Book - Umbilicus (1916) 16

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

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Chapter XVI. Abscess in the Subumbilical Space

Description of Heurtaux's observations.

Fischer's injections of the subumbilical space.

An empyema opening into the subumbihcal space.

A liver abscess opening into the subumbilical space.

An appendix abscess opening into the subumbilical space.

An echinococcus cyst in the subumbilical space.

Actinomycosis in the subumbilical space.

Resume.

Heuktaux,* in 1877, described what he called a phlegmonous subumbilical inflammation deep in the anterior abdominal wall. He said that, up to that time, so far as he knew, this condition had never been reported. The affection is characterized by the presence of an inflammatory tumor, which is sharply circumscribed and is in the median line. It is symmetric and oval inform; its base occupies the umbilicus. The tumor is deep-seated. On examination it will be found to have

developed exactly at the umbilicus (Fig. 153) . It varies from 6 to 10 cm. in diameter, is immobile, firm in consistence, and after a few days may give deep fluctuation. When suppuration commences, the tumor becomes prominent and the umbilicus may be reddened and perforate, the quantity of escaping pus varying from 120 to 150 c.c. In Heurtaux' cases there never was any escape of gas. A sound sometimes entered toward the pubes for 6 cm., and to the right or left for 3 cm. In three acute cases, fluctuation was detected in from nine to seventeen days after the onset ; in subacute cases, after a period varying from four to five weeks.

In all of the six cases reported by Heurtaux the phlegmon terminated in suppuration. In four it opened spontaneously, the opening being in the umbilical cicatrix in two of these. According to Heurtaux, the lesion is always found in the same situation and the prognosis is good.

An analysis of Heurtaux' cases shows that the youngest patient was six and one-half years, the oldest, fifty-five. Nearly all of them had been ill before. Three were males and three females. In Case 2 a labor had occurred three weeks before the abscess developed; in Case 3 it followed a pleurisy; in Case 6 it developed in the course of measles, and a severe bronchopneumonia also complicated matters. In Case 1 the patient was in the second

• Heurtaux, A.: Phlegmon sous-ombilical. Bull, et Mem. de la Soc. de chir. de Paris,

n. s., 1877, iii, 641.

262

Fig. 153. — Subumbilical Phlegmon - . (After Heurtaux.) According to Heurtaux, the swelling is sometimes visible with the naked eye, and appears as an oval tumefaction, slightly prominent, and shading off into the surrounding tissue.

ABSCESS IN THE SUBUMBILICAL SPACE. 263

stages of syphilis, and in Case 4 the patient had recovered from a grave attack of typhoid fever. In four of the cases the symptoms were acute; in two, subacute. In the acute cases there were severe pain, sensitiveness in the umbilical region, and a tendency toward constipation. In some cases there was vomiting.

The observations of Heurtaux seem in a large measure to have been overlooked, and it was not until the work of Fischer* that we again hear much on this subject. Fischer wrote a most extensive article in which he discussed acute subumbilical phlegmon, chronic abscess in the subumbilical space, and the breaking through of purulent collections into the subumbilical space. In the beginning he refers to the work of Heurtaux, and says that Jolion and Heurtaux in 1877 studied the anatomy and pathology of the subumbilical region and found on each side of the linea alba a triangular space. He says that Charpy, in 1888, found that the subumbilical space was in part retroperitoneal, in part prefascial.

Fischer tried to fill the subumbilical space by injecting colored gelatin with a syringe introduced through an incision in the lateral wall of the rectus, the needle being directed inward and between the sheath of the rectus and the peritoneum. By this procedure he was able to produce a tumor, heart-shaped in form, with its base at the umbilicus and the apex about 6 cm. below it (Fig. 154). It was most prominent laterally, and diminished toward the linea alba, where it was represented by a fine furrow. At its base it was 14.6 cm. broad; at its apex, 1.6 cm.; its greatest length was from 8 to 9 cm. In men and women, in young and old, in fat and thin, the space was always the same size. Above it was closed partly by the umbilical scar, partly by firm adhesions between the peritoneum and the sheath of the rectus, at the outer side and below only by adhesions between the peritoneum and the sheath of the rectus. Jouon said that there was no definite walling-off below, but that a loose connective tissue existed through which the space communicated with the cavity of Retzius.

On page 523 Fischer says that suppurations which start in the subumbilical space run either an acute or a chronic course, and whereas some develop in the space, others wander in. He then goes on to describe briefly the clinical picture.

In speaking of acute subumbilical phlegmon, he says that he had five definite cases of subumbilical inflammation, such as were described by Heurtaux, and that in all he found the same characteristic picture. Fischer's tumors developed in men from seventeen to thirty-four years of age, who, apart from a gonococcal infection, had always been well. None of them had had a definite trauma nor was there any evidence of such a condition having existed.

The affection commences with a chill, and there is fever during the entire course of the disease, the temperature varying from 38.5° to 39.5° C. There is marked pain on attempting to straighten out the legs and on pressure on the abdomen. The pain commences at the umbilicus and spreads in all directions. The patient accordingly lies perfectly flat on the back, with the legs drawn up and the abdomen tense. In addition there is constant vomiting of slimy, pale-stained masses, the effort naturally increasing the amount of abdominal pain. The vomiting increases, and there is a feeling of faintness. The patient becomes pale and shows signs of collapse. The extremities, however, remain warm. The pulse is quick and the expression anxious. These symptoms are so pronounced at times that peritonitis

• Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Samml. klin. Vortrage, n. F., No. 89 (Chir. No. 24), Leipzig, 1890-94, 519.

264

THE UMBILICUS AND ITS DISEASES.

is thought of and a bad prognosis is given. Nevertheless, after the distressing symptoms have lasted two to four days the vomiting disappears. The bowels move again and flatus is expelled. The pain becomes more marked in the umbilical region, and a faint reddening and edema are noted in this situation. On palpation one can now feel a dense but movable infiltration, triangular in form,

Fig. 154. — The Subumbilical Space. (Schematic.) Heurtaux has described a series of cases in which abscesses have developed just below the umbilicus. He speaks of these as subumbilical abscesses. Fischer has attempted to outline these spaces by using injections of gelatin. This sketch has been drawn after the description and measurements of Fischer. The umbilicus is seen in the midline. On each side of this the fascia and muscle have been removed. The space is situated just below the umbilicus, and lies behind the rectus muscles. The base of the space is indicated by a line drawn between o and b. The apex of the space is at c and d. The space is usually partially or completely divided by a septum which extends from the umbilicus above to the apex below. The anterior wall of the space is composed of the sheath of the rectus, its posterior wall, of peritoneum. The distance between a and b averages 14.6 cm. The distance between the umbilicus and c averages 8 or 9 cm. The distance between c and d averages 1.6 cm.

limited by the outer walls of the recti, and with its base directed upward. The skin can be pushed over, but is not gathered up into folds. There is dulness on percussion.

In the course of from nine to twelve days, with the gradual disappearance of the general disturbances, there develops on both sides of the linea alba a firm, elastic tumor below the umbilicus. This, as was pointed out by Heurtaux, is of the size

ABSCESS IN THE SUBUMBILICAL SPACE. 265

and form of the urinary bladder. Not infrequently a definite long furrow can be traced downward from the umbilicus. This is the linea alba, which partially or completely divides this space into two parts. Finally, this tumor rises 5 or 6 cm. above the level of the abdominal wall. Under chloroform narcosis the recti muscles can be pushed over the tumor. The fluctuation becomes more and more evident. Fischer, contrary to the observations of others, has never noted spontaneous rupture either outward or into the peritoneal cavity.

Fischer says that in four of the cases, after making the incision, he found that he was dealing with a single abscess cavity, although there are two subumbilical spaces separated from each other by the linea alba. It could very readily happen he decides, that in these cases one portion of the cavity might be infected and the inflammation extend to the opposite side. Fischer, in one case, was able to carry his finger from the first cavity over to the second through an opening, a dividing partition still persisting.

Differential Diagnosis. — The differential diagnosis in this group of cases is not always perfectly clear. Fischer mentions the fact that in two cases he found flat epithelial cells in the pus contents. Their presence would be against the existence of a subumbilical abscess. Where flat epithelial cells are found in such an abscess the inflammatory process is usually of urachal origin. This group is a very characteristic one, and is described on page 567.

ABSCESSES BREAKING THROUGH INTO THE SUBUMBILICAL SPACE.

Fischer, after describing the subumbilical space, records three cases in which a

purulent accumulation from distant points found its way into the subumbilical

space. One was an empyema, another a liver abscess, and the third an appendix

abscess. In each of these cases the subumbilical space was involved secondarily.

An Empyema Opening into the Subumbilical Space.

Fischer, on page 535, mentions the case of a Russian girl, eight years of age, who had a left-sided empyema which reached as high as the scapula. In addition there was a fluctuating, egg-shaped tumor below the umbilicus, and to the left of the linea alba. When the patient coughed, this swelling increased in size at the subumbilical space. Fischer resected several ribs and found that water would flow through the entire space as far as the umbilicus. The child finally recovered. In this case there was a fistulous opening from the pleural cavity downward to the subumbilical space.

A Liver Abscess Opening into the Subumbilical Space.

Fischer and Biermer, in 1876, treated a patient suffering from liver abscess, which, however, gave no characteristic symptoms. The patient was twenty-seven years of age. There was a history of injury, followed some time later by an irregular fever. The liver dulness was increased. Six months after the injury, when Fischer saw the patient, there was an oval tumor to the right of and below the umbilicus, with the base directed upward and the apex downward. The tumor was soft and fluctuating and increased in size when the patient coughed. On pressure it could be made smaller. It was 8 cm. in length and 9 cm. in its greatest breadth. It was incised, and there escaped a yellowish-tinged, foul-smelling pus in which liver substance could be detected. The abscess cavity had the size and form of a subumbilical

266 THE UMBILICUS AND ITS DISEASES.

space. As the fever persisted Fischer made an incision parallel to the margins of the ribs, and opened into a large retroperitoneal abscess which had been shut off on all sides. From this an opening extended downward into the subumbilical space. The patient improved slowly and gradually recovered.

An Appendix Abscess Opening into the Subumbilical Space. Fischer says that an appendix abscess occasionally opens into the subumbilical space. On page 536 he reports the case of a woman, twenty-seven years of age, who came to the Breslau clinic on account of a fecal fistula below and to the right of the umbilicus. Ten months previously she had had severe abdominal pain, vomiting, and obstruction. After six weeks of much suffering an egg-shaped tumor had developed and a fistula had followed. First there had escaped foul-smelling pus and then fecal matter. On splitting the abdominal walls Fischer noticed a cavity lined with granulations. The abscess in position, form, and size corresponded exactly with the subumbilical space. In its posterior wall in the lower and outer angle was a fecal fistula which had arisen from an ulcerated vermiform appendix. In its lumen was a cherry-stone. After removal of the stone, resection of the appendix, and cureting of the abscess cavity, healing took place.

AN ECHINOCOCCUS CYST IN THE SUBUMBILICAL SPACE. This condition is evidently rare, as I have found but one case recorded. Fischer said that he operated on a man, thirty-two years of age, in whom a fluctuating, smooth, painless, immovable tumor, the size of a fist, had developed beneath and to right of the umbilicus, near the median line. It had been noted for six years. The patient during this time had often vomited, but otherwise had been healthy. For three weeks the tumor had been painful and increasing in size. Fever had been present, and the skin had become reddened and edematous. In size, form, and position the tumor corresponded with the subumbilical space. Fischer made an incision at the outer wall of the rectus and into the subumbilical space. There was a densely adherent echinococcus sac, which could not be extirpated on account of firm adhesions binding it to the peritoneum. It was split, scraped out, and packed. The patient made a good recovery and remained apparently well.

ACTINOMYCOSIS IN THE SUBUMBILICAL SPACE. Fischer furnishes the only record of such a case that I am familiar with. The patient was a man in whom an actinomycotic infiltration was noted as a firm, circumscribed tumor the size of an apple in the subumbilical space. It gave the patient little discomfort. The skin was movable over the tumor and was not altered. At first there was no fever. Later, at intervals, there appeared an inflammatory but painless swelling. Four months after the patient first noticed his trouble, edema developed, and there were thickening and reddening over the tumor, which broke through the skin at several points. The escaping pus contained a few actinomycotic bodies. On the third day feces escaped. The fistulse lay below the umbilicus, one on each side of the linea alba, and communicated with each other. In attempting an extirpation and clearing-out of the sinuses, Fischer found a

ABSCESS IN THE SUBUMBILICAL SPACE. 267

sieve-like fistula representing the points at which the intestine had broken through. The patient died fourteen days after the operation.

Resume. — ■ From the foregoing it is clearly evident that below the umbilicus there is a definite, heart-shaped cavity — the subumbilical space — about 8 cm. in length and 14 cm. broad. This is situated between the peritoneum and the sheaths of the muscles. It is often divided longitudinally into two cavities by the linea alba, which forms a septum between the muscle-sheath in front and the peritoneum behind. This subperitoneal space can be definitely outlined by injection methods.

There is no doubt that subumbilical abscesses can develop. The symptoms in the early stages strongly suggest a peritonitis; later the general abdominal symptoms subside, and a localized tumor can be detected just below the umbilicus. When opened, the abscess is found to lie between the muscle-sheath and the peritoneum. Usually the septum between the two sacs disappears, leaving only one abscess cavity.

Whether all the hitherto reported cases were really abscesses in the subumbilical spaces or not is problematical. Those cases in which epithelial elements were detected probably represented abscesses resulting from infection of remnants of the urachus.

That the subumbilical space may be secondarily involved seems to be clearly shown by the cases of empyema and liver abscess reported by Fischer. The possible presence of echinococcus cysts and actinomycosis in the subumbilical space is proved by the cases above described.

Treatment.— As soon as these abscesses are diagnosed, they should be opened and drained. Not much force should be used in the packing, as the posterior wall of the abscess consists merely of the thickened peritoneum. Recovery promptly follows evacuation of the pus.

Reference

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

Historic Disclaimer - information about historic embryology pages

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

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