ammonia cal
| |
| urine from the urethra; or an opening may develop at the umbilicus; or the urine
| |
| may escape from both the urethra and the umbilicus.
| |
|
| |
| Sex. — Of the cases here recorded, and in which data as to the sex are available, 14 were in males and 12 in females.
| |
|
| |
| Age. — The youngest patient (Savory's) was thirteen months old. Weiser's
| |
| patient, a woman of seventy-five, was the oldest. The age table is as follows:
| |
|
| |
| Under ten years of age 4 cases
| |
|
| |
| Between ten and twenty years of age 2 "
| |
|
| |
| Between twenty and thirty years of age 7 "
| |
|
| |
| Between thirty and forty years of age 1 case
| |
|
| |
| Between forty and fifty years of age 4 cases
| |
|
| |
| Between fifty and sixty years of age 1 case
| |
|
| |
| Between sixty and seventy years of age 1 "
| |
|
| |
| Over seventy years of age 2 cases
| |
|
| |
| These figures are of only relative value. Bramann's patient, who came under
| |
| observation at twelve, had definite symptoms when nine years old. Freer's patient came under treatment at fifty-four, but from the history it was evident that
| |
| symptoms were first noted when the patient was seven years old. Newman's
| |
| patient was thirty-nine years old, but he had had an enlargement in the lower
| |
| abdomen as long as he could remember. Vaughan's patient, a man of forty, had
| |
| experienced pain in the suprapubic region when seventeen.
| |
|
| |
| SYMPTOMS.
| |
| The chief symptoms are those referable to the bladder and to the development
| |
| of a tumor between the symphysis and umbilicus. When infection occurs, constitutional disturbances are superadded.
| |
|
| |
| 578
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS.
| |
|
| |
|
| |
|
| |
| 579
| |
|
| |
|
| |
|
| |
| A reference to the accompanying histories will show that the vesical
| |
| s y m p t o m s varied greatly. Some patients complained of frequent micturition,
| |
| others of incontinence, while others had difficult micturition, retention, or an almost
| |
| total inability to void.
| |
|
| |
| In some the vesical symptoms had been of short duration; others had had defi
| |
|
| |
|
| |
|
| |
| Fig. 244. — A Dilated Urachus Communicating with
| |
| the Bladder. (Schematic.)
| |
| Where such a condition exists, when the bladder contracts during micturition part of the urine escapes from
| |
| the urethra and part may be forced into the urachal sac.
| |
| Finally the urachal sac will empty itself into the bladder.
| |
|
| |
|
| |
|
| |
| Fig. 245. — Large Accumulation op Urine in a
| |
| Partially Patent Urachus. (Schematic.)
| |
| Some patients give a history of cystitis, and a few
| |
| months later a hard, globular tumor is noted between
| |
| the umbilicus and symphysis. After the bladder has
| |
| been emptied with a catheter the tumor still persists.
| |
| Finally, after a very large amount of fluid has accumulated, it may all be discharged at once through the
| |
| bladder, or the urachus may open at the umbilicus,
| |
| allowing the accumulated urine and pus to escape by
| |
| this avenue. In these cases there is usually a periodic
| |
| filling and emptying of the urachal sac.
| |
|
| |
|
| |
|
| |
| nite bladder disturbances for years. In Patel's case, for example, a child three
| |
| years old had had incontinence of urine day and night since birth, the urine being
| |
| passed involuntarily and at frequent intervals. In Freer's patient, a woman fiftyfour years old, vesical symptoms were first noted when she was seven years old.
| |
| Schnellenbach's patient, who was sixty-six years old, had had frequent micturition
| |
| for one year and pressure was necessary to start the flow. When the patient was
| |
|
| |
|
| |
|
| |
| 5S0
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| catheterized, 1500 c.c. of urine came away. Worster's patient gave a history
| |
| of having developed a cystitis with incontinence after diphtheria, and eleven
| |
| years before coming under observation had passed a large amount of pus from the
| |
| urethra.
| |
|
| |
| In some cases the urine was turbid and contained pus and occasionally blood.
| |
| In other cases the urine was clear; occasionally, as in Graf's, Lexer's, and Matthias'
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 24(i. — Ax Infected Urachus Opening at
| |
| the Umbilicus. (Schematic.)
| |
| 1 (ccasionally urachal remains become infected, and after a time open at the umbilicus. In
| |
| i hose cases in which the vesical end of the urachus
| |
| i- closed i here is no escape of urine from the umbilicus, the discharge being purulent or slimy in
| |
| character.
| |
|
| |
|
| |
|
| |
| Fig. 217. — A Patent Urachus Dilated in its Middle Portion. (Schematic.)
| |
| In such cases the middle portion of the urachus may become markedly distended, sometimes containing a liter or more
| |
| of decomposing urine. (See Fig. 248.)
| |
|
| |
|
| |
|
| |
| cases, the patients had previously had a gonorrheal infection. This naturally
| |
| confused the clinical picture to some extent.
| |
|
| |
| P a i if. — More or less pain in the lower abdomen was a frequent symptom.
| |
| In Bourgeois' ease there was an almost insupportable feeling of tension in the lower
| |
| abdomen, and the suprapubic region was particularly sensitive after fatigue. In
| |
| Matthias' case there was a feeling of pressure in the lower abdomen, accompanied
| |
| by malaise. Worster's patient had to bend forward at an angle of 45 degrees to
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS.
| |
|
| |
|
| |
|
| |
| 581
| |
|
| |
|
| |
|
| |
| get relief, and was incapable of stooping down to pick up anything. Newman's
| |
| patient suffered much pain, walked with difficulty, and had an anxious expression.
| |
| Hind's patient had a steady pain in the lower abdomen. Suddenly something
| |
| gave way, there was a feeling of relief, and a large amount of pus escaped from the
| |
| bladder.
| |
|
| |
| The Umbilicus. — With the progress of the disease the umbilicus in
| |
| about half of the cases
| |
| became inflamed and ruptured, with the escape of
| |
| pus, and later of urine. In
| |
| Bourgeois' case a small, soft,
| |
| red tumor the size of an
| |
| almond developed at the
| |
| navel. During micturition
| |
| it would become prominent
| |
| and painful. It was opened
| |
| and urine escaped.
| |
|
| |
| Bramann's patient, two
| |
| years after vesical symptoms had been noted, had
| |
| a sudden discharge of urine
| |
| from the umbilicus. In
| |
| Hastings' case the urine for
| |
| a time ceased entirely to
| |
| pass from the urethra. On
| |
| one occasion, when the patient had not voided at all
| |
| for a long period, there was
| |
| a sudden gush of two quarts
| |
| from the umbilicus.
| |
|
| |
| Lexer's patient, one and
| |
| a half years after the onset
| |
| of symptoms, complained of
| |
| pain in the umbilical region.
| |
| The tissues swelled up, became red, and a quantity of
| |
| purulent material escaped.
| |
| On pressure pus and urine
| |
| were discharged from the
| |
| umbilicus. Savory's patient
| |
| developed a tense umbilical
| |
|
| |
| swelling two to three inches in diameter. This was tender during micturition. It
| |
| was opened later, pus escaped, and finally nearly all the urine was passed by this
| |
| avenue.
| |
|
| |
| In Schnellenbach's case there was pain in the umbilical region, followed by the
| |
| escape of pus. Vaughan's patient had poultices applied to the umbilical region.
| |
| Two weeks later pus and urine passed from the umbilicus. Occasionally the opening would close for a couple of days. This closure was accompanied by much pain,
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 248.
| |
|
| |
|
| |
| Urine in
| |
|
| |
|
| |
|
| |
| Accumulation op a Large Quantity
| |
| Urachal Pouch. (Schematic.)
| |
| Occasionally the urachal pouch is very large, and when the bladder
| |
| contracts, part of the urine escapes from the urethra, part is forced up into
| |
| the sac. An opening may or may not exist at the umbilicus. If there be
| |
| no exit at the umbilicus, the valve-like opening between the urachus and
| |
| bladder is after a time temporarily overcome, and suddenly there escapes
| |
| from the bladder a large quantity of ammoniacal urine mixed with pus,
| |
| the urachal tumor at once disappearing. Such a sac will fill up and empty
| |
| periodically.
| |
|
| |
|
| |
|
| |
| 582 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| which was not relieved until the fistula reopened. The discharge was so offensive
| |
| that the patient could not mingle with his friends. Worster's patient also developed a tumefaction in the umbilical region, followed by the escape of pus and
| |
| urine.
| |
|
| |
| The opening in Weiser's Case 3, did not develop at the umbilicus, but 2 inches
| |
| below it. Urine only escaped; at no time was there any pus.
| |
|
| |
| When the infection of the urachus extends up to the umbilicus, it is but natural
| |
| that the latter should be secondarily involved, particularly when much tension
| |
| exists in the sac.
| |
|
| |
| Constitutional symptoms have not been at all prominent in these
| |
| cases, evidently because there was a certain amount of drainage by the bladder,
| |
| umbilicus, or both. In Hastings', Lexer's, and Morgan's cases fever was present,
| |
| and in Morgan's case there was vomiting accompanied by diarrhea.
| |
|
| |
| The carefully recorded case reported by Hastings in 1829- (p. 589) is well worth
| |
| a thorough study. This case clearly shows that, notwithstanding most alarming
| |
| symptoms, such as convulsions, the patient may recover. Savory's patient, a
| |
| sickly child thirteen months old, died; in this case the inflammatory process had
| |
| extended to the abdomen, as indicated by the adherent omentum. Ball's eightyear-old child died of peritonitis.
| |
|
| |
| In Xicaise's (p. 597) and Roser's (p. 598) cases the patients successfully passed
| |
| through a pregnancy while suffering from an infected urachal cyst. Roser's
| |
| patient miscarried during a subsequent pregnancy four years later.
| |
|
| |
| The urachal cyst varies considerably in size. It is attached to the
| |
| bladder below and to the umbilicus above, and any great increase in size, as a rule,
| |
| will be in its central portion. In Bramann's case the tumor resembled a long
| |
| sausage. In Worster's patient it was recognized as a large cord, two inches in
| |
| diameter. In Freer 's case, when the patient was fourteen years old, it was the
| |
| size of an apple, but when she came under observation, at fifty-four, it was much
| |
| larger. In Patel's case the tumor was the size of two fists. Vaughan's patient
| |
| had a pyriform tumor three inches long, and having a capacity of about three
| |
| ounces. Schnellenbach's tumor was the size of a head, while in Timmerman's
| |
| case the sac contained about 1500 c.c. of fluid.
| |
|
| |
| Urachal cysts communicating with the bladder can hardly reach as large proportions as some of those that have no external opening. In Roser's case, however,
| |
| notwithstanding the opening into the bladder, the sac contained between three and
| |
| four liters of fluid.
| |
|
| |
| The walls of the sac may be thin or thick, depending in a large measure upon
| |
| the amount of inflammatory reaction. In Newman's case the walls were thin;
| |
| in Bramann's case they were several millimeters thick, and in Matthias' case they
| |
| varied from 2 to 20 mm. in thickness.
| |
|
| |
| The interior usually consists of but one cavity. The inner surface may be perfectly smooth, or lined with granulation tissue. On histologic examination the
| |
| inner surface may have a lining of transitional epithelium, as noted in Bramann's
| |
| case, or of one layer of squamous epithelium, as found by Schnellenbach. In the
| |
| latter 's case the underlying stroma showed small-round-cell infiltration.
| |
|
| |
| The cyst fluid in Patel's case was pale yellow. In the greater number of the
| |
| cases it consisted of urine and pus. The urine in Newman's and in Roser's case
| |
| was very ammoniacal. In Vaughan's case the cavity contained laminated clots.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 583
| |
|
| |
| DIFFERENTIAL DIAGNOSIS.
| |
|
| |
| The history of cystitis, coupled with the development of a tumor just above the
| |
| symphysis, is strong presumptive evidence of a dilated urachus, particularly if the
| |
| tumor increases in size when the patient has not voided for several hours, or if it
| |
| decreases markedly in size after catheterization, accompanied simultaneously by
| |
| pressure on the tumor. There are some cases, however, in which the effort to void
| |
| forces a large part of the urine out of the bladder into the sac, only a portion escaping
| |
| from the urethra. In such cases the tumor is larger after the bladder has been
| |
| emptied.
| |
|
| |
| With the aid of the cystoscope the diagnosis becomes more easy. In Matthias'
| |
| case, for example, on exploration of the bladder a transverse oval opening was found
| |
| near the top of the anterior blaclder-wall. This passed into a funnel-shaped
| |
| diverticulum, which extended upward toward the umbilicus.
| |
|
| |
| Occasionally a suppurating dermoid or an inflamed appendix ulcerates through
| |
| into the bladder. When the dermoid opens into the bladder, the tumor is situated
| |
| in one side of the pelvis. The urachal tumor, on the other hand, is in the mid-line,
| |
| and lies in the anterior abdominal wall. Furthermore, in the case of a dermoid
| |
| cyst, on cystoscopic examination it may be possible to see a tuft of hair projecting
| |
| from it into the bladder. When an appendix opens into the bladder, there has
| |
| usually been a definite history of appendicitis and the discharge passing from the
| |
| bladder has a distinctly fecal odor. The following case although not exactly
| |
| germane to the subject has several points in common, and is of such interest that
| |
| I shall briefly report it.
| |
|
| |
| In May, 1907, I saw a very interesting case of extra-uterine pregnancy, in
| |
| which, long after the death of the fetus, the sac opened into the bladder. The
| |
| patient, L. S., colored, aged thirty-three (Gyn. No. 13806), was admitted to the
| |
| Johns Hopkins Hospital on May 3, 1907. For the previous five years she had complained of much pain in the lower right abdomen. This was usually dull, and
| |
| occasionally accompanied by nausea. Three years before admission she was supposed to be pregnant and to have proceeded to about the eighth month. Severe,
| |
| labor-like pains lasting five minutes suddenly developed, and the patient passed
| |
| blood from the uterus. Shortly afterward she noticed that the abdominal girth
| |
| was diminishing, and that a hard, tender lump was present in the right lower abdomen. This gradually became smaller. She gave no history of chills or of fever,
| |
| but had had some vomiting, had suffered from pain from time to time, and had lost
| |
| in strength and in weight.
| |
|
| |
| On admission the right lower abdomen was distended by an irregular nodular
| |
| mass, which on palpation gave a peculiar feeling of crepitus. On pelvic examination
| |
| the uterus was found slightly enlarged and lying posteriorly. On the right side
| |
| was a pelvic mass attached to the side of the uterus.
| |
|
| |
| On catheterization under ether a large amount of thick, tenacious urine came away,
| |
| and the catheter came in contact with a substance feeling very much like a stone.
| |
|
| |
| Operation. — A median incision, after liberation of the adherent omentum, disclosed a large, irregular mass in the right lower abdomen. The large and small
| |
| bowel were found densely adherent to the sac. The small bowel was dissected free,
| |
| but its coats were slightly injured.
| |
|
| |
| The sac contained a large number of fetal bones (Fig. 249) . The bladder was
| |
|
| |
|
| |
|
| |
| 584
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| densely adherent to the mass, and after it had been freed, an opening was found to
| |
| exist between the sac and the bladder. One of the long bones, a femur, was seen projecting from the sac into the
| |
| bladder, and the portion lying in the bladder was heavily coated with urinary salts
| |
| (Fig. 250) . The vesical opening was closed.
| |
|
| |
| In the cecum, near the
| |
| ileocecal valve, long bones
| |
| projected from the fetal sac
| |
| into the lumen of the bowel..
| |
| There was a second opening into the large bowel six
| |
| inches above the ileocecal
| |
| valve. After closing the
| |
| intestinal openings and removing the appendix, which
| |
| was thickened and indurated, I also removed a parovarian cyst from the right
| |
| side. The abdomen was
| |
| then drained. The patient
| |
| made a good recovery.
| |
|
| |
| In such a case as this the
| |
| previous history pointed to
| |
| a pregnancy. Bimanual examination revealed an intraabdominal tumor situated
| |
| on one side, and not in the
| |
| mid-line. Cystoscopic examination would have determined the presence of a
| |
| foreign substance projecting
| |
| into the bladder.
| |
|
| |
| From the foregoing it is
| |
| seen that urachal tumors
| |
| connected with the bladder
| |
| are relatively easy to diagnose.
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 249. — Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac.
| |
|
| |
| Oyii. No. 13806. The bones have been roughly assembled. They are
| |
| very well preserved. 'J'Ik- ends of t wo long bones projected into the lumen of
| |
| the cecum :i in 1 one into I In- cavity of the bladder. The end of this bone is
| |
| heavily coated with phosphates. This is particularly well shown in Fig. 250.
| |
|
| |
|
| |
|
| |
| TREATMENT.
| |
| WJiere a marked infection is present, it is advisable merely to open up and drain the sac. If possible, at the same time the bladder
| |
| should be separated from the sac and the vesical opening closed. The sac is then
| |
| packed and allowed to contract down.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS.
| |
|
| |
|
| |
|
| |
| 585
| |
|
| |
|
| |
|
| |
| If there is little danger of infection, the umbilicus is encircled and removed,
| |
| together with the sac, and the bladder opening closed.
| |
|
| |
| The vesical symptoms usually disappear as soon as the source of irritation —
| |
| the dilated urachus — is eliminated.
| |
|
| |
|
| |
|
| |
| EXISTENCE OF A URACHAL CAVITY BETWEEN THE SYMPHYSIS AND UMBILICUS,
| |
| AND COMMUNICATING WITH THE BLADDER OR UMBILICUS OR BOTH.
| |
|
| |
| Quite a number of the cases in the literature were not sufficiently definite to
| |
| warrant citation; only those that clearly illustrate the condition have been selected.
| |
|
| |
| Cystitis with Tu m o r
| |
| Formation in the Bladder.— In 1882 Ball* saw a boy
| |
| eight years old who had suffered from
| |
| incontinence of urine at night from
| |
| birth, and during the previous six
| |
| weeks also by day. In March, 1882,
| |
| the urine was bloody and contained
| |
| pus, but the boy improved, although
| |
| he was still complaining of pain in the
| |
| lower abdomen. When he next came
| |
| to Ball, in January, 1883, he had an
| |
| umbilical fistula, which he stated had
| |
| appeared three weeks previously after
| |
| rupture of an abscess. Since that time
| |
| all the urine had passed through the
| |
| navel. The urethra was very small,
| |
| but later a moderate amount escaped
| |
| by this passage also.
| |
|
| |
| The treatment consisted in cauterizing the opening. This was clone three
| |
| times. The parts remained healed only
| |
| for a short time. A fourth operation
| |
| was of a plastic nature; the fistula remained closed for two months. One
| |
| month later the boy died of peritonitis.
| |
|
| |
| At autopsy the urinary organs were
| |
| removed entire. On the next day the
| |
| cavities were first injected with colored
| |
|
| |
| lard through an opening in one of the ureters. A minute hole about 13^ inches below
| |
| the umbilicus and 2}^ inches above the fundus of the bladder was found. From this
| |
| urine had escaped into the abdominal cavity. In the upper abdomen there was
| |
| abundant evidence of a recent peritonitis. The omentum was adherent to the anterior abdominal wall, apparently as the result of a long antecedent inflammation.
| |
| The amount of fluid in the abdominal cavity was small, but there was an abundance of lymph matting the abdominal viscera together.
| |
|
| |
| * Ball, C. B. : Case of Pervious Urachus with Remarkable Disease of Bladder. Trans. Acad.
| |
| Med. Ireland, 1883-84, Dublin, 1884, ii, 376. This case is probably identical with that referred
| |
| to by Freer in 1887. Although the age does not correspond, the findings were precisely the same.
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 250. — A Phosphatic Deposit ox the End of a
| |
| Long Bone.
| |
| Gyn. No. 13S06. One end of this bone projected into
| |
| the bladder and has a heavy covering of urinary phosphates. This is clearly evident in the lower part of the
| |
| picture.
| |
|
| |
|
| |
|
| |
| 586 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| The ureters and pelves of the kidneys were much dilated. The bladder was
| |
| very small and firm; the walls were much thickened. From the fundus of the
| |
| bladder to the umbilicus extended a tongue-like cavity, 23^ by 1% inches. This
| |
| was situated between the peritoneal covering and the muscular layers of the anterior abdominal wall. It was in the anterior wall of this cavity that the fatal
| |
| rupture had taken place.
| |
|
| |
| During the separation of the bladder from the other pelvic contents it was found
| |
| that the viscus was surrounded by cicatricial adhesions. The bladder-walls were
| |
| enormously hypertrophied, and projecting into the cavity were a number of newgrowths which resembled the columnse carnese of the heart. Some were attached
| |
| by one end only to the vesical wall, the other end being free in the cavity; others
| |
| were attached at both ends, but were free along the sides, so that a probe could be
| |
| passed between them and the bladder-wall. Microscopic examination showed that
| |
| they were composed of fibrous tissue with a covering of mucosa.
| |
|
| |
| The bladder was divided into two compartments by a septum. This was
| |
| attached posteriorly about the middle of the trigonum. Immediately above the
| |
| septum was a minute opening leading off into the cicatricial tissue in front of the
| |
| bladder. There had evidently been an extravasation of urine which had become
| |
| localized as the result of an inflammation.
| |
|
| |
| The fundus of the bladder communicated with the cavity lying between it and
| |
| the umbilicus by a wide opening. The cavity contrasted remarkably with the
| |
| bladder proper. Its walls were extremely thin and the inner surface smooth. The
| |
| openings by which the extravasation had taken place into the peritoneal cavity
| |
| were two in number — one a small aperture, the other a rent apparently of recent
| |
| origin.
| |
|
| |
| \Yhether this case was one in which the urachus had remained patent up to the
| |
| umbilicus and in which, upon supervention of bladder obstruction, suppuration had
| |
| occurred at the umbilical cicatrix, leaving a fistulous opening, or whether, in consequence of an extravasation of urine in the neighborhood of the fundus, an abscess
| |
| cavity had been formed which followed the track of the obliterated urachus, are
| |
| among the interesting pathologic features of the case.
| |
|
| |
| An Abscess Between the Umbilicus and Symphysis
| |
| Opening at the Umbilicus. — On August 7, 1821, Bourgeois* presented to the Paris Society a young soldier, aged twenty, who had at the lower portion of the umbilical cicatrix a granular excrescence the size of a small lentil. At its
| |
| summit was a minute cavity, from which there escaped, drop by drop, and sometimes in a jet, a fluid which resembled urine. The patient had pain in the anterior
| |
| abdominal wall which extended from the pubes to the umbilicus. Several times
| |
| after fatigue the discomfort became severe and it was necessary to apply liniments.
| |
| Later he had an attack of retention of urine and complained of a feeling of insupportable tension. After several days a round tumor developed. It was the size
| |
| of an almond, and was red, soft, and fluctuating. When the patient attempted
| |
| to urinate, this mass became tense. He was brought to the hospital and came under
| |
| the care of Larrey, who incised the tumor. The skin was very thin, and there
| |
| escaped a large quantity of serosanguineous and purulent fluid of a strongly urinary
| |
| odor, which suggested a communication between this cavity and the urinary tract.
| |
|
| |
| * Bourgeois: Jour. gen. de med., annee 1821, lxxvi, 219.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 587
| |
|
| |
| Tumor Formation Between the Umbilicus and Symphysis Due to Remains of the Urachus. — Bramann,* in 1887,
| |
| reported a case from von Bergmann's clinic. The patient was a girl of twelve
| |
| who had been normal until her ninth year. She then complained of pain and frequent micturition, and there was a discharge of pus and a little blood from the bladder.
| |
| Two years later the urine suddenly came through the umbilicus and continued to
| |
| pass by this route, although her physician tried to close the opening by cauterization. The urachus was dissected out and the bladder opening closed. A fistula
| |
| followed, and this still persisted up to the time that the case was reported. When
| |
| she came under observation a granulation the size of a pea was detected at the
| |
| umbilicus; in the center of this was a depression from which urine escaped. Behind the abdominal wall, in the median line, and below the umbilicus, and reaching
| |
| to the symphysis, was a long, sausage-shaped tumor, which was soft and adherent
| |
| to the umbilicus, but movable low down. Rectal examination showed that the
| |
| lower end passed to the bladder. The urethra was normal.
| |
|
| |
| After appropriate treatment for the cystitis a radical operation was undertaken.
| |
| The fistulous tract was dissected out as far as the bladder, but the peritoneum tore
| |
| at one point and the omentum protruded. It was wiped off and replaced and the
| |
| peritoneum closed. The urachus was several millimeters thick, dark red, yielding,
| |
| and lined with a membrane resembling mucosa. Here and there it was apparently
| |
| lined with granulation tissue. It opened directly into the bladder. Microscopicexamination showed that the canal was lined with transitional epithelium, next to
| |
| which was connective tissue, and external to this non-striped muscle-fiber. After
| |
| operation the fistula persisted.
| |
|
| |
| Escape of Urine From the Umbilicus, f — The patient was
| |
| a married woman, forty years of age, suffering from what was said to be a vesicoumbilical fistula. This patient came under Freer's care while he was resident
| |
| surgeon at the Ward's Island Hospital. She complained of a chronic purulent
| |
| discharge from the umbilicus, as a result of which she had become so exhausted that
| |
| she was scarcely able to walk. Freer discovered at the umbilicus a fistulous opening. A uterine sound was introduced and glided without obstruction downward
| |
| almost its entire length, and by giving it a lateral motion, Freer found that it
| |
| entered a cavity which had a breadth of almost three inches in its widest portion.
| |
| On removal of the probe pus welled up from the opening, and when pressure was
| |
| exercised from below upward, several ounces of pus escaped. The cavity was
| |
| washed out with a 2 per cent carbolic-acid solution, and it was not until the disproportion between the amount of fluid injected and that which returned was
| |
| noticed that the true nature of the case was surmised. This was afterward proved
| |
| by the injection of a starchy solution, after which the bladder was emptied and the
| |
| iodin test applied to the evacuated fluid, which yielded the characteristic appearance
| |
| of the blue iodid of starch. The patient was put on a nourishing diet, and after
| |
| local treatment in a short time the purulent discharge ceased and the fistula closed
| |
| spontaneously. She stated that a similar result had been achieved at other hospitals on previous occasions, but that the fistula, after remaining closed for a short
| |
| time, would then reopen, with a repetition of the above symptoms. Sometimes,
| |
|
| |
| * Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir.,
| |
| 1887, xxxvi, 996.
| |
|
| |
| t Freer, J. A. : Abnormalities of the Urachus. Annals of Surg., 1887, v, 107.
| |
|
| |
|
| |
|
| |
| 588 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| when she strained, urine would be forced up through the opening, but this was so
| |
| infrequent that she considered it of slight importance. She had no difficulty in
| |
| passing the urine by the natural channel.
| |
|
| |
| Cyst of the Urachus Communicating With the Bladder. — Freer* cites a case reported by Helmuth in The Homeopathic Journal
| |
| of Obstetrics, 1884, vi, 24. This patient was a married woman, fifty-four years of
| |
| age, of small stature and slight build. At the age of seven years her abdomen
| |
| appeared to be enlarged; at fourteen a tumDr the size of an apple appeared
| |
| at the umbilicus and burst, sending forth a stream of fluid with considerable
| |
| force. Her menses ceased at the age of forty-four, after which her abdomen became enlarged and sensitive to pressure. Incontinence of urine was a source of
| |
| great discomfort to her, especially at night, when the dripping would awaken her.
| |
| Helmuth withdrew with the aspirator about a quart of viscid, dark fluid, which
| |
| showed "inflammatory" and pus corpuscles. Subsequently, when performing
| |
| an ovariotomy, after dividing the peritoneum, he says: "I came upon a substance
| |
| which puzzled me. It looked something like a cyst- wall, but was so densely
| |
| adherent to the abdomen at the umbilicus that it was impossible to separate the adhesions. Laterally, on each side of the incision, the substance disappeared. After
| |
| vainly endeavoring to push this sufficiently aside, I determined to incise it, which I
| |
| did. A gush of fluid followed, and for a moment I believed I had opened the sac.
| |
| Upon introducing my finger into the incision I soon discovered that the canal communicated directly with the bladder. I then forcibly drew this emptied sac aside,
| |
| and without difficulty removed the [ovarian] tumor. From some experience in
| |
| suprapubic lithotomy I determined to bring the wall of the bladder-cyst together
| |
| with carbolized catgut, which I did. A self-retaining catheter was placed in the
| |
| bladder and the woman put to bed. The patient died on the evening of the fifth
| |
| daj' from peritonitis." Helmuth says the patulous and cystic urachus, leading from
| |
| the fundus of the bladder to the umbilicus, accounts for many peculiar symptoms
| |
| detailed by the patient.
| |
|
| |
| That the bursting of the umbilicus in early life, when the "water spouted up to
| |
| the ceiling," was due to the rupture of the external wall of the cyst was proved by
| |
| the cicatrix, smooth and white, which occupied the site of the umbilicus.
| |
|
| |
| Persistence of the Urachus in Adult Women. — Garriguest did an autopsy on a woman aged forty-five. He found that, owing to the
| |
| presence of a dilated urachus, the bladder extended as far as the navel, where it
| |
| was closed. The patient had been operated on for myoma ten days before and
| |
| had died of nephritis. The urachus was noted at the time of operation. The
| |
| bladder extended to the umbilicus and lay between the aponeurosis of the abdominal
| |
| muscles and the transversalis fascia on one side, and the peritoneum on the other.
| |
|
| |
| An Infected Urachus Communicating With the Bladder and U m b i 1 i c u s . — Graft cites the case of a man aged twenty. At
| |
| twelve years of age he had inflammation of the diaphragm, and four years later
| |
| gastric fever. A year and a half before Graf saw him he had noticed that the urine
| |
| escaped from the umbilicus. The tissue in the vicinity of the umbilicus was somewhat swollen, reddened, and painful. He did not know whether he had had fever.
| |
| On admission he was found to be pale and anemic. He had a frequent desire to
| |
|
| |
| * Freer, J. A.: Op. cit. t Garrigues, H. J.: Med. Record, New York, 1899, lvi, 720.
| |
|
| |
| % Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896, 16.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 589
| |
|
| |
| urinate. He had pain in the abdomen, and from time to time fluid escaped from
| |
| the umbilicus. Passing downward in the mid-line from the umbilicus was a hard
| |
| cord, as wide as two fingers, which could be felt going toward the bladder. The
| |
| symptoms indicated a vesical catarrh, and there was a gonorrheal inflammation of
| |
| the urethra. After lavage of the bladder, carried out for three weeks, the patient
| |
| was better. The pus had stopped escaping from the umbilicus.
| |
|
| |
| Operation. — The umbilicus was cut around and the cord dissected out. The
| |
| peritoneum was opened over an area of 10 cm. It was walled off with iodoform
| |
| gauze; the bladder opening, which was about 0.5 cm. in diameter, was closed.
| |
| The patient made a good recovery.
| |
|
| |
| The inner surface of the fistula consisted of granular tissue. In places it had
| |
| grown into the lumen. Only near the umbilical opening had the cavity an epithelial
| |
| lining, the cells being of the squamous type.
| |
|
| |
| A Singular Case of Ischuria.* — "On the 9th of April, 1814,
| |
| M. H., aged twenty-three, was admitted an in-patient of the Worcester Infirmary.
| |
| She represented herself as having been particularly healthy. Within the last week
| |
| she had been exposed to cold, whilst the catamenia were flowing abundantly.
| |
| For the first day or two she appeared to suffer only from feverish symptoms; soon
| |
| afterward, however, the secretion of urine became very deficient, and she had
| |
| difficulty in passing it.
| |
|
| |
| "On the evening of her admission she became much worse, and complained
| |
| specially of pain and tenderness over the whole of the lower part of the abdomen
| |
| and in the loins. There was vomiting and a disposition to convulsions. The
| |
| lower part of the abdomen was much distended. A catheter was introduced, and
| |
| ten ounces of urine were drawn off, after which the pain was relieved. She was
| |
| ordered to take a scruple of cathartic extract immediately, and one drachm of
| |
| sulphate of magnesia, dissolved in camphor mixture, three times a day.
| |
|
| |
| "The next morning the bowels had not been moved. She was afflicted with
| |
| severe headache, as well as the abdominal pains. She had passed no water, and
| |
| was delirious during the night.
| |
|
| |
| "She was cupped on the back, and had a blister applied, and took cathartic
| |
| mixture every four hours till the bowels moved freely; after which she w T ent into a
| |
| warm bath.
| |
|
| |
| "The symptoms remained for several days very much in the same state. Delirium usually came on during the night. No urine was passed by the natural
| |
| effort, but about three ounces were drawn off by the catheter in the course of
| |
| twenty-four hours. She very frequently vomited, and suffered much from pain,
| |
| tenderness, and tension of the lower part of the abdomen.
| |
|
| |
| "On the evening of the 17th insensibility came on, for which a blister was applied to. the back of the neck; the pulse was sixty. An active aperient was given.
| |
|
| |
| "On the 19th no improvement had taken place, for the vomiting was incessant,
| |
| and the pain in the abdomen and back was more severe. Pulse, 80. She was bled
| |
| three days in succession, with some alleviation of the pain, but the abdomen became
| |
| generally enlarged and very tender; there also ceased to be any urine drawn from
| |
| the bladder by the catheter. This continued to be the case for five days. The
| |
| bowels were open. She took saline diuretics without avail.
| |
|
| |
| * Hastings, Charles: London Med. and Phys. Jour., 1829, X. S., vi, 515.
| |
|
| |
|
| |
|
| |
| 590 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| "On the 25th there was much vomiting, pain, and distention of the abdomen,
| |
| but she passed a little urine. Pulse, 80. She was bled to eight ounces.
| |
|
| |
| "On the 27th a bloody discharge appeared at the umbilicus, after which the abdominal pain and tension were relieved. She also passed some urine by the urethra.
| |
| The vomiting was, however, worse than it had previously been.
| |
|
| |
| "The bloody discharge from the umbilicus and the other symptoms continued
| |
| very much the same till the 2d of May, when there was a discharge, of urinous appearance and smell, from the umbilicus. She had passed no urine by the urethra
| |
| for three days. The head was very painful, the pupils dilated; pulse, 56; bowels
| |
| costive. Some leeches were applied to the temples, and a blister to the back of the
| |
| neck; a brisk purge was administered. The catheter was introduced, but no urine
| |
| found in the bladder.
| |
|
| |
| "The discharge of urine from the umbilicus continued till the 5th, when the
| |
| catamenia appeared, but quickly vanished. The abdomen became less tense and
| |
| tender; there was not so much vomiting ; the bowels were open.
| |
|
| |
| " From the 7th to the 9th there was no discharge of urine from the umbilicus,
| |
| nor was there any passed by the urethra; as a consequence, the abdomen became
| |
| much distended and severe pain followed, with vomiting. The tension was most
| |
| remarkable at the umbilicus, forming a circumscribed tumor.
| |
|
| |
| "On the 10th, in the morning, six ounces of urine were drawn off by the catheter;
| |
| and in an hour after, two quarts of urine of the same appearance gushed from the
| |
| umbilicus. This was followed by much relief of the abdominal pains. The discharge of urine from the umbilicus continued for three days and was accompanied
| |
| with great improvement of the general symptoms.
| |
|
| |
| "The amendment, however, did not last, for the discharge from the umbilicus
| |
| again ceased, and for three days the vomiting, the headache, the abdominal tension
| |
| and pain returned with their former severity.
| |
|
| |
| "On the 17th the catheter was introduced into the bladder and no urine was
| |
| found. In an hour after this, two quarts of urine passed from the umbilicus, and
| |
| soon afterward great relief was experienced.
| |
|
| |
| "From this time to the 25th there was little variation; but the young woman
| |
| suffered during that interval very much from vomiting and daily passed urine from
| |
| the umbilicus. The catheter was passed every day, and no urine was found, but
| |
| the bladder contracted strongly on the instrument; sometimes, immediately after
| |
| the catheter was removed, a discharge of urine would take place by the umbilicus,
| |
| and once as much as three quarts were thus passed.
| |
|
| |
| "On the 26th, for the first time after many days, four ounces of urine were
| |
| drawn from the bladder. Each succeeding day this quantity was now increased
| |
| and the quantity passed by the umbilicus was diminished. There was also
| |
| a general improvement of the symptoms, with the exception of vomiting; this
| |
| continued obstinate. All this time the medicine that she took was confined
| |
| chiefly to the class of purgatives; blisters were also applied to the neck and epigastrium.
| |
|
| |
| "The bladder was regularly emptied every day by the catheter for more than a
| |
| month after this date, during which time the abdominal pain and vomiting subsided, and there was no discharge from the umbilicus. Early in July she began to
| |
| pass some urine, and the power over the bladder was gradually restored. She was
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 591
| |
|
| |
| discharged in the middle of July in tolerable health, but still often complained of
| |
| pain in the pelvic region. She menstruated.
| |
|
| |
| "Observations. — This curious case of ischuria is well worthy of consideration.
| |
| The remarkable sympathy observable between the brain, the stomach, the kidneys,
| |
| is common to all cases of this description, and is so obvious as not to require any
| |
| further comment.
| |
|
| |
| "The very remarkable feature in the case is the occurrence of the urinary discharge from the umbilicus many days after the ischuria had been noticed. Such
| |
| instances, although rare, are not without parallel in the annals of medicine. Schenck
| |
| relates two instances of this kind. In the one, a male, the urine was discharged in
| |
| consequence of an obstruction at the neck of the bladder, 'tanquam mictione ex
| |
| umbilico,' for many months without any detriment to health. In the other, a
| |
| female, and more resembling the one now related, 'cum suppressa per multas dies
| |
| fuisset urina, tandem per umbilicum urinam profuclit.' (Schenck, Obs., Lib. iii,
| |
| deUrina, p. 489.)
| |
|
| |
| "The interesting question is to determine in what manner the urine is conveyed
| |
| to the umbilicus in these instances. The urachus offers itself as a means by which
| |
| the discharge may be determined to that part, and it seems probable that, in the
| |
| case of mechanical obstruction related by Schenck at the neck of the bladder, a
| |
| channel of communication was formed by the urachus between the bladder and the
| |
| umbilicus. But, in the case we now remark upon, there had been no urine secreted
| |
| into the bladder long before its appearance at the umbilicus, nor was there for some
| |
| time after; and the first discharge from the umbilicus was not of a urinary but
| |
| bloody nature. We must consequently, I think, regard the urinary discharge in
| |
| this instance as vicarious, and as proceeding probably from the peritoneal surface.
| |
| This view seems confirmed by the great abdominal distention, which took place
| |
| for some time previous to the discharge from the umbilicus, when it was invariably
| |
| found, from introducing the catheter, that the bladder was empty, and that it contracted on the instrument.
| |
|
| |
| "Some cases of this description have been placed upon record by eminent men
| |
| worthy of great credit. There is none, perhaps, more deserving of attention than
| |
| that by Platerus, which is thus related by the renowned Sennertus: 'Puellae
| |
| cuidam annos natae tredecim, cum aliquando copiose minxisset, urinam subito
| |
| suppressam esse, atque tunc aquam serosam ex aure dextra adeo affatim coepisset
| |
| effluere, ut una vice mensurae duae ssepe emanarint, idque dies aliquot.' He then
| |
| adds that, on diuretics being administered, the urine was passed freely from the
| |
| bladder, and the discharge from the ear ceased; but as soon as the diuretics were
| |
| discontinued, the discharge again took place from the ear, but was altogether removed by general terebinthinate remedies, and local repellents to the ear. The
| |
| health did not suffer. (Sennerti Opera, Lib. iii, p. 8, § ii, cap. ix.)
| |
|
| |
| "In our case it was evident that much inflammatory action was going on in the
| |
| pelvic viscera previous to and during the discharge of urine from the umbilicus;
| |
| and there was a considerable sympathy of the general health with the local inflammatory action.
| |
|
| |
| "I may further add, as a notice to this case, that the young woman was again
| |
| admitted into the infirmary in May, 1827, for paralysis of the lower extremities,
| |
| from which she recovered by appropriate remedies. The urine for a time was drawn
| |
| off by the catheter, but there was no return of the former disease."
| |
|
| |
|
| |
|
| |
| 592 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| Umbilical Urinary Fistula in a Middle-aged Man.* —
| |
| ( lase IV. — The patient was a middle-aged man, who complained of a tender and
| |
| irritable bladder when he was jolted. A fixed pain developed just above the pubes,
| |
| and he noticed an increased desire to urinate. A hardness could be detected above
| |
| the pubes. Suddenly the patient felt something give way, and pus passed from the
| |
| bladder through the urethra. He was greatly relieved. Recovery followed, and
| |
| three years later he was well. Hind thought that in this case there had been an
| |
| abscess of the patent portion of a urachus.
| |
|
| |
| Cyst of the Urachus. — In discussing Douglas's paper Illf said that
| |
| recently he had removed a cyst of the urachus as large as two fists without difficulty.
| |
| The patient was a woman who had some prolapse of the anterior vaginal wall, and
| |
| when she attempted to pass her urine, some of it passed into the cyst and some
| |
| escaped through the urethra. This did not have the effect, however, of producing
| |
| an inflammatory condition about the cyst. The condition was annoying to her,
| |
| because she had to pass her urine in installments, as it were.
| |
|
| |
| The operation consisted in removal of the cyst and ligation of that portion of the
| |
| duct which entered the bladder. As he was closing the wound he said to himself:
| |
| ''This is a dangerous procedure, and it is likely that this ligature will not destroy
| |
| the epithelium and that the bladder will open in a short time." Some infiltration
| |
| of urine taking place, he removed the ligature, cut the duct very short, turned in
| |
| the edges, and closed it over, as a surgeon would do with an appendix stump.
| |
|
| |
| Cystitis Followed by the Opening Up of a Partially
| |
| Patent Urachus, Producing a Urinary Fistula at the
| |
| Umbilicus. — Lexer! reports the case of a poorly developed young man,
| |
| twenty years old, who said that previously he had never noticed anything abnormal
| |
| at the umbilicus. A year and a half before admission, after several weeks of difficulty in urinating, the urine being cloudy, he had pain in the region of the umbilicus,
| |
| the tissue in the vicinity of the navel swelled up and became red. Shortly after
| |
| a quantity of purulent fluid escaped from the umbilicus. The bladder discomfort
| |
| became more severe; he frequently had fever and chills and became thinner. In
| |
| addition to a marked degree of cystitis there was blennorrhea of the urethra. Gonococci were isolated from the urethral discharge. On account of the swelling and
| |
| inflammatory infiltration, the fistula at the umbilicus was not visible, but the
| |
| umbilical funnel filled up when pressure was made by the patient, and when pressure on the bladder was exerted the umbilical cavity filled up with pus and foulsmelling urine.
| |
|
| |
| The cystitis was first treated. In the washing-out of the bladder purulent
| |
| flocculi escaped from the umbilicus, so that finally the entire fluid escaped from the
| |
| umbilical opening. Nevertheless, it was impossible to introduce a sound farther
| |
| than 2 cm. into the fistula. By the third Aveek the patient had improved greatly.
| |
| He had no further fever, the urine was passed without pain, he looked well, and the
| |
| escape of pus from the umbilical fistula had ceased. Urine, however, continued to
| |
| escape from the umbilicus as soon as the bladder contained an appreciable amount of
| |
| fluid.
| |
|
| |
| On account of the gonococcus infection it was felt wiser not to leave in a perma
| |
| * Hind, \V.: Diseases of the Urachus and Umbilicus. Brit. Med. Jour., 1902, ii, 242.
| |
|
| |
| t 111, Edward J.: Amer. Jour. Obst., 1897, xxxvi, 568.
| |
|
| |
| X Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1893, lvii, 73.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 593
| |
|
| |
| nent catheter. The abdominal walls were not so painful on pressure, and one could
| |
| now make out a hard cord, the thickness of a finger, in the mid-line, extending from
| |
| the umbilicus to the bladder. After the cystitis had subsided, closure of the umbilical
| |
| fistula was considered. As it was impossible to introduce a sound far, an excision
| |
| of the upper portion of the cord was undertaken. The umbilicus was dissected
| |
| free, and the fistulous tract about 2 cm. below this point was opened. Here there
| |
| was a small lumen into which a sound could be introduced without difficulty and
| |
| carried toward the bladder region. The farther dissection of the cord was easily
| |
| accomplished without injury to the peritoneum. Midway between the umbilicus
| |
| and symphysis, however, it was impossible to avoid entering the abdominal cavity.
| |
| From the opening in the peritoneum one could see the relation of the bladder very
| |
| well. This cord spread out and passed without any definite margin gradually
| |
| into the upper portion of the bladder, just as is the case in the embryo. Care was
| |
| taken not to injure the general peritoneal cavity. The urachus was freed to the
| |
| point where it entered the bladder. It was then cut across transversely, so that
| |
| the entire tract from the umbilicus to the bladder was excised. A funnel-like
| |
| opening, 1.5 cm. wide, was left in the bladder. Examination of the inner surface
| |
| of the bladder showed that this organ was a long, thick-walled tube, similar to that
| |
| noted in Bramann's case. The opening in the bladder was closed, and a drain laid
| |
| into the incision. The wound had healed completely in four weeks.
| |
|
| |
| At the end of two and a half years there was no evidence of any fistula, and the
| |
| patient was completely cured, the only discomfort being frequent urination.
| |
|
| |
| A Case of Patent Urachus Over One Inch in Diameter
| |
| Forming a Tubular Prolongation of the Bladder. —
| |
| Marshall* reports the case of a woman, aged forty-three, who had complete procidentia. On opening the abdomen to suspend the uterus, and while making a short
| |
| incision midway between the pubes and umbilicus, he found the subperitoneal fat
| |
| very abundant. On dividing this he could see what appeared to be peritoneum.
| |
| A nick having been made into it, a pair of scissors was passed upward and then
| |
| downward to enlarge the incision.
| |
|
| |
| On lifting the retroflexed uterus up to the abdominal opening and thus compressing the bladder, Marshall noted an escape of some clear fluid into the lower
| |
| part of the wound. This aroused his suspicions. A bougie introduced into the
| |
| bladder through the urethra entered the abdominal incision through a large opening. What was at first thought to be peritoneum was in reality the anterior wall
| |
| of a patent urachus. The first cut upward had slit through the upper blind end in
| |
| the peritoneum into the abdominal cavity. The downward cut had opened the
| |
| peritoneum and both walls of the urachus.
| |
|
| |
| The urachal opening was V/i inches in diameter and formed a large opening in
| |
| the conic-shaped bladder. The bladder was closed with a double layer of continuous catgut sutures and a catheter was kept in for one week. The patient made
| |
| a good recovery.
| |
|
| |
| Suppuration of the Persistent Urachus With Rupture
| |
| into the Bladder and the Abdominal Wall.f — In November,
| |
| 1901, a forty-eight-year-old man came to Mikulicz's clinic. He had had a gonococcal
| |
|
| |
| * Marshall: Jour, of Obst. and Gyn. of the Brit. Empire, 1907, xi, 259.
| |
|
| |
| t Matthias, F. : Vereiterung des persistierenden Urachus mit Durchbruch in die Blase und
| |
| in die Bauchdecken. Beitrage z. khn. Chir.; herausg. von Paul Bruns, Tubingen, 190-1, xlii, 339.
| |
| 39
| |
|
| |
|
| |
|
| |
| 594 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| infection ten years before, which had not been promptly treated. For the last
| |
| few years he had had an abundant discharge from the urethra. Apart from this
| |
| the patient had been well. Six months before admission, he began to have a
| |
| pressure in the lower abdominal region and suffered from a general feeling of
| |
| malaise. The urine was cloudy and contained whitish threads and flocculi. There
| |
| was a cramp-like, sticking pain in the urethra. During the three months following
| |
| this the patient lost weight and the urine was cloudy. Two months later there was
| |
| again pain in the lower abdomen, and a tumor could be felt above the top of the
| |
| bladder. Mikulicz found a firm, ill-defined tumor lying below the umbilicus.
| |
| This occupied the mid-line and extended a little more to the right. It commenced
| |
| three fingerbreadths below the umbilicus, and ended 5 cm. above the symphysis.
| |
| There was a cord passing from the tumor to the umbilicus. The umbilicus itself
| |
| appeared normal. , Mikulicz thought that he was dealing with an abscess of the
| |
| abdominal wall, and one that communicated with the bladder, and that its origin
| |
| was due to the extension of a cystitis by way of a persistent urachus. Bladder
| |
| irrigations were employed. When there was a large quantity of pus in the urine,
| |
| the tumor became smaller and the patient felt better. The reverse was the case
| |
| when the urine contained but little pus. The difference in the size of the tumor was
| |
| manifested in its transverse diameter. When a large amount of pus escaped in the
| |
| urine and the tumor had diminished to half its volume, a cystoscopic examination
| |
| was made. In the anterior bladder-wall, in the neighborhood of the top of the
| |
| bladder and in the mid-line, was a transverse oval opening passing into a funnelshaped diverticulum. The walls of this could be seen for some distance, but the
| |
| point ended in darkness.
| |
|
| |
| Operation. — A median incision was made. The skin was dissected free from
| |
| the tumor, which was covered with thick and edematous fascia, and on the left
| |
| side the peritoneal cavity was opened. From this point the tumor was separated
| |
| from the abdominal wall, and in the lower angle of the incision the bladder was
| |
| recognized by means of a metal catheter which had been introduced from below. The
| |
| tumor sat on the top of the bladder, and on the right and on the left, between the
| |
| tumor and bladder, was a loop of small bowel which was separated without injury.
| |
| The tumor was the size of a billiard ball, and sat as a cap on the top of the bladder.
| |
| The muscular covering of the bladder extended over on it, particularly on the posterior surface. The peritoneal cavity was well walled off and the tumor opened.
| |
| Its walls were 12 mm. thick, and the cavity was the size of a walnut. From it
| |
| escaped an old clot mixed with pus. An attempt was made, by filling the bladder with
| |
| 300 c.c. of salt solution, to find a communication with the abscess cavity. In this
| |
| the operator was unsuccessful ; no fluid escaped, but a sound could be passed from
| |
| the cavity into the bladder. The tumor was separated from the bladder. The small
| |
| opening in the bladder-wall was closed with catgut, and the muscularis, which formed
| |
| two flaps over the tumor, was brought together. A retention catheter was introduced into the bladder and kept in place for ten days. The urine then came away
| |
| spontaneously, and the pus disappeared almost completely. The extirpated tumor
| |
| was the size of an apple and irregularly round. Its walls varied from 2 to 20 mm.
| |
| in thickness, and there were irregular dilatations in the interior. It consisted of
| |
| striated, dense connective tissue. Here and there were citron-yellow portions,
| |
| undoubtedly fatty tissue. The inner surface of the sac, apart from dilatations,
| |
| was uneven; no mucosa was visible.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 595
| |
|
| |
| Microscopic Examination. — Sections showed that the wall was made up of
| |
| smooth muscle-fibers, connective tissue, and an inner zone consisting of old connective tissue containing many round-cells and small blood-vessels. There were
| |
| hemorrhages, and here and there the tissue was necrotic. There was no evidence
| |
| of epithelium. Mikulicz found a small opening in the wall of the tumor. This
| |
| was lined with epithelium. It could be traced for a distance of 2 mm. in serial
| |
| sections, and had a breadth of 1 mm. The epithelium lining the canal was several
| |
| layers thick; only in a few places did it consist of a single layer.
| |
|
| |
| In conclusion Mikulicz said that very probably the normal dilatation of the
| |
| opening of the urachus in the bladder, being funnel-shaped, had allowed the cystitis
| |
| to extend to the urachus, and through breaking of the wall there had resulted
| |
| abscess formation in the musculature of the bladder-wall and of the abdominal
| |
| wall to the umbilicus. Since the abscess originally lay within the bladder musculature, its rupture into the interior of the bladder near the actual opening of the
| |
| urachus was not exceptional.
| |
|
| |
| [There is no doubt in this case that there was an abscess between the bladder
| |
| and the umbilicus. It was probably of urachal origin, but Matthias's description
| |
| is not particularly clear. — T. S. C]
| |
|
| |
| Escape of a Calculus From the Umbilicus.* — This case
| |
| had been reported by Gennaro in 1890. After a mucopurulent discharge from
| |
| the umbilicus had lasted several days, a calculus escaped from the umbilical opening. It consisted of urate of soda, phosphate of lime, and magnesia. The urachus
| |
| was a diverticulum of the bladder. Gennaro thought that the calculus was due to
| |
| fermentation of the stagnant ammoniacal urine.
| |
|
| |
| A Case of Dilated Urachus Accidentally Opened
| |
| During an Abdominal Section for Peritonitis. Recovery. f — A boy, aged five, was brought to the Children's Hospital, Brighton,
| |
| on February 18, 1896. There was a history of vomiting and diarrhea for two days.
| |
| On admission he was suffering with severe abdominal pain, but there was no marked
| |
| tenderness. His temperature was 102° F. The next day he was much worse, and
| |
| lay on his left side, with his thighs fully flexed. The distention, tenderness, and
| |
| pain were more severe. There was no localized swelling. His diarrhea was almost
| |
| constant. His temperature was 103.6° F., his pulse, 108. In the next five days
| |
| there was some improvement in his general condition. The abdomen was still
| |
| distended, but the vomiting and diarrhea were improved. On the ninth day, in
| |
| the region of the bladder and extending nearly to the umbilicus, there could be
| |
| made out a certain amount of resistance that was fairly sharply defined. Micturition was frequent, but there was no dribbling. On the suspicion that the swelling
| |
| might be the bladder, a catheter was passed, but only about half an ounce of urine
| |
| was drawn off. This did not affect the size or position of the hypogastric fulness.
| |
| On February 27th the general condition was better, except that he was passing a
| |
| large quantity of mucus by bowel. The distention and hypogastric fulness were
| |
| less marked. On the evening of the next day, twelve days after the first symptoms, the boy was much worse, his vomiting had returned, and the distention was
| |
|
| |
| * Monod, Jean: Des fistules urinaires ombilicales dues a. la persistance de l'ouraque. These
| |
| de Paris, 1899 (obs. 47), 168.
| |
|
| |
| t Morgan, G.: The Lancet, 1896, ii, 1154.
| |
|
| |
|
| |
|
| |
| 596 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| very severe. His temperature was 103° F. and his condition so critical that it was
| |
| decided to operate at once.
| |
|
| |
| An incision was made extending from the umbilicus to a point near the pubes.
| |
| The deeper abdominal layers were divided carefully over a director. An incision
| |
| was made into what was taken for the subperitoneal fat and peritoneum, and there
| |
| was a gush of about one ounce of clear urine. The wound was at once clamped and
| |
| a catheter was passed. The bladder was found to be quite empty and lying in the
| |
| pelvis, but the catheter could be passed up into the wound in the cyst where the
| |
| clamp was. After carefully dissecting around the cyst, Morgan opened the abdominal cavity and found signs of recent peritonitis, with flakes of lymph, but no
| |
| pus. The abdominal cavity was flushed with hot water, and the intestines were
| |
| carefully sponged. The boy was too ill to have a prolonged examination or have
| |
| the mass dissected out, but it was certain that the cyst was in the mid-line, running
| |
| up to the umbilicus and communicating with the bladder. After the bladder and
| |
| cyst had been washed out with boric acid solution, the wound in the bladder was
| |
| closed with a double row of silk sutures, the stitches not penetrating to the mucous
| |
| membrane. The abdominal wall was also carefully closed. On the following day
| |
| the boy was much better, but on the fourth day pus began to well up from the suture
| |
| line. Three stitches were taken out and the pus cavity was irrigated. For ten
| |
| days after this there was some escape of urine from the abdominal wound, but
| |
| this became less and less, and the boy's general condition improved. Twentysix days after operation the wound was closed and the boy was quite well.
| |
|
| |
| A Rare Variety of Cyst of the Urinary Bladder,
| |
| Probably Arising From the Urachus, Cured by Operation.* — A. M'V., a miner, aged thirty-nine, was admitted to the Glasgow
| |
| Royal Infirmary on October 21, 1895. He complained of severe pain in the hypogastric region. This had commenced four days before, and had continued ever since.
| |
| Coincident with the onset of the pain he found that he was unable to micturate,
| |
| and his doctor had to pass a catheter. When the urine was drawn off, it contained a large quantity of blood. Vomiting came on soon after the onset of the
| |
| pain and was followed by attacks of diarrhea.
| |
|
| |
| On admission he was suffering considerable pain, had an anxious expression and
| |
| walked with difficulty. The skin over the region of the bladder was red and blistered from the use of hot fomentations and applications of mustard. The abdomen
| |
| was considerably swollen, very tense over the region of the bladder, and from the
| |
| umbilicus to the pubes it was absolutely dull on percussion. After admission a
| |
| catheter was passed and 20 ounces of urine, containing a large quantity of blood,
| |
| were drawn off. This gave the patient considerable relief, but even after the bladder had been completely emptied, the dulness in the hypogastric region did not
| |
| disappear. From the 1st until the 8th of November the patient's condition steadily
| |
| improved, and at the latter date he was able to pass his urine without difficulty.
| |
| On examination the abdomen still showed a considerable amount of swelling in the
| |
| hypogastric region. The swelling in appearance greatly resembled a distended
| |
| bladder.
| |
|
| |
| Operation. — A free incision was made in the mid-line, midway between the pubes
| |
|
| |
| * Newman, D.: Throe Renal Cases, a Case of Cyst of the Urachus, and a Case of Strangulated Hernia, Treated in the Surgical Wards of the Glasgow Royal Infirmary. Glasgow Med.
| |
| Jour., 1896, xlvi, 20.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 597
| |
|
| |
| and the umbilicus. On incision into the transversalis fascia, a large quantity of
| |
| gelatinous fluid escaped which had a strongly ammoniacal odor. The cyst-wall
| |
| was thin and smooth, and its anterior wall was not covered with peritoneum. The
| |
| cyst extended from the apex of the bladder to the umbilicus. After evacuation of
| |
| the contents the cyst was washed out with carbolic acid solution, and a drainagetube inserted. In the evening the dressing was found to be soiled with urine which
| |
| had a strongly ammoniacal odor.
| |
|
| |
| On November 16th the greater part of the urine was passing through the abdominal wound and a retention catheter was now introduced into the urethra.
| |
| Notwithstanding this the urine continued to escape from the wound, and not until
| |
| December 16th did the cyst become completely obliterated and the wound in the
| |
| abdomen close. On careful inquiry into the history of the patient it was found
| |
| that he had noticed a swelling in the hypogastric region as long as he could
| |
| remember, but until this occasion it had never given him any trouble.
| |
|
| |
| Probably a Partially Patent Urachus with Infection.* — This patient was observed by Chopart. She was pregnant, and had
| |
| suffered from retention of urine for some time. The abdomen became tender and
| |
| painful. Fluctuation was felt, and was specially marked in the region of the
| |
| umbilicus. An incision was made between the right rectus muscle and the umbilicus, and much pus escaped. On the following clay the bed and the apparel of the
| |
| patient were soaked with urine. This escaped for some time by the umbilicus
| |
| until, after repeated catheterization, the urine commenced to pass through the
| |
| urethra and the umbilicus closed.
| |
|
| |
| Dilatation of the Urachus; Communication with
| |
| the Bladder. — Patel'sf patient was a child three years of age who, from
| |
| birth, had incontinence of urine both day and night. The urine did not escape drop
| |
| by drop, but at frequent intervals and involuntarily. There were no malformations.
| |
|
| |
| Below the umbilicus was a voluminous tumefaction, fusiform, and prominent
| |
| in its central portion. In its middle portion it was the size of two fists. It was
| |
| exactly in the median line; above it reached the umbilicus, and below passed into
| |
| the pelvis, although its termination could not be felt. It was movable. Catheterization yielded a small glass of clear urine. There was evidently a tumor lying
| |
| behind the abdominal walls, adherent to the umbilicus, and clinically independent
| |
| of the bladder.
| |
|
| |
| A median incision was made below the umbilicus. The tumor was found adherent to the umbilicus. Half a liter of pale-yellow fluid escaped, which contained
| |
| large quantities of albumin. The sac was lined with an irregularly wrinkled muscular layer. Above the finger impinged on the umbilicus. The inferior end was very
| |
| narrow and was dilated with difficulty. It led to a small circular cavity in which
| |
| the vesical trigonum was recognized. Removal of the diverticulum was not undertaken on account of the size of the tumor and of its probable adhesion to the peritoneum, and on account of the patient's age. The walls of the sac were sutured
| |
| much in the way that cavities resulting from removal of hydatids of the liver are
| |
| obliterated. The walls were brought together and a catheter was left in the blad
| |
| * Xicaise: Ombilic. Diet, encycloped. des sci. med., Paris, 1881, 2. ser., xv, 140.
| |
|
| |
| | Patel: Malformation congenitale de 1'ouraque. Dilatation kystique de la partie interieure
| |
| de 1'ouraque demeure en communication avec la vessie; incontinence d'urine symptornatique.
| |
| Capitonnage de la poche. Rev. mens, des maladies de l'enfance, Paris, 1904, xxii, 77.
| |
|
| |
|
| |
|
| |
| 598
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| der. During the five days that the catheter remained in place there was some discharge from the abdominal wall. When the child left the hospital, the abdomen
| |
| was soft. The bladder was large enough and the child urinated about every three
| |
| hours. There was no incontinence. Recovery was permanent.
| |
| This case was also reported by Gabriel Renard.*
| |
|
| |
| The Diagnosis and Treatment of a Case of Patent
| |
| Urachus. f — The patient was a woman twenty-five years of age. Six months
| |
| previously she had begun to have pain in the umbilical region. Two weeks later a
| |
| swelling had appeared at the umbilicus. This had ruptured, and since then pus
| |
| had been discharging, except during occasional intervals of a week. A probe was
| |
|
| |
| passed through the umbilicus into the
| |
| bladder, and the end emerged at the
| |
| external urinary meatus.
| |
|
| |
| The urachus was opened on a director about two inches above the symphysis. It showed a dilatation in the middle, with a constriction above, and
| |
| below, where it connected with the
| |
| bladder. The actual cautery was used
| |
| to destroy about one inch of the lower
| |
| portion of the urachus. The portion
| |
| above was packed, a piece of iodoform
| |
| gauze being passed through the fistula
| |
| to the umbilicus. The bladder was
| |
| accidentally opened, but at once closed
| |
| with catgut. The patient made a good
| |
| recovery.
| |
|
| |
| Urachal Cyst Communicating with the Bladder.
| |
| — Robinson+ says: " I worked several
| |
| years in the dissecting room, paying
| |
| special attention to visceral and pelvic
| |
| anatomy, but did not see any urachal
| |
| cyst in but one autopsy (Fig. 251)." In
| |
| this case the urachus was dilated, forming a fusiform tumor. It opened into
| |
| the bladder and extended upward as far as the umbilicus. . . . "I understand
| |
| from veterinarians that the horse is one of the most typical animals to show urachal
| |
| cysts, and that quite late in horse fetal life the urachus is found often quite a distance above the bladder."
| |
|
| |
| A Urachal Cyst Communicating With the Bladder. —
| |
| In Roser's § case the urachal cyst had a small opening into the bladder (Fig. 252) .
| |
| When the patient wished to void, the contraction of the bladder muscles forced the
| |
|
| |
| * Etenard, Gabriel: Sur un kyste de l'ouraque. These de Lyon, 1905, No. 89.
| |
| fReid, \Y. L.: Glasgow Hosp. Reports, 1899, ii, 76.
| |
| % Robinson, F. Byron: Annals of Surg., 1891, xiv, 336.
| |
|
| |
| § Roser, W '.: Ueber Operation der Urachuscysten. Langenbeck's Arch. f. klin. Chir., 1877,
| |
| xx, 47:;.
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 251. — A Dilated Urachus Communicating With
| |
| the Bladder. (After F. Byron Robinson.)
| |
| The urachus (6) is patent from the bladder (a) almost
| |
| to the umbilicus. It is markedly dilated, and its cavity
| |
| communicates directly with the bladder. It resembles a
| |
| secondary bladder.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS.
| |
|
| |
|
| |
|
| |
| 599
| |
|
| |
|
| |
|
| |
| urine into the cyst more easily than through the urethra. The cyst, therefore,
| |
| became more and more distended, until three or four liters of urine accumulated.
| |
| When it was desired to empty the bladder, a catheter had to be introduced into it
| |
| and the cyst was then pressed upon. In order to keep the patient free from trouble
| |
| catheterization several times a day was necessary.
| |
|
| |
| The patient had what appeared to be a greatly distended bladder when she was
| |
| three months pregnant. A puncture was made in the linea alba above, and a large
| |
| amount of urine removed. The pregnancy went to term. Four years later she
| |
| had a similar attack when she was again pregnant. The old cyst had refilled. It
| |
| was tapped from above, and the patient miscarried. The cyst again filled, and
| |
| operation became necessary. The urine was ammoniacal, owing to stasis in the
| |
| sac. There was foul urine in the cyst, which at that time had reached the umbilicus.
| |
|
| |
| An extraperitoneal opening, about 3 cm. long, was made in the mid-line, and two
| |
| chambers full of stinking ammoniacal purulent fluid escaped. There was temporary
| |
| relief. A retention catheter failed to bring
| |
| about closure of the bladder, and when last
| |
| seen, the patient still had the urachal cyst
| |
| opening into the bladder.
| |
|
| |
| Polypus of the Urinary Bladder with the Development of
| |
| a Urinary Fistula at the Umbilicus. — ■ Savory's* patient was a male,
| |
| thirteen months old and sickly. Immediately beneath and partly surrounding the
| |
| umbilicus was a firm, tense swelling, two or
| |
| three inches in diameter. Its limits were not
| |
| well defined. It was very tender, and pain
| |
| was increased by attempts to void. The urine
| |
| merely dribbled away. The child had been
| |
| ill eight weeks. The first thing noticed was
| |
| that micturition caused pain in the lower abdomen, followed by an almost constant desire to void
| |
| rupted temporarily and then started again.
| |
|
| |
| The umbilical induration was incised and pus escaped; later urine appeared,
| |
| and nearly all came this way
| |
| Autopsy. — On section of the abdomen an abscess was found between the
| |
| posterior surface of the abdominal parietes and the peritoneum and extending
| |
| from the umbilicus almost to the symphysis. The omentum was adherent to
| |
| the abdominal wall. The growth in the bladder stretched across behind the ureteral orifices, which were dilated. This mass was attached at each side, but was
| |
| free in the center, and could block the urethra. It was a polyp. It was impossible
| |
| to find the opening between the bladder and the abscess by which the urine escaped
| |
| from the umbilicus.
| |
|
| |
| A Partially Patent Urachus.t — Simon reports the case of a
| |
|
| |
| * Savory, W. S.: Med. Times, London, 1852, N. S., v, 106.
| |
|
| |
| t Simon, Charles: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. SO (obs. 12), 26.
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 252. — Urachal Cyst. (Redrawn by August
| |
| Horn after W. Roser.)
| |
| The bladder itself looks normal, except that
| |
| at the upper part anteriorly there is a small opening which communicates with a large cyst extending as high as the umbilicus.
| |
|
| |
|
| |
|
| |
| The stream was often inter
| |
|
| |
|
| |
| 600 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| patient of Portal, a man forty-five years of age, who died shortly after a fall on the
| |
| abdomen resulting in a severe injur}' to the bladder. Some time after the accident
| |
| he had noticed that the urine was escaping at the umbilicus. Portal says: "On
| |
| opening the bod}' I found a tube which extended from the umbilicus to the bladder. This was cone-shaped. Its diameter toward the umbilicus was ^4 inch and
| |
| 1^2 inches at the bladder. The thickness was unequal. The volume of the bladder did not exceed that of a small apple."
| |
|
| |
| An Infected Urachal Cyst Communicating With the
| |
| Bladder.* — This patient, a man sixty-six years of age, came under Trendelenburg's observation on July 3, 1887. For a year or more he had had frequent
| |
| urination. The urine was cloudy, and often much pressure was necessary to start
| |
| it. Six months before he had noticed a swelling in the lower abdomen, above the
| |
| symphysis. For three or four days he had had pain in this region, and soon after
| |
| a spontaneous opening had appeared at the umbilicus from which a purulent fluid
| |
| had escaped. Recently he had become weaker.
| |
|
| |
| On admission to the hospital he showed, in the hypogastric region, a marked
| |
| swelling about the size of a head. This began just above the symphysis and reached
| |
| to the umbilicus. Rectal examination revealed an enlarged prostate, especially on
| |
| the right, and above this a distended bladder. A very fine sound was passed from
| |
| the umbilicus and entered into a large cavity. The fluid from the umbilicus showed
| |
| round-cells undergoing fatty change. After catheterization with the removal of
| |
| 1500 c.c. of cloudy urine the swelling to a large extent disappeared, but there persisted a long tumor reaching from the umbilicus to the symphysis.
| |
|
| |
| Operation. — An incision was made between the umbilicus and the symphysis.
| |
| Immediately behind the fascia was a sac containing about a liter of urine mixed with
| |
| pus. A piece of the wall was removed, and the wound closed with drainage. A
| |
| purulent fluid continued to escape from the sac. Microscopic examination of the
| |
| wall showed it to be lined with one layer of squamous epithelium resembling that
| |
| of the bladder. There was no muscle in the wall. The connective tissue contained many round-cells.
| |
|
| |
| A Dilated Urachus Communicating With the Bladder . f — The patient was a very frail woman, weighing probably 85 pounds.
| |
| At labor she had had a bad tear and developed a fever, from 100° to 101.5° F., for
| |
| nearly six weeks. In the following spring she entered the hospital for operation,
| |
| but later developed pain and swelling in the right side.
| |
|
| |
| A median incision, 2^ inches long, was made. The peritoneum was exposed
| |
| and cut, but the bladder was opened. The patient had just voided before the operation. The wound was closed, but the operator, in attempting to enter the peritoneum, got into the same cavity again. It proved to be an accessory bladder —
| |
| really a dilated urachus — and contained l}/£ to 2 pints of urine. A catheter introduced into the urethra could be passed into this cavity. It was closed and the
| |
| patient recovered.
| |
|
| |
| Escape of Urine From the Umbilicus. — UnterbergerJ reporter! the case of a woman, twenty-three years of age. She was supposed to have
| |
|
| |
| Schnellenbach: [Jeber die (Jrachuscysten. Inaug. Diss., Bonn, 1888.
| |
| f Timmerman, C. F.: Trans. Med. Soc. State of New York, 1904, 331.
| |
|
| |
| tTJnterberger: Retroversio-flexio uteri gravidi partialis incarcerata. Urachus-fistel.
| |
| Monatssohr. f. Geb. u. Gyn., 1900, xi, 657.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 601
| |
|
| |
| had an ovarian cyst that had ruptured through the umbilicus, and for three weeks
| |
| clear fluid had continued to escape from the navel.
| |
|
| |
| The trouble had begun with pain in the lower abdomen. This had become so
| |
| severe that the patient had been forced to remain in bed and local applications
| |
| had been applied. Urination and defecation at this time were normal.
| |
|
| |
| The patient had fever and gradually became weaker. One month before her
| |
| admission to the hospital urinary disturbances developed, and after a time the urine
| |
| commenced to escape through the umbilicus and the pain disappeared. Pus sometimes escaped from the umbilicus with the urine.
| |
|
| |
| For fourteen days before the patient entered the hospital no urine had been
| |
| passed from the urethra. The umbilical opening had the caliber of a hair, and was
| |
| surrounded by a small red zone. The abdominal walls were somewhat infiltrated.
| |
| A catheter passed into the bladder entered for its entire length and about 2000 c.c.
| |
| of urine mixed with pus were removed. The uterus, which contained a pregnancy,
| |
| was retroverted and partially incarcerated. No operation was performed, but
| |
| Unterberger regarded the case as one of patent urachus.
| |
|
| |
| A Dilated and Infected Urachus Communicating
| |
| With the Bladder and Umbilicus.* — A. W., white, male, aged
| |
| forty, was admitted to the Georgetown University Hospital, June 21, 1904. When
| |
| twenty years old he had gonorrhea, from which he made a good recovery. His
| |
| present trouble began when he was seventeen years of age, with pain in the suprapubic region extending to the umbilicus. There was induration and tenderness of
| |
| the parts on pressure. These symptoms grew worse; poultices were applied, and
| |
| two weeks later an opening appeared at the umbilicus through which was discharged
| |
| a moderate amount of pus. From this time the fistula remained patulous almost
| |
| constantly, with a discharge of pus and urine. Occasionally it would close — never
| |
| longer than for two days, during which time there would be considerable pain,
| |
| especially on urination. When the opening closed, the area around and below the
| |
| navel would become inflamed, and when it was reestablished, spontaneously or by
| |
| the patient, there would be immediate relief from pain and the escape of a large
| |
| quantity of dark, offensive-smelling fluid. The odor was worse after the fistula had
| |
| been closed a day or two than when it was discharging freely, but at all times it
| |
| was offensive, to a great extent barring the patient from the society of his friends.
| |
| The discharge had always been most profuse during urination, and in the morning,
| |
| when the patient would begin to move about, but there was at all times enough to
| |
| keep his clothing soiled. At thirty-four years of age he had an attack of pain in the
| |
| region of the right kidney, with nausea, vomiting, and elevation of temperature,
| |
| and he had to keep to his bed for three weeks. Since then he had had other attacks
| |
| of less severity, usually beginning with pain in the loin and extending to the testicle, sometimes accompanied by vomiting and the passage of blood through the
| |
| urethra. The attacks had always been most severe after exertion.
| |
|
| |
| Examination showed a large, robust, well-nourished man, with good color and
| |
| apparently in excellent health. At the umbilicus was a flat area of scar tissue of a
| |
| bluish color, containing a small opening through which a probe could be passed
| |
|
| |
| * Vaughan, George T. : Patent Urachus. Review of the Cases Reported. Operation on a
| |
| Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus.
| |
| Trans. Amer. Surg. Assoc, 1905, xxiii, 273.
| |
|
| |
|
| |
|
| |
| 602 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| downward and slightly backward for a distance of three and one-half inches into
| |
| a pouch which lay in front of the bladder.
| |
|
| |
| The urine from the bladder contained urates and epithelial cells. A diagnosis of
| |
| patent urachus with dilatation into a pouch and infection of its contents was made,
| |
| and operation was advised.
| |
|
| |
| Operation (June 25, 1904). — The bladder was distended with water through
| |
| the urethra, and a grooved director was passed through the umbilical fistula to the
| |
| bottom. The cavity was opened, and a considerable amount of bloody pus, with
| |
| an offensive urinary odor, was evacuated. The sac was pyriform in shape, with
| |
| the small end above: it lay in front of the peritoneum, and above and in front
| |
| of the bladder, with which it communicated through a very small opening. The
| |
| sac was about three inches in length, and had a capacity of about three ounces;
| |
| it contained many laminated clots and resembled very much a small urinary bladder, the walls containing muscular and fibrous tissue and being lined with mucous
| |
| membrane. The sac was carefully dissected out, the peritoneum being opened in
| |
| two places accidentally, and the walls were brought together. Recovery was without incident except for the high temperature that occurred on the day after operation (107° F. in the axilla), and he was well three weeks after the operation.
| |
|
| |
| On August 13, 1904, just a month after leaving the hospital, the patient had a
| |
| severe attack of renal colic on the right side, with chills, vomiting, blood}^ urine,
| |
| dehrium, and swelling of the face and extremities. His pulse was 140, the temperature 104° F. On August 21st the right kidney was incised, and a round stone, half
| |
| an inch in diameter, was removed. After this the patient had no further trouble
| |
| until February, 1905, when he had an attack of renal colic on the left side, with the
| |
| passage of several small, pea-sized calculi from the bladder. A month later he had
| |
| another attack, which was much more severe and was complicated with almost
| |
| complete suppression of urine for forty-eight hours, delirium, chills, and a temperature of 106° F. On May 1, 1905, the left kidney was incised and two stones
| |
| were removed. Up to June 27, 1905, the patient had had no further trouble with
| |
| his bladder, but had had an attack of appendicitis which he managed to pass through
| |
| without operation.
| |
|
| |
| Under date of May 12, 1915, Dr. Vaughan writes: "After an operation on both
| |
| kidneys for stone the patient got along pretty well until December 6, 1906, when I
| |
| had to operate on the left kidney again, removing a large oval stone. Patient recovered, but had trouble again during the summer of 1914 (during my absence),
| |
| and Dr. Fowler removed stones from the right kidney. He is in pretty good condition now, but evidently has stones, probably in both kidneys. Since June 25,
| |
| 1904, patient has had five operations — excision of urachus and two operations on
| |
| each kidney.'"
| |
|
| |
| Suppuration of a Urachal Cyst. — In Weiser's* Case 3 the patient was a man aged seventy-three, who had always been well except for an attack
| |
| of orchitis four months before the present sickness. For six months he had suffered
| |
| with pain and soreness in the abdomen, but had noticed no tumor. Two weeks
| |
| before Weiser's visit the abdominal wall had opened spontaneously two inches below the umbilicus, and discharged urine. There had never been any pus. When
| |
| the patient was lying down quietly, the urine did not escape, but as soon as he assumed an upright position, there was a constant discharge. The old gentleman
| |
| * Weiser, W. R.: Annals of Surg., 1906, xliv, 529.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS.
| |
|
| |
|
| |
|
| |
| 603
| |
|
| |
|
| |
|
| |
| OOTteo LINE
| |
| REPRESENTS
| |
| UVACHUS *-*
| |
| CYST WALLS
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| appeared perfectly well aside from this urinary sinus, which in caliber was about
| |
|
| |
| the size of a pencil, and entered immediately into a large sac, the lower limit
| |
|
| |
| of which Weiser could not reach with an eightinch probe.
| |
|
| |
| Weiser entered the peritoneal cavity above the
| |
|
| |
| sinus, and found the sac anterior to the parietal
| |
|
| |
| peritoneum. The sac extended to within one inch
| |
|
| |
| of the umbilicus, above which the urachus was not
| |
|
| |
| patulous (Fig. 253), and downward into the pelvis.
| |
|
| |
| It was intimately connected with the bladder at the
| |
|
| |
| point of urachal attachment, and was densely adherent to the posterior bladder-wall as well as to
| |
|
| |
| the intestines, the greater part of the sac being made
| |
|
| |
| up of abdominal viscera. After freeing the anterior
| |
|
| |
| wall of the cyst sufficiently, he made a plastic closure
| |
|
| |
| of the original point of rupture through the abdominal wall. A catheter was placed in the
| |
| bladder through the
| |
| urethra and allowed
| |
| to remain for several
| |
| days. The abdominal wound was closed
| |
| without drainage.
| |
| The patient made a
| |
| good recovery, and
| |
| was about the house
| |
| on the fourteenth
| |
|
| |
| day. Two months later Dr. Stowell, under whose
| |
| care the patient had been originally, told Dr. Weiser
| |
| that the abdominal wall had given way again a trifle
| |
| lower down toward the symphysis, and urine was
| |
| again discharging through a small sinus. Later the
| |
| opening closed spontaneously.
| |
|
| |
| A Very Large Abscess-sac Extending into the Pelvis, Opening
| |
| a t t h e Umbilicus, and Containing
| |
| a Calculus. — This case in many respects suggests an umbilical abscess that reaches very large
| |
| proportions and contains a concretion. On the other
| |
| hand, it makes one think of certain cases of abscess
| |
| of the urachus. I wrote Dr. Weiser* as to the character of the calculus. From his reply it was evidently
| |
| of urinary origin, and probably made up largely of
| |
| oxalates.
| |
| A woman, seventy-five years of age, had for fifteen years suffered inconvenience
| |
|
| |
| from a discharge of pus from the umbilicus. The discharge was constant and at
| |
| * Weiser, W. R.: Annals of Surg., 1906, xliv, 531.
| |
|
| |
|
| |
|
| |
| Fig. 253. — Urachal Cyst. (After W.
| |
| R. Weiser, Case 3, Fig. 3.)
| |
| Male, aged seventy-three. The abdominal wall opened spontaneously two
| |
| inches below the umbilicus and urine was
| |
| discharged. The sac extended upward
| |
| to within an inch of the umbilicus ; downward into the pelvis. It was intimately
| |
| attached to the fundus of the bladder.
| |
|
| |
|
| |
|
| |
| Fig. 254.
| |
|
| |
|
| |
|
| |
| (After
| |
|
| |
|
| |
|
| |
| -Urachal Cyst.
| |
| W. R. Weiser.)
| |
|
| |
| Revised from Case 1. At the operation Weiser tapped the cyst, evacuating five ounces of horribly fetid pus,
| |
| followed by a calculus weighing 70
| |
| grains. The cyst had a thick and indurated wall and dipped well down
| |
| into the pelvis. It was extraperitoneal. [Dr. Weiser tells me that in his
| |
| article two of his pictures were not
| |
| properly placed, hence the "revision."— T. S. C.l
| |
|
| |
|
| |
|
| |
| 604 THE UMBILICUS AXD ITS DISEASES.
| |
|
| |
| times profuse. At various times she had consulted a physician in reference to the
| |
| condition, but, aside from prescribing various washes and ointments, no treatment or
| |
| diagnosis was offered.
| |
|
| |
| She finally consulted Dr. Weiser. The patient at this time was well nourished
| |
| and active for her age. The abdomen was very fat, and a tumor the size of a cocoanut presented in the median line, between the umbilicus and the symphysis. The
| |
| mass could be raised with the abdominal wall and was apparently attached thereto.
| |
|
| |
| There was a copious discharge of foul-smelling pus from the umbilicus, and an
| |
| eight-inch probe, passed into the sinus, failed to reach the lower wall of the sac. The
| |
| temperature was 101° F., her pulse, 100. She volunteered the information that the
| |
| condition was no worse than usual, but that she was not feeling well generally, and
| |
| during the past month there had been very frequent micturition.
| |
|
| |
| Under ether Weiser excised the umbilicus and unhealthy skin surrounding it, and
| |
| cutting down through two inches of fat, came upon a bulging mass extending from
| |
| the umbilicus as far down as he could feel toward the symphysis (Fig. 254). This
| |
| he tapped, and evacuated about five ounces of horribly fetid pus, followed by a
| |
| calculus weighing 70 grains. Exploration with the finger demonstrated the fact that
| |
| the cyst had a thick and indurated wall, and dipped well down into the pelvis. Up to
| |
| this point in the operation he had not opened the peritoneal cavity. He now washed
| |
| out the sac. packed it with gauze, and entered the peritoneal cavity, above the
| |
| location of the tumor. To his surprise he found the mass densely adherent to the
| |
| intestine posteriorly, and on passing his hand down into the pelvis on the outside of
| |
| the cyst, discovered it to be closely associated with the bladder. He now concluded
| |
| that he was dealing with a urachal cyst, and, as the posterior wall was almost entirely made up of intestines, he concluded to cut away such portions of the sac as
| |
| seemed safe. He left the posterior wall intact, as well as that portion which dipped
| |
| down into the pelvis. The wound was closed as- far as the peritoneum, and the rest
| |
| was walled off with a coffer-dam drain of iodoform gauze. Her recovery was uneventful, but it required three months for the sinus to close.
| |
|
| |
| March 11, 1912.
| |
| My Dear Dr. Cullen: Replying to your letter of the eighth inst. and referring to
| |
| the urachal calculus: The stone was quite hard, and the surface was dark brown,
| |
| resembling in color a type of gall-stone. Upon cutting open, the substance of the
| |
| stone resembled a hard bladder stone in color and general appearance.
| |
|
| |
| Unfortunately, this stone was lost before reaching the laboratory, but I think it
| |
| was probably made up largely of oxalates. My opinion was that this was a urinary
| |
| calculus which became discolored on its outer strata by lying in a bed of foul pus and
| |
| being exposed through the discharging sinus at the umbilicus.
| |
|
| |
| Cordially yours,
| |
|
| |
| Walter R. Weiser.
| |
|
| |
| Case of Vesico-umbilical Fistula of FourteenYears'
| |
| Standing. — Wbrster* reports the case of Miss H., aged twenty-one. She had
| |
| good health until a severe attack of diphtheria when eight years old. Following this
| |
| she had incontinence of urine and cystitis. From about this time she could not
| |
| straighten herself up properly and had a habit of standing with the body bent forward at an angle of 45 degrees. She was also incapable of stooping to pick up any
| |
| * Worster, Joseph: Med. Record, 1877, xii, 196.
| |
|
| |
|
| |
|
| |
| URACHAL CAVITIES AND INFECTIONS. 605
| |
|
| |
| thing. Two years after the diphtheria she suffered from a cystitis, accompanied by
| |
| a copious flow of purulent matter from the urethra, and shortly afterward a swelling
| |
| was noted in the umbilical region, the appearance of which was followed by large and
| |
| repeated discharges of pus from the umbilical opening, and subsequently of urineThe umbilical inflammation subsided, but pus escaped from time to time, and the
| |
| urine continually. In her eleventh year, as a result of a contusion, an opening
| |
| occurred below the umbilicus, from which urine escaped. Extending from the bladder to the umbilicus was a hard, cord-like mass, two inches in diameter and uniform
| |
| in size.
| |
|
| |
| Operation (April 14, 1875). — Two elliptic incisions were made and the umbilical
| |
| area removed. Eight days after the operation urine escaped from the wound. A
| |
| second operation was undertaken at once, with good results.
| |
|
| |
|
| |
|
| |
| LITERATURE CONSULTED ON URACHAL CAVITIES COMMUNICATING WITH THE
| |
| BLADDER OR UMBILICUS OR WITH BOTH.
| |
|
| |
| Ball, C. B. : A Case of Pervious Urachus with Remarkable Disease of Bladder. Trans. Acad.
| |
|
| |
| Med. Ireland, 1883-84, Dublin, 1884, ii, 376.
| |
| Bourgeois: Jour. gen. de med., 1821, lxxvi, 219.
| |
| Bramann, F. : Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., 1887,
| |
|
| |
| xxxvi, 996.
| |
| Freer, J. A. : Abnormalities of the Urachus. Annals of Surg., 1887, v, 107.
| |
| Garrigues, H. J.: Persistent Urachus in an Adult Woman. Med. Record, New York, 1899, lvi,
| |
|
| |
| 720.
| |
| Graf, F. : Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.
| |
| Hastings, C: A Singular Case of Ischuria. London Med. and Phys. Jour., 1829, N. S., vi,
| |
|
| |
| 515.
| |
| Hind, W. : Diseases of the Urachus and Umbilicus. Brit. Med. Jour., 1902, ii, 242.
| |
| Ill, E. J.: Tumors of the Urachus. Trans. Amer. Assoc. Obst. and Gyn., 1892, v, 238. Amer.
| |
|
| |
| Jour. Obst., 1897, xxxvi, 568.
| |
| Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73.
| |
| Marshall, G. B. : Case of Patent Urachus over One Inch in diameter, forming a Tubular Prolongation of the Bladder. Jour. Obst. and Gyn. of the Brit. Empire, 1907, xi, 259.
| |
| Matthias, F. : Vereiterung des persistierenden Urachus mit Durchbruch in die Blase und in die
| |
|
| |
| Bauchdecken. Beitriige z. klin. Chir.; herausg. von Paul Bruns, Tubingen, 1904, xlii, 339.
| |
| Monod, J. : Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,
| |
|
| |
| 1899, No. 62.
| |
| Morgan, G. : A Case of Dilated Urachus Accidentally Opened Whilst Performing Abdominal
| |
|
| |
| Section for Peritonitis; Recovery. The Lancet, 1896, ii, 1154.
| |
| Newman, D.: Three Renal Cases, a Case of Cyst of the Urachus, and a Case of Strangulated
| |
|
| |
| Hernia, Treated in the Surgical Wards of the Glasgow Royal Infirmary. Glasgow Med.
| |
|
| |
| Jour., 1896, xlvi, 20.
| |
| Nicaise: Ombilic. Diet, encycloped. des sci. med., Paris, 1881, 2. ser., xv, 140.
| |
| Patel, M.: Malformation congenitale de l'ouraque; dilatation kystique de la partie interieure de
| |
|
| |
| l'ouraque demeure en communication avec la vessie; incontinence d'urine symptomatique.
| |
|
| |
| Capitonnage de la poche. Rev. mensuelle des mal. de l'enfance, Paris, 1904, xxii, 77.
| |
| Reid, W. L.: On the Diagnosis and Treatment of a Case of Patent Urachus. Glasgow Hosp.
| |
|
| |
| Rep., 1899, ii, 76.
| |
| Renard, Gabriel: Sur un kyste de l'ouraque. These de Lyon, 1905, No. 89.
| |
| Robinson, F. B.: Cysts of the Urachus (Congenital Cysts, Extraperitoneal Cysts, or Dilatation
| |
|
| |
| of Functionless Ducts). Annals of Surg., 1891, xiv, 336.
| |
| Roser, W.: Ueber Operation der Urachuscysten. Langenbeck's Arch. f. klin. Chir., 1877, xx,
| |
|
| |
| 473.
| |
| Savory, W. S.: Polypus of the Urinary Bladder. Med. Times, London, 1852, N. S., v, 106.
| |
|
| |
|
| |
|
| |
| 606 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| Schnellenbach: TJeber die Urachuscysten. Inaug. Diss., Bonn, 1888.
| |
|
| |
| Simon, C: Quels sont les phenoinenes et le traitement des fistules urinaires ombilicales? These
| |
| de Paris, 1843, No. 80.
| |
|
| |
| Timnierman, C. F. : Dilated Urachus. Trans. Med. Soc. State of New York, 1904, 331.
| |
|
| |
| Unterberger: Retro versio-flexio uteri gravidi partialis incarcerata. Urachus-fistel. Monatsschr.
| |
| f. Geb. u. Gyn., 1900, xi, 657.
| |
|
| |
| Vaughan, G. T.: Patent Urachus. Review of the Cases Reported. Operation on a Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus. Trans.
| |
| Arner. Surg. Assoc, 1905, xxiii, 273.
| |
|
| |
| Weiser, W. R. : Cysts of the Urachus. Annals of Surg., 1906, xliv, 529.
| |
|
| |
| Worster, J.: Case of Vesico-abdominal Fistula of Fourteen Years' Standing. Med. Record,
| |
| 1877, xii, 196.
| |
|
| |
|
| |
|
| |
| ==Chapter XXXV. Acquired Urinary Fistula at the Umbilicus==
| |
|
| |
| General consideration.
| |
|
| |
| 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.
| |
|
| |
| 607
| |
|
| |
|
| |
|
| |
| 608 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| 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
| |
|
| |
| THE URETHRA.
| |
|
| |
| 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.
| |
|
| |
|
| |
|
| |
| ==Chapter XXXVI. Urachal Concretions and Urinary Calculi associated with Urachal Remains==
| |
|
| |
| Historic sketch.
| |
|
| |
| Urachal stones or concretions.
| |
|
| |
| Urinary calculi in the urachus.
| |
|
| |
| Removal of vesical stones through the umbilical opening.
| |
|
| |
| Other calculi in the umbilical region.
| |
|
| |
| Phillips, in an article in Todd's Cyclopaedia of Anatomy and Physiology (1835),
| |
| said that in January, 1787, Boyer exhibited a bladder taken from a man thirty-six
| |
| years of age. The urachus formed a canal 1^2 inches long, and contained 12 urinary
| |
| calculi each the size of a millet-seed. It was demonstrated that this canal was not
| |
| a vesical sac or a prolongation of the vesical mucous membrane.
| |
|
| |
| In 1838 Civiale, in his treatise on calculous affections, called attention to the
| |
| fact that the anatomist Colombus had observed calculi at the umbilicus. Civiale
| |
| refers to the case of a woman coming under Hagendorn's care, who had a very
| |
| painful abdominal abscess which contained two calculi. He also refers to Vallisnieri, who spoke of stones escaping from the umbilicus. In Helwig's case, cited by
| |
| the same author, a woman seventy years old had an umbilical abscess; it broke,
| |
| and several stones escaped, one of which weighed 15 grains. In another case a man
| |
| discharged from the umbilicus a calculus which weighed about an ounce and was
| |
| as large as a pigeon's egg. Civiale also referred to cases observed by Tolet,
| |
| Rhodius, and Roesler. The stones varied from the size of the kernel of an olive to
| |
| that of a hazelnut. They escaped from the umbilicus.
| |
|
| |
| Simon, in 1843, mentioned the fact that calcareous concretions had been found
| |
| along the course of the urachus and had also escaped through the umbilical ring.
| |
| He said that Colombus, Donatus, Harder, Bartholin, and Cruveilhier had reported
| |
| such cases. '
| |
|
| |
| Simon said that Rhodius and Helwig had reported cases similar in character.
| |
| In the case of Helwig's patient, a man, the stone was the size of a pigeon's egg.
| |
|
| |
| Concretions or calculi escaping from the umbilicus may originate from several
| |
| sources. They may be formed in the bladder or in the urachus, which communicates with the bladder, and where, consequently, urinary salts can become concentrated, or, again, in a urachus, that is completely isolated from the bladder. Finally
| |
| we have umbilical concretions. The escape of gall-stones from the umbilicus has
| |
| been considered elsewhere.
| |
|
| |
| Calculi developing in a urachus communicating with the bladder are identical in
| |
| their composition with vesical stones. Those developing in the urachus, when no
| |
| connection exists between it and the bladder, are very small; umbilical concretions
| |
| are cheesy in character. These last have been considered in detail in Chapter XV
| |
| (p. 247).
| |
|
| |
| The majority of the cases mentioned in the historic sketch just given are not
| |
|
| |
| 620
| |
|
| |
|
| |
|
| |
| CALCULI ASSOCIATED WITH URACHAL REMAINS. 621
| |
|
| |
| sufficiently clear to enable one to determine with any degree of accuracy to which
| |
| group they belong.
| |
|
| |
| URACHAL STONES OR CONCRETIONS.
| |
|
| |
| The careful and painstaking investigations of Luschka, published in 1862, give
| |
| us a very comprehensive knowledge of the urachus. He says the urachal contents
| |
| are not all alike. The fluid is usually pale yellow, thin, and translucent. It may,
| |
| however, be cloudy, and brown or reddish in color. It contains a large number of
| |
| cells, numerous fat-globules, and not infrequently corpora amylacea. In the dilatations and in the isolated cysts the contents are frequently sticky and of a dirty brown
| |
| color, and scattered throughout the field are bodies which have a marked resemblance to prostatic concretions.
| |
|
| |
| Urachal concretions were also described by Hoffmann in 1870.
| |
|
| |
| Suchannek, in 1879, when describing the contents of a patent portion of the
| |
| urachus, discussed the granular bodies. These, he said, judging from their reaction
| |
| to acetic acid, are due to a degeneration of the epithelium, which is probably colloid
| |
| or amyloid in character.
| |
|
| |
| Wutz briefly details his findings in the cyst contents of the many cases he
| |
| examined.
| |
|
| |
| In Case 11 he noted that, a short distance from the bladder, the urachus contained an oval body 0.17 x 0.1 mm. It was brownish in color and homogeneous in
| |
| consistence. In the further course of the tube were several diverticula and nippedoff cysts of various shapes. They contained firm brownish contents.
| |
|
| |
| In Case 15 Wutz says that the cysts were filled with lumps of brownish and
| |
| yellow material.
| |
|
| |
| In Case 17 the cyst contents were yellowish white and friable.
| |
|
| |
| In Case 18 Wutz found a spindle-shaped urachal cyst, 2x1 mm. Its contents
| |
| were brownish yellow in color.
| |
|
| |
| Wutz, in summing up his observations on cyst-contents, said that they consisted
| |
| of fat-crystals, fat-droplets, free fat, large flat epithelial cells, brownish-yellow amorphous masses, isolated cholesterin crystals, and small, round, very glistening bodies.
| |
| In one of the cysts in Case 22 he found a small, firm, stony hard, yellowish-brown,
| |
| glistening body. Under the microscope this was irregular, nodular,\ and partly
| |
| transparent. It was 0.37 x 0.36 mm. in diameter. On the addition of hydrochloric
| |
| acid free carbonic acid escaped.
| |
|
| |
| Ledderhose referred briefly to urachal concretions in 1890.
| |
|
| |
| In Boyer's case, which we have already considered and In which 12 millet-seedsized stones were found in the urachus, these bodies were urinary stones.
| |
|
| |
| Rokitansky (1861) referred to a case in which 21 calculi the size of linseeds were
| |
| found in a urachal dilatation 0.6 mm. above the top of the bladder.
| |
|
| |
| Veiel, one of Luschka's pupils, in his dissertation on the urachus published in
| |
| 1862, described his findings in the body of a man forty-five years old. "Passing
| |
| downward in the mid-line from the umbilicus was a delicate cord 1 mm. broad. Three
| |
| centimeters above the bladder it commenced to get thicker, and at the bladder was
| |
| 1.2 cm. broad. The urachus could be divided into four sections. The lowest
| |
| section, situated nearest the bladder, was 14 mm. long and patent. The next was
| |
| 7 mm. long, solid, and thread-like. The third was 8 mm. long and was also patent.
| |
| The fourth section— nearest the umbilicus— was solid. After the urachus had been
| |
|
| |
|
| |
|
| |
| 622 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| treated with acetic acid, three dilatations of the canal could be seen. They contained yellowish concretions.
| |
|
| |
| Arrou, in 1910, in an article entitled A Suppurating Cyst of the Urachus, reported a case in which an abscess contained a stone or concretion the size of an olive;
| |
| it was like a piece of incompletely dried mortar. [I should be inclined to look upon
| |
| it as a simple umbilical concretion accompanied by inflammation, were it not for the
| |
| fact that the lower end of the sac bore a definite relation to the urachus. — T. S. C]
| |
|
| |
| Suppurating Cyst of the Urachus. — Arrou* reports the case
| |
| of a patient operated upon by Tricot. A soldier with absolutely no history of bladder trouble complained of vague pain in the umbilical region. The pain became
| |
| acute, and the patient when marching had to bend forward. There was no nausea
| |
| and no intestinal disturbance. Urination was normal; there was no fever.
| |
|
| |
| Examination revealed a painful plaque, as large as the palm of the hand, a little
| |
| below the umbilicus. There was no edema or redness. Gradually a little swelling
| |
| was noted over the painful area; this was accompanied by some fever.
| |
|
| |
| Operation. — An exploratory incision was made under the supposition that there
| |
| was an abscess in the abdominal wall, but when the patient was in the operatingroom, there was an escape of a small amount of pus from the lower margin of the
| |
| umbilicus. A probe introduced into the small orifice passed downward and backward into a cavity, measuring 6 cm. in its vertical direction. The patient was at
| |
| once anesthetized and the cavity incised. It proved to be the size of a mandarin
| |
| orange. It contained a calculus the size of an olive, that was like a piece of incompletely dried mortar. 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 a closed cul-de-sac. Attached to the lower portion of the
| |
| sac was a large cord, the size of the little finger, which became smaller and terminated in the fundus of the bladder. Arrou was sure that it was the urachus. The
| |
| peritoneum was opened above and laterally. The intestines were protected and
| |
| the urachus was cut across with the cautery at a point several millimeters above the
| |
| bladder. The sac was completely removed and the wound closed. The patient
| |
| made a good recovery.
| |
|
| |
| From the data at hand it is evident that urachal concretions or stones are very
| |
| rare. They are usually no larger than linseed grains or millet-seeds. They are
| |
| usually yellowish brown or brown in color, and may resemble corpora amylacea.
| |
| They are too small to be a surgical factor, and are of interest only to the pathologist.
| |
|
| |
|
| |
|
| |
| URINARY CALCULI IN THE URACHUS.
| |
| In 1877 Vosburgh reported his observations on a man aged fifty, who had been
| |
| complaining of a soreness and constant pain at the navel. Examination showed
| |
| redness, tenderness, and a hard swelling around the umbilicus. The tumor was
| |
| incised, and at the depth of half an inch a stone, the size of a hickory-nut, was felt
| |
| and at once removed. The stone was phosphatic in character and had a strong
| |
| urinary odor. The wound healed. The patient stated that, about twenty years
| |
| before, a stone had been removed in a similar manner from this location.
| |
| * Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832.
| |
|
| |
|
| |
|
| |
| CALCULI ASSOCIATED WITH URACHAL REMAINS. 623
| |
|
| |
| Monod, in 1899, referred to the stagnation of urine in the interior of the urachus
| |
| as giving rise to calculi. He said that Colombus, Marcellus, Donatus, Harder, and
| |
| Bartholin had cited examples of this kind. He added that the calculi may be eliminated through the umbilicus, as was noted by Hagendorn, Rhodius, and Hehvig.
| |
|
| |
| The same author mentions a case recorded by Peyer in 1721, in which a calculus
| |
| escaped from the umbilicus after retention of urine. In the chapter on Urachal
| |
| Infections I have referred to a case reported by Weiser (p. 603). The patient, a
| |
| woman seventy-five years of age, had had a purulent discharge from the umbilicus
| |
| for fifteen years. When Weiser saw her she had a tumor the size of a cocoanut situated in the mid-line, between the umbilicus and symphysis. When this was opened,
| |
| five ounces of very fetid pus escaped, and also a calculus weighing 70 grains. The
| |
| wound healed in three months. Wishing to find out the character of this stone, I
| |
| wrote Dr. Weiser, and from his reply it appears probable that it closely resembled a
| |
| vesical calculus, but, as noted from the history, there was no opening into the bladder
| |
| and no urine escaped from the incision during the patient's convalescence.
| |
|
| |
| Probably one of the most interesting cases is the one recorded by Dykes. It
| |
| might be claimed that the extravesical portion of the stone developed in a diverticulum of the bladder, but the location of the opening in the top of the bladder and in
| |
| the median line leaves little doubt that the cavity was a dilated portion of the urachus, especially as the probe in the cavity could be carried up to within two inches of
| |
| the umbilicus.
| |
|
| |
| Patent Urachus and Encysted Urinary Calculi.* —
| |
| "This case, which both in its clinical and pathologic bearings I believe to be of some
| |
| interest, came under observation on January 27, 1908, at Rae Bareli Oudh:
| |
|
| |
| "The patient was a Hindu male, aged about thirty years, apparently healthy
| |
| apart from his urinary complaint, which dated back some five years or more. Owing
| |
| to pressure of work I had not seen him until he was on the operating table, prepared
| |
| for litholapaxy. The urine, I was informed, was acid and free from albumin. Several small concretions lay free on the base of the bladder, but on commencing to
| |
| crush the first, the beak of the lithotrite impinged upon what appeared to be a much
| |
| larger calculus, occupying a position at the apex of the half -distended bladder. After
| |
| the first stone had been crushed the projecting portion of this larger calculus was
| |
| easily seized between the blades of the lithotrite, but was found to be fixed to the
| |
| bladder- wall.
| |
|
| |
| "To crush this calculus in situ appeared dangerous, if not impossible, so lateral
| |
| lithotomy was performed and the forefinger passed into the bladder. The calculus
| |
| was now found j ust within reach of the finger. With the forefinger on the tip of the
| |
| calculus and the other hand on the abdominal wall, it was estimated to be of considerable size, and its upper portion seemed very close under the examining hand
| |
| beneath the abdominal wall in the middle line. It was evidently an 'hour-glass'
| |
| stone, the deeper half being considerably larger than the projecting portion felt by
| |
| the finger. The projecting portion being steadied in the grasp of the lithotomy
| |
| forceps, the perforated end of a long probe was insinuated alongside the neck, and
| |
| gradually manceuvered around the whole circumference, loosening the retaining
| |
| tissue, until, by gentle traction and rotation of the forceps, an 'hour-glass' calculus
| |
| was safely delivered. A second calculus immediately dropped from the same pocket
| |
| into the bladder cavity. It, together with the three small concretions, the presence
| |
| * Dykes, Campbell: The Lancet, 1910, i, 566.
| |
|
| |
|
| |
|
| |
| 624 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| of which, on the bladder floor, had already been detected, was now removed, and the
| |
| debris of the small stone, first crushed, washed out. In case other concretions might
| |
| still be lying in the pocket its recesses were explored with a probe. Nothing further
| |
| was found, but the probe passed up in the middle line, easily palpable through the
| |
| abdominal wall, to a point two inches below the umbilicus. At the upper end the
| |
| pocket seemed to be contracted to a mere sinus. Convalescence was rapid and
| |
| uncomplicated.
| |
|
| |
| "The ' hour-glass ' calculus weighed over l^ ounces. Its neck was of about the
| |
| thickness of a cedar pencil, but somewhat flattened. The deeper lobe was larger
| |
| than the projecting head, which was capped by a pea-sized, rough, dark-colored
| |
| concretion, easily broken off, when drj", from the head proper. This terminal concretion resembled exactly, in color and approximately in size, the four small concretions which had been found free in the bladder, differing only in being rough and
| |
| not polished or faceted by attrition. This resemblance strongly suggested that
| |
| these four also owned the same source, from the head of the ' hour-glass ' calculus.
| |
| Each weighed about 10 or 12 grains. The second encysted calculus showed a large
| |
| oval facet corresponding to a like facet on the base of the 'hour-glass' calculus. Its
| |
| longer axis had lain at right angles to that of the diverticulum in which it lay. It
| |
| weighed just over half an ounce.
| |
|
| |
| ''Neither in recorded cases nor in museum specimens have I come across any
| |
| instance in which an encj^sted calculus had occupied the apex of the bladder. All
| |
| the records I have found refer to basal or lateral sacculi, such as are commonly
| |
| associated with enlarged prostate and chronic cystitis. This is so, for instance, in
| |
| all the cases of encysted calculus included in the late Sir Henry Thompson's series of
| |
| over 800 cases, the specimens of which are now in the museum of the Royal College
| |
| of Surgeons of England. From the position and relations of the diverticulum this
| |
| case appears to be an example of persistent patency of the lower end of the urachus,
| |
| with calculus formation following, presumably on the accidental lodgment of a small
| |
| concretion in it.
| |
|
| |
| "While urachal cysts are much commoner in the female than in the male, a
| |
| patent condition of the urachus leading to urinary umbilical fistula is much commoner in the male."
| |
|
| |
| A Patent Urachus; Vesical Calculi; Sac-like Dilatations in the Urachus Containing Urinary Calculi; Removal of All the Calculi; Recovery. — During the meeting of
| |
| the Southern Surgical and Gynecological Association held in Cincinnati on December 13, 1915, the President, Dr. Bacon Saunders, of Fort Worth, Texas, told me of
| |
| the following interesting case that came under his care several years ago.
| |
|
| |
| The patient was a boy about eleven years of age. He had had all the classic
| |
| symptoms of stone in the bladder since infancy. Examination disclosed a fistulous
| |
| opening at the umbilicus through which escaped quantities of foul-smelling urine.
| |
| On a line from the umbilicus to the pubic region were five nodules ranging in size
| |
| from a hazelnut to an almond.
| |
|
| |
| A number of small calculi, resembling prostatic stones were removed from the
| |
| bladder. An incision was made over each of the nodules in the mid-line below the
| |
| umbilicus and a stone removed from each. These stones were of the same character as those found in the bladder. Urine escaped from the multiple openings for
| |
| a while, but these openings eventually all closed, and the boy made a satisfactory
| |
| recovery.
| |
|
| |
|
| |
|
| |
| CALCULI ASSOCIATED WITH URACHAL REMAINS.
| |
|
| |
|
| |
|
| |
| 625
| |
|
| |
|
| |
|
| |
| REMOVAL OF VESICAL STONES THROUGH THE UMBILICAL OPENING.
| |
|
| |
| In the chapter on Congenital Umbilical Urinary Fistula (p. 507) I have quoted
| |
| the well-known case of Paget and Bowman. The patient, John Conquest, an iron
| |
| founder, forty years old, had had a urinary fistula at the umbilicus since birth.
| |
| Paget detected a stone in the bladder. The umbilical opening being rather large, he
| |
| introduced a finger, engaged the stone in the urachus, and brought it out through
| |
| the umbilicus. This stone was irregularly ring-shaped, having developed around a
| |
| curled-up hair (Fig. 221, p. 507).
| |
| It was by getting the tip of his
| |
| finger into the central hole in the
| |
| stone that he was enabled to remove it by this route.
| |
|
| |
| Nicaise refers to a case published by Faivre in the Journal de
| |
| mecl. et chir., 1786. The patient,
| |
| a small girl of twelve, had for four
| |
| years passed her urine from the
| |
| umbilicus. The urethra was obstructed by a calculus. Finally
| |
| there was considerable engorgement of the surface of the abdomen, due to the urine escaping
| |
| into the cellular tissue. Faivre
| |
| entered the bladder through the
| |
| umbilicus and removed the stone.
| |
| A sound was introduced into the
| |
| urethra, and the child made a
| |
| complete recovery.
| |
|
| |
| If urinary calculi develop in
| |
| the urachus, they will naturally
| |
| be found near the bladder, as indicated in Fig. 255.
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 255. — A Patent Urachus Containing a Vesical Calculus. (Schematic.)
| |
| The urachus is recognized as an open channel from the upper
| |
| part of the bladder to the umbilicus. Just above the bladder it
| |
| contains a spheric and rough vesical calculus. In the upper part
| |
| of the umbilicus is a small umbilical hernia.
| |
|
| |
|
| |
|
| |
| OTHER CALCULI IN THE UMBILICAL REGION.
| |
|
| |
| On p. 337 we have discussed
| |
| at length the escape of gall-stones
| |
| at the umbilicus. The following
| |
| cases, reported by Kostlin and
| |
| by Bramann, while not strictly germane to the subject, are of considerable interest.
| |
|
| |
| Communication Between the Gall-bladder and the
| |
| Urinary Bladder, With Escape of Gall-stones Through
| |
| the Urinary Tract. — Kostlin* cites the case of a patient whose history
| |
| Faber had already reported in an inaugural dissertation. This woman first had
| |
|
| |
| * Kostlin, O.: Verbindung zwischen Gallenblase und Harnblase, mit Abgang von Gallensteinen durch die Harnwege. Deutsche Klinik, 1864, xvi, 116.
| |
| 41
| |
|
| |
|
| |
|
| |
| 626 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| trouble when thirty-five yea,vs of age. In the autumn of 1834 she had signs of
| |
| peritonitis, with pains in the umbilical region. Later the pain was more marked
| |
| above the symphysis. In October, 1835, she was again ill, this time with bronchopneumonia. On the fourth day there was pain over the symphysis, and the urine
| |
| was blackish green (bile). The patient soon passed gall-stones, large and small, by
| |
| the urethra. The gall-stones were examined chemically. The patient was kept
| |
| under observation for years. She died, at sixty-three, with symptoms of bronchial catarrh and asthma.
| |
|
| |
| Autopsy. — The liver was normal, but the entire organ was situated lower than
| |
| usual. From the middle of the lower edge a rounded cord extended to the base of
| |
| the bladder, passing in front of the intestine and pushing the transverse colon downward and to the left. The cord consisted of two portions — the lower and larger half
| |
| was 1" 7.6"' (about one and three-fourth inches long) and was composed of the
| |
| urachus. The upper, shorter half belonged to the lower portion of the gall-bladder.
| |
| The entire length of this was 3" 1.5"' (about 3}4 inches long). The route which
| |
| the bile and gall-stones traveled was from the gall-bladder through the urachus
| |
| to the urinary bladder.
| |
|
| |
| Kostlin mentions a similar case, reported by Pelletan.* In this case there was
| |
| no autopsy.
| |
|
| |
| Probably a Distended Gall-bladder Opening at the
| |
| Umbilicus.! — The patient was a single woman, sixty-three years of age.
| |
| She had had typhoid when thirteen. At the age of forty-five she had had sudden
| |
| abdominal pain, accompanied by high fever, and there was much discomfort in the
| |
| gall-bladder region. There was a tendency to vomit, and the abdomen was somewhat swollen. A tumor could be made out above and to the right of the
| |
| umbilicus. It was the size of a fist and painful. The tumor persisted, grew slowly,
| |
| and tended to pass more and more downward toward the symphysis.
| |
|
| |
| Two years later a large quantity of foul pus escaped from the umbilicus. Pus
| |
| continued to be discharged in varying amounts from the umbilicus for about sixteen
| |
| years. The patient was otherwise in good condition.
| |
|
| |
| On admission the abdomen was found to be slightly distended. The skin surrounding the umbilicus was covered with crusts, exfoliated epithelium, and small
| |
| cysts. The umbilicus was drawn in, and in its center was a small discharging fistula.
| |
| The escaping pus was foul-smelling. On palpation exactly in the mid-line a long,
| |
| egg-shaped tumor was noted. At the umbilicus this was 5 cm. broad. It extended
| |
| almost to the symphysis, and in its lower portion it was 7 to 8 cm. wide. The tumor
| |
| lay distinctly behind the abdominal wall, and only in the neighborhood of the umbilicus was it intimately attached. In the lower part it was somewhat movable. On
| |
| pressure it was found to be of dense consistence. A sound could be passed 12 cm.
| |
| toward the symphysis and the cavity widened out. Calculi were detected at the
| |
| bottom. Urination was always normal.
| |
|
| |
| Operation. — The abdominal wall was incised for 8 cm. from the umbilicus downward. Four faceted calculi the size of pigeon's eggs were removed, and the tract was
| |
| curetted out. Healing occurred after three months, but in the mean time it was
| |
| necessary to curet the cavity several times. After several vain attempts Bramann
| |
| found in some places many layers of squamous epithelium.
| |
|
| |
| * Pelletan: Jour, de chimie med., 2. ser., ii, Nos. 11 et 12.
| |
| t Bramann, F.: Arch. f. klin. Chir., 1887, xxxvi, 996.
| |
|
| |
|
| |
|
| |
| CALCULI ASSOCIATED WITH URACHAL REMAINS. 627
| |
|
| |
| Microscopic examination of the calculi yielded cholesterin and bile-pigment ; no
| |
| urinary salts.
| |
|
| |
| [The condition might well be explained by a gall-bladder extending into the pelvis
| |
| and at the same time becoming adherent to the umbilicus. Everything points to
| |
| this explanation, although Bramann considered the case to be one of open urachus.
| |
| — T. S. C]
| |
|
| |
|
| |
|
| |
| LITERATURE CONSULTED ON URACHAL CONCRETIONS AND URINARY CALCULI
| |
|
| |
| ASSOCIATED WITH URACHAL REMAINS.
| |
| Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832.
| |
| Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., 1887,
| |
|
| |
| xxxvi, 996.
| |
| Civiale, J.: Traite de l'affection calculeuse, Paris, 1838, 257.
| |
|
| |
| Dykes, C: Patent Urachus and Encj r sted Urinary Calculi. The Lancet, 1910, i, 566.
| |
| Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch, der
| |
|
| |
| Heilkunde, 1870, xi, 373.
| |
| Kostlin, O.: Verbindung zwischen Gallenblase und Harnblase, mit Abgang von Gahensteinen
| |
|
| |
| durch die Harnwege. Deutsche Klinik, 1864, xvi, 116.
| |
| Ledderhose, G.: Chir. Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b.
| |
| Luschka, H.: Ueber den Bau des menschlichen Harnstranges. Arch. f. pathologische Anatoniie
| |
|
| |
| u. Physiologie u. f. klin. Med., 1862, xxiii, 1.
| |
| Monod, J.: Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,
| |
|
| |
| 1899, No. 62.
| |
| Nicaise: Ombilic. Diet, encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv, 140.
| |
| Phillips, B.: Persistence of the Urachus. Todd's Cyclopaedia of Anatomy and Physiology,
| |
|
| |
| 1835, i, 393.
| |
| Rokitansky, C: Pathologische Anatomie. 3. Aufl., Wien, 1861, hi, 372.
| |
| Simon, C: Quels sont les phenomenes et le trait ement des fistules urinaires ombilicales. These
| |
|
| |
| de Paris, 1843, No. 80.
| |
| Suchannek, H.: Beitrage zur Kenntnis des Urachus. Inaug. Diss., Konigsberg, 1879.
| |
| Veiel, E. : Die Metamorphose des Urachus. Diss., Tubingen, 1862.
| |
| Vosburgh, H. D. : Patent Urachus with Calculus. Medical Record, New York, 1877, 606.
| |
| Weiser, W. R.: Cysts of Urachus. Annals of Surg., 1906, xliv, 529.
| |
| Worster, J.: Case of Vesico-abdominal Fistula of Fourteen Years' Standing. Medical Record.
| |
|
| |
| 1877, xii, 196.
| |
| Wutz, J. B.: Ueber Urachus und Urachuscysten. Virchows Arch., 1883, xch, 387.
| |
|
| |
|
| |
|
| |
| ==Chapter XXXVII. Malignant Changes in the Urachus==
| |
|
| |
| Carcinoma of the urachus.
| |
|
| |
| Historic sketch.
| |
|
| |
| Symptoms.
| |
|
| |
| Report of cases.
| |
| Sarcoma in the urachal region.
| |
| An extraperitoneal abdominal tumor.
| |
|
| |
| A large multilocular carcinomatous cyst of the urachus; secondary growths in the pelvis (personal observation).
| |
| A rare umbilical cyst.
| |
|
| |
| CARCINOMA OF THE URACHUS.
| |
|
| |
| I have been able to find three cases of carcinoma of the urachus recorded in
| |
| the literature.
| |
|
| |
| Sex. — All of the patients were men. Two of the patients had had congenital urinary fistula? at the umbilicus, and in each of these the discharge of urine
| |
| had ceased after the use of escharotics. The third patient also evidently had a
| |
| congenital fistula, as he gave a history of "moisture at the umbilicus" during
| |
| childhood. This had ceased without treatment.
| |
|
| |
| Age. — The patients were twenty-five, twenty-seven, and thirty-two respectively, indicating that, when carcinoma of the patent urachus develops, the malignant change occurs in early adult life.
| |
|
| |
| Hoffmann and Fischer gave very careful and full histories of their cases. Hoffmann's patient, when twenty-seven years of age, noted a raised hardening between
| |
| the umbilicus and symphysis. It was the size of a goose's egg, non-painful, and
| |
| movable from side to side. It gradually extended toward the symphysis and right
| |
| inguinal region.
| |
|
| |
| Shortly after the tumor was noticed the patient experienced pain on urination.
| |
| At times the urine was abundant, at times it came drop by drop. The man rapidly
| |
| grew weaker and lost 25 pounds in four months. When Hoffmann saw him. the
| |
| umbilicus presented a peculiar radiating appearance, while in the mid-line, just below
| |
| the umbilicus, was a roundish, nodular tumor, 8 to 10 cm. long, adherent to the umbilicus and very painful. After the patient had urinated an area of tympany could
| |
| be elicited between the tumor and the symphysis. On account of tenesmus, the
| |
| patient urinated every hour. The urine contained pus and aggregations of epithelial cells.
| |
|
| |
| The tumor became fluctuant, ruptured, and a large amount of purulent and
| |
| bloody fluid escaped, but the growth did not diminish in size. From time to time
| |
| onion-like balls escaped with the pus. These consisted of quantities of squamous
| |
| epithelial cells that had become agglutinated. Precisely similar balls escaped in
| |
| Fischer's case.
| |
|
| |
| The urethra was normal.
| |
|
| |
| 628
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. 629
| |
|
| |
| The umbilical opening closed temporarily, but soon reopened, and in the late
| |
| stages of the disease the inguinal glands were swollen.
| |
|
| |
| As noted in the autopsy report, the cavity between the umbilicus and bladder
| |
| had walls 1 cm. thick. Its inner surface had an irregular, ulcerated, and eaten-out
| |
| appearance (Fig. 256). The bladder-wall had been involved by continuity, and also
| |
| contained secondary nodules. The growth was a squamous-cell carcinoma.
| |
|
| |
| Fischer's patient, when thirty-one years old, first noted a small, hard tumor the
| |
| size of a pigeon's egg below the umbilicus. Seven or eight months later he had pain
| |
| on micturition, and noticed a sediment in the urine. The nodule was incised on the
| |
| supposition that it was fluctuant, and slimy, necrotic tissue escaped. The tumor
| |
| soon grew out of the incision, bled a great deal, and finally left an ulcerated area, the
| |
| walls of which were raised and hard, while the floor consisted of hard nodules. From
| |
| the ulcerated area onion-like balls of epithelial cells escaped.
| |
|
| |
| The inguinal glands on both sides became swollen. At autopsy the bladder
| |
| mucosa showed a catarrhal swelling, but no involvement by the malignant growth.
| |
| The prostate was normal. The growth was a carcinoma, evidently of the squamouscell type, as indicated by the onion-like balls.
| |
|
| |
| Death in these cases may occur from gradual weakening as a result of the disease, or from a perforation of the growth posteriorly into the abdominal cavity,
| |
| causing a peritonitis. The occurrence of three cases of carcinoma of the urachus
| |
| is another point in favor of the early removal of the patent urachus.
| |
|
| |
| In the future cancer of the urachus, when met with, will undoubtedly be operated on early. The growth can be given a relatively wide berth, and the block dissection should include the inguinal glands on both sides.
| |
|
| |
| Cases of Carcinoma of the Urachus Developing Years After the Closure of a
| |
|
| |
| Congenital Patent Urachus.
| |
|
| |
| Carcinoma Evidently D e v e 1 o p i n g F r o m Remains of
| |
| the Urachus. — Fischer* saw this patient in consultation with Hanuschke in
| |
| 1874. The man, thirty-two years of age, sought treatment on account of an ulcer
| |
| of the umbilicus. During his childhood, when voiding, there was a moisture at the
| |
| umbilicus. Later these symptoms disappeared and there was never any trouble with
| |
| urination. Early in 1873 he casually noticed below the umbilicus a hard tumor the
| |
| size of a pigeon's egg. This gave rise to no symptoms. It gradually grew, and seven
| |
| or eight months later there were pain and a burning sensation on micturition and sediment in the urine. Toward the end of 1873 he consulted a physician. The difficulty in urination had increased, and the tumor had grown markedly. His general
| |
| condition was not satisfactory. Hanuschke thought that the tumor was soft, and
| |
| that he could make out fluctuation. Accordingly he made an incision, and purulent, slimy masses escaped — evidently pieces of necrotic tissue. The tumor mass
| |
| grew out of the incision wound ; it very soon broke down, with a good deal of bleeding, and an ulcer resulted. When Fischer saw the patient, he was pale and weak,
| |
| had difficulty in micturition, and suffered from strangury. The ulcer was situated
| |
| 2 cm. below the umbilicus, and formed a deep crater, which was heart-shaped. Its
| |
| walls were elevated, hard, and extended below the level of the skin about 4 cm. Its
| |
| greatest breadth was 8 cm. Its greatest length, 7 cm. The floor was very irregular
| |
|
| |
| * Fischer: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, n. F. No. 89 (Chir. No. 24), Leipzig, 1894, 519.
| |
|
| |
|
| |
|
| |
| 630 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| and covered with hard nodules. It reached a depth of 5 cm. below the skin surface. Surrounding the ulcer the tissue was hard. On pressure there escaped a thin,
| |
| bloody, foul-smelling pus from the ulcer, and there were also portions of the tumor
| |
| forced out as small balls suggesting onions. These were composed of quantities of
| |
| flat epithelial cells.
| |
|
| |
| The urine was acid, slightly cloudy, and had a purulent sediment. The inguinal
| |
| glands on both sides were swollen.
| |
|
| |
| Complete removal of the growth was impossible. The abdominal walls, however, were split in the mid-line as far as the symphysis, and beneath the muscle thick,
| |
| pork-like tumor masses were found adherent. As much of the tumor as possible
| |
| was removed, and the cautery was employed. The patient died fourteen days
| |
| after the operation. Microscopic examination of the tumor mass showed it to be a
| |
| carcinoma. At autopsy the inner surface of the bladder was found to show catarrhal
| |
| swelling. It was intact. There was no abnormality in the prostate. The intestines
| |
| were normal.
| |
|
| |
| A Patent Urachus, Closure; Later Carcinoma of the
| |
| Urachus.* — This case was also mentioned in the Deutsche Klinik, 1864, xvi,
| |
| 116. The patient was a man, twenty-eight years of age, who had a urachal fistula
| |
| at birth. This was healed with escharotics. Twenty-five years later a tumor
| |
| developed between the umbilicus and the symphysis. This broke and discharged
| |
| pus and later urine. The autopsy revealed a carcinoma of the mucosa of the
| |
| urachus, which had perforated into the umbilicus and into the bladder.
| |
|
| |
| A Patent Urachus Partly Closed by the Use of Escharotics; Later, Carcinoma of the Urachus. — Hoffmannf first
| |
| reports the case of Hermann R., in which there was an enormous sac formation and
| |
| accumulation of fluid outside of the abdomen. This Hoffmann attributed to a
| |
| dilated urachus.
| |
|
| |
| Hoffmann reports the case of Alexander Wanner, a postal employee, who
| |
| was born in 1841 with an opening at the umbilicus through which urine
| |
| escaped, while it also passed from the urethra. This condition lasted until
| |
| his third year, when the opening closed after the use of escharotics. The
| |
| patient had no further difficulty, and with the exception of several inflammations of the eye was perfectly well. About the middle of the year 1868
| |
| he noticed between the umbilicus and the symphysis, near the umbilicus, a
| |
| raised hardening of the abdomen about the size of a goose's egg, which was
| |
| not painful and could be pushed from side to side. This gradually grew and
| |
| extended toward the symphysis, and spread toward the right inguinal region.
| |
| Shortly after the appearance of the tumor the patient began to have pain on urination. The urine sometimes came in an abundant stream; at other times only in
| |
| drops. As a result the patient had a continuous desire to urinate. The pains
| |
| became severe and he grew weaker. He had lost weight — in the last four months,
| |
| 25 pounds. On admission to the hospital, November 10, 1868, he weighed 99
| |
| pounds, was poorly nourished, anemic, and had a peculiar radiating formation
| |
| of the umbilicus, in the folds of which no opening could be discovered. Immediately
| |
| below the umbilicus was a tumor, 8 to 10 cm. long, situated in the middle line. It
| |
|
| |
| * Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.
| |
| t Hoffmann: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch. d.
| |
| Heilkunde, 1870, xi, 373.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. 631
| |
|
| |
| was roundish, nodular, very painful, and adherent to the umbilicus, but on both
| |
| sides it was free. After urination, between the tumor and the symphysis was an
| |
| area of tympany. On account of the tenesmus the patient urinated every hour,
| |
| and the urine contained pus and aggregations of epithelial cells. The patient drank
| |
| quantities of soda-water and local applications were made. His pain diminished,
| |
| but the tumor continued to grow. The umbilicus became prominent, fluctuation
| |
| was detected, and on December 1st the swelling broke and a large quantity of
| |
| thick, purulent, bloody fluid escaped. The tumor, however, did not diminish in
| |
| size, although the pain became less and less. In the fluid numerous onion-like
| |
| balls were found. These consisted of large quantities of squamous epithelial cells
| |
| which had become agglutinated.
| |
|
| |
| Examination of the urethra with a bougie yielded nothing abnormal. The
| |
| prostate was not enlarged, the bladder-wall was thick and did not contract completely after the escape of urine. From September 4th urine and purulent fluid
| |
| often escaped from the umbilicus, and the urine passed from the bladder from
| |
| that time on was cloudy. The opening at the umbilicus gradually contracted, and
| |
| for some time only purulent fluid escaped from it. The tumor became smaller, and
| |
| toward the middle of January, 1869, the umbilicus closed completely.
| |
|
| |
| Diarrhea developed and marked emaciation. At the end of January the opening at the umbilicus reappeared, and a purulent-like material escaped. The pain
| |
| became more severe. The inguinal glands were swollen and the patient grew weaker.
| |
| On January 31st he weighed 88 pounds. He died in the middle of May, 1869.
| |
|
| |
| Only an incomplete autopsy could be obtained. The family physician who
| |
| made it said there were appearances of peritonitis. The umbilicus had a peculiar,
| |
| radiating, stellar appearance, and there was an opening 3 mm. in diameter. Through
| |
| this there was a passage going downward and backward into a canal which gradually widened. The cavity had walls 1 cm. thick. It extended from the umbilicus
| |
| to the top of the bladder. It was 10 cm. in length, and in its middle portion was
| |
| 2.5 cm. broad. The entire inner surface presented an ulcerated, irregular, much
| |
| eaten-out, reddish appearance (Fig. 256).
| |
|
| |
| At its lower part this cavity communicated with the bladder by an opening
| |
| 3.3 cm. broad, and the posterior wall of the bladder was invaded by this ulcerated
| |
| growth over an area 4 cm. in diameter. The bladder-walls, where invaded, were
| |
| 1.8 cm. thick, while the unchanged portions were 0.8 cm. thick. At the point
| |
| where the cavity communicated with the bladder posteriorly was a perforation, the
| |
| exact size of which could not be determined on account of the tearing of the specimen. The bladder mucosa, on the whole, looked normal, but at one point in the
| |
| anterior wall was a round nodule, 1 cm. in diameter; in the posterior wall were
| |
| several smaller ones.
| |
|
| |
| Microscopic examination showed that the growth of the urachus was a squamouscell carcinoma, and that the secondary nodules were also carcinomatous.
| |
|
| |
| Hoffmann says that this patient was born with a patent urachus. The opening
| |
| at the umbilicus had closed after the use of escharotics in the third year. In the
| |
| twenty-seventh year a carcinoma developed in the urachus and extended to the
| |
| bladder. The perforation caused by the cancer led to a local peritonitis.
| |
|
| |
| A Urachal Cyst and Cancer of the Bladder Occurring
| |
| Independently. — ■ Rotter's case may well be considered here. The urachus
| |
|
| |
|
| |
|
| |
| 632
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
|
| |
| J- 'ig. 256. — Carcinoma of the Patent Ubachus. (After C. E. E. Hoffmann.)
| |
| A is a partially diagrammatic picture: ", The anterior abdominal wall; b, the opening of the urachus at the umbilibe urachus, which is occupied by a carcinoma; at d the growth has broken through into the abdominal cavity;
| |
| < , the bladder. At points /, /, /, /, on the bladder mucosa are small secondary carcinomatous masses. B represents the
| |
| appearance of the umbilicus with the opening of the urachal fistula in its center.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. 633
| |
|
| |
| was the seat of a cyst and the bladder showed a carcinoma. The one was absolutely independent of the other.
| |
|
| |
| Rotter's* patient was a forty-three-year-old man, who, for nine months, had
| |
| had bleeding from the bladder. Cystoscopic examination showed a tumor in the
| |
| upper portion of the bladder. This did not grow rapidly. Above the symphysis,
| |
| and reaching to the umbilicus, was another tumor, which on aspiration yielded a
| |
| fluid containing cholesterin. This tumor was diagnosed as a urachal cyst. At
| |
| operation the upper tumor was found lying between the peritoneum and the abdominal muscles. In its upper portion it was free, but over the lower half it was so
| |
| intimately blended with the peritoneum that it was necessary to remove a portion
| |
| of the peritoneum with the tumor. The urachal tumor pressed so into the bladder
| |
| muscle that it was also necessary to open this viscus.
| |
|
| |
| The cancer of the bladder was removed, and a defect 7 by 8 cm. in the bladder
| |
| closed by layers. This patient was shown by Rotter at the Berlin Surgical Society.
| |
| Microscopic examination demonstrated carcinoma of the bladder. This had perforated at the point where the cyst was found. The cyst contained many polymorphous epithelial cells. There was no doubt that it was a urachal cyst.
| |
|
| |
| Possibly an Adenocarcinoma of the Urachus. — I am at
| |
| a loss where to place this case of Koslowski's.f The situation of the tumor suggests a urachal growth. Furthermore, the variation in the size of the glands might
| |
| very readily correspond to the cyst-like spaces we have noted where isolated segments of the urachus have persisted. The invasion of the rectus sheath and of the
| |
| rectus muscle naturally points toward malignancy. We shall accordingly leave this
| |
| case among those of carcinoma of the urachus. Whether it really belongs here or
| |
| not is problematic.
| |
|
| |
| The patient was a man, fifty-five years of age, who five weeks before had noticed
| |
| in the mid-line, between the symphysis and the umbilicus, a small, painful tumor
| |
| which grew to the size of a walnut. This man was markedly emaciated, looked to
| |
| be seventy years of age, had frequent diarrhea, and was bent over from guarding
| |
| the abdominal muscles. Between the umbilicus and symphysis, near the mid-line,
| |
| was a tumor which suggested a patella. The overlying skin was free. The tumor
| |
| was slightly movable and very painful. It felt very tense, and gradually merged
| |
| into the surrounding tissue. Passing from the tumor toward the umbilicus was a
| |
| cord the size of a goose-quill. Koslowski thought the tumor was a malignant
| |
| epithelial growth developing from remains of the urachus.
| |
|
| |
| Operation. — A median incision showed that the linea alba and sheath of the
| |
| rectus had been penetrated by the tumor. An elliptic incision encircled the umbilicus and the tumor. Removed with the tumor were portions of the sheath of the
| |
| recti and some of the rectus muscle, the transversalis fascia, and peritoneum. After
| |
| the abdomen was opened, the tumor was drawn up and brought into view fibrous
| |
| cords passing to the umbilicus. The upper cord was the size of a goose-quill, firm,
| |
| and infiltrated. The lower cord was less firm and contained veins; these passed
| |
| into the vesico-umbilical ligament. The peritoneum covering the posterior surface
| |
| of the tumor showed evidence of scar and of ulceration. The patient made a good
| |
| recovery. The tumor in form resembled a patella. The peritoneum was firmly
| |
|
| |
| * Rotter: Blasencarcinom combinirt mit Urachuscyste. Centralbl. f. Chir., 1897, xxiv, 604.
| |
| t Koslowski, B. S.: Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir.. 1903,
| |
| lxix. 469.
| |
|
| |
|
| |
|
| |
| 634 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| attached to it. The surrounding muscle was penetrated by the tumor. Microscopic examination showed that it was made up of glands of various sizes. They
| |
| varied from the size of urinary tubules to those large enough to be noted with the
| |
| naked eye. The diagnosis was fibro-adenoma submalignum. The glands resembled
| |
| intestinal glands.
| |
|
| |
| [It is difficult to establish the exact character of this tumor. — T. S. C]
| |
|
| |
|
| |
|
| |
| SARCOMA IN THE URACHAL REGION.
| |
|
| |
| Frank, in 1893, recorded a very interesting case of sarcoma probably developing
| |
| in the sheath of the urachus in a young lad. Unfortunately, the subsequent history
| |
| of the case is lacking, but the histologic picture of the growth, the invasion of the
| |
| muscles of the abdominal wall, and the secondary nodules in the omentum leave
| |
| no doubt as to its malignancy.
| |
|
| |
| Alban Doran reports a case of sarcoma developing in the wall of a cyst of the
| |
| urachus. This is so interesting that I shall also record it in detail.
| |
|
| |
| Sarcoma Probably Developing in the Sheath of the
| |
| Urachus. — Frank* gives a good resume of the literature and reports the
| |
| case of a boy eleven years of age. For several weeks he had had loss of appetite
| |
| and was losing weight. About fourteen days before the boy came under observation the father noticed a swelling in the umbilical region, and from a small opening
| |
| at the umbilicus a little pus could be pressed. There was no urinary difficulty and
| |
| no discomfort on defecation. The urine, however, had recently became cloudy and
| |
| stringy. The child's mother had died of pulmonary disease, otherwise the family
| |
| history was good.
| |
|
| |
| On examination the boy was found to be strong and well nourished. In the
| |
| umbilical region was a hard, circumscribed thickening, only slightly painful on
| |
| pressure, reaching about a fingerbreadth above the umbilicus. Here it could be
| |
| traced three fingerbreadths to the right and to the left of the linea alba. Below
| |
| it extended almost to the symphysis. The skin over the tumor was only slightly
| |
| movable. A sound introduced into the sinus passed from 4 to 6 cm. downward.
| |
| With a sharp curette friable, sanguineopurulent masses were removed. These on
| |
| examination were found to consist of pus-cells, granulation tissue, and debris.
| |
|
| |
| Operation. — An elliptic incision was made, commencing 3 cm. above the umbilicus. The recti muscles at the umbilicus were found to be infiltrated by the growth.
| |
| The incision was then carried through healthy muscle to the peritoneum. Loops
| |
| of small bowel were adherent to the peritoneal surfaces of the tumor, and nodules
| |
| were found scattered throughout the omentum. The tumor was gradually turned
| |
| out ward and was removed without much difficulty. Its lower end was intimately
| |
| adherent to the bladder, and the outer walls of this viscus were removed and
| |
| the small opening in it was closed. The omentum was removed on account of
| |
| the tumor nodules. The abdomen was closed with difficulty. The patient's
| |
| recovery was slow.
| |
|
| |
| The tumor, on section, was found to have invaded the recti in all directions.
| |
| Its chief extension was along the course of the urachus as far as the bladder. The
| |
| tumor itself, with the surrounding parts, was as large as a man's fist, and was nodular and uneven.
| |
|
| |
| * Frank, Theodor: Zur Casuistik der Urachustumoren. Inaug. Diss., Wurzburg, 1893.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. 635
| |
|
| |
| On microscopic examination the sarcomatous character of the tumor was evident. In the center of the tumor the intercellular substance was most marked, but
| |
| toward the periphery it consisted almost entirely of spindle-cells with little connective tissue. The growth of the spindle-cells into the recti and into the bladder
| |
| was especially evident. The entire picture indicated that the tumor had developed
| |
| in the connective-tissue layers of the urachus and that it had then spread out in all
| |
| directions.
| |
|
| |
| The case is perfectly clear, but there is no after-history beyond two months, and
| |
| no description of the omental nodules.
| |
|
| |
| AUniqueSpecimenofCystic Sarcomaof the Urachus.*
| |
| — Alban Doran says: "Mr. F. S. Eve has presented to the Museum of the Royal
| |
| College of Surgeons of England a unique specimen of cystic sarcoma of the urachus,
| |
| and has kindly supplied me with the following notes :
| |
|
| |
| ' ' A man, aged thirty-eight years, was admitted into the London Hospital with
| |
| a swelling in the hypogastrium noticed for several weeks and associated with pain
| |
| after micturition. A cystic tumor filled the lower part of the abdomen, especially
| |
| to the right, where it extended toward the loin. It did not dip into the pelvis.
| |
| On puncture, dark blood came away; a few days later a rigor occurred, with vomiting and a rise of temperature to 104° F. Mr. Eve then operated, exposing a large
| |
| cystic tumor; the parietal peritoneum was reflected over its anterior and superior
| |
| surfaces. Five pints of dark, bloody material were removed. The cyst adhered to
| |
| the omentum, which bore engorged veins, and to an inch and a half of small intestine which was infiltrated where adherent. The adherent portion of the wall of the
| |
| gut was excised, and the wound closed with sutures. The lower part of the cyst
| |
| was intimately connected with the bladder, the serous coat of which organ was
| |
| reflected onto its surface. This peritoneal covering was divided, and the cyst carefully dissected away from the bladder. During the process the bladder was opened,
| |
| for the vesical wall at this point was so thin that the cavities of the cyst and the
| |
| bladder were only separated by the vesical mucous membrane covered by a few
| |
| muscular fibers. The opening was sutured, but not without great difficulty, owing
| |
| to the thinness of the walls at this point. The sutures were further protected by
| |
| gauze packing. A gauze drain was passed into the pelvis, and a catheter retained
| |
| for a while in the bladder. Neither flatus nor feces could be made to pass after the
| |
| operation, and the patient died on the fourth day. There was no general peritonitis, but the pelvic peritoneum had become inflamed at the point where the
| |
| gauze had been applied.'
| |
|
| |
| "Mr. Eve examined the specimen and found that it was a large allantoic cyst
| |
| separated from the posterior superior surface of the bladder by nothing except a
| |
| very much thinned mucous membrane. Their cavities, however, did not. communicate. The inner wall of the cyst was lined at certain points with very vascular
| |
| polypoid masses, which proved to be, on microscopic examination, sarcomatous.
| |
| The most unusual feature of this cyst was its malignancy, but its peritoneal relations were of greater importance in respect to the subject of this communication."
| |
|
| |
|
| |
|
| |
| AN EXTRAPERITONEAL ABDOMINAL TUMOR.
| |
| The following interesting case, the specimen from which was exhibited by Dr.
| |
| Aveling, may be considered here, although from the description one could not say
| |
| * Doran, Alban H. G.: The Lancet, 1909, i, 1304.
| |
|
| |
|
| |
|
| |
| 636 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| that the growth was a sarcoma. It may serve, however, to form the nucleus around
| |
| which similar cases may be collected.
| |
|
| |
| Dr. Aveling* exhibited before the British Gynecological Society a subperitoneal tumor which had grown in the anterior abdominal wall and reached from two
| |
| inches above the umbilicus to the pubes. It was removed after death, the patient
| |
| having succumbed after an exploratory operation. Sir Spencer Wells, who saw the
| |
| tumor, said he had seen only two similar cases, and he classified the tumor, according to Virchow, as a fibroma molluscum cysticum abdominale. The specimen was
| |
| referred to Mr. Bland-Sutton and Dr. Aveling for further examination.
| |
|
| |
| The tumor was ovoid in shape, and measured 10 inches in length, 7 inches in
| |
| width, and weighed 4% pounds. It was surrounded by a distinct, thick, fibrous
| |
| capsule. On section the tissue was of a dirty white color, and the cut surface
| |
| looked like a sponge. The loculi were filled with gelatinous tissue, which readily
| |
| broke down on scraping the cavities with the handle of a scalpel. Inside the growth
| |
| six or seven hard nodules, of the size of walnuts, could be felt. These, when dissected out and divided, looked like small leiomyomata, such as occasionally exist
| |
| in the uterus. They presented the same whorled arrangement of the fibers, and
| |
| corresponded with them histologically. On microscopic examination of the tumor
| |
| the outer portion was found to consist of non-striped muscle-fibers, some of large
| |
| size. Internal to this the cells assumed more the shape and characters of those
| |
| seen in spindle-cell sarcomata, while the gelatinous material contained in the loculi
| |
| was the result of mucoid degeneration of the sarcomatous elements.
| |
|
| |
| Sutton and Aveling then go on to say that the specimen was of great interest
| |
| from an etiologic standpoint. "Man, in common with other mammals, possesses
| |
| a persistent pedicle of the allantois, familiar under the name of the urachus. This
| |
| structure is frequently found dilated into a cyst, usually of small size. An account
| |
| of these allantois cysts, with reference to a few recorded cases, will be found in the
| |
| Path. Soc. Trans., xxxvi, 523." They drew attention to the fact that Mr. Lawson
| |
| Tait, in his work on Diseases of the Ovaries, had described certain growths which
| |
| he regarded as probably originating in the urachus, and which attained such considerable dimensions as to require operative interference.
| |
|
| |
| They thought that, in the present case, they had to deal with an allantois cyst,
| |
| the walls of which had become sarcomatous, thus affording another illustration of
| |
| the great tendency exhibited so often by aberrant and ill-developed structures to
| |
| become the seat of morbid growths, such as sarcoma or carcinoma.
| |
|
| |
| [After a somewhat careful study of the literature on the subject of umbilical
| |
| tumors, the interpretation of Bland-Sutton and Aveling is not altogether clear. It
| |
| would rather seem as if we are dealing with a myoma. The gross description speaks
| |
| of non-striped muscle, and this the histologic picture substantiates. The gross and
| |
| histologic appearance of the nodule coincides with the appearances presented by
| |
| uterine myomata. The areas that were supposed to be sarcomatous and inclosed
| |
| cavities presenl ing a m ucoid appearance might very readily have been due to hyaline
| |
| degeneration. Without an opportunity of examining their specimen we should hesitate to express any definite opinion as to this case, further than that their interpretation does not seem to tally with the recorded cases of secondary growths attributed
| |
| to the allantois. — T. S. C]
| |
|
| |
| Doran* says that Aveling and Bland-Sutton had already reported a case of
| |
|
| |
| * Aveling: Brit. Gyn. Jour., 1886-87, ii, 56 and 187.
| |
| t Doran, Alban H. G. : The Lancet, 1909, i, 1304.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS.
| |
|
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|
| |
|
| |
| 637
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|
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|
| |
|
| |
| multilocular myxosarcoma of the sheath of the urachus, but it did not involve the
| |
| urachal canal, and was quite unconnected with the bladder. The specimen (No.
| |
| 417 b) in the pathologic series of the Museum of the Royal College of Surgeons of
| |
| England was supposed, when first examined, to have developed in the urachus, but
| |
| Mr. J. H. Targett considered that it was a myxosarcoma which had originated in
| |
| the connective tissue surrounding the bladder.
| |
|
| |
| After I had made my comment on Aveling and Bland-Sutton's case, Alban
| |
| Doran's note on the case came to my notice, clearly showing a lack of unanimity
| |
| of opinion among those who had examined the specimen, not only as to the exact
| |
| character of the tumor, but also as to its precise source of origin.
| |
|
| |
|
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|
| |
| Multilocular urachus cvsi
| |
|
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|
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|
| |
| Omentum, adherent"
| |
| to tumor
| |
|
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|
| |
|
| |
|
| |
| Fig. 257. — A Multilocular and Malignant Cyst of the Urachus.
| |
| Gyn.-Path. Nos. 10368 and 1048S. The cyst lay between the abdominal muscles and the peritoneum of the
| |
| anterior abdominal wall. Below it was attached by a pedicle near the top of the bladder. Upward it extended for
| |
| a considerable distance above the umbilicus. The omentum was densely adherent to its upper surface. The cyst -wall
| |
| anteriorly was so thin that I cut it, thinking that it was peritoneum. The cyst is composed of one large and many
| |
| smaller cavities. Projecting into the large cyst are many smaller cysts, and papillary and solid growths spring from the
| |
| inner surface of the cyst. Some of the smaller cysts have smooth walls, as is well seen in the one near the pedicle of the
| |
| tumor. Cross-sections of other small cysts show that they are partially filled with secondary growths. It will be
| |
| noted that the uterus, tubes, and ovaries are absolutely independent of the cystic tumor. They are, however, partially
| |
| covered over with secondary cancerous nodules. (For the histologic appearances in this case see Figs. 261, 262, 263.)
| |
|
| |
|
| |
|
| |
| A LARGE MULTILOCULAR CARCINOMATOUS CYST OF THE URACHUS; SECONDARY
| |
|
| |
| GROWTHS IN THE PELVIS.
| |
|
| |
| I saw Mrs. W. W., aged thirty-seven, in consultation with Dr. E. S. Mann, of
| |
| Dallastown, Pa., and had her admitted to the Johns Hopkins Hospital, October 6,
| |
| 1906. This patient had never been pregnant. Her menses had commenced at
| |
| fourteen and had always been regular until the previous year. Her last period
| |
| had occurred sixteen months before admission. About two years before I saw her,
| |
|
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|
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|
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| 638
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|
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|
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|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| she had noticed, on moving, a sharp, sticking pain in the left lower abdomen. For
| |
| about a year and a half she had had some abdominal enlargement, and eight weeks
| |
| before admission the abdomen had commenced to swell a great deal. The feet and
| |
| legs had also been swollen. The patient gave a history of having lost 20 pounds in
| |
|
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|
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|
| |
| ■■■:■•■ H.V.?^. • •: .- -•• ■ »I ■..'■:■•• -. >-..••••.'.'• ■ ",/ .-. ■ <■«, '.. . . >? • • ■ '. .v. • • •
| |
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| |
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| |
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| -.
| |
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| |
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| |
|
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| |
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| |
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|
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|
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| -VV'-^v
| |
|
| |
|
| |
|
| |
| c
| |
| Fig. 258. — Giant-cells in the Wall op an Adenocarcinomatous Cyst of the Urachus. (X 90 diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. Occupying the center of the field are slit-like spaces lined on one or both sides
| |
| with giant-colls. The most perfect picture is that seen at a. At 6 is a giant-cell lying in the stroma. From this picture
| |
| as a whole one gets the impression that these slit-like spaces may be due to the cracking of brittle giant-cells. At c
| |
| are the epithelial cells lining a gland-like space of the carcinomatous cyst. Scattered throughout the field are quantities
| |
| of small round-cells. Many of these have absorbed brown pigment, have swollen up, and at first sight look like vacuoles.
| |
| In the center of these pale round or oval spaces the small round, deeply staining nucleus is still clearly visible. At d
| |
| the stroma has undergone almost complete hyaline transformation.
| |
|
| |
|
| |
|
| |
| the past six months. She had had dysuria, and had had to void four or five times
| |
| during the night.
| |
|
| |
| On admission it was noted that she was a well-nourished woman, weighing 172
| |
| pounds. The abdomen was markedly distended. It rose rather abruptly from
| |
| the symphysis to the umbilicus, and then gradually shaded off to the xiphoid. On
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS.
| |
|
| |
|
| |
|
| |
| 639
| |
|
| |
|
| |
|
| |
| percussion fluid was evident in all parts of the abdomen. About two months
| |
| before she had noticed large and small lumps in various parts of the abdomen.
| |
| Some of these were fully an inch in diameter, and they had sharp edges.
| |
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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| y\i
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|
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|
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|
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| ;
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|
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|
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|
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|
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|
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|
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|
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|
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|
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| v.
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|
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|
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|
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| mi
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|
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|
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|
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| /**\ \
| |
|
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|
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|
| |
| Fig. 259. — Giant-cells in the Wall of an Adenocarcinoma of the Urachus. ( X 90 diam.)
| |
| Gyn.-Path. Nos. 10368 and 104SS. At a is a slit-like space lined on both sides with a large giant-cell. The nuclei
| |
| of the giant-cells are irregularly distributed and stain deeply. Extending from one end of the space to the other is a
| |
| delicate strand. This, under a higher power, was found to contain two small nuclei. At b is an irregular oblong space
| |
| with a large giant-cell in the center of its upper margin, and an irregular mass of protoplasm containing numerous nuclei
| |
| bordering its lower margin; projecting into the cavity from either end are delicate filaments of stroma devoid of nuclei.
| |
| At c is a series of parallel slits. The tissue at this point consists of hyaline material. Most of these slits have no lining
| |
| whatsoever, but both the upper and lower slit have small giant-cells attached to their margins. At d is a slit-like space
| |
| lined with giant-cells, e is a giant-cell that could be clearly focused at another level. It was irregularly triangular in
| |
| shape, and contained a quantity of oval, uniformly staining nuclei arranged chiefly at one end of the cell. There were
| |
| other giant-cells scattered throughout the field. The protoplasm of some of these was brownish in color, apparently
| |
| owing to the absorption of old blood-pigment. The stroma of the cyst-wall in this region consisted of fibrous tissue.
| |
| In the vicinity of these giant-cells and in the neighborhood of the slit-like spaces it showed a great deal of hyaline trans
| |
| formation; many of the small round-cells that still persisted were swollen and contained a yellowish or brownish pigment — undoubtedly caused by old hemorrhage.
| |
|
| |
|
| |
|
| |
| On pelvic examination the cervix was found to be perfectly normal; nothingfurther could be made out.
| |
|
| |
| Operation (October 8, 1906). — On opening the abdomen I immediately came
| |
|
| |
|
| |
|
| |
| 640
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| •
| |
|
| |
|
| |
|
| |
| >>
| |
|
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| <a
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| a
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| |
| mm ise*
| |
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| ipm
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| d
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| C
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| /^ -->' , -" * ' ■.."".'-' ; I-- :'_ - 1^
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| |
| Fig. 260.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. G41
| |
|
| |
| in contact with the contents of a cyst. This cyst was large, multilocular, and
| |
| intimately adherent to the anterior and lateral abdominal walls (Fig. 257). At
| |
| first I thought it was impossible to remove it, but on continuing the incision upward
| |
| we entered the general peritoneal cavity. I then delivered the tumor from above
| |
| downward. Its pedicle sprang from the top of the bladder. This pedicle was 1
| |
| cm. broad and 2 mm. thick. Raw areas were left, both on the anterior and lateral
| |
| abdominal walls. The bleeding was checked by sliding over the peritoneum as far
| |
| as possible, thus bringing the raw areas together and diminishing the size of the
| |
| denuded space.
| |
|
| |
| Both ovaries were normal in size, but were somewhat glued down to the pelvic
| |
| floor. As the pedicle of the cyst sprang from the bladder, I thought it advisable
| |
| to turn it in, fearing that there might be an opening between the bladder and the
| |
| cyst. In the pelvis were metastatic deposits, some of them very minute, others
| |
| irregular, somewhat translucent, and fully 1 cm. in diameter. The appendix was
| |
| removed, and the abdomen closed. The patient was discharged November 5,
| |
| 1906. In answer to an inquiry Dr. Mann wrote me that the patient died January
| |
| 8, 1908.
| |
|
| |
| Gyn.-Path. Nos. 10368 and 10488.— The cyst-walls vary
| |
| considerably in thickness. At some points they are thin and transparent; at
| |
| others they reach the thickness of about 2 cm. These solid areas also contain cysts,
| |
| and in the small cysts is a blackish-colored fluid. The entire specimen is vascular,
| |
| and in some places friable and apparently malignant.
| |
|
| |
| On histologic examination the walls are found to consist in part of fibrous tissue,
| |
| with a definite laminated arrangement. In many places necrosis has taken place,
| |
| and the tissue presents a homogeneous appearance or takes the stain very poorly.
| |
| At other points in the walls the connective-tissue cells have taken up much brown
| |
| pigment, evidently from a long-standing hemorrhage. Here and there throughout
| |
| the walls are slit-like spaces, the smaller ones surrounded by giant-cells * (Fig. 258) .
| |
| The giant-cells really consist of large masses of protoplasm containing oval or round,
| |
| deeply staining nuclei (Fig. 260), and some of these nuclei are four or five times
| |
| the size of the surrounding ones. Where the cavities are larger, giant-cells may
| |
| be seen clinging to one side of the cavity, other portions of the cavity being devoid
| |
| of a lining (Fig. 259). At certain points are aggregations of giant-cells, and interspersed are small, slit-like spaces. One is instantly reminded of the giant-cells
| |
| and slit-like spaces noted by Bondi, and on careful examination we found here and
| |
|
| |
| * I am fully aware of the frequency with which foreign-body giant-cells are prone to occur
| |
| in the walls of certain cysts and elsewhere, but the giant-cells in this case are rather unusual,
| |
| hence I have described them more or less in detail.
| |
|
| |
|
| |
|
| |
| Fig. 260. — Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Ukachus. ( X 90 and 300 diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. A. a seems to be a large, gland-like space filled with coagulated blood and
| |
| exfoliated epithelium. It is lined with one layer of low cuboid epithelium, well seen at b. c is a large blood-vessel.
| |
| Scattered throughout the stroma of the cyst-wall are giant-cells and quite a number of slit-like spaces lined with giantcells. Traversing the slit-like spaces (d) are delicate strands, one of which contains very small nuclei.
| |
|
| |
| B. This shows an enlargement of the oblong area in A. The stroma consists of fibrous tissue. At a is a nest of
| |
| cancer-cells which has retracted from the surrounding connective tissue. 6 is a deposit of calcareous material near
| |
| the wall of a blood-vessel, c and d are slit-like spaces, c is lined with a ribbon of protoplasm showing nuclei scattered fairly evenly throughout it. It is impossible to detect any division of the protoplasm into individual cells. The
| |
| space d is lined with a wide zone of protoplasm showing many nuclei, uniform in size and staining properties, equally
| |
| distributed throughout the protoplasm, e is another slit-like space lined with a ribbon of protoplasm containing
| |
| only a single row of nuclei.
| |
| 42
| |
|
| |
|
| |
|
| |
| 642
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| there crystals lying in the cavity, such as were also found by Bondi. Other portions
| |
| of the tumor show gland-like spaces lined with one or more layers of epithelium
| |
| (Fig. 261). The nuclei of the epithelial cells are oval and vesicular, or are deeply
| |
| staining, and the epithelium itself is of the low cylindric variety. In some places
| |
| the epithelium has proliferated to a moderate extent. The gland arrangement in
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| 5r#
| |
|
| |
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| |
|
| |
|
| |
| «£*#"
| |
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| |
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| |
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| |
| •."*«»«*.„"
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| |
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| |
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| |
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| |
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| |
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| |
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| |
|
| |
| Fig. 261. — Adenocarcinoma op the Urachus. ( X 90diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. The growth at this point bears considerable resemblance to a papillocystoma
| |
| of the ovary; it consists of large and small irregular spaces lined almost exclusively with one layer of cuboid or low cylindric epithelium, a is a very good example of one of the spaces with a projection into it from the side. This space is
| |
| lined with one layer of cuboid epithelium containing relatively round and deeply staining nuclei. These nuclei are
| |
| particularly well seen at 6. The granular contents in the gland-spaces consist of coagulated epithelial secretion. The
| |
| epithelial elements in the left lower part of the picture have to a large extent melted away. The fibrous stroma of the
| |
| growth contains very few nuclei, c is one of the blood-vessels in the stroma. From this picture alone one could not
| |
| tell definitely whether the growth was malignant or not. That it is malignant, however, is definitely settled by a reference to Kig. I'll:',, and also by the fact that at operation metastases were found.
| |
|
| |
|
| |
|
| |
| some places suggests a papillary formation (Fig. 262), and the gland cavities are
| |
| filled with a homogeneous material that takes the eosin stain. The epithelial cells
| |
| at other points are almost flat. There does not seem to be much variation in the
| |
| size of the cells, and such a picture alone would suggest a papillocystoma. At
| |
| other points the epithelium has proliferated markedly, so that we have what
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS.
| |
|
| |
|
| |
|
| |
| 643
| |
|
| |
|
| |
|
| |
| appears to be solid nests; or the epithelium has melted away, as is noted in
| |
| colloid carcinoma.
| |
|
| |
| There is no doubt we are dealing with a multilocular cyst that has become
| |
| malignant. This cyst certainly belongs to a rare type. Of the malignancy, there
| |
| can be no doubt, because metastases in the pelvic peritoneum were noted at operation (Fig. 263). It did not spring from the ovaries, as they were perfectly normal in
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 262. — A Papillary- like Area in an Adexocarcixomatous Cyst of the Urachus. (X 90 diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. The picture is a rather confused one. At a the complex papillary mass is
| |
| seen covered with one layer of cuboid epithelium having round, uniformly staining nuclei. At b are two definite glandlike spaces. At c is a bluntish projection of the stroma into a gland-space, d indicates the stroma, consisting of spindleshaped connective-tissue cells. The gland-spaces are filled with a granular, homogeneous material seen at e. (For the
| |
| appearances of the metastases see Fig. 263.)
| |
|
| |
| size and distant from the growth. Its pedicle, as noted from the history, sprang
| |
| from the top of the bladder. It will further be noted that during the removal of
| |
| the tumor a large part of the peritoneum of the anterior and lateral abdominal walls
| |
| had to be sacrificed. This tumor evidently originated from the urachus.
| |
|
| |
| The mode of origin of the giant-cells has been of especial interest to me. It will
| |
| be noted that these giant-cells have been found almost entirelv in the outer con
| |
|
| |
|
| |
| 644
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| nective-tissue wall of the large cyst, and that the cavities that they line are slitlike. This is particularly well seen in Fig. 258. Furthermore, in the vicinity of
| |
| these slit-like spaces are well-formed giant-cells lying completely surrounded by
| |
| stroma (Fig. 258, b). On examining the space b in Fig. 259, one gathers the
| |
| impression that the tissue has been especially brittle, and that during the process
| |
| of hardening the giant-cells may have split lengthwise; this impression is still
| |
| further strengthened by examining the area c in Fig. 259. Here the protoplasm
| |
| has apparently been split up into several long strands. At the upper end of this
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 263. — Metastasis from Adenocarcinoma of the Urachus. ( X 90 diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. o and a are blood-vessels. Scattered throughout the field are nests of epithelial
| |
| cells. Although originally the growth was glandular, the metastases have tended to form solid nests. At 6, however,
| |
| two gland-like spaces can be faintly made out. During the process of hardening the cancerous tissue tended to retract
| |
| from the stroma. This is especially well seen at c. The stroma of the growth showed considerable small-round-cell
| |
| infiltration.
| |
|
| |
|
| |
|
| |
| area there is an intact giant-cell. The finer structure of the giant-cell is well seen
| |
| in Fig. 260, B, d.
| |
|
| |
| In an examination of a large number of ovarian cysts I have never seen a picture
| |
| analogous to the one here depicted. To be sure, in very young dermoid cysts of
| |
| the ovary, giant-cells are the rule, but here they are invariably lining or clinging
| |
| to the walls of small cysts — such giant-cells are the embryonic stages of squamous
| |
| epithelium.
| |
|
| |
| Dr. William H. Welch informed me that he had occasionally seen giant-cells
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS.
| |
|
| |
|
| |
|
| |
| 645
| |
|
| |
|
| |
|
| |
| similar to these in the walls of cysts and elsewhere, and suggested that they might
| |
| be foreign-body giant-cells. He further suggested the possibility of their developing around crystals. On careful examination of many giant-cells I found just one
| |
| crystal. This was irregular in form. Whether the giant-cells in this case are foreign-body cells or not I cannot say. This point, of course, is of interest only to the
| |
| pathologist.
| |
|
| |
| Bondi reported a small umbilical cyst of unknown origin. He found quantities
| |
| of giant-cells analogous to those here depicted (Fig. 266), and in his case some of
| |
| the giant-cells surrounded crystals. Although his
| |
| cyst was not malignant, it is of such interest in
| |
| connection with my case that I shall here report
| |
| it somewhat in detail.
| |
|
| |
|
| |
|
| |
| A RARE UMBILICAL CYST.
| |
| Bondi* reports this case from Schauta's clinic.
| |
| The patient was a woman, sixty-two years of age.
| |
| She had had three normal labors. About twenty
| |
| months before coming under observation she
| |
| noticed that the umbilicus was larger than usual,
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| **
| |
|
| |
|
| |
|
| |
| pi.
| |
|
| |
|
| |
|
| |
| :>F
| |
|
| |
|
| |
|
| |
| Fig. 264. — An Umbilical Cyst. (After Bondi.)
| |
| The original tumor was 5 cm. in diameter. The drawing has been
| |
| made from the hardened specimen, which was much contracted. Nearly
| |
| two years before operation the patient had noted an enlargement at the
| |
| umbilicus. The overlying skin was brownish in color, tense, and elastic.
| |
| It was slightly compressible. H is the skin covering the cyst; Nr, the
| |
| confines of the umbilical depression; P, a prolongation of the peritoneal
| |
| cavity into the mass. The walls of the cyst were composed of two layers
| |
| — an outer, consisting of whitish tissue, and an inner, homogeneous zone,
| |
| grayish brown in color. The cyst contents were spongy, yellowish brown,
| |
| and soft. (For the histologic picture see Figs. 265 and 266.)
| |
|
| |
|
| |
|
| |
| Fig. 26.5. — Wall of an Umbilical Cyst.
| |
| (After Bondi.)
| |
| This is a section of the cyst-wall seen
| |
| in Fig. 264. H represents the skin, with
| |
| connective tissue immediately beneath it ;
| |
| B, a dense layer of connective tissue. Rx,
| |
| granulation tissue. In this are areas containing small spaces. These spaces, as seen
| |
| in Fig. 266, are lined with giant-cells. The
| |
| cells in this layer contain blood-pigment.
| |
| The inner surface (F) consists of coarse
| |
| and fine threads of fibrin.
| |
|
| |
|
| |
|
| |
| and that the abdomen had increased in size. She had never noticed a tumor projecting outward beyond the level of the umbilicus.
| |
|
| |
| At operation, at the umbilicus was a tumor 5 cm. in diameter, the skin over it
| |
| being brownish in color. It was tense and elastic, showed no marked fluctuation,
| |
| and was slightly compressible. The abdominal enlargement was due to a multilocular ovarian cyst the size of a man's head, with torsion of the pedicle to the extent
| |
| of 180 degrees; the wall of the cyst was partially necrotic.
| |
|
| |
| * Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 190.5, xxi, 729.
| |
|
| |
|
| |
|
| |
| 646 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| In the hardened specimen the umbilical cyst was 2.5 cm. in diameter. It
| |
| lav over an outward prolongation of the abdominal cavity, much as a cap
| |
|
| |
| would fit (Fig. 264). The walls of the
| |
|
| |
| .v^^T^^- c y s ^ nac * two layers, the outer consist
| |
| ■ > .'!''' "'''•' <. j n g f whitish tissue 2 mm. thick. It
| |
|
| |
| V, ' /Sl'Vi* y&SZ?' "I "".s*' "' was adherent to the skin and to the
| |
| *." 'Mi' 1 ^,^ '' *is*» peritoneum, and the inner zone consisted
| |
| \ ii ^ v -''F~'~' u; $?l£'Z •^N;* of a broad, homogeneous, gray-brown
| |
| H%» . -, - : ^ tissue. The cyst contents were spongy,
| |
| % %\Sj ! /<?^j.- M ?^ ,; l||-: yellowish brown, and soft. Its length
| |
| } » ;f ' "^/v^C — *^^ in the hardened specimen was 2.5 cm.,
| |
| ^ l*^/j§^- '^" "<#^ : f and its greatest thickness, 1.5 cm. The
| |
| v\'%fj|&/^/; )' ^,;f.-."--^'* *£• V outer wall of the cyst consisted of fibrous
| |
| ,Ui ^ ^-^^^'v^^ tissue, which gradually passed over into
| |
| s^- •*'-'* v *|^' the inner, homogeneous lining, consist'* V *'^ ;* 'o» '"■* ing of young fibrous tissue. This gradu"*%t£ j , v-** ally merged into the granulation tissue
| |
| *" **- bx which lined the cavity. The granulation
| |
| fig. 266.— Giaxt-cells in the Wall of an u.mbili- tissue here and there contained blood-pigon i.) ment. Here and there near the inner
| |
|
| |
| Scattered throughout the inner wall of the cyst
| |
|
| |
| (Fig. 26.5) were aggregations of small, siit-iike spaces. surf ace were numerous spaces, often oc
| |
| Some of these are lined with one layer of epithelium, CU lTmg ill groups. These Were regularly
| |
|
| |
| others with giant-cells. The nuclei of the giant-cells .... ,-,-,. __ _ . o^^x
| |
|
| |
| are uniform and fairly evenly distributed throughout lmed With giailt-CellS (t lgS. 265 and 266) .
| |
|
| |
| the protoplasm. j n t nese spaces were crystals showing that
| |
|
| |
| the spaces were not artefacts. Bondi
| |
| says that it was not a dermoid, but a peritoneal cyst, into which a hemorrhage had
| |
| occurred.
| |
|
| |
| It is possible that these giant-cells were foreign-body giant-cells. As already
| |
| pointed out, they bear a marked resemblance to those noted in the malignant cyst
| |
| of the urachus I have just recorded so fully. (See Figs. 258, 259, and 260.)
| |
|
| |
|
| |
|
| |
| LITERATURE CONSULTED ON MALIGNANT GROWTHS OF THE URACHUS AND URACHAL REGION.
| |
|
| |
| Aveling: Brit. Gyn. Jour., 1886-87, ii, 56, 187.
| |
|
| |
| Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 1905, xxi, 729.
| |
|
| |
| Doran, A.: Stanley's Case of Patent Urachus with Observations on Urachal Cysts. St. Bartholomew's Hospital Reports, 1898, xxxiv, 33.
| |
|
| |
| Doran, A. H. G.: Urachal Cyst Simulating Appendicular Abscess; Arrested Development of
| |
| Genital Tract; with Notes on Recently Reported Cases of Urachal Cysts. The Lancet,
| |
| 1909, i, 1304.
| |
|
| |
| Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, N. F., No. 89 (Chir. No. 24), Leipzig, 1894, 519.
| |
|
| |
| Frank, T.: Zur Casuistik der Urachustumoren. Inaug. Diss., Wurzburg, 1893.
| |
|
| |
| Graf, F.: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.
| |
|
| |
| Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch.
| |
| der Heilkunde, 1870, xi, 373.
| |
|
| |
| Koslowski, B. S. : Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir., 1903, lxix, 469.
| |
|
| |
| Rotter: Blasencarcinom kombinirt mit Urachuscyste. Centralbl. f. Chir., 1897, xxiv, 604.
| |
|
| |
| Wolff, C. C. : Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873.
| |
|
| |
|
| |
|
| |
| ==Chapter XXXVIII. Bleeding from the Urachus into the Bladder==
| |
|
| |
| The literature on this subject is a negligible quantity. W. Ramsay Smith *
| |
| reports a case which, although somewhat obscure, may be mentioned here.
| |
|
| |
| The patient, a female infant, was born August 3d. The labor was short, and
| |
| the child brought away with forceps. The cord appeared to be normal. On the
| |
| second night, August 5th, a large quantity of bright-red blood was noticed on the
| |
| infant's binder. It appeared on that night only, and the nurse noticed that it was
| |
| coming not from the cord,- but from the umbilicus at the side of the cord. Two
| |
| days later (August 7th) the child had an attack of diarrhea, and there was a good
| |
| deal of blood in the stools, and it was noticed that this blood was coming from the
| |
| urethra. On August 8th the bleeding was very severe, there being over two teaspoonfuls at a time. The blood always appeared when the bowels moved, but it
| |
| came from the urethra. The diarrhea ceased, and the bleeding stopped on August
| |
| 9th. Smith thought that the bleeding took place from the hypogastrics, and
| |
| escaped to the bladder along the urachus. Ballantyne felt somewhat reluctant
| |
| to accept this explanation, but said that, under the circumstances, it was difficult
| |
| to suggest any that was more satisfactory.
| |
|
| |
| A few years ago, while discussing diseases of the umbilical region with Dr.
| |
| Edward Reynolds, of Boston, he mentioned the fact that on several occasions he
| |
| had noted bleeding from the urachus into the bladder. Later I wrote asking him
| |
| kindly to furnish me with the data he had bearing on the subject. His reply was as
| |
| follows :
| |
|
| |
| "With regard to my recent hematuric case, the patient was a physician about
| |
| thirty-five years old, from whom I removed the appendix about two years ago.
| |
| She came to me on the seventh of February, saying that, after very hard and long
| |
| automobiling over rough country roads a few days before, she had been seized by
| |
| a sudden urgent desire to urinate, and had passed a quantity of bloody urine.
| |
| Since then urination had been normal, but the urine was slightly blood-stained.
| |
| She informed me that she had noticed that the first part of the urine was clear and
| |
| that the blood came with the last few drops. When I first looked into her bladder
| |
| the small amount of urine was clear (she had just emptied it). I inspected the
| |
| trigonum and fundus of a normal bladder carefully in the knee-chest position, and,
| |
| on turning the point of the cystoscope forward, found that in the interval the urine
| |
| had become distinctly pink. I then emptied the bladder thoroughly with the
| |
| evacuator, and saw a small stream of blood flowing from the orifice of the urachus.
| |
| The patient has written me since that the hematuria stopped within forty-eight
| |
| hours after her visit to me, and that there was no recurrence. I told her that I
| |
| thought there was no other treatment than the removal of the urachus; that I
| |
| should not advise that unless the symptoms were persistent; that I should advise
| |
|
| |
| * Smith, W. Ramsay: Obstet. Trans., Edinburgh, 1892-93, xviii, 53.
| |
|
| |
| 647
| |
|
| |
|
| |
|
| |
| 648 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| it if the hematuria were recurrent. I asked her to keep me informed of her progress, and I think that she will do so.
| |
|
| |
| ''This is not my first case of the kind. A good many years ago, when I was
| |
| doing a large out-patient clinic and making a great many cystoscopic examinations,
| |
| I saw a number of cases, I should guess from half a dozen to a dozen, in which minor
| |
| vesical symptoms seemed to be associated with a reddened, eroded condition of the
| |
| vesical mucous membrane immediately about a small orifice in the upper and anterior part of the bladder, which, after some study, I grew to consider as the orifice
| |
| of a patent urachus, and which, on close inspection, I could recognize in a considerable proportion of bladders in which it was not making trouble. I believe that this
| |
| slight anomaly is very common, and that it is a not unimportant lurking-place for
| |
| bacteria in infected bladders. In at least two cases in these old days I saw bleeding
| |
| from this orifice; I think in more than that number, but the conditions of the
| |
| clinic made careful record keeping very difficult. I should say that the hematuria
| |
| was transient but recurrent. I do not know the ultimate outcome. The patients
| |
| in that clinic were all of a class which it is difficult to follow up afterward."
| |
|
| |
| Dr. Reynolds' observation clearly demonstrates that in some cases blood does
| |
| escape from the persistent urachus into the bladder. His suggestion that the
| |
| urachal opening is probably the lurking-place of bladder infections is fully borne
| |
| out by the cystitis frequently noted where a partially patent urachus exists.
| |
|
| |
|
| |
|
| |
| CHAPTER XXXIX.
| |
| TUBERCULOSIS OF THE PATENT URACHUS.
| |
|
| |
| I have been able to find only two cases of this character in the literature. The
| |
| first case was recorded by Briddon and Eliot, the second by Eastman.
| |
|
| |
| Dr. Thacher, who made the pathologic report on the extirpated urachus in
| |
| Briddon and Eliot's case, after giving a very careful and guarded description,
| |
| decided that the condition was probably tuberculous. Dr. Eastman sent us his
| |
| specimen and we have been able to demonstrate tubercle bacilli in the urachus.
| |
|
| |
| "Tubercular Degeneration of the Patent Urachus
| |
| in the Adult.* — R. M., aged nineteen, Roumanian; married. Admitted July
| |
| 17, 1899. No tubercular family or personal history. The patient has always been
| |
| well until five weeks ago, when she began to have slight pain, with heat, redness',
| |
| and swelling in the region of the umbilicus, the navel having previously been always
| |
| normal in appearance. The symptoms increased for two weeks, at the end of
| |
| which time there was a small red tumor, the size of a pea, in the region of the
| |
| umbilicus. During this time the patient suffered intensely from severe, sharp
| |
| pain, almost constantly present, in the hypogastric region, with well-marked
| |
| vesical tenesmus, increased frequency of micturition (often voiding urine every
| |
| hour), and occasionally a small amount of blood in the urine. At the end of the
| |
| two weeks the swelling opened spontaneously, discharging some cloudy fluid with
| |
| a uriniferous and foul odor, the pain and swelling soon subsiding. About four
| |
| days after the discharge of fluid at the umbilicus, she ceased to pass water normally,
| |
| and since then she has had a constant discharge of cloudy fluid of a uriniferous
| |
| odor, at times slightly blood-stained, through the opening at the umbilicus. She
| |
| has lost considerable flesh and strength during the period of five weeks.
| |
|
| |
| "Physical Examination. — The patient is markedly anemic and is apathetic.
| |
| The facies is flushed; the tongue is moist and not heavily coated. The superficial
| |
| glands are not enlarged. In the heart there is a hemic murmur over the pulmonic
| |
| area, systolic in time. Percussion of the lungs is normal, but the breathing is
| |
| rather poor. The abdomen is soft, retracted, and no masses can be felt. At the
| |
| inferior portion of the umbilicus is a small sinus with everted and ulcerated edges,
| |
| which discharges a seropurulent fluid of uriniferous odor. A probe introduced into
| |
| the sinus goes downward and extends evidently as far as the bladder. The bladder
| |
| does not percuss high, but there is some tenderness on pressure over the suprapubic
| |
| region. Urine analysis at the time of admission showed very turbid and cloudy
| |
| urine, with specific gravity of 1014, 15 per cent of sediment, reaction strongly
| |
| alkaline, and odor foul and ammoniacal. There was 10 per cent of albumin, no
| |
| blood, a large amount of mucus, much pus, and many vesical cells, with many
| |
| crystals of triple phosphate. No casts were found. She was placed upon bladder
| |
| irrigations twice daily, with warm 0.5 per cent, boric-acid solution, and salol (gr. v)
| |
|
| |
| * Briddon, C. K., and Eliot, E.: Med. and Surg. Reports, Presbyterian Hospital, New York,
| |
| January, 1900, iv, 30.
| |
|
| |
| 649
| |
|
| |
|
| |
|
| |
| 650 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| three times a day. There was no improvement under this treatment, either in the
| |
| character of the urine or in the patient's general condition, except that she had
| |
| slightly less pain. At the end of a week the bladder irrigation was changed to
| |
| carbolic acid, in strength of 1 : 120. This also seemed to have no effect upon the
| |
| urine, frequent examinations up to the time of operation giving about the same
| |
| result. As at the first analysis, the specific gravity never rose above 1014; the
| |
| urine always remained alkaline and was full of pus and mucus. The temperature
| |
| course was irregular, varying between 99.5° F. and 102° F., and did not seem to be
| |
| influenced in any way by the bladder washing. During a period of several days of
| |
| fairly constant low temperature the patient gave a moderately characteristic
| |
| tuberculin reaction. The average daily amount of urine voided by the urachus
| |
| varied from 15 to 20 ounces. At intervals of several days she voided a few drams
| |
| or an ounce of urine per urethram.
| |
|
| |
| " Owing to the obstinate, unyielding cystitis, it was thought advisable to do
| |
| a suprapubic cystotomy for purposes of drainage.
| |
|
| |
| " Operation (August 25th) . — Dr. Eliot. Nitrous oxid and ether; asepsis; dorsal position. A catheter was introduced through the urethra into the bladder and
| |
| urine was withdrawn. Four ounces of warm 1 per cent boric-acid solution were
| |
| then gently thrown into the bladder by a fountain syringe, six ounces of water,
| |
| injected into a Barnes dilator, having been previously inserted into the rectum.
| |
| A 23^-inch median incision was then made above the pubis and deepened down to
| |
| the space of Retzius. The soft cellular tissue here being pushed aside and the
| |
| bladder presenting, two silk sutures were passed in a longitudinal fashion through
| |
| its wall, separated by a distance of one inch, these sutures being placed for purposes
| |
| of traction. The bladder was then opened between the silk sutures, the boricacid fluid pouring out into the wound. The incision in the bladder-wall being
| |
| subsequently enlarged upward, disclosed the urachus opening into the fundus of
| |
| the bladder. There were several small areas of ulceration on the posterior wall of
| |
| the bladder, and parts of the ulcers, together with a portion of the urachus, were
| |
| secured for microscopic examination. The ulcerated areas upon the bladder-wall
| |
| were cauterized with a thermocautery. The lumen of the urachus was packed
| |
| with a strip of iodoform gauze, the cavity of the bladder being drained through the
| |
| suprapubic wound in the usual way by means of a tube.
| |
|
| |
| "Report by J. S. Thacher, Pathologist.- — A. Minute fragment of tissue from
| |
| urachus. Microscopic examination shows a mass of smooth muscle and connective tissue. The muscle-cells vary somewhat in size and shape, and are irregular
| |
| in arrangement.
| |
|
| |
| "B. Minute fragments from base of bladder. The epithelium is partly destroyed, and the tissues are much inflamed. The inflammation appears to be of
| |
| some standing.
| |
|
| |
| "The bladder was drained very satisfactorily for ten days by the siphon drainage apparatus, the suprapubic wound remaining comparatively clean and dry. The
| |
| patient's temperature was increased for six days following the operation. Recovery
| |
| was uneventful. Bladder irrigation with carbolic acid, 1:40, was employed, when
| |
| the drainage apparatus was dispensed with, the urine clearing up slightly and the
| |
| pain becoming much less severe. She seemed to improve in general health to a
| |
| moderate degree. Urine was not voided normally after the suprapubic operation
| |
| had been performed.
| |
|
| |
|
| |
|
| |
| TUBERCULOSIS OF THE PATENT URACHUS. 651
| |
|
| |
| "September 25th: Urine, for about one week, has had much less pus and mucus in it, and hypogastric pain has been much less severe. It was then decided
| |
| to attempt an extirpation of the patent urachus, leaving the suprapubic wound
| |
| unmolested.
| |
|
| |
| "Operation (September 27th). — Dr. Briddon; nitrous oxid and ether; asepsis;
| |
| dorsal position. A median incision was made from the umbilicus down to the
| |
| suprapubic wound of the previous operation, exposing the linea alba, which was
| |
| split up in the line of the incision, exposing granulation tissue forming the wall
| |
| of the patent urachus. By blunt dissection this tissue was then dissected free
| |
| from the underlying thickened peritoneum, during which process the urachus was
| |
| opened longitudinally through a portion of its extent. The walls of the urachus
| |
| were nearly a quarter of an inch thick, and their diameter was about half an inch.
| |
| At its point of junction with the bladder it was cut transversely and removed, the
| |
| general cavity of the peritoneum not being opened. A clean surface was thus left,
| |
| whose floor was formed by the thickened peritoneum, and its sides by the divided
| |
| portion of the linea alba. This tract was closed by eight interrupted chromic
| |
| catgut sutures, passing from one side to the other through the skin and linea
| |
| alba, thus approximating the raw edges of the tract. A sterile dressing was
| |
| placed on the sutured wound, a rubber drainage-tube and iodoform gauze being
| |
| left in the suprapubic wound.
| |
|
| |
| " Report of J. S. Thacher, Pathologist. — Extirpation of patent urachus. Microscopic examination : Granulation tissue ; spots of marked infiltration by leukocytes; several small necrotic spots; many giant-cells; some tissue resembling
| |
| tubercle tissue — probably tubercular.
| |
|
| |
| " Recovery from the operation was uneventful. The bladder was drained satisfactorily for ten days, the wound for urachus extirpation healing by primary union
| |
| without complication. Her general health rapidly improved, and she had gradually
| |
| less hypogastric pain and discomfort. For a few weeks the patient voided no urine
| |
| normally, all being discharged through the suprapubic wound. Since then she
| |
| has passed almost every day one or more ounces of urine per urethram, in gradually
| |
| increasing quantity. Her general condition is very much improved, the suprapubic
| |
| wound is steadily closing, and urinary analysis now gives but 3 per cent, of albumin,
| |
| with much less pus and mucus.
| |
|
| |
| "Repeated examination of urine failed to discover any tubercle bacilli, and
| |
| careful physical examination by G. A. Tuttle failed to detect any evidence of
| |
| pulmonary or other visceral tuberculosis.
| |
|
| |
| "Examination conducted by Dr. Tuttle, in the pathologic laboratory, of the
| |
| small ulcers which were excised from the wall of the bladder at the time of the first
| |
| operation, failed to yield positive indications of tuberculosis; conclusive evidence
| |
| at last was furnished by the examination by Dr. Thacher of the urachus itself,
| |
| removed by Dr. Briddon at the time of the second operation. Inferences are
| |
| always uncertain, and although the statement that the tubercular process originated
| |
| in the patent remnant of the duct itself is not entirely justifiable, nevertheless, the
| |
| fact remains that examination of its wall after removal showed much more abundant
| |
| evidence of tuberculosis than did the portion of the bladder-wall removed earlier
| |
| by suprapubic cystotomy."
| |
|
| |
| In the case under discussion the removal of the urachus was accomplished without opening the general peritoneal cavity.
| |
|
| |
|
| |
|
| |
| 652
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| I was particularly anxious to see a section from this case, and accordingly wrote
| |
| Dr. Thacher. In his reply, dated New York, April 8, 1914, he gave me the results
| |
| of his examination, but said the original slide could not be located.
| |
|
| |
| Tuberculosis of the Urachus.* ■ — Dr. Eastman has just recorded
| |
| a very interesting case of tuberculosis of the urachus in a girl aged nineteen.
| |
|
| |
| "Family History. — Father died of cancer of the stomach at the age of fifty-one;
| |
| one brother died during infancy of meningitis; history otherwise negative, particularly as relates to tuberculosis or neoplasms.
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 267. — Tuberculosis of the Urachus.
| |
|
| |
| This is a low-power photomicrograph from Dr. J. R. Eastman's case. At a is an area of caseation surrounded by
| |
| tissue closely resembling that found in tuberculosis. The outer walls are composed of non-striped muscle and fibrous
| |
| tissue. Scattered throughout this tissue are localized foci more or less characteristic of those noted in tuberculosis.
| |
| The areas b and c are very suggestive of tubercles.
| |
|
| |
| The high-power picture of the area b is shown in Fig. 268; that of the area c, in Fig. 269.
| |
|
| |
|
| |
|
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| "Personal History. — Typhoid at seventeen with good recovery; history otherwise negative; patient married two years and four months; one pregnancy, child
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| living and well; at no time night-sweats or protracted cough; no characteristic
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| temperature history; no other evidences of tuberculosis.
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| "Menstrual History. — Menstruation began at twelve; regular; duration five
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| days and free; no change in type since marriage or labor.
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| "Urination. — No increase in frequency, no nocturnal urination. Three diurnal
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| urinations; never any blood or burning or stinging.
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| "History of illness for which patient entered hospital. — This trouble began ten
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| * Eastman, Joseph Rilus: Amer. Jour, of Obstetrics, 1915, lxxii, 640.
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| TUBERCULOSIS OF THE PATENT URACHUS.
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| 653
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| months before entrance. While working in the garden, pain was felt at a point in
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| the mid-line of the abdomen between the symphysis pubis and the umbilicus. At
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| this time patient noticed a lump at the point designated, the size of a small apple.
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| There was not much actual pain nor soreness. The mass did not increase in size
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| but the tenderness remained. This condition persisted for three months when a
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| pin-point opening appeared in the mid-line of the anterior abdominal wall, half-way
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| between the symphysis pubis and the umbilicus. This opening discharged a clear
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| watery fluid for about a week. Then a serous crust closed the opening. The
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| opening again discharged after about a week, continuing to do so for one week and
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| again the crust was formed. This process of closing and opening continued for
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| several months. The size of the tumor did not change. The tenderness still persisted. There had never been any disturbance of the bladder, intestines or uterus.
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| a
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| •1
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| b
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| x
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| d c
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| Fig. 26S. — An Area Suggesting a Tubercle.
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| This picture is a high-power magnification of the area b in Fig. 267. Its confines are indicated by x and x. Scattered throughout this area are spindle cells and round cells. At a and b are giant-cells. At c the cells are so arranged
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| as to suggest a small gland. At d is a large cell bearing a strong resemblance to a squamous cell.
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| The discharge had always been free from odor. She is positive that the discharge
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| never had a urinous odor.
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|
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| "Status Prsesens. — The patient's general health was unimpaired. Urinalysis
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| and physical examination of the chest and abdomen were negative. There were
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| no evidences of pulmonary tuberculosis nor of tuberculosis elsewhere. Through
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| the discharging sinus below the umbilicus a small sound could be passed downward behind the symphysis pubis.
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|
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| "Operation. — The fistulous tract, upon being dissected free, was found to pass
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| downward from the discharging orifice, coursing in front of the peritoneum, crossing
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| the space of Retzius and terminating in a thin cord attached to the anterior bladder
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| wall in the median line and near to the vesico-urethral junction. Upon being split
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| open the definite tube-like structure was found to be thin-walled, showing no evidence of inflammation or other pathological condition except near the external
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| discharging orifice, where an ulcerated mass about 2 cm. in width was situate upon
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| the dorsal wall of the tube.
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|
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| "Cystoscopic Examination. — Bladder distended with 8 ounces of water for
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| 654 THE UMBILICUS AND ITS DISEASES.
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|
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| examination: vesical sphincter normal in outline; trigone normal; both ureteral
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| openings and the mucosa surrounding them were normal as to contractility and
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| rhythm. There were no ulcers, tubercles, or any other abnormalities upon the floor
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| of the bladder. The vesical roof was examined carefully and this portion of the
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| bladder was found to be absolutely devoid of any ulcer, tubercles, opening, or any
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| other abnormality of the vesical mucous membrane; and there was not the slightest
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| hint of any communication with the patent urachus.
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|
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| "•Chemical and Microscopic Urinalysis. — After operation as before the urine
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| was normal.
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| ••Clinical Course since Operation. — "Wound closed slowly; there have been no
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| Fig. 269. — A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus.
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| This L= a high-power picture made by Mr. H. Schapiro from Fig. 267 at c.
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| The tubercle is oval in form and is fairly well differentiated from the surrounding stroma. The cells of the tubercle
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| are spindle-shaped, oval, round, or irregular. In the lower part of the tubercle is a large giant cell containing a large
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| number of nuclei arranged chiefly in its center. The grouping of the nuclei in this giant cell resembles to some extent
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| that usually found in foreign-body giant cells, but the picture as a whole is strongly suggestive of tuberculosis.
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|
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| symptoms of any kind relating to the genitourinary organs; there is no evidence of
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| return of the disease."
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| I wrote Dr. Eastman asking if he could send me sections of the urachus. This
| | # [[:File:Cullen1916 plate01.jpg|Drawings of Normal Umbilici]] |
| he promptly did. An examination of them shows the following:
| | # [[:File:Cullen1916 plate02.jpg|Drawings of Normal Umbilici]] |
| | # [[:File:Cullen1916 plate03.jpg|Drawings of Normal Umbilici]] |
| | # [[:File:Cullen1916 plate04.jpg|Drawings of Normal Umbilici]] |
| | # [[:File:Cullen1916 plate05.jpg|Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary]] |
| | # [[:File:Cullen1916 plate06.jpg|Umbilical Hernia]] |
| | # [[:File:Cullen1916 plate07.jpg|Exstrophy of the Bladder]] |
|
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| The central portion of the specimen consists of granular tissue containing a few
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| cells. It looks very much like caseous tissue (Fig. 267a). External to this is a
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| tissue made up of young connective-tissue cells and fairly large round cells with
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| small round nuclei, and beneath this a zone containing a few giant cells. The
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| outer wall apparently consists of non-striped muscle and connective tissue infiltrated with small round cells. In this are round or oval areas containing aggregations of epithelioid cells with giant cells scattered here and there throughout them
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| [Figs. 208 and 269;. External to this zone is the surrounding adipose tissue. The
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| entire picture strongly indicates tuberculosis of the urachus.
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|
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| Dr. Benjamin O. McCleary and Dr. George L. Stickney have each independently demonstrated tubercle bacilli in the sections; consequently this is a definite
| | {{Cullen1916 footer}} |
| of tuberculosis of the urachus.
| | [[Category:Draft]] |