Difference between revisions of "Book - Umbilicus (1916) 29"
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=Chapter XXIX. Congenital Patent Urachus=
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An umbilicus with tumor formation.
An umbilicus with tumor formation.
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umbilical cord was unusually thick near the abdomen. In these cases, of course,
umbilical cord was unusually thick near the abdomen. In these cases, of course,
the urachus was patent from the bladder to a point in the cord distal from
the urachus was patent from the bladder to a point in the cord distal from
the point of ligation, and naturally no urine could escape until the ligature had
the point of ligation, and naturally no urine could escape until the ligature had
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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 XXIX. Congenital Patent Urachus
Appearance of the umbilicus.
An umbilicus without tumor formation.
An umbilicus with tumor formation.
Patent urachus and patent omphalomesenteric duct in the same child. Detailed report of cases of children born with a patent urachus.
Occasionally an infant is brought to the physician with the history that a few days after birth a watery discharge was noted at the umbilicus and that this discharge has continued. Where the discharge is abundant, it is invariably due to a patent urachus.
Escape of Urine. — The manner in which the urine escapes from the umbilicus varies. It may come away in very small quantities or be discharged in abundance. In Jacoby's case the umbilical depression was often filled with urine. In Goupil's case it came drop by drop, as from a still. In Alric's Case 1 it came drop by drop when the child cried. In Charles' case urine would "fall" from the umbilicus. In Jahn's case urine escaped when pressure was made upon the abdomen. Stierlin's patient passed only a small quantity from the umbilicus during the day, but at night the bed was saturated. In Paget's case the urine gushed from the umbilicus, while in Marx's case it came away in jets. French's patient discharged a small umbilical stream when crying. Annandale's patient, who was thirty-nine years of age, passed two-thirds of his urine from the umbilicus in a stream, when in the upright position; when he was lying down, the urine escaped involuntarily from the umbilicus. Erdmann's patient, who was four years old, at times passed an umbilical stream 4 to 12 inches high. In Hue's case the urine escaped from the umbilicus at night.
In Pauchet's case the escape of urine from the umbilicus was intermittent, occurring at intervals of from four to five days and persisting from one to two days each time.
In Cabrol's case, in which the urethra was completely blocked, all the urine, of course, escaped from the umbilicus.
The character and size of the umbilical stream will, of course, depend on the caliber of the patent urachus, the size of the umbilical opening, and occasionally on the ease or difficulty with which urine can escape from the urethra. The urine naturally follows the path of least resistance.
On questioning the parent it will be found that the urine commenced to escape from the umbilicus just after the cord came away; and some of the more careful observers among the physicians, midwives, and mothers will have noted that the umbilical cord was unusually thick near the abdomen. In these cases, of course, the urachus was patent from the bladder to a point in the cord distal from the point of ligation, and naturally no urine could escape until the ligature had sloughed off.
In Delageniere's case the urachus was evidently almost patent at birth, but did not open until the child was six months old.
Membranous veil at internal urethral orifice
APPEARANCE OF THE UMBILICUS. In glancing over the detailed histories of the cases of patent urachus it will be noted that in some cases the umbilicus was but little altered (Fig. 210), while in
others a definite, tumor-like mass was found.
An Umbilicus Without Tumor Formation. — The umbilicus may show little deviation from the normal, and the urachal opening be scarcely visible. In other cases the umbilicus is a little broader than usual and has five or six radial folds. At the place where these meet the urachal opening is usually found, and sometimes there is a definite funnel-like depression. Occasionally, as noted in Huggins' case, the urachal opening may be found in the lower margin of the umbilical ring. In Stevens' case there was a small hernial protrusion at the umbilicus. Fig. 255 (p. 625) represents a small hernial protrusion associated with a patent urachus.
An Umbilicus with Tumor Formation. — As a rule, the umbilical growth is small. Sometimes it is very minute, as in Florentin's case, in which it was the size of a pea. The nodule is usually spoken of as being the size of a nut, a cherry, or small strawberry. Sometimes it is dark red, flabby, and suggests granulation tissue. In other cases it may be firm, and red or violet in color. In a few cases it resembled a mushroom or flattened button, and was attached to the umbilicus by a pedicle (Fig. 211).
In Starr's case the umbilicus was larger and more widely open than usual, and in the center of the cartilaginous, nipple-like projection was an orifice which admitted an ordinary probe. In Cabrol's case (quoted by Florentin) there was a projection at least four fingerbreadths long which resembled the crest of a turkey. In Alric's Case 1, a boy ten months old, had a bright-red umbilical projection, 3 or 4 cm. long. This also bore a marked resemblance to the comb of a turkey-gobbler.
Occasionally the umbilical tumor resembled a glans penis (Fig. 212). Meyer's patient was a child one year old. The umbilicus was thickened and, although no hernia existed, it was prominent and in contour resembled a glans penis.
Fig. 210. — Escape of Urine from the Umbilicus When the Inner Urethral Orifice is Blocked by a Membrane. (Schematic.)
At least one case of this character has been recorded. As soon as the membrane was severed, nearly all the urine escaped by the urethra, and in a short time the discharge from the umbilicus ceased.
CONGENITAL PATENT URACHUS.
Fig. 211. — A Patent Urachus tvith a Mushroom-like Projection at the Umbilicus. (Schematic.)
French's patient was a female infant six weeks old. At the umbilicus there was a hernia-like protrusion of the skin about three-quarters of an inch in length, surmounted by a red, fleshy outgrowth like a swollen and fungoid glans penis; whenever the child cried or struggled, this growth became very prominent and vascular. In practically all of the cases in which the umbilical tumor existed, the urachal opening was situated in the center of its most prominent point.
Size of the Umbilical Opening. — Sometimes it is not larger than a pin-point and is hardly demonstrable. In other cases it is one or more millimeters in diameter, and may admit a fine probe or a mediumsized catheter. Sometimes the probe or catheter can be carried from the umbilicus directly into the bladder, and, if the bladder extends almost to the umbilicus, the distal end of the probe can be swung as a pendulum from side to side. In some
cases, particularly in those in which the urachus is tortuous, the probe can be passed only a short distance.
Irritation. — Occasionally there is a mild or severe inflammation of the skin around the umbilicus, the degree evidently depending on the irritating qualities of the escaping urine. At times the inflammation of the skin may be so severe that small ulcerations develop.
In Hind's case, in a very young infant extravasation of urine occurred around the umbilicus and finally extended all over the abdomen. The child soon died.
Sex. — In 53 of the cases here recorded, 35 of the patients were males and 18 females. These figures seem to coincide with those of other observers in showing that a patent urachus at birth is more common in males than in females.
Fig. 212. — A Patent Urachus tvtth a Penile Projection at the Umbilicus. (Schematic.) Where the urachus remains patent the umbilical end may appear as a small depression in the floor of the umbilicus. In some instances a mushroom-like elevation occupies the site of the umbilicus. In exceptional cases a definite penile projection springs from the umbilicus, and at the end of this is the opening of the urachus, as indicated in the picture.
490 THE UMBILICUS AND ITS DISEASES.
Monod, in his splendid monograph, says that it is three times more common in males than in females.
Race. — It will be noted that both Cabell's and Stites' patients were colored. Future observations will probably demonstrate that a patent urachus is relatively as common in the colored as in the white races. The majority of our observations to date have come from countries and localities where few negroes are found.
General Condition of the Child. — - From the histories it will be seen that nearly all the children were in good health. A few were anemic or slightly emaciated, but no greater percentage than one would expect to find under ordinary conditions. The presence of a patent urachus seems to have little effect on the general health of the child.
Before undertaking the closure of the umbilical fistula the patency of the urethra must first be ascertained. In the majority of the cases the urethra has been perfectly normal. In some cases, however, a phimosis exists, and under these a circumcision should first be performed.
Goupil, in 1756, reported the case of a twelve-year-old boy all of whose urine escaped from the umbilicus. In this case there was a congenital malformation and the penis was not perforated. Draudt reports a case of urinary umbilical fistula in a child a day old. Death occurred on the fifteenth day, and at autopsy it was found that the urethra was almost totally obliterated. It is obvious that in Goupil's and in Draudt's case any attempt to close the umbilical fistula would not only have been useless, but essentially harmful.
Quite a number of the patients were never operated upon, and the urinary umbilical fistula persisted even in adult life. Spontaneous closure of the fistula is exceptional. Lugeol, however, reports the case of a female child who had at the umbilicus a small, soft, reddish- violet tumor, in the center of which was a small fistulous opening. Little by little the urinary discharge from this diminished and finally disappeared. Five months later the child was well.
Tuholske also reports a case of spontaneous healing. His patient was a man fifty-two years of age. In infancy he had passed urine from the umbilicus. This condition ceased in his fourth year without treatment, and he had no further trouble until his forty-eighth year, when, apparently without cause, the urine again commenced to flow through the navel.
Monod reports the case of a patient that came under the care of Jaboulay. A man sixty-two years of age, who was suffering with painful micturition and symptoms of an enlarged prostate, noticed urine escaping from the umbilicus. When questioned, he said that his mother had often told him that shortly after birth he was treated for the escape of urine from the umbilicus, and that this discharge had disappeared in the course of fifteen days after the application of an appropriate bandage. Jaboulay's case is another example of spontaneous closure of the fistula.
In the early days the fistulous opening was usually treated with caustics or with the actual cautery, and in quite a number of instances the fistula soon closed. ( Occasionally a simple plastic operation gave very fair results.
In those cases in which a definite umbilical tumor was present, it was in some instances transfixed with needles and ligated. The tumor would slough off in a few days, and the umbilical end of the fistulous tract usually remained closed.
CONGENITAL PATENT URACHUS- 491
Where the urachus still persists, there is always a chance of subsequent trouble, and there are at least three cases on record in which the patient later developed cancer of the urachus. Graf reported the case of a man, twenty-eight years old, who died of cancer of the urachus. This patient at birth had an umbilical fistula. It was healed with escharotics. Twenty-five years later carcinoma of the urachus developed. Hoffmann also reports a case in which the patent urachus was closed with escharotics when the child was in his third year. This man, when twenty-seven years old, developed a fatal carcinoma of the urachus.
Fischer records the case of a man of thirty-two who had an inoperable carcinoma of the urachus. During childhood this man, when voiding, had been aware of a "moisture at the umbilicus." Later this symptom had disappeared and he had noticed no further trouble until he was thirty-one years old.
In the light of our present knowledge of abdominal surgery the wise plan is always to remove the fistulous tract. The umbilicus is encircled and freed, and, together with the fistulous tract, is dissected free to the bladder. The bladder attachment of the urachus is treated in precisely the same manner that an appendix stump is dealt with, namely, by the employment of a purse-string suture. After the stump has been inverted into the bladder, the closure is reinforced with one or two more sutures and the wound closed. The purse-string suture should consist of fine black silk or of catgut that will last for several weeks. This method of treatment has been in use for several years, and has yielded excellent immediate results. It has also insured absolutely against any subsequent urachal trouble.
In those cases in which the urachus gradually broadens out into the bladder, the bladder opening is naturally large and sometimes cannot be satisfactorily closed with a purse-string suture. In such cases it may be necessary to close it with a continuous suture, as in the procedure for closing the bladder after a suprapubic operation.
PATENT URACHUS AND PATENT OMPHALOMESENTERIC DUCT IN THE SAME CHILD.
We have found numerous examples of a patent omphalomesenteric duct and of a patent urachus, but there are only two cases, as far as we could learn, in which both were patent in the same child.
Lexer, in his article on the Treatment of Urachal Fistulas, refers to the case of a boy a year old. Urine escaped in large quantities from the umbilicus. From the accompanying history it is certain that at operation a patent omphalomesenteric duct was found, in that it is stated that the fistula was lined with typical intestinal mucosa. There seems to be little doubt that both the vitelline duct and the urachus were patent.
In the second case — related to me by Dr. Heflin — at operation a fistulous tract passing directly from the umbilicus to the small bowel was found. This tract was three inches long. After it had been cut away and the bowel closed, a second tube was found extending from the umbilicus to the bladder. This was also patent.
I have had microscopic sections made from this case. One duct, the vitelline, is lined with typical intestinal mucosa, the other, the urachus, with remnants of transitional epithelium. The patency of both ducts in this case cannot be questioned (Fig. 214).
Both of these cases are of such interest that I wall cite them in detail.
492 THE UMBILICUS AND ITS DISEASES.
A Patent Urachus and Probably a Patent Omphalomesenteric Duct. — Lexer* in his article reports the case of a boy, a year and a half old. The cord came away on the fifth day and clear fluid was noticed coming from the umbilicus. It is said that at this time there was a reddish tumor, the size of the end of the little finger, at the umbilicus. This gradually became smaller and finally disappeared. When the child was six months old the fistula was closed by a physician by means of salves and plasters. It remained closed, however, for only two weeks. The child was restless, and there were general systemic disturbances. When the fistula reopened, a large quantity of watery fluid escaped, and pus was said to have come away at one time. Wnen Lexer saw the child he was somewhat weak and pale. About 5 mm. below the umbilicus was a fistulous opening surrounded by an area of inflammation. Each time the child urinated a large quantity of urine escaped from the fistula, whereas from the urethra it passed drop by drop. There was a marked congenital phimosis. The case was diagnosed as one of urachal fistula. By placing a glass at the umbilicus the observer estimated that about one-quarter to one-third of the urine escaped from the navel. With a sound it was possible to make out only a small, bay-like cavity beneath the skin.
The prepuce was cut; four weeks later the urine was flowing normally and there had been a diminution in the size of the fistula. After excision of the skin around the umbilicus there was disclosed a depression lined with granulations, and scarcely larger than a hazelnut, communicating with the fistula. From this fistulous opening a sound could be passed exactly in the mid-line of the abdomen toward the bladder region. Further examination could not be made, as the child did not take the anesthetic well. As the mucosa of the fistulous tract was exposed, it was grasped with forceps and gradually drawn out. The sac was dissected out and the wound closed.
The tube was 7 cm. long, and microscopic examination showed that it was not a patent urachus, but a persistent omphalomesenteric duct. This on cross-section showed a well-developed intestinal mucosa; the lumen increased in size as it passed inward. It was lined with cylindric epithelium, had the typical Lieberkiihn's glands, and also the circular and longitudinal muscle-fibers. Lexer said that from the above picture it was clear that he was dealing with a Meckel's diverticulum. The child remained well.
The history clearly demonstrates the existence of a urinary fistula, and the microscopic examination of the specimen shows a tube lined with intestinal mucosa. The only way in which the picture can be adequately explained is by a persistence of both the urachus and the omphalomesenteric duct.
A Patent Urachus and a Patent Omphalomesenteric Duct in the Same Child. — Wliile conversing with Dr. H. T. Heflin, of Birmingham, Ala., on May 6, 1912, he related to Dr. Cunningham Wilson and myself his experience with a child fourteen months old. He saw the patient (J. S.J on August 29, 1911. Two or three days after birth bleeding occurred from the umbilicus. This bleeding at times was moderate in amount, but at other times severe, and as a result the child became very anemic. Apart from this he was perfectly well except for a tight prepuce, which had to be released. He was often constipated and cried a great deal. The more he cried the more he bled. Dr.
- Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73.
CONGENITAL PATENT URACHUS.
Fig. 213. — The Appearance of the Umbilicus in a Case in Which Both a Patent Omphalomesenteric Duct and a Patent Urachus Existed. (Heflin's case.) The umbilical depression is irregularly funnel-shaped and lobulated, and along one side is a small opening no larger than a pin-head. The picture to the right shows the cross-section of the omphalomesenteric duct in the abdominal wall. It is nearly 1 cm. in its longest diameter. It was lined with typical mucosa. To the extreme right are seen the ligated ends of the omphalomesenteric duct and the urachus. For the microscopic picture see Fig. 214.
Fig. 214. — Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same
Child. (Heflin's case.) The large cavity (a), to the right, is the lumen of the omphalomesenteric duct, which has been cut slightly on the slant. The mucosa is drawn up into long, papillary-like folds. Surrounding the lumen is a circular layer of non-striped muscle. The small cavity (6) to the left is what remains of the urachus. This cavity was partly filled with debris containing small round-cells and some polymorphonuclear leukocytes. The tissue immediately surrounding the lumen was very delicate in texture and has retracted from the surrounding dense tissue. The elongate dark area just below the lumen is a lymph-nodule. The tissue for a considerable distance around the urachus was infiltrated with small round-cells and polymorphonuclear leukocytes. (Photomicrograph by Mr. Herman Schapiro.)
THE L^MBILICUS AND ITS DISEASES.
Hefiin had him under observation for some time. The mother would bring him every day or two for examination. He became paler and more exsanguinated. The bleeding was stopped temporarily sometimes by pressure, sometimes by the use of the cautery, adrenalin, or hydrogen dioxid, but, instead of diminishing, the amount of hemorrhage increased. At a later date stick silver nitrate was used.
Finally, a small piece of the umbilicus was cut outrfor examination. The glands found in it suggested malignancy. From the time of his birth there had been some discharge from the umbilicus which had an odor of urine and at other times strongly suggested feces. Finally Dr. Hefiin decided that the only proper procedure was removal of the umbilicus. He made an elliptic incision, and on lifting the umbilicus out found that there was a continuous fistula about three inches long, from the umbilicus to the small bowel. He removed it, and treated the opening in the bowel precisely as if it had been the stump of an appendix. The mesentery of the small bowel opposite the point of this opening contained quite a number of large lymph-glands, some of them nearly 1 cm. in diameter.
He also found a second tube attached to the umbilicus, which passed downward toward the bladder. It was patent. He tied it off with catgut and brought it up into the abdominal incision. The abdominal wound was brought together without difficulty and the child made a good recovery (Fig. 215).
Sections through the mass removed by Dr. Hefiin from the umbilicus show two distinct tubes. One is almost circular and nearly 1 cm. across; the other about 2 or 2.5 mm. in diameter. The larger one, on histologic examination, is found to be lined with long, shaggy intestinal mucosa of the type found in the small bowel (Fig. 214) . The epithelium is everywhere intact. Surrounding the mucosa is a circular muscular layer and outside of this again a cylindric layer. The smaller tube is somewhat disorganized. Its walls are surrounded by muscle, and its inner surface consists in large measure of granulation tissue which has become organized. The nuclei have mostly disappeared. Clumps of polygonal cells are seen here and there clinging to the wall. Surrounding the lumen are large numbers of lymphoid cells, reminding one a good deal of young lymphglands. In the walls arc polymorphonuclear leukocytes and small round-cells. Un
flg. 215. a plctube of the child three
Weeks after Removal of a Patent Omphalomesenteric Duct and a Patulous Qrachus. He is Now in Good Health. (Heflin's catu.)
CONGENITAL PATENT URACHUS. 495
doiibtedly the tube represents the degenerated urachus. In this case there was a patent omphalomesenteric duct and also an open urachus.
REPORT OF CASES OF CHILDREN BORN WITH A PATENT URACHUS.
The following cases represent nearly all the cases we could find in the literature. Some in which the history was inconclusive, have been omitted.
A Patent Urachus with a Long Projection at the Umbilicus. — In Alric's Case 1* the patient was a boy ten months old, seen in 1862. He was well developed, but had at the umbilicus a tumor 3 to 4 cm. long. This was regular, round, with a diameter a little larger than that of a goose-quill. It was firm and resembled mucosa. It was bright red, and, as in Cabrol's case, bore a marked resemblance to the comb of a turkey-cock. In the center was an openinghaving the diameter of a fine probe, and when the infant cried, urine passed from the umbilicus drop by drop. Its nature was recognized by the color and odor.
The genital organs were normal, and the child urinated naturally through the urethra. This state of affairs had existed since birth.
As the child did not return to the hospital, no operation was done.
A Patent Urachus. — Alric's Case 2f was seen in 1873. The child was five years of age, and in every other respect seemed to be healthy except that it had a urinary odor. The umbilical depression was replaced by a soft, flabby, fungus-like, dark-red, somewhat rounded tumor, the size of a walnut. On manipulation it was found to have a short pedicle about the size of a pen-holder. Continually escaping from the center was a liquid, recognized by its odor as urine. When the bladder contracted, the urine escaped more freely from the umbilicus; at one time the force was sufficient to cause it to pass out in a jet. The urethra was normal.
The tumor was raised and transfixed with a needle threaded with double-waxed thread. The loop was cut, making two threads. These tied both halves of the tumor firmly. The tumor in a few minutes became dark and separated in a few days. By the fifteenth day cicatrization was complete. There was no further escape of urine and the boy remained well.
A Case of Unclosed Urachus with Umbilical Fistula. J —The patient was a big, strong, healthy, well-formed man thirty-nine years of age. He had passed a portion of his urine through the umbilicus ever since his birth. When he urinated in the upright position, about two-thirds would come out of the fistula in a full stream, the other third passing by way of the urethra, in a strong but small stream. When the patient was lying down, the urine would flow out spontaneously through the fistula — more markedly so when he was lying on his left side. He had to pass water regularly about every two hours, and in doing this he found it necessary to loosen all his clothes in front and bend forward. His health was good, but on one or two occasions he had passed fine calculous material with the urine.
The genital organs were well formed. The abdominal walls were perfect. The umbilicus was a little flatter than usual. In the center was an opening with depressed margins. The opening would admit the tip of the little finger. A No. 12
- Alric: Sur deux cas de persistance de l'ouraque. Bull, de therapeutique, 1879, xcvii, 34.
t Alric: Loc. cit., Case 2. J Annandale, T.: Edinb. Med. Jour., 1870, xv, 680.
496 THE UMBILICUS AND ITS DISEASES.
catheter passed easily from above into the bladder. There was no excoriation. A Xo. 6 catheter passed readily through the urethra into the bladder.
Operation was suggested, but refused.
Urachal Fistula. — H. R. Wharton reports a case that came under Ashhurst's* care. The patient was a boy nine months old. At the umbilicus was an opening through which urine had escaped since birth . Occupying the position of the umbilicus was a flattened tumor the size of a filbert. It was covered over with mucosa, and in its center was a depressed opening, through which the urine escaped. There was no obstruction in the urethra.
The actual cautery was applied to the fistulous tract and the projection at the navel was ligated. Recovery followed.
Patent Urachus. — Binnief says that J. D. Griffith, in a girl fifteen years of age, split, cauterized, and packed the fistula with splendid results. In this case the mother said that there had been more or less umbilical discharge from the time the cord had separated.
A Patent Urachus. — In 1847 Cabell J examined a mulatto girl fourteen or fifteen years old. She was in good health, but had an umbilical fistula, through which she had passed urine since her earliest childhood. Most of it, however, was passed through the natural channel. She claimed to have the power of passing it either way at will.
The umbilicus presented a flattened, disc-like appearance about the size of a quarter of a dollar. The skin around it was loose and in folds, but not so much as to attract particular attention to it. In the center was a small aperture of the usual appearance, and through this urine escaped. A catheter could be passed six to seven inches downward toward the bladder, and urine escaped from it. The urethra was rather smaller than usual.
A Patent Urachus. § — The patient was a well-developed boy one year old. The urine was first noticed escaping from the umbilicus when the cord dropped off. From the urethra it was passed with difficulty, coming only in drops. No tumor was noted at the umbilicus, but the urine filled the umbilical cup and ran over.
The prepuce was long, contracted, and adherent to the glans. The child was circumcised, and the urine later was projected through the urethra some distance, very little coming away from the umbilicus.
Charles says that sometimes it is necessary to operate on the fistula. He did not do so in this case, and the cure was not complete.
A Patent Urachus. || — The patient, C. F., was five and a half years of age. The baby had at the umbilicus a small, violet-colored tumor, the size of a currant. At the age of six months this small tumor began to grow; it became prominent and enlarged considerably, until it reached the size of a strawberry. Some time later an orifice formed at its summit, from which a stream of serosanguineous fluid escaped. This was never examined. Since that time, according to the mother,
- Ashhurst: Med. News, Philadelphia, 1882, xli, 122.
t Binnie, J. F.: Jour. Amer. Med. Assoc., 1906, xlvii, 109. % Cabell, R. G.: Amer. Jour. Med. Sci., Philadelphia, 1848, n. s., xv, 313. § Charles, J. J.: The Treatment of Patent Urachus. Brit. Med. Jour., 1875, ii, 486. || Delageniere, H.: Traitement de l'ouraque dilate et fistuleux par la resection et la suture. Une observation. Arch, provinc. de chir., 1892, i, 222.
CONGENITAL PATENT URACHUS.
there had been sometimes a cessation of the discharge, but then immediately there had developed a severe pain at the umbilical region. It was on acccount of this pain that the mother sought surgical aid.
On examination the child was well nourished, but rather backward in development, and looked more like a four-year-old child than one of five and a half. The umbilicus was the seat of marked irritation. It was deformed and showed a transverse furrow, dividing it into two halves, an upper and a lower, both of which were indurated and red. This furrow measured about 2 cm., and was surrounded by an inflammatory zone several centimeters broad, which presented multiple erosions of the skin and several indurated points — veritable hard nodules. The principal one was situated 3 cm. below the fold of the umbilicus. Through the furrow it was possible to introduce a probe and pass it easily downward toward the nodule mentioned. The fluid escaping from the umbilicus was usually clear and transparent, sometimes tinged with blood, chiefly when the child walked. The urine escaped from the urethra in a jet, and a short time afterward some could be seen coming from the umbilicus. When the urine ceased to pass by the urethra, the discharge from the umbilicus increased.
On May 2, 1892, a median incision was made. The tissue on section had a lardaceous appearance. The operator entered into an excavation lined with f ungosities and numerous diverticula. This cavity was cureted. In the lower part was a pocket into which a sound could be introduced. Delageniere decided to remove the sac (Fig. 216). He opened it and entered the peritoneal cavity. He then easily recognized the urachus, which showed as a duct lined with smooth mucous membrane. The duct was isolated for a distance of 3 cm. and ligated. The sac was then removed, a drain introduced, and the abdomen closed. The patient made a satisfactory recovery.
A Patent Urachus. — Draudt* describes the case of Fritz R., six months old. For several weeks a clear fluid had been escaping from the umbilicus. Whether it had begun almost immediately after birth was not known. The child was healthy and otherwise normally formed. The umbilical ring was completely closed. There was, however, an escape, drop by drop, of a clear, acid-reacting fluid from the umbilicus. After a 4 per cent, solution of indigo-carmin was introduced into the gluteus muscle, the urine from the urethra and the fluid from the umbilicus both took on a deep blue color. There was a phimosis, but the stream from the urethra was fairly well developed.
Operation. — Professor Lexer, with the patient in the Trendelenburg position, made an incision around the umbilicus and continued it to within a fmgerbreadth
Fig. 216. — A Patent Urachus. Delageniere.) Anteroposterior section through the lower part of the abdomen. P, peritoneum; V, the bladder; O, the urachus; U, the urinary pouch; a, the orifice of the fistula at the umbilicus.
- Draudt, M.
1907, lxxxvii, 487. 33
Beitrag zur Kenntnis der Urachusanomalien. Deutsche Zeitschr. f. Chir.
THE UMBILICUS AND ITS DISEASES.
of the symphysis (Fig. 217). The incision was deepened and the parts dissected free. On the posterior surface of the cord, passing from the umbilicus to the bladder, the peritoneum was very thin. The opening in the bladder- wall was closed with a continuous mattress suture, which was reinforced, and the abdomen was closed.
The specimen was 7 cm. long, with a canal about 2 mm. in diameter extending throughout its entire length. About 1.5 cm. from the outer skin, at the umbilicus, the lumen became wider. It was funnel-shaped and passed gradually into the skin. The portion toward the bladder was similarly arranged. The funnel-like dilatation imperceptibly passed over into the bladder mucosa. There was no evidence of a fold or of a valve.
Microscopic examination gave findings similar to those obtained by Luschka, Suchannek, and Wutz. The inner surface of the tube was everywhere lined with several layers of epithelium, usually three layers in thickness.
A Patent Urachus Associated with a Partially Obliterated Urethra.* — In the case of K. B., a male infant one day old, no evidence of a urethra was found externally and the bladder did not seem to be very full. Under these circumstances a urethral orifice was sought for in the perineum. The entire bulbus was laid free and carefully examined, but no urethra was discovered. The opening made in the perineum was not closed. The dressings a few hours later were found to be moist. Injections of indigo-carmin into the gluteus muscles did not, however, give a very clear blue color. The moisture on the clothes continued, but no opening corresponding to the urethra could be seen. After gradually becoming weaker, the child died when fourteen days old. At autopsy it was found possible to remove the urachus, bladder, and urethra intact. (Fig. 218 gives a typical picture of the condition.) The bladder itself was spindleshaped, approximately 4 cm. in length. At its broadest point it measured 2 cm. in diameter. The walls were very thick, especially near the fundus. The mucosa was folded. The ureters opened at the normal points. Projecting from the fundus was a canal 1.8 cm. long and about 5.5 mm. in diameter. This passed gradually into the funnel-like opening at the top of the bladder, and there was no evidence of a fold-like formation at the junction of the bladder with the canal. The tube was lined with epithelium, extended to the umbilicus and was open
- Draudt, M.: Loc. cit.
217. — A Urachus Open from Bladder to Umbilicus. (After Draudt.) The child is in the Trendelenburg posture. The umbilicus has been encircled by the incision, and the cord dissected free to the bladder. It was cut off at the top of the bladder, and the bladder closed. The patient made a good recovery.
CONGENITAL PATENT URACHUS.
Remains of umbilical arteries
there. The opening, being not over 0.1 mm. in diameter, macroscopically was hardly visible, but in serial sections the condition became apparent. The inner surface was lined with a very definite epithelium, four or five layers in thickness. The superficial epithelium was also cylindric in character.
On examination of the urethra it was found that the bulbous portion followed an eccentric course and lay to the left. In the course of the urethrotomy it had been cut a little, — sufficiently to allow urine to escape, — but not enough to be recognized macroscopically. The urethra was eccentric and ended as a connective-tissue thread about 2 cm. beneath the point of the glans. This case belongs to the rather rare group of defects of the urethra in its glandular portion. Kaufmann, in 1886, could find only 11 cases of this anomaly.
Vesi co-umbilical Fistula.* — This case was also recorded by Dupuytren and Roux and also forms Gueniot's Observation 5.
Madam L. brought a male child twenty-three and one-half months old to the hospital on May 14, 1810. The child looked well. From birth he had presented a remarkable and extraordinary phenomenon. Part of the urine had passed from the urethra and part from the umbilicus. The umbilicus was radiating in form, and in the center could be seen the umbilical extremity of the urachus. At the umbilicus at birth was an oblong tumor. The cord was situated in the middle of the extremity of this tumor, which was red and bloody. After the cord had dropped off the boy had commenced to emit jets of urine from the umbilicus. The extremity of the tumor was always red, and covering it was a small quantity of pus. In the course of fifteen days the tumor assumed a more favorable aspect. It commenced to cicatrize, and after six weeks healing was complete, but the fistula persisted.
A Patent Urachus in a Child Four Years 1 d . f — In this child, four years of age, there was a leakage of urine from the umbilicus. At times the stream was from four to twelve inches high.
The boy was well nourished, had normal genital organs, and voided some of his urine from the urethra.
At the umbilicus was a large, mushroom-like eversion fully half an inch high, with a crater-like center. The entire structure was covered with epithelium, and showed no erosions. In the center there was a small cicatricial area surrounding the opening, which admitted an ordinary probe. The boy was kept under observation and was found to have a fairly good stream from the urethra.
Operation. — A probe could be passed from side to side like a pendulum, showing
Fig. 218. — An Open Urachus. (After Draudt.) The bladder is spindle-shaped. The upper portion is narrow and gradually passes over into the open urachus, which can be followed up to the umbilicus.
- Marx: Enfant de vingt-trois mois et demi, qui rendait Purine en partie par la verge et en
partie par l'ouverture ombilicale de l'ouraque. Repertoire general d'anatomie et de physiologie pathologique, 1827, iv, 120.
f Erdmann, John F.: Pediatrics, 1908, xx, 356.
500 THE UMBILICUS AND ITS DISEASES.
a rather wide urachus with a diameter of fully half an inch. A free incision was made from an inch above the pubes to the umbilicus. In dissecting the urachus free the operator made several small openings in the peritoneum. The bladder was fusiform in shape, and the urachus, which was three-quarters of an inch wide and about three inches long, was apparently continuous with the bladder itself. The umbilicus was excised, and about an inch of the urachus with the umbilicus cut off. Direct apposition sutures were then applied, followed by a circular row below, with inversion of the sutured portion, as in the case of an appendix stump. A third row of catgut sutures was placed over the inverted end, and the abdominal wound closed. A catheter was placed in the bladder and kept in three days. The boy made a good recovery, and was discharged on the seventeenth day.
A Patent Urachus. — Florentin* quotes Cabrol's case. In the year 1550, in the village of Beaucaire, there was an exhibition by the village guard before the house of Mile, de Varie. Several of the young ladies were accidentally injured. When treating these patients, Cabrol noticed a most offensive odor of urine, and tried to find out the cause. The next day he examined a girl and found at the umbilicus an elongation the length of four fingerbreadths, resembling the crest of a turkey-cock, whose urine is passed through the cloaca. The surgeon was at once impressed with the danger of closing this opening without allowing the urine to pass by the ordinary channel. The girl was eighteen years of age. He found the vesical orifice closed by a membrane. He opened this and passed a lead cannula into the bladder. The next day he closed the opening at the umbilicus. It had entirely healed by the twelfth day.
A Patent Urachus. — Florentinf reports a case of urinary fungus in a girl of four years, from the clinic of Professor Froelich. She was admitted to the surgical department for fistula at the umbilicus. At birth nothing abnormal was noted. The cord came away on the ninth day. At that time the mother noticed at the base of the umbilical cicatrix a tumor the size of a small pea. This discharged continuously a whitish liquid with the odor of urine. Since that time the tubercle had gradually increased in volume, the discharge had persisted and produced a marked erythema at the orifice of the umbilicus. This condition had persisted for four years, without any interference with the health of the child. On examination, at the base of the umbilical fold was seen a violet-colored tumor the size of a pea. A probe could be introduced downward and backward. The tumor was irreducible. There was no hernia at the umbilicus. At intervals a drop of clear liquid with a urinous odor escaped.
Operation. — The tumor was encircled and dissected down to the peritoneum. All that could be drawn out was cut off and the wound closed. Microscopic examination showed an outer coat of connective tissue, then the cell-fibers of non-striped muscle, and in the center a duct lined with pavement epithelium. The child made a good recovery.
A Patent Urachus. J — A male child, two or three months old, was brought to Professor Helmuth's College Clinic in 1885. The nurse who accompanied the child said that it passed urine through the umbilicus. On examination an outgrowth, about an inch and a quarter in length, was discovered in this locality. It
- Cabrol: Quoted by Florentin, P.: Fongus de l'ombilic chez le nouveau-ne et chez 1'enfant. These de Nancy, 1908-09, No. 22.
t Florentin, P.: Op. fit,, obs. 9. \ Freer: Annals of Surg., 1887, v, 107.
CONGENITAL PATENT URACHUS. 501
was hollow and was connected by a completely pervious urachus with the bladder. This point was proved by the continuous discharge of urine through it. The urine excoriated the parts and rendered the child exceedingly uncomfortable. The method of treatment suggested for the deformity was ligation of the excrescence, but, owing to the absence of the child's parents, this was deferred.
A Patent Urachus. — Freer* says that in cases of vesico-umbilical fistula several methods of treatment have been devised. He cites the case of a child of five months. The urachus was completely pervious and admitted a mediumsized catheter. At its umbilical extremity was an outgrowth that resembled a strawberry. This was encircled with a subcutaneous ligature and removed; the edges were pared and sutured, and complete closure followed.
A Case of Fleshy Tumor of the Umbilicus with Patent Urachus. — French's! patient was a female six weeks old. There was at the umbilicus a hernia-like protrusion of the skin about three-quarters of an inch in length, surmounted by a red fleshy outgrowth, like a swollen and fungoid glans penis. Whenever the child cried or struggled, this growth became very prominent and vascular, and through a small opening urine was expelled.
Operation. — After it had been determined that no knuckle of intestine was in the way, a harelip pin was driven through the fleshy mass at its junction with the cuticle and transversely to the body axis. Beneath this and at right angles to it a needle armed with a stout double ligature was passed, and the threads were drawn through. These were tied tightly on each side under the pin. The fleshy mass came away with the pad on the third day. On the tenth day the wound had completely healed and was covered with skin. An umbilical truss was ordered as a simple precaution.
Escape of Urine from the Umbilicus. % — The patient was a boy of twelve who, for three years, had had an oval tumor directly above the symphysis. It was about the size of a hen's egg. The overlying skin was tender and apparently inflamed, but showing no great amount of reaction. To theleft of the tumor was an oblique cleft about 9 mm. long. It was through this opening that the child urinated, but drop by drop, as from a still. Below the tumor was a transverse opening, from which air escaped with some noise, and there was sometimes a foul odor. Immediately beneath this was another tumor, which may have been a penile gland. The penis was not perforated. Goupil asks how the urine could come from the umbilicus, but quotes Graf, Diemerbroeck, du Laurent, Fernel, and others as having seen it escaping. He wonders whether the foul odor could have been from the bowel, but says that no feces were passed through the umbilicus.
A Patent Urachus. § — This case was recorded in the Deutsche Klinik, 1864, xvi, 116. A man twenty-eight years of age had a urachal fistula at birth. This was healed after the employment of escharotics. Twenty-five years later a tumor developed between the umbilicus and the symphysis. This broke and discharged pus, then urine. Autopsy revealed a carcinoma of the mucosa of the urachus, which had perforated into the umbilicus and the bladder.
Possibly a Patent Urachus. || — This case was reported in Vaughan's article. No reference is given as to the original source.
- Freer: Loc. cit. t French, John G.: The Lancet, London, 1882, i, 60.
t Goupil: Sur un vice de conformation singuliere. Jour, de med. de Paris, 1756, v, 108. § Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896. || Griffith, F.: See Vaughan, G. T.: Trans. Amer. Surg. Assoc, 1905, xxiii, 273.
THE UMBILICUS AND ITS DISEASES.
The patient was a male infant five months old, from whose navel there had been a discharge of clear fluid ever since the detachment of the cord. This fluid was colorless, limpid, and did not have a urinous odor. The parts were kept clean, dressed frequently, and adhesive plaster was used to approximate the edges. After three months recovery took place.
A Patent U r a c h u s . * — The child was presented before the Society of Surgery first at the meeting on June 5, 1872; and during the second meeting on July 10th, several days after complete healing had taken place. Gueniot says that it is incontestable. that the continuity of the vesical cavity with the persistent canal of the urachus has been confirmed in a certain number of cases in the bodies of adults.
He says that Albinus, Beudt, and Haller have reported examples of this character.
On June 1, 1872, Alfred R., ten and a half months old, was admitted to Gueniot's service. He was in good general health, but had a tumor at the umbilicus. This was dull red, had a mucous surface, was moist, and resembled a cherry in form, color, and volume. It was 2.2 cm. in diameter, and was attached at the umbilicus by a pedicle 6 to 8 mm. long and 16 mm. broad. It was rather soft and covered with delicate skin. On pressure it was irreducible. The umbilical ring was enlarged, slightly indurated, and hypertrophied, and formed a circular elevation which increased in size with any movement of the child. There was weakness at the umbilical ring. The tumor looked like a mushroom with a short pedicle. Finally — and this is the most important point — there was an expulsion of a transparent liquid from the orifice in the tumor, and the patient also urinated in the natural way. There was, in other words, a urinary fistula, with hernia and hypertrophy of the mucosa at the umbilicus. The genital organs were well developed. The testicles appeared to have been arrested at the rings. On June 10th, after several ineffectual attempts at compression and the employment of iron perchlorid and zinc chlorid, Gueniot ligated the umbilical tumor. This caused pain, and at the same time he noticed redness of the tumor. The passage of urine was not stopped. On the twelfth a second ligature was applied at the same point. On the fifteenth he noticed that the tumor had ulcerated circularly, and where the ligature had been applied there was a deep furrow. The surface of the ulcer was cauterized with silver nitrate and a new ligature applied. On the nineteenth the discharge of urine from the umbilicus still persisted ; the ulceration at the base of the tumor had increased, and the furrow had become deeper. The fourth ligature was applied and tied more tightly than the one preceding. This time the
- Gueniot, R.: Des fistules urinaires de l'ombilic dues a la persistance de l'ouraque, et du
1 raitement qui leur est applicable. Bull, de therapeutique, 1872, lxxxiii, 299; 348.
Fig. 219. — Escape of Urine from the Umbilicus Due to a Patent Urachus. (After Gueniot.) ■
The upper picture represents the urine escaping from the umbilicus prior to operation. Surrounding the opening is a dark area where there had been a rolling out of the mucosa. The lower picture shows the umbilicus after operation. Cicatrization is perfect. There is no escape of urine.
CONGENITAL PATENT URACHUS. 503
tumor was markedly congested, and on the twentieth for the first time the urine ceased to pass from the umbilicus. The tumor was black and gangrenous. On the twenty-second there was a marked diminution in the secretion from the umbilicus and no escape of urine. The tumor was dead. On the twenty-fourth the ligature came away, and by the twenty-eighth the umbilicus had assumed a more normal conformation. The pedicle of the tumor had diminished markedly in its dimensions, and nothing but a small tubercle about the size of a pea remained. There was no farther escape of urine, and the child was discharged well.
A Partially Patent Urachus.* — This case is quoted by Simon (Obs. 4). (I have been unable to locate the original article.) He says that during the year 1648 Haran received at the Hotel-Dieu a new-born child who had at the umbilicus a tumor the size of a pigeon's egg. This contained clear fluid and was adherent to the extremity of the cord below the ligature. It was opened in the presence of several people, and there escaped a serous fluid which proved to be urine. Urine then escaped in abundance. All present thought that it came from the bladder.
A Patent Urachus. f — Case 1. — The patient was a male child who, when five weeks old, began to discharge urine from the umbilicus. There was inflammation resulting from extravasation of urine around the umbilicus. The extravasation spread all over the abdomen and the child died in a few days.
A Partially Patent Urachus. t — Case 3. — The patient was a girl four years of age who had a chronic discharge from the umbilicus and pain between the umbilicus and symphysis. A probe was passed nearly to the vertex of the bladder. The urachus was ligated and cut and then treated in exactly the same manner as the vermiform appendix. No opening was detected at the bladder. The peritoneum was accidentally opened during the operation. The child recovered.
A Patent Urachus. § — The patient was a vigorous boy, fifteen years of age. Since infancy he had sometimes lost urine at night through the umbilicus. During the day the bladder had held it better.
In a discussion following the presentation of Hue's case, one physician asked if the tract could not have been injected with some substance impermeable to the x-ray and then a radiograph made. Another suggested the introduction of milk or some coloring-matter to see if it would pass into the bladder.
A Patent Urachus. — On April 20, 1911, I received from Dr. PL H. Huggins, of Pittsburgh, the following abstract from one of his histories:
" The patient was the third child of a healthy mother. It weighed seven and a half pounds. It was well developed and apparently normal in every way. About ten days after delivery the nurse called attention to the escape of fluid, from the umbilicus. Examination revealed an opening in the lower border of the umbilical ring. This was surrounded by a small inflamed area by which urine escaped at times, not, however, in large quantities, but sufficient to saturate the bandage and neighboring clothing. A small probe was passed to a point about 4 cm. from the bladder. Repeated cauterizations for about four weeks effected a closure of the fistula and there was no further trouble."
- Haran: La pratique des accouchements, i, 38.
fHind, W.: Diseases of the Urachus and Umbilicus. Brit. Med. Jour., London, 1902, ii, 242.
t Hind, W.: Loc. cit.
§ Hue, Francois: Persistance du canal de l'ouraque; fistule ombilicale. La Xormandie medicale, 1905, xx, 311.
504 THE UMBILICUS AND ITS DISEASES.
A Patent Urachus.* — This case was reported in Vaughan's article. I have not been able to obtain the original.
A girl, aged six years, had passed urine from the umbilicus from the twelfth day, that is, from the time that the cord dropped off.
The urachus was excised, and the lower end ligated with catgut. The wound was closed, leaving the end of the catgut ligature projecting. The patient had scarlet fever, and the wound opened superficially, but it was reunited and healed without further trouble.
A Patent Urachus. — Jacoby'sf patient was a strong, normally developed boy, but he had an unusually thick cord. Jacoby tied the cord himself. The umbilical ring was the size of a silver gulden. After the cord came away the wound was the same size. It rapidly became smaller, so that in three weeks it formed nothing but a funnel-shaped opening, but a few weeks after this the nurse casually mentioned that the umbilicus was often wet or filled with water. On investigation it was found that there was a fine fistulous opening through which fluid escaped when the bladder was full. The water came drop by drop and filled the umbilicus. The opening was so small that a sound could not be made to enter it.
Jaeoby tried compression, which answered very well until the pressure was removed. Later he tried the actual cautery, and as soon as the slough had come away he drew the surfaces together. This procedure proved successful after the second treatment. The umbilicus became ditch-like instead of funnel-shaped, and no trace of the fistula remained.
A Patent Urachus. — JahnJ reports a case coming under Mikulicz's care. A boy five years of age was seen in February, 1895. There was no hereditary taint. Soon after his birth the parents noticed that he passed little urine in the natural way, but that an abundance escaped by the umbilicus.
On examination the boy was found to be well developed. The umbilicus was the size of a mark piece, flat and prominent, and gathered into radial folds. In the middle was a funnel-shaped depression from which, when abdominal pressure was made, urine escaped. A sound 6 mm. in diameter passed without difficulty 14 to 16 cm. downward toward the symphysis, and could be moved freely in all directions, there being no indication of a septum. When the umbilical opening was closed, the boy could urinate well by the urethra, but in a small stream. A catheter could be readily carried into the bladder, and a sound introduced from above came into direct contact with it.
A cystoscope introduced from above passed into the bladder, and a careful examination of the viscus was thus rendered possible. A diagnosis of congenital umbilical fistula, due to an open urachus, was made.
Mikulicz, on February 5, 1895, cut around the umbilicus and dissected the canal free for 3 cm. Here it passed over into the apex of the bladder. During the dissection the peritoneum was opened at one point. This opening was closed. The urachus with its opening into the bladder was cut away, and the wound in the bladder closed. The abdominal walls were brought together, a small gauze drain being passed down to the bladder sutures.
- Imbert, I..: See Yuughan, G. T.: Trans. Amer. Surg. Assoc, 1905, xxiii, 273.
t Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, xiv, 202.
+ Jahn, A.: Ueber Urachusfisteln. Beitrage z. klin. Chir., Tubingen, 1900, xxvi, 323.
CONGENITAL PATENT URACHUS.
The boy was able to urinate on the next day. The result was excellent, and three and a half years later the boy was still well.
Jahn gives a very good review of the literature.
A Patent Urachus.* — The patient was a child seven months old (sex not given). It had been passing urine from the umbilicus since birth. At the umbilicus was a sort of flattened, button-shaped tumor, the size of a cherry. It was red, and evidently due to everted mucosa at the umbilicus. A probe passed into the urachus three inches. The greater part of the urine was passed by the urethra.
A Patent Urachus. — Lannelongue'sf patient was a child three months old. The mother said that it had two penises, and that it urinated from both at the same time (Fig. 220). One penis was normal; the other organ was situated at the umbilicus, and looked exactly like a normal penis. The child died later. There was an umbilical hernia and a patent urachus which had been tied off with the cord; hence there had resulted a fistula when the cord came away.
A Patent Urachus.} — In the case of Meyer-Kempen the urine escaped in a stream from the umbilicus when the child cried. Ledderhose says that excoriations of the skin in the neighborhood of the fistula may or may not be present. As long as the urine is acid, the irritation of the skin is only small in amount. In some cases ecchymosis has been noted. The prognosis is good.
A Fistula of the U r a c h u s . § — The patient was a female child. On the seventh day the cord, which was still partially attached, was cut with scissors. In a few days the clothes at the umbilicus were wet. The discharge of fluid continued. Litmus
paper showed that the umbilical fluid had an acid reaction. When the child was examined, a small, soft tumor, reddish violet in color, and with a small hole in its center, was noted at the umbilicus. A probe was easily passed 3 cm. downward toward the bladder. The child was taken to the country five weeks after birth. Little by little the fluid diminished and then disappeared. Five months later the child was perfectly well.
- Kennedy, A. : Brit. Med. Jour., London, 1899, i, 1396.
t Lannelongue : Un cas de faux penis ombilical. Lecons de clinique chirurgicale, Paris, 1905, 388.
i Ledderhose, G.: Chirurgische Erkrankungen des Xabels. Deutsche Chirurgie, 1890, Lief. 45 b, 109.
§ Lugeol : Fistule urinaire ombilicale par persistance de l'ouraque. Jour, de med. de Bordeaux, 1S79-80, ix, 3.
Fig. 220. — A Patent Urachus tvith a Penile Projection at the Umbilicus. (After Lannelongue.)
The penile projection at the umbilicus conformed in shape and size to the penis of a child. The urine escaped from the urethra and also from the umbilicus.
506 THE UMBILICUS AND ITS DISEASES.
Congenital Vesico-umbilical Fistula.* — The child, a year old, had an opening at the umbilicus through which, when it cried, the urine escaped in a stream. The opening had the form of a urethral orifice. The umbilicus was thickened and, although no hernia existed, it was prominent and in its contour resembled a glans penis. When the child was quiet, the urine passed by the urethra, but, when abdominal pressure was made or the child cried, it came in a stream from the umbilical opening. The urachus had evidently remained patent. Operation was refused by the parents.
A Patent Urachus. f — Monod, on pp. 122 and 123 of his splendid treatise, gives somewhat full tabulations of the cases heretofore recorded.
On p. 124 he reports a case of congenital urinary fistula at the umbilicus clue to persistence of the urachus: G. G., aged ten, admitted to the hospital in June, 1899. When the cord came away there was a plaque the size of a franc at the umbilicus. The urine escaped from it and also from the urethra. The flow was intermittent. He had never had any tumor at the umbilicus. The orifice was small, but admitted without pain a No. 13 bougie. Around the opening the skin was like scar tissue and showed transverse, raised folds radiating from the periphery to the center. The surrounding skin was smooth. .The sound could be introduced through the fistula into the bladder. At times the urine passed from the umbilicus, at other times from the urethra. Sometimes all of it was passed from the umbilicus and a few drops only from the meatus. At other times the reverse occurred, and occasionally all the urine passed by the urethra and none by the fistula. The child had a phimosis, but there was no obstruction in the urethra.
The entire urachal tract was removed. Histologic examination showed that the cavity was lined with a stratified squamous epithelium similar to that of the skin.
A Patent Urachus that Closed and Reopened Later in Life as a Result of Hypertrophy of the Prostate. — MonodJ describes a case seen by Jaboulay and reported in 1897. The patient was a man, sixty-two years of age, who had been in good health up to that time. He had painful micturition and symptoms of hypertrophy of the prostate, the diagnosis being confirmed on examination. One day after painful micturition he noticed that drops of urine with a fetid oclor were escaping from the umbilicus. The quantity of urine that escaped the first time was probably 150 to 200 c.c. He entered the hospital for the fistula, and said that he had never had any accident, but that his mother had often told him that shortly after birth he was treated for escape of urine at the umbilicus, and that the discharge had disappeared in the course of fifteen days after the application of an appropriate bandage.
The urachus was dissected out for 3 or 4 cm. and tied off. Later, however, it reopened.
Operation for Pervious Urachus. § — The patient was a female child four months old. The urine escaped from the umbilicus, keeping the bedclothes soaked. When the umbilical folds were drawn apart, an opening which
- Meyer: Offenbleiben des Urachus nach der Geburt. Casper's Wochenschr. f. d. gesammte
Heilkunde, is 11, 424.
f Monod, Jean: Des fistules urinaires ombilicales dues a la persistence de l'ouraque. These de Paris, 1899, 62.
t Monod, Jean: Op. cit., 184.
§ Paget and Bowman: On an Operation for Pervious Urachus. Medico-Chir. Trans., London, 1861, xliv, 13.
CONGENITAL PATENT URACHUS. 507
would admit a lead-pencil was found and the skin was inverted. When the skin was drawn apart, urine gushed out. The circumference of the opening was denuded, and the edges coapted with a suture pin and lint, as in a case of harelip. On the third day a small amount of urine escaped by the umbilicus. The result was perfect.
A Case in Which the U r a c h u s Remained Open and the Ring-shaped Calculus that had Formed upon a H a i r in the Bladder was Extracte d T h r o u g h t h e U m bilious.* — ■ The patient, John Conquest, an ironfounder, aged forty, had for a year or more suffered from frequent and painful micturition. He also said that, when attempting to pass water or when doing strenuous work, urine would escape from the navel. On being questioned it was found that from the time of his birth some of the urine had come away from the umbilicus — a clear indication of a patent urachus.
He was admitted to the Leicester Infirmary on August 15, 1844. Paget, on sounding him, readily made out a vesical calculus, and further found that the sound could be carried up through the bladder to the umbilical opening. Hoping that it might be possible to remove the vesical stone through the umbilicus, he temporarily plugged the umbilical opening, distended the bladder with warm water, and placed the patient upon a Heurteloup table with his head lower than the pelvis; in other words, he put the patient in what we
1 ' Fig. 221. — A Rixg now call the Trendelenburg posture. The plug was now re- shaped vesical
moved, and a ringer introduced into the umbilical opening. Calculus with a
' ° ii Fine Hair in its
The tip of the finger caught in the center of the ring-shaped cal- axis. (After Paget
cuius (Fig. 221), and with care Paget was able to extract the and Bowman.)
• i i ,i i "V i • mi' i i This calculus had
stone through the umbilical opening. This calculus was ring- formed on a hair in the shaped because it had developed around a curled-up hair. bladder and was ex -n . ,i ,i i -t ,i - ii tracted through the um Paget says that at the umbilicus there was a circular de- biiicus. The calculus ficiency in the linea alba one inch in diameter. The margins was as thick as a me r ,i • ,i • i i i r ,•! t_ j i dium-sized writing quill.
of this ring were thickened and of cartilaginous hardness, and The urachus was patent through the opening protruded a hernial mass the size of a throughout, goose's egg. This hernia was covered over with mucous membrane which became dry when exposed to the air for any length of time. The patient could not pass water when this hernia was out, and when he tried to void, the projection gradually withdrew into the abdomen, and urine then forcibly escaped from the umbilicus, and in a moderate stream from the urethra.
It was clearly evident that the muscular walls of the bladder made traction on the umbilical hernial projection. Paget says that the bladder and urachus formed a urinary receptacle that in shape might be compared with a curved-necked cuppingglass.
The description of the case strongly suggests a partial exstrophy of the bladder.
After the extraction of the calculus the man was relieved of his bladder symptoms. No attempt, however, was made to repair the congenital defect.
Paget again saw the man in April, 1860. f When the patient was fifty-five years old (Paget said) the opening in the linea alba was elliptic in shape, and admitted
- Paget and Bowman: Medico-Chir. Trans., pub. by the Royal Med. and Chir. Soc, London,
1850, 2. ser., xv, 293.
tLoc. cit., 1861, xliv, 13.
508 THE UMBILICUS AND ITS DISEASES.
three fingers. In the mean time the man had developed a second vesical calculus. This was disc-shaped and had come away. Paget, after passing a finger through the umbilical opening into the bladder, to exclude the possibility of another calculus, successfully closed the umbilical opening.
A Yesico-umbilieal Fistula. — Pauehet's* patient was a boy five vears of age. Shortly after the cord came awaj^ a large mass of "proud flesh" was noted at the umbilicus, and from it a clear fluid with a urinary odor escaped. The discharge of fluid would occur at intervals of four or five days, persist for one or two days, coming unexpectedly and never in a jet, and accompanied b}' abdominal pain. The granular area was destroyed with silver nitrate.
When seen, the boy was emaciated. A Xo. 6 bougie passed the urethra easily. The fistula admitted a bristle, which penetrated 3 or 4 cm. without giving any indication of the direction of the canal. The umbilicus occupied its normal site and was surrounded by an area of induration about 1 cm. in diameter. On palpation of the abdomen some urine escaped from the umbilicus. There existed in reality a retroperitoneal pocket, at one end communicating with the bladder, at the other with the umbilical fistula. The amount of urine discharged from the navel during the twenty-four hours was about 80 c.c. There was no cystitis. Urination was painless, not too frequent, and the urine was clear.
The existence of a retro-umbilical pocket was not known prior to operation. A median incision was made 3 cm. above the fistula, encircling the umbilicus and extending to within 2 cm. of the pubes. After obtaining good exposure b}^ separating the muscles Pauchet freed the tissues around the umbilicus and the subjacent tissue and made traction. He was easily able to detach a fibrous mass the size of a walnut from the peritoneum without opening the peritoneal cavity. The urachus was then visible as a delicate, transparent cord, resembling an empty vein. It passed to the summit of the bladder. It was tied off with catgut and severed. The stump was turned in with a catgut suture and the abdominal wound closed with interrupted sutures. Xo drainage was employed. The wound healed in ten days.
The ovoid mass was the size of a walnut. Its surface was adherent to the surrounding skin, and at its center was the fistula. The lower extremity of the mass was continuous with the urachus for a length of 3 cm. On section, the cavity resembled a small and contracted bladder. The walls were fibrous, and the mucosa presented a large number of folds.
A Patent Urachus. — In 1887 Pennyf reported the case of a healthy child, aged eleven months, who, after separation of the cord on the ninth day, had been passing urine through the navel. A probe passed into the fistula could be felt to touch a catheter passed up the urethra into the bladder.
After the cord came away the umbilicus was represented by a raised rounded mass the size of a hazelnut. Its surface was intensely red and covered with mucosa. A constriction fxistf j d at the junction with the abdomen. Surrounding the umbilicus was a dusky red areola, about one inch in width, due to irritation from the fluid. In the center was a sinus through which the urine escaped.
Operation was declined.
- Pauchet. V.: Fistule ombilico-vesicale. Resection sous-peritoneale de l'ouraque et d'un
poche urineuse n'tro-ombilicale, guerison. Bull, et Mem. de la Soc. de chir. de Paris, 1902, xxviii, 785.
t Penny, W. J.: Bristol Medico-Chir. Jour., 1888, vi, 30.
CONGENITAL PATENT URACHUS. 509
A Congenitally Patent Urachus. — Petit's* patient in Case 4 was a young boy who, since his birth, had had an escape of urine from the umbilicus. At the navel was a kind of cushion, in the middle of which was a round opening through which the urine escaped. There was no obstruction in the urethra because the urine passed also by the natural way, and, when the patient did not wear a bandage, it escaped also from the umbilicus.
Urinary Fistula at the Umbilicus. — Pierre'sf patient was a boy with a congenital urinary fistula at the umbilicus, without any obstruction in the urethra. At the umbilicus was a ring, 2 cm. in diameter, in the center of which was an irregular opening 5 mm. in diameter. Behind this was a discoid cavity from which a small amount of urine escaped. No operation is mentioned.
A Patent Urachus. — In 1876 PrestonJ saw an infant so malformed that its sex could not be determined. It had an opening through the umbilicus from which urine came. The child weighed nine pounds. Two years later it was still passing urine from the umbilicus, but was in good health. The mother informed Preston that there was never any urinary odor on the diapers used to receive the feces, indicating that little or no urine escaped from the urethra.
A Case of Congenital V e s i c o - u m b i 1 i c a 1 Fistula — ■ Patent Urachus. § — The patient was a boy eleven years of age. At birth there was a rounded swelling in the umbilical region the size of a duck's egg. It was easily reduced and kept in place by a bandage. Urine escaped from this swelling. Up to his seventh year compresses were used, but these were of little value. On examination the boy was found to be strong. In the center of the umbilicus was an opening which admitted a uterine sound. Urine passed by the urethra and also by the umbilicus. Jacobi saw the child and passed a catheter from the umbilicus into the bladder.
Operation. — A raw surface was made above the fistula; a flap was dissected up from below and attached to the raw area. At the end of a week a small amount of urine escaped from the umbilicus, but the opening soon closed after the use of silver nitrate. A year later Jacobi introduced 12 ounces of water into the bladder through the urethra and none escaped from the umbilicus.
A Series of Cases with Patent Urachus. — Smit|| reported three cases:
Case 1: A woman, aged fifty-eight, complained of retention of urine which dribbled from the navel. A vesicovaginal fistula was established and the urachus closed spontaneously. Later the vesicovaginal fistula closed.
Case 2: A girl aged seventeen had constant dribbling of urine from the navel; also of blood at the menstrual period. The edges of the fistula were split and a purse-string suture applied, with a perfect result.
Case 3 : A boy, one and a half years old, had an offensive discharge of urine from the navel. There was also an eczematous condition at the umbilicus. The boy had marked phimosis. Circumcision failed to cure the fistula. The navel was excised and the urachus successfully closed with a purse-string suture.
- Petit, J. L.: Traitedes maladies chirurgicales, Chap, xi, 3. Oeuvres completes. 8°. Limoges,
1837, 799. (Quoted from Simon.)
f Pierre: Bull. Soc. de med. de Rouen, 1888, 2. serie, ii, 32.
X Preston, W.: Med. Record, New York, 1898, liv, 315.
§ Rose, A.: Med. Record, 1877, xii, 516.
|| Smit, J. A. R. : Abstract from Zentralbl. f. Gym, 1904, Nr. 41.
510 THE UMBILICUS AND ITS DISEASES.
It is not stated in these cases whether the urine had passed from the umbilicus from birth. We are including them all as instances of patent urachus.
A n Ope n U r a c h us. — Smith* reported the case of a boy, aged two years, who had a papilla-like projection at the umbilicus. In the center of this was an opening from which, at all times, there transuded a fluid looking and smelling like urine. A ligature was firmly applied to this projection, and after a few days it dried up and fell off. The fistula seemed to be permanently closed.
Fistula of the Urachus. — Stadfeldt t reports a case of fistula of the urachus and gives a table of cases from the literature. [Xo translation of the article could be obtained.]
Escape of Urine fro m the Umbilicus. — Starr's i patient was a female child thirteen weeks old. Since birth the urine had escaped from the umbilicus. The urethra was normal. The flow from the umbilicus was not continuous, but occurred at intervals, regulated by the detrusive action of the bladder. The general appearance of the umbilicus was larger and more open than usual, and in the center of the cartilaginous, nipple-like projection was an orifice which admitted an ordinary probe. This passed in the direction of the linea alba toward the bladder. Starr diagnosed the condition as one of open urachus, although he pointed out that a leading authority claimed that the urachus was open only in those cases in which the urethra was closed.
The Radical Cure of a Patent Urachus. § — The patient was a tall youth, seventeen years of age, who had had urine escaping from the umbilicus since birth. The umbilicus bulged forward; there was a small hernia of subperitoneal fat and an eczematous condition around the umbilicus. The patient had always had some pain when voiding.
Operation. — The bladder was emptied and four ounces of boric solution were allowed to run in. A transverse incision was made one inch above the symphysis. The recti muscles were separated, and a good view of the bladder and its peritoneal reflection was obtained. In caliber the urachus was as large as the stem of a clay pipe. The part close to the bladder was clamped, a second clamp was applied high up and a cut made between. A purse-string of celluloid thread was placed around the vesical stump of the urachus, and the latter was invaginated as in dealing with an appendix. The umbilical end of the urachus was brought up out of the abdomen between the recti muscles and anchored to the muscle, and the sheath covered over with fat and skin. Further dissection was not made on account of the eczematous condition of the skin. The patient made a good recovery.
A Patent Urachus. — Stierlinj] reports the case of a twelve-year-old girl brought to the hospital on June 28, 1896. At the umbilicus was an opening from which urine flowed. During the daytime only a small amount escaped, but at night so much came away that practically every morning the bed was wet through. The urine escaped only drop by drop from the umbilicus. There was never any pain. This watery discharge from the umbilicus was noted as soon as the umbilical cord
- Smith, Thomas: Mel. Times, London. 1863, new series, i, 320.
f Stadfeldt, A.: Bidrag til Laren om den medfodte Yesiko-umbilikalfistel i Urachus-fisteln) og dens Behandling. Nordiskt Mediciniskt Arkiv, Stockholm, 1871, iii, Xo. 23, 1. Starr, T. II.: Med. '1 a z., London, 1844, xxxiii, 484. 5 evens, B. Crossfield: The Lancet, London, 1904, ii, 584.
Stierlin, Ii.: Zur Casuistik angeborener Xabelfisteln. Deutsche med. Wochenschr., 1897, xxiii, 1 38.
CONGENITAL PATENT URACHUS. 511
came away. The child was well nourished. The umbilicus was flat, broad, and about 3 cm. in diameter. In its lower portion was a depression toward which the skin on all sides passed in radiating folds. The umbilical ring was wide, so that the point of the finger could be passed into it. If the patient coughed, the upper part of the umbilicus became distended. In addition, in the linea alba there was a small prominence the size of a pea. Stierlin diagnosed the case as one of hernia of the linea alba. The depression in the lower part of the umbilicus formed the entrance to a large, roomy, fistulous canal. When pressure was made upon the hypogastrium, several drops of clear fluid with a urinary odor escaped. A No. 9 bougie could be passed into the fistula with ease and entered a cavity. When a metallic sound was introduced through the urethra at the same time, both instruments were found to have entered the bladder.
Operation. — On both sides of the fistula the skin was divided in transverse directions for 1.5 cm. The walls were freshened up, and the urachus closed with continuous catgut. The abdominal walls were then brought together and a catheter was placed in the bladder. There was no hematuria, and the patient made a good recovery.
Patulous Urachus in a Child of Nine Months.* — The patient was a negro girl nine months of age. Ever since the separation of the cord she had discharged urine from the umbilicus. At the navel was a protruding mass of granulation tissue, but bulging only about one-sixteenth of an inch from the skin. In its center was an opening. In five or six weeks a cure was effected after cauterization of the orifice several times at various intervals.
A Patent Urachus That Closed in the Fourth Year and Opened Again at Forty-eight. — Tuholske's f patient was a man fifty-two years of age, who in infancy had passed urine through the umbilicus. This condition ceased in his fourth year without treatment, and he had no further trouble until he was forty-eight years of age, when, apparently without cause, the urine again commenced to flow through the navel. The margins of the opening were pared and sewed together, but without effecting a cure. Six months later the canal was exposed by incision, and half an inch beyond the margin was found to spread out into the bladder, no division existing between the bladder and urachus. The urachus was split down to what should have been the summit of the bladder and sewed across for a distance of two inches. The operation was extraperitoneal. Recovery followed.
Congenital Sinus of the Urachus. — Vander Veer,| in 1886, saw in consultation with Dr. DuBois, a female twenty years of age who, since the tenth day after her birth, had discharged urine from the umbilicus at irregular intervals. For the last two years she had had pain, the discharge had become offensive, and the parts about the umbilicus had become excoriated. A probe passed downward toward the symphysis for three inches. The sinus lay just extraperitoneally.
The operation consisted in slitting up the urachus, curetting, suturing the lower part, and packing the upper part with iodoform gauze. Recovery followed.
A Patent Urachus. — Velpeau § reports a case of a boy two years of age,
- Stites, T. H. : Amer. Medicine, Philadelphia, 1903, vi, 136.
f Tuholske, H. : St. Louis Medical Review, February 11, 1905. (From Vaughan's article.)
t Vander Veer, A.: Med. and Surg. Reporter, 1889, lxi, 661.
§ Velpeau: Arch, de med., 1826, xi, 554. (Quoted from Gueniot, obs. 6.)
512 THE UMBILICUS AND ITS DISEASES.
who was seen in consultation by Professor Ronx for congenital tumor of the umbilicus. The child was in a condition of continuous suffering. The greater part of the urine escaped from the urethra. The umbilical tumor was the size of a walnut and resembled a fungus. It was bright red, and in its center was an orifice from which the urine continued to pass. It escaped when the child cried or moved. A small sound was left in the urethra, and in the course of three weeks, when this had done no good, an elastic bandage was put on to compress the tumor. It, however, produced an ulcer without diminishing the discharge.
Patent Urachus in a Child Five Months Old. Operation. Recovery. — Waller,* in 1884, had a male patient, five months old, who had passed urine through the umbilicus ever since the cord had separated. The aunt said that the child had a tumor growing from the navel and that this had gradually become larger since birth. Caustics had been applied several times without result. At the umbilicus was a tumor about 1 inch in diameter. This apparently consisted of a flabby granulation tissue. It was red, inflamed, and very sensitive. From a slight depression at its summit drops of urine were constantly oozing. The drops came fast when the child micturated. The skin around the tumor was excoriated. The child was otherwise well.
Under anesthesia, a catheter could be passed from the umbilicus to the bladder. The urachus formed a cord the thickness of the little finger, and during the dissection the peritoneum was opened. The upper part for one inch was removed; the lower part was ligated with silk. The parts united and recovery followed.
Operation for Open Urachus. — De Forest Willard,f in 1888, reported the case of a female child, two years of age, who had passed urine through the urachus ever since birth, about half a dram escaping during the course of the day. There was a spot two inches in diameter about the umbilicus where the epithelium was excoriated, and from which there was an offensive discharge. The urethra was free. The labia minora were adherent in front of the orifice.
Several vain attempts were made to close the opening by cauterization with silver nitrate. An operation was undertaken, and the edges of the navel were freshened up. Union resulted, but in a month the wound broke down and the discharge returned. The parts were then opened, curetted, cauterized, and a drainage-tube was put in. A cure resulted.
A Patent Urachus — Urachus Cysts. | — A woman, twentyeight years of age, from her birth up to three years of age had discharged urine from the umbilicus. The opening was closed by the use of escharotics, but in her twenty-seventh year cancer developed at the open umbilicus. This perforated into the abdominal cavity, and the patient died of acute peritonitis.
A Pervious Urachus. § — The patient was a male, three weeks old. When the cord came away a protuberance half an inch long, with blood oozing from the surface, was noted at the umbilicus. From this urine had passed ever since the cord had come away. In the center was a slight depression that freely admitted a small probe, which could be passed into the bladder.
- Waller, C. B.: Med. Bull., Philadelphia, 1885, vii, 371.
t Willard, De Forest: Med. News, Philadelphia, 1888, liii, 710.
\ Wolff. Carl Christian: Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1 ^74, Case 3.
§ Yates, \Y. S.: Phila. Med. Journal, 1902, x, 173.
CONGENITAL PATENT URACHUS. 513
The umbilical opening was closed with a purse-string suture passed around the protruding portion subcutaneouslv; the protruding part was then cut off. The wound healed and there was no further trouble.
LITERATURE CONSULTED ON CONGENITAL PATENT URACHUS. Alric: Sur deux cas de persistance de l'ouraque. Bull, de therapeutique, 1879. xcvii, 34. Annandale, T.: Case of Inclosed LTrachus with Umbilical Fistula. Edinb. Med. Jour., 1870, xv,
680. Ashhurst: Urachal Fistula. Med. News, Philadelphia, 1882, xli, 122. Berard, P. H. : Fistules urinaires. Diet, de med., Paris, 1840, xxii, 64. Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc, 1906, xlvii, 109. Cabell, R. G.: Amer. Jour. Med. Sci., Philadelphia, 1849, n. s., xv, 313. Charles, J. J.: Treatment of Patent Urachus. Brit. Med. Jour., 1875, ii, 486. Delageniere, H. : Traitement de l'ouraque dilate et fistuleux par la resection et la suture. Une
observation. Arch, provinciales de chir., 1892, i, 222. Draudt, M.: Beitrag zur Kenntnis der Urachusanomalien. Deutsche Zeitschr. f. Chir., 1907,
lxxxvii, 487. Dupuytren and Roux : Un ouraque ouvert. (Cited by Gueniot.)
Erdmann, J. F. : A Patent Urachus in a Child Four Years Old. Pediatrics, 190S, xx, 356. Florentin, P.: Fongus de l'ombilic chez le nouveau-ne et chez l'enfant. These de Nancy,
1908-09, No. 22. Freer, J. A.: Annals of Surgery, 1887, v, 107. French, J. G.: A Case of Fleshy Tumor of the Lmibilicus with Patent Urachus. The Lancet,
1882, i, 60. Goupil: Sur un vice de conformation singuliere. Jour, de med. de Paris, 1756, v, 108. Graf, Fritz: U/rachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896. Griffith, F.: Possibly a Patent Urachus. (Vaughan's article.)
Gueniot, R.: Des fistules urinaires de l'ombilic dues a. la persistance de l'ouraque, et du traitement qui leur est applicable. Bull, de therapeutique, 1872, lxxxiii, 299; 348. Haran: La pratique des accouchement s, i, 38. (Quoted by Simon.) Heflin, H. T.: Personal communication.
Hind, W.: Diseases of the L"rachus and Lmibilicus. Brit. Med. Jour., London, 1902, ii, 242. Hue, F.: Persistance du canal de l'ouraque; fistule ombilicale. La Normandie medicale, 1905,
xx, 311. Huggins, R. B.: Personal communication. Imbert, L.: See Vaughan's article.
Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, xiv, 202. Jahn, A.: Beit rage z. klin. Chir., Tubingen, 1900, xxvi, 323. Kennedy, A.: A Patent L'rachus. Brit. Med. Jour., London, 1899, i, 1396. Lannelongue: In cas de faux penis ombilical. Lecons de clinique chirurgicale, Paris, 1905,
388. Ledderhose, G.: Chirurgische Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Lexer, E.: L'eber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. Lugeol: Fistule urinaire ombilicale par persistance de l'ouraque. Jour, de med. de Bordeaux,
1879-80, ix, 3. Marx: Enfant de vingt-trois mois et demi, qui rendait Purine en partie par la verge et en partie
par l'ouverture ombiheale de l'ouraque. Repertoire general d'anatomie et de physiologic
pathologique, 1827, iv, 120. Meyer: Offenbleiben des U/rachus nach der Geburt. Casper's Wochenschr. f. d. gesammte
Heilkunde, 1S44, 424. Monod: Des fistules urinaires ombilicales dues a la persistance de l'om-aque. These de Paris,
1899, No. 62. Paget and Bowman: Medico-Chir. Trans., pub. by the Royal Med. and Chir. Soc, London, 1850,
2. ser., xv, 293. 34
514 THE UMBILICUS AND ITS DISEASES.
Paget and Bowman: On an Operation for Pervious Urachus. Medico-Chirurgical Trans., London, 1861, xliv, 13.
Pauchet, V.: Fistule ombilico-vesicale. Resection sous-peritoneale de l'ouraque et d'une poche urineuse retro-ombilicale, guerison. Bull, et Mem. de la Soc. de chir. de Paris, 1902, xxviii, 785.
Penny, W. J.: Bristol Medico-Chirurgical Jour., 1888, vi, 36.
Petit, J. L. : Traite des maladies chirurg., chap. xi. Oeuvres completes, Limoges, 1837, 799.
Pierre: Bull. Soc. de med. de Rouen, 1888, 2 e serie, ii, 32.
Preston, W.: Med. Record, New York, 1898, liv, 315.
Rose, A.: A Case of Congenital Vesico-umbilical Fistula, Patent Urachus. Med. Rec, 1877, xii, 516.
Simon, C: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. 80.
Smit, J. A. R.: Abstract from Zentralbl. f. Gyn., 1904, Nr. 41.
Smith, T.: An Open Urachus. Med. Times, London, 1863, new series, i, 320.
Stadfeldt, A. : Bidrag til Laren om den medfodte Vesiko-umbilikalfistel (Urachus- fisteln) og dens Behandling. Nordiskt Mediciniskt Arkiv, Stockholm, 1871, iii, No. 23.
Starr, T. H.: Escape of Urine at the Umbilicus. Med. Gaz., 1844, xxxiii, 484.
Stevens, B. C. : The Radical Cure of a Patent Urachus. The Lancet, London, 1904, ii, 584.
Stierlin, R.: Zur Casuistik angeborener Nabelfisteln. Deutsche med. Wochenschr., 1897, xxiii, 188.
Stites, T. H.: Patulous Urachus in a Child of Nine Months. Amer. Medicine, Philadelphia, 1903, vi, 136.
Tuholske, H.: A Patent Urachus That Closed in the Fourth Year and Began Again at Fortyeight. St. Louis Med. Review, February 11, 1905. (From Vaughan's article.)
Vander Veer, A. : Congenital Sinus of the Urachus. Med. and Surg. Reporter, 1889, lxi, 661.
Vaughan, G. T.: Trans. Amer. Surg. Assoc, 1905, xxiii, 273.
Velpeau: Cited by Gueniot.
Waller, C. B.: Patent Urachus in a Child Five Months Old. Operation. Recovery. Med. Bull., Philadelphia, 1885, vii, 371.
Willard, De Forest: Med. News, Philadelphia, 1888, liii, 710.
Wolff, C. C. : Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873.
Yates, W. S.: Phila. Med. Jour., 1902, x, 173.
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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