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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 XXXIV. Urachal Cavities between the Symphysis and Umbilicus Communicating with the Bladder or Umbilicus or with Both

General consideration.

Symptoms.

Differential diagnosis.

Treatment.

Instance of a urachal cavity between the symplrysis and umbilicus and communicating with the bladder or umbilicus or both.

Figs. 244 and 245 graphically illustrate urachal cavities communicating with the bladder. Fig. 246 shows in a schematic manner the way in which a distended urachus may open at the umbilicus. Dilatation of the urachus with the escape of urine from both the bladder and umbilicus is indicated in Fig. 247, while in Fig. 248 we see the tremendous quantities of stagnant urine that niay be forced little by little into the pervious urachus when the bladder contracts during micturition. Finally, the valve-like opening is overcome and there is a sudden gush of ammonia cal urine from the urethra; or an opening may develop at the umbilicus; or the urine may escape from both the urethra and the umbilicus.

Sex. — Of the cases here recorded, and in which data as to the sex are available, 14 were in males and 12 in females.

Age. — The youngest patient (Savory's) was thirteen months old. Weiser's patient, a woman of seventy-five, was the oldest. The age table is as follows:

Under ten years of age 4 cases

Between ten and twenty years of age 2 "

Between twenty and thirty years of age 7 "

Between thirty and forty years of age 1 case

Between forty and fifty years of age 4 cases

Between fifty and sixty years of age 1 case

Between sixty and seventy years of age 1 "

Over seventy years of age 2 cases

These figures are of only relative value. Bramann's patient, who came under observation at twelve, had definite symptoms when nine years old. Freer's patient came under treatment at fifty-four, but from the history it was evident that symptoms were first noted when the patient was seven years old. Newman's patient was thirty-nine years old, but he had had an enlargement in the lower abdomen as long as he could remember. Vaughan's patient, a man of forty, had experienced pain in the suprapubic region when seventeen.

SYMPTOMS.

The chief symptoms are those referable to the bladder and to the development of a tumor between the symphysis and umbilicus. When infection occurs, constitutional disturbances are superadded.

A reference to the accompanying histories will show that the vesical s y m p t o m s varied greatly. Some patients complained of frequent micturition, others of incontinence, while others had difficult micturition, retention, or an almost total inability to void.

In some the vesical symptoms had been of short duration; others had had defi

Fig. 244. — A Dilated Urachus Communicating with the Bladder. (Schematic.) Where such a condition exists, when the bladder contracts during micturition part of the urine escapes from the urethra and part may be forced into the urachal sac. Finally the urachal sac will empty itself into the bladder.

Fig. 245. — Large Accumulation op Urine in a Partially Patent Urachus. (Schematic.) Some patients give a history of cystitis, and a few months later a hard, globular tumor is noted between the umbilicus and symphysis. After the bladder has been emptied with a catheter the tumor still persists. Finally, after a very large amount of fluid has accumulated, it may all be discharged at once through the bladder, or the urachus may open at the umbilicus, allowing the accumulated urine and pus to escape by this avenue. In these cases there is usually a periodic filling and emptying of the urachal sac.

nite bladder disturbances for years. In Patel's case, for example, a child three years old had had incontinence of urine day and night since birth, the urine being passed involuntarily and at frequent intervals. In Freer's patient, a woman fiftyfour years old, vesical symptoms were first noted when she was seven years old. Schnellenbach's patient, who was sixty-six years old, had had frequent micturition for one year and pressure was necessary to start the flow. When the patient was

5S0

THE UMBILICUS AND ITS DISEASES.

catheterized, 1500 c.c. of urine came away. Worster's patient gave a history of having developed a cystitis with incontinence after diphtheria, and eleven years before coming under observation had passed a large amount of pus from the urethra.

In some cases the urine was turbid and contained pus and occasionally blood. In other cases the urine was clear; occasionally, as in Graf's, Lexer's, and Matthias'

Fig. 24(i. — Ax Infected Urachus Opening at the Umbilicus. (Schematic.) 1 (ccasionally urachal remains become infected, and after a time open at the umbilicus. In i hose cases in which the vesical end of the urachus i- closed i here is no escape of urine from the umbilicus, the discharge being purulent or slimy in character.

Fig. 217. — A Patent Urachus Dilated in its Middle Portion. (Schematic.) In such cases the middle portion of the urachus may become markedly distended, sometimes containing a liter or more of decomposing urine. (See Fig. 248.)

cases, the patients had previously had a gonorrheal infection. This naturally confused the clinical picture to some extent.

P a i if. — More or less pain in the lower abdomen was a frequent symptom. In Bourgeois' ease there was an almost insupportable feeling of tension in the lower abdomen, and the suprapubic region was particularly sensitive after fatigue. In Matthias' case there was a feeling of pressure in the lower abdomen, accompanied by malaise. Worster's patient had to bend forward at an angle of 45 degrees to

URACHAL CAVITIES AND INFECTIONS.

581

get relief, and was incapable of stooping down to pick up anything. Newman's patient suffered much pain, walked with difficulty, and had an anxious expression. Hind's patient had a steady pain in the lower abdomen. Suddenly something gave way, there was a feeling of relief, and a large amount of pus escaped from the bladder.

The Umbilicus. — With the progress of the disease the umbilicus in about half of the cases became inflamed and ruptured, with the escape of pus, and later of urine. In Bourgeois' case a small, soft, red tumor the size of an almond developed at the navel. During micturition it would become prominent and painful. It was opened and urine escaped.

Bramann's patient, two years after vesical symptoms had been noted, had a sudden discharge of urine from the umbilicus. In Hastings' case the urine for a time ceased entirely to pass from the urethra. On one occasion, when the patient had not voided at all for a long period, there was a sudden gush of two quarts from the umbilicus.

Lexer's patient, one and a half years after the onset of symptoms, complained of pain in the umbilical region. The tissues swelled up, became red, and a quantity of purulent material escaped. On pressure pus and urine were discharged from the umbilicus. Savory's patient developed a tense umbilical

swelling two to three inches in diameter. This was tender during micturition. It was opened later, pus escaped, and finally nearly all the urine was passed by this avenue.

In Schnellenbach's case there was pain in the umbilical region, followed by the escape of pus. Vaughan's patient had poultices applied to the umbilical region. Two weeks later pus and urine passed from the umbilicus. Occasionally the opening would close for a couple of days. This closure was accompanied by much pain,

Fig. 248.

Urine in

Accumulation op a Large Quantity Urachal Pouch. (Schematic.) Occasionally the urachal pouch is very large, and when the bladder contracts, part of the urine escapes from the urethra, part is forced up into the sac. An opening may or may not exist at the umbilicus. If there be no exit at the umbilicus, the valve-like opening between the urachus and bladder is after a time temporarily overcome, and suddenly there escapes from the bladder a large quantity of ammoniacal urine mixed with pus, the urachal tumor at once disappearing. Such a sac will fill up and empty periodically.

582 THE UMBILICUS AND ITS DISEASES.

which was not relieved until the fistula reopened. The discharge was so offensive that the patient could not mingle with his friends. Worster's patient also developed a tumefaction in the umbilical region, followed by the escape of pus and urine.

The opening in Weiser's Case 3, did not develop at the umbilicus, but 2 inches below it. Urine only escaped; at no time was there any pus.

When the infection of the urachus extends up to the umbilicus, it is but natural that the latter should be secondarily involved, particularly when much tension exists in the sac.

Constitutional symptoms have not been at all prominent in these cases, evidently because there was a certain amount of drainage by the bladder, umbilicus, or both. In Hastings', Lexer's, and Morgan's cases fever was present, and in Morgan's case there was vomiting accompanied by diarrhea.

The carefully recorded case reported by Hastings in 1829- (p. 589) is well worth a thorough study. This case clearly shows that, notwithstanding most alarming symptoms, such as convulsions, the patient may recover. Savory's patient, a sickly child thirteen months old, died; in this case the inflammatory process had extended to the abdomen, as indicated by the adherent omentum. Ball's eightyear-old child died of peritonitis.

In Xicaise's (p. 597) and Roser's (p. 598) cases the patients successfully passed through a pregnancy while suffering from an infected urachal cyst. Roser's patient miscarried during a subsequent pregnancy four years later.

The urachal cyst varies considerably in size. It is attached to the bladder below and to the umbilicus above, and any great increase in size, as a rule, will be in its central portion. In Bramann's case the tumor resembled a long sausage. In Worster's patient it was recognized as a large cord, two inches in diameter. In Freer 's case, when the patient was fourteen years old, it was the size of an apple, but when she came under observation, at fifty-four, it was much larger. In Patel's case the tumor was the size of two fists. Vaughan's patient had a pyriform tumor three inches long, and having a capacity of about three ounces. Schnellenbach's tumor was the size of a head, while in Timmerman's case the sac contained about 1500 c.c. of fluid.

Urachal cysts communicating with the bladder can hardly reach as large proportions as some of those that have no external opening. In Roser's case, however, notwithstanding the opening into the bladder, the sac contained between three and four liters of fluid.

The walls of the sac may be thin or thick, depending in a large measure upon the amount of inflammatory reaction. In Newman's case the walls were thin; in Bramann's case they were several millimeters thick, and in Matthias' case they varied from 2 to 20 mm. in thickness.

The interior usually consists of but one cavity. The inner surface may be perfectly smooth, or lined with granulation tissue. On histologic examination the inner surface may have a lining of transitional epithelium, as noted in Bramann's case, or of one layer of squamous epithelium, as found by Schnellenbach. In the latter 's case the underlying stroma showed small-round-cell infiltration.

The cyst fluid in Patel's case was pale yellow. In the greater number of the cases it consisted of urine and pus. The urine in Newman's and in Roser's case was very ammoniacal. In Vaughan's case the cavity contained laminated clots.

URACHAL CAVITIES AND INFECTIONS. 583

DIFFERENTIAL DIAGNOSIS.

The history of cystitis, coupled with the development of a tumor just above the symphysis, is strong presumptive evidence of a dilated urachus, particularly if the tumor increases in size when the patient has not voided for several hours, or if it decreases markedly in size after catheterization, accompanied simultaneously by pressure on the tumor. There are some cases, however, in which the effort to void forces a large part of the urine out of the bladder into the sac, only a portion escaping from the urethra. In such cases the tumor is larger after the bladder has been emptied.

With the aid of the cystoscope the diagnosis becomes more easy. In Matthias' case, for example, on exploration of the bladder a transverse oval opening was found near the top of the anterior blaclder-wall. This passed into a funnel-shaped diverticulum, which extended upward toward the umbilicus.

Occasionally a suppurating dermoid or an inflamed appendix ulcerates through into the bladder. When the dermoid opens into the bladder, the tumor is situated in one side of the pelvis. The urachal tumor, on the other hand, is in the mid-line, and lies in the anterior abdominal wall. Furthermore, in the case of a dermoid cyst, on cystoscopic examination it may be possible to see a tuft of hair projecting from it into the bladder. When an appendix opens into the bladder, there has usually been a definite history of appendicitis and the discharge passing from the bladder has a distinctly fecal odor. The following case although not exactly germane to the subject has several points in common, and is of such interest that I shall briefly report it.

In May, 1907, I saw a very interesting case of extra-uterine pregnancy, in which, long after the death of the fetus, the sac opened into the bladder. The patient, L. S., colored, aged thirty-three (Gyn. No. 13806), was admitted to the Johns Hopkins Hospital on May 3, 1907. For the previous five years she had complained of much pain in the lower right abdomen. This was usually dull, and occasionally accompanied by nausea. Three years before admission she was supposed to be pregnant and to have proceeded to about the eighth month. Severe, labor-like pains lasting five minutes suddenly developed, and the patient passed blood from the uterus. Shortly afterward she noticed that the abdominal girth was diminishing, and that a hard, tender lump was present in the right lower abdomen. This gradually became smaller. She gave no history of chills or of fever, but had had some vomiting, had suffered from pain from time to time, and had lost in strength and in weight.

On admission the right lower abdomen was distended by an irregular nodular mass, which on palpation gave a peculiar feeling of crepitus. On pelvic examination the uterus was found slightly enlarged and lying posteriorly. On the right side was a pelvic mass attached to the side of the uterus.

On catheterization under ether a large amount of thick, tenacious urine came away, and the catheter came in contact with a substance feeling very much like a stone.

Operation. — A median incision, after liberation of the adherent omentum, disclosed a large, irregular mass in the right lower abdomen. The large and small bowel were found densely adherent to the sac. The small bowel was dissected free, but its coats were slightly injured.

The sac contained a large number of fetal bones (Fig. 249) . The bladder was

584

THE UMBILICUS AND ITS DISEASES.

densely adherent to the mass, and after it had been freed, an opening was found to exist between the sac and the bladder. One of the long bones, a femur, was seen projecting from the sac into the bladder, and the portion lying in the bladder was heavily coated with urinary salts (Fig. 250) . The vesical opening was closed.

In the cecum, near the ileocecal valve, long bones projected from the fetal sac into the lumen of the bowel.. There was a second opening into the large bowel six inches above the ileocecal valve. After closing the intestinal openings and removing the appendix, which was thickened and indurated, I also removed a parovarian cyst from the right side. The abdomen was then drained. The patient made a good recovery.

In such a case as this the previous history pointed to a pregnancy. Bimanual examination revealed an intraabdominal tumor situated on one side, and not in the mid-line. Cystoscopic examination would have determined the presence of a foreign substance projecting into the bladder.

From the foregoing it is seen that urachal tumors connected with the bladder are relatively easy to diagnose.

Fig. 249. — Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac.

Oyii. No. 13806. The bones have been roughly assembled. They are very well preserved. 'J'Ik- ends of t wo long bones projected into the lumen of the cecum :i in 1 one into I In- cavity of the bladder. The end of this bone is heavily coated with phosphates. This is particularly well shown in Fig. 250.

TREATMENT. WJiere a marked infection is present, it is advisable merely to open up and drain the sac. If possible, at the same time the bladder should be separated from the sac and the vesical opening closed. The sac is then packed and allowed to contract down.

URACHAL CAVITIES AND INFECTIONS.

585

If there is little danger of infection, the umbilicus is encircled and removed, together with the sac, and the bladder opening closed.

The vesical symptoms usually disappear as soon as the source of irritation — the dilated urachus — is eliminated.

EXISTENCE OF A URACHAL CAVITY BETWEEN THE SYMPHYSIS AND UMBILICUS, AND COMMUNICATING WITH THE BLADDER OR UMBILICUS OR BOTH.

Quite a number of the cases in the literature were not sufficiently definite to warrant citation; only those that clearly illustrate the condition have been selected.

Cystitis with Tu m o r Formation in the Bladder.— In 1882 Ball* saw a boy eight years old who had suffered from incontinence of urine at night from birth, and during the previous six weeks also by day. In March, 1882, the urine was bloody and contained pus, but the boy improved, although he was still complaining of pain in the lower abdomen. When he next came to Ball, in January, 1883, he had an umbilical fistula, which he stated had appeared three weeks previously after rupture of an abscess. Since that time all the urine had passed through the navel. The urethra was very small, but later a moderate amount escaped by this passage also.

The treatment consisted in cauterizing the opening. This was clone three times. The parts remained healed only for a short time. A fourth operation was of a plastic nature; the fistula remained closed for two months. One month later the boy died of peritonitis.

At autopsy the urinary organs were removed entire. On the next day the cavities were first injected with colored

lard through an opening in one of the ureters. A minute hole about 13^ inches below the umbilicus and 2}^ inches above the fundus of the bladder was found. From this urine had escaped into the abdominal cavity. In the upper abdomen there was abundant evidence of a recent peritonitis. The omentum was adherent to the anterior abdominal wall, apparently as the result of a long antecedent inflammation. The amount of fluid in the abdominal cavity was small, but there was an abundance of lymph matting the abdominal viscera together.

• Ball, C. B. : Case of Pervious Urachus with Remarkable Disease of Bladder. Trans. Acad.

Med. Ireland, 1883-84, Dublin, 1884, ii, 376. This case is probably identical with that referred to by Freer in 1887. Although the age does not correspond, the findings were precisely the same.

Fig. 250. — A Phosphatic Deposit ox the End of a Long Bone. Gyn. No. 13S06. One end of this bone projected into the bladder and has a heavy covering of urinary phosphates. This is clearly evident in the lower part of the picture.

586 THE UMBILICUS AND ITS DISEASES.

The ureters and pelves of the kidneys were much dilated. The bladder was very small and firm; the walls were much thickened. From the fundus of the bladder to the umbilicus extended a tongue-like cavity, 23^ by 1% inches. This was situated between the peritoneal covering and the muscular layers of the anterior abdominal wall. It was in the anterior wall of this cavity that the fatal rupture had taken place.

During the separation of the bladder from the other pelvic contents it was found that the viscus was surrounded by cicatricial adhesions. The bladder-walls were enormously hypertrophied, and projecting into the cavity were a number of newgrowths which resembled the columnse carnese of the heart. Some were attached by one end only to the vesical wall, the other end being free in the cavity; others were attached at both ends, but were free along the sides, so that a probe could be passed between them and the bladder-wall. Microscopic examination showed that they were composed of fibrous tissue with a covering of mucosa.

The bladder was divided into two compartments by a septum. This was attached posteriorly about the middle of the trigonum. Immediately above the septum was a minute opening leading off into the cicatricial tissue in front of the bladder. There had evidently been an extravasation of urine which had become localized as the result of an inflammation.

The fundus of the bladder communicated with the cavity lying between it and the umbilicus by a wide opening. The cavity contrasted remarkably with the bladder proper. Its walls were extremely thin and the inner surface smooth. The openings by which the extravasation had taken place into the peritoneal cavity were two in number — one a small aperture, the other a rent apparently of recent origin.

\Yhether this case was one in which the urachus had remained patent up to the umbilicus and in which, upon supervention of bladder obstruction, suppuration had occurred at the umbilical cicatrix, leaving a fistulous opening, or whether, in consequence of an extravasation of urine in the neighborhood of the fundus, an abscess cavity had been formed which followed the track of the obliterated urachus, are among the interesting pathologic features of the case.

An Abscess Between the Umbilicus and Symphysis Opening at the Umbilicus. — On August 7, 1821, Bourgeois* presented to the Paris Society a young soldier, aged twenty, who had at the lower portion of the umbilical cicatrix a granular excrescence the size of a small lentil. At its summit was a minute cavity, from which there escaped, drop by drop, and sometimes in a jet, a fluid which resembled urine. The patient had pain in the anterior abdominal wall which extended from the pubes to the umbilicus. Several times after fatigue the discomfort became severe and it was necessary to apply liniments. Later he had an attack of retention of urine and complained of a feeling of insupportable tension. After several days a round tumor developed. It was the size of an almond, and was red, soft, and fluctuating. When the patient attempted to urinate, this mass became tense. He was brought to the hospital and came under the care of Larrey, who incised the tumor. The skin was very thin, and there escaped a large quantity of serosanguineous and purulent fluid of a strongly urinary odor, which suggested a communication between this cavity and the urinary tract.

• Bourgeois: Jour. gen. de med., annee 1821, lxxvi, 219.

URACHAL CAVITIES AND INFECTIONS. 587

Tumor Formation Between the Umbilicus and Symphysis Due to Remains of the Urachus. — Bramann,* in 1887, reported a case from von Bergmann's clinic. The patient was a girl of twelve who had been normal until her ninth year. She then complained of pain and frequent micturition, and there was a discharge of pus and a little blood from the bladder. Two years later the urine suddenly came through the umbilicus and continued to pass by this route, although her physician tried to close the opening by cauterization. The urachus was dissected out and the bladder opening closed. A fistula followed, and this still persisted up to the time that the case was reported. When she came under observation a granulation the size of a pea was detected at the umbilicus; in the center of this was a depression from which urine escaped. Behind the abdominal wall, in the median line, and below the umbilicus, and reaching to the symphysis, was a long, sausage-shaped tumor, which was soft and adherent to the umbilicus, but movable low down. Rectal examination showed that the lower end passed to the bladder. The urethra was normal.

After appropriate treatment for the cystitis a radical operation was undertaken. The fistulous tract was dissected out as far as the bladder, but the peritoneum tore at one point and the omentum protruded. It was wiped off and replaced and the peritoneum closed. The urachus was several millimeters thick, dark red, yielding, and lined with a membrane resembling mucosa. Here and there it was apparently lined with granulation tissue. It opened directly into the bladder. Microscopicexamination showed that the canal was lined with transitional epithelium, next to which was connective tissue, and external to this non-striped muscle-fiber. After operation the fistula persisted.

Escape of Urine From the Umbilicus, f — The patient was a married woman, forty years of age, suffering from what was said to be a vesicoumbilical fistula. This patient came under Freer's care while he was resident surgeon at the Ward's Island Hospital. She complained of a chronic purulent discharge from the umbilicus, as a result of which she had become so exhausted that she was scarcely able to walk. Freer discovered at the umbilicus a fistulous opening. A uterine sound was introduced and glided without obstruction downward almost its entire length, and by giving it a lateral motion, Freer found that it entered a cavity which had a breadth of almost three inches in its widest portion. On removal of the probe pus welled up from the opening, and when pressure was exercised from below upward, several ounces of pus escaped. The cavity was washed out with a 2 per cent carbolic-acid solution, and it was not until the disproportion between the amount of fluid injected and that which returned was noticed that the true nature of the case was surmised. This was afterward proved by the injection of a starchy solution, after which the bladder was emptied and the iodin test applied to the evacuated fluid, which yielded the characteristic appearance of the blue iodid of starch. The patient was put on a nourishing diet, and after local treatment in a short time the purulent discharge ceased and the fistula closed spontaneously. She stated that a similar result had been achieved at other hospitals on previous occasions, but that the fistula, after remaining closed for a short time, would then reopen, with a repetition of the above symptoms. Sometimes,

• Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir.,

1887, xxxvi, 996.

t Freer, J. A. : Abnormalities of the Urachus. Annals of Surg., 1887, v, 107.

588 THE UMBILICUS AND ITS DISEASES.

when she strained, urine would be forced up through the opening, but this was so infrequent that she considered it of slight importance. She had no difficulty in passing the urine by the natural channel.

Cyst of the Urachus Communicating With the Bladder. — Freer* cites a case reported by Helmuth in The Homeopathic Journal of Obstetrics, 1884, vi, 24. This patient was a married woman, fifty-four years of age, of small stature and slight build. At the age of seven years her abdomen appeared to be enlarged; at fourteen a tumDr the size of an apple appeared at the umbilicus and burst, sending forth a stream of fluid with considerable force. Her menses ceased at the age of forty-four, after which her abdomen became enlarged and sensitive to pressure. Incontinence of urine was a source of great discomfort to her, especially at night, when the dripping would awaken her. Helmuth withdrew with the aspirator about a quart of viscid, dark fluid, which showed "inflammatory" and pus corpuscles. Subsequently, when performing an ovariotomy, after dividing the peritoneum, he says: "I came upon a substance which puzzled me. It looked something like a cyst- wall, but was so densely adherent to the abdomen at the umbilicus that it was impossible to separate the adhesions. Laterally, on each side of the incision, the substance disappeared. After vainly endeavoring to push this sufficiently aside, I determined to incise it, which I did. A gush of fluid followed, and for a moment I believed I had opened the sac. Upon introducing my finger into the incision I soon discovered that the canal communicated directly with the bladder. I then forcibly drew this emptied sac aside, and without difficulty removed the [ovarian] tumor. From some experience in suprapubic lithotomy I determined to bring the wall of the bladder-cyst together with carbolized catgut, which I did. A self-retaining catheter was placed in the bladder and the woman put to bed. The patient died on the evening of the fifth daj' from peritonitis." Helmuth says the patulous and cystic urachus, leading from the fundus of the bladder to the umbilicus, accounts for many peculiar symptoms detailed by the patient.

That the bursting of the umbilicus in early life, when the "water spouted up to the ceiling," was due to the rupture of the external wall of the cyst was proved by the cicatrix, smooth and white, which occupied the site of the umbilicus.

Persistence of the Urachus in Adult Women. — Garriguest did an autopsy on a woman aged forty-five. He found that, owing to the presence of a dilated urachus, the bladder extended as far as the navel, where it was closed. The patient had been operated on for myoma ten days before and had died of nephritis. The urachus was noted at the time of operation. The bladder extended to the umbilicus and lay between the aponeurosis of the abdominal muscles and the transversalis fascia on one side, and the peritoneum on the other.

An Infected Urachus Communicating With the Bladder and U m b i 1 i c u s . — Graft cites the case of a man aged twenty. At twelve years of age he had inflammation of the diaphragm, and four years later gastric fever. A year and a half before Graf saw him he had noticed that the urine escaped from the umbilicus. The tissue in the vicinity of the umbilicus was somewhat swollen, reddened, and painful. He did not know whether he had had fever. On admission he was found to be pale and anemic. He had a frequent desire to

• Freer, J. A.: Op. cit. t Garrigues, H. J.: Med. Record, New York, 1899, lvi, 720.

% Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896, 16.

URACHAL CAVITIES AND INFECTIONS. 589

urinate. He had pain in the abdomen, and from time to time fluid escaped from the umbilicus. Passing downward in the mid-line from the umbilicus was a hard cord, as wide as two fingers, which could be felt going toward the bladder. The symptoms indicated a vesical catarrh, and there was a gonorrheal inflammation of the urethra. After lavage of the bladder, carried out for three weeks, the patient was better. The pus had stopped escaping from the umbilicus.

Operation. — The umbilicus was cut around and the cord dissected out. The peritoneum was opened over an area of 10 cm. It was walled off with iodoform gauze; the bladder opening, which was about 0.5 cm. in diameter, was closed. The patient made a good recovery.

The inner surface of the fistula consisted of granular tissue. In places it had grown into the lumen. Only near the umbilical opening had the cavity an epithelial lining, the cells being of the squamous type.

A Singular Case of Ischuria.* — "On the 9th of April, 1814, M. H., aged twenty-three, was admitted an in-patient of the Worcester Infirmary. She represented herself as having been particularly healthy. Within the last week she had been exposed to cold, whilst the catamenia were flowing abundantly. For the first day or two she appeared to suffer only from feverish symptoms; soon afterward, however, the secretion of urine became very deficient, and she had difficulty in passing it.

"On the evening of her admission she became much worse, and complained specially of pain and tenderness over the whole of the lower part of the abdomen and in the loins. There was vomiting and a disposition to convulsions. The lower part of the abdomen was much distended. A catheter was introduced, and ten ounces of urine were drawn off, after which the pain was relieved. She was ordered to take a scruple of cathartic extract immediately, and one drachm of sulphate of magnesia, dissolved in camphor mixture, three times a day.

"The next morning the bowels had not been moved. She was afflicted with severe headache, as well as the abdominal pains. She had passed no water, and was delirious during the night.

"She was cupped on the back, and had a blister applied, and took cathartic mixture every four hours till the bowels moved freely; after which she w T ent into a warm bath.

"The symptoms remained for several days very much in the same state. Delirium usually came on during the night. No urine was passed by the natural effort, but about three ounces were drawn off by the catheter in the course of twenty-four hours. She very frequently vomited, and suffered much from pain, tenderness, and tension of the lower part of the abdomen.

"On the evening of the 17th insensibility came on, for which a blister was applied to. the back of the neck; the pulse was sixty. An active aperient was given.

"On the 19th no improvement had taken place, for the vomiting was incessant, and the pain in the abdomen and back was more severe. Pulse, 80. She was bled three days in succession, with some alleviation of the pain, but the abdomen became generally enlarged and very tender; there also ceased to be any urine drawn from the bladder by the catheter. This continued to be the case for five days. The bowels were open. She took saline diuretics without avail.

• Hastings, Charles: London Med. and Phys. Jour., 1829, X. S., vi, 515.

590 THE UMBILICUS AND ITS DISEASES.

"On the 25th there was much vomiting, pain, and distention of the abdomen, but she passed a little urine. Pulse, 80. She was bled to eight ounces.

"On the 27th a bloody discharge appeared at the umbilicus, after which the abdominal pain and tension were relieved. She also passed some urine by the urethra. The vomiting was, however, worse than it had previously been.

"The bloody discharge from the umbilicus and the other symptoms continued very much the same till the 2d of May, when there was a discharge, of urinous appearance and smell, from the umbilicus. She had passed no urine by the urethra for three days. The head was very painful, the pupils dilated; pulse, 56; bowels costive. Some leeches were applied to the temples, and a blister to the back of the neck; a brisk purge was administered. The catheter was introduced, but no urine found in the bladder.

"The discharge of urine from the umbilicus continued till the 5th, when the catamenia appeared, but quickly vanished. The abdomen became less tense and tender; there was not so much vomiting ; the bowels were open.

" From the 7th to the 9th there was no discharge of urine from the umbilicus, nor was there any passed by the urethra; as a consequence, the abdomen became much distended and severe pain followed, with vomiting. The tension was most remarkable at the umbilicus, forming a circumscribed tumor.

"On the 10th, in the morning, six ounces of urine were drawn off by the catheter; and in an hour after, two quarts of urine of the same appearance gushed from the umbilicus. This was followed by much relief of the abdominal pains. The discharge of urine from the umbilicus continued for three days and was accompanied with great improvement of the general symptoms.

"The amendment, however, did not last, for the discharge from the umbilicus again ceased, and for three days the vomiting, the headache, the abdominal tension and pain returned with their former severity.

"On the 17th the catheter was introduced into the bladder and no urine was found. In an hour after this, two quarts of urine passed from the umbilicus, and soon afterward great relief was experienced.

"From this time to the 25th there was little variation; but the young woman suffered during that interval very much from vomiting and daily passed urine from the umbilicus. The catheter was passed every day, and no urine was found, but the bladder contracted strongly on the instrument; sometimes, immediately after the catheter was removed, a discharge of urine would take place by the umbilicus, and once as much as three quarts were thus passed.

"On the 26th, for the first time after many days, four ounces of urine were drawn from the bladder. Each succeeding day this quantity was now increased and the quantity passed by the umbilicus was diminished. There was also a general improvement of the symptoms, with the exception of vomiting; this continued obstinate. All this time the medicine that she took was confined chiefly to the class of purgatives; blisters were also applied to the neck and epigastrium.

"The bladder was regularly emptied every day by the catheter for more than a month after this date, during which time the abdominal pain and vomiting subsided, and there was no discharge from the umbilicus. Early in July she began to pass some urine, and the power over the bladder was gradually restored. She was

URACHAL CAVITIES AND INFECTIONS. 591

discharged in the middle of July in tolerable health, but still often complained of pain in the pelvic region. She menstruated.

"Observations. — This curious case of ischuria is well worthy of consideration. The remarkable sympathy observable between the brain, the stomach, the kidneys, is common to all cases of this description, and is so obvious as not to require any further comment.

"The very remarkable feature in the case is the occurrence of the urinary discharge from the umbilicus many days after the ischuria had been noticed. Such instances, although rare, are not without parallel in the annals of medicine. Schenck relates two instances of this kind. In the one, a male, the urine was discharged in consequence of an obstruction at the neck of the bladder, 'tanquam mictione ex umbilico,' for many months without any detriment to health. In the other, a female, and more resembling the one now related, 'cum suppressa per multas dies fuisset urina, tandem per umbilicum urinam profuclit.' (Schenck, Obs., Lib. iii, deUrina, p. 489.)

"The interesting question is to determine in what manner the urine is conveyed to the umbilicus in these instances. The urachus offers itself as a means by which the discharge may be determined to that part, and it seems probable that, in the case of mechanical obstruction related by Schenck at the neck of the bladder, a channel of communication was formed by the urachus between the bladder and the umbilicus. But, in the case we now remark upon, there had been no urine secreted into the bladder long before its appearance at the umbilicus, nor was there for some time after; and the first discharge from the umbilicus was not of a urinary but bloody nature. We must consequently, I think, regard the urinary discharge in this instance as vicarious, and as proceeding probably from the peritoneal surface. This view seems confirmed by the great abdominal distention, which took place for some time previous to the discharge from the umbilicus, when it was invariably found, from introducing the catheter, that the bladder was empty, and that it contracted on the instrument.

"Some cases of this description have been placed upon record by eminent men worthy of great credit. There is none, perhaps, more deserving of attention than that by Platerus, which is thus related by the renowned Sennertus: 'Puellae cuidam annos natae tredecim, cum aliquando copiose minxisset, urinam subito suppressam esse, atque tunc aquam serosam ex aure dextra adeo affatim coepisset effluere, ut una vice mensurae duae ssepe emanarint, idque dies aliquot.' He then adds that, on diuretics being administered, the urine was passed freely from the bladder, and the discharge from the ear ceased; but as soon as the diuretics were discontinued, the discharge again took place from the ear, but was altogether removed by general terebinthinate remedies, and local repellents to the ear. The health did not suffer. (Sennerti Opera, Lib. iii, p. 8, § ii, cap. ix.)

"In our case it was evident that much inflammatory action was going on in the pelvic viscera previous to and during the discharge of urine from the umbilicus; and there was a considerable sympathy of the general health with the local inflammatory action.

"I may further add, as a notice to this case, that the young woman was again admitted into the infirmary in May, 1827, for paralysis of the lower extremities, from which she recovered by appropriate remedies. The urine for a time was drawn off by the catheter, but there was no return of the former disease."

592 THE UMBILICUS AND ITS DISEASES.

Umbilical Urinary Fistula in a Middle-aged Man.* — ( lase IV. — The patient was a middle-aged man, who complained of a tender and irritable bladder when he was jolted. A fixed pain developed just above the pubes, and he noticed an increased desire to urinate. A hardness could be detected above the pubes. Suddenly the patient felt something give way, and pus passed from the bladder through the urethra. He was greatly relieved. Recovery followed, and three years later he was well. Hind thought that in this case there had been an abscess of the patent portion of a urachus.

Cyst of the Urachus. — In discussing Douglas's paper Illf said that recently he had removed a cyst of the urachus as large as two fists without difficulty. The patient was a woman who had some prolapse of the anterior vaginal wall, and when she attempted to pass her urine, some of it passed into the cyst and some escaped through the urethra. This did not have the effect, however, of producing an inflammatory condition about the cyst. The condition was annoying to her, because she had to pass her urine in installments, as it were.

The operation consisted in removal of the cyst and ligation of that portion of the duct which entered the bladder. As he was closing the wound he said to himself: This is a dangerous procedure, and it is likely that this ligature will not destroy the epithelium and that the bladder will open in a short time." Some infiltration of urine taking place, he removed the ligature, cut the duct very short, turned in the edges, and closed it over, as a surgeon would do with an appendix stump.

Cystitis Followed by the Opening Up of a Partially Patent Urachus, Producing a Urinary Fistula at the Umbilicus. — Lexer! reports the case of a poorly developed young man, twenty years old, who said that previously he had never noticed anything abnormal at the umbilicus. A year and a half before admission, after several weeks of difficulty in urinating, the urine being cloudy, he had pain in the region of the umbilicus, the tissue in the vicinity of the navel swelled up and became red. Shortly after a quantity of purulent fluid escaped from the umbilicus. The bladder discomfort became more severe; he frequently had fever and chills and became thinner. In addition to a marked degree of cystitis there was blennorrhea of the urethra. Gonococci were isolated from the urethral discharge. On account of the swelling and inflammatory infiltration, the fistula at the umbilicus was not visible, but the umbilical funnel filled up when pressure was made by the patient, and when pressure on the bladder was exerted the umbilical cavity filled up with pus and foulsmelling urine.

The cystitis was first treated. In the washing-out of the bladder purulent flocculi escaped from the umbilicus, so that finally the entire fluid escaped from the umbilical opening. Nevertheless, it was impossible to introduce a sound farther than 2 cm. into the fistula. By the third Aveek the patient had improved greatly. He had no further fever, the urine was passed without pain, he looked well, and the escape of pus from the umbilical fistula had ceased. Urine, however, continued to escape from the umbilicus as soon as the bladder contained an appreciable amount of fluid.

On account of the gonococcus infection it was felt wiser not to leave in a perma

• Hind, \V.: Diseases of the Urachus and Umbilicus. Brit. Med. Jour., 1902, ii, 242.

t 111, Edward J.: Amer. Jour. Obst., 1897, xxxvi, 568.

X Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1893, lvii, 73.

URACHAL CAVITIES AND INFECTIONS. 593

nent catheter. The abdominal walls were not so painful on pressure, and one could now make out a hard cord, the thickness of a finger, in the mid-line, extending from the umbilicus to the bladder. After the cystitis had subsided, closure of the umbilical fistula was considered. As it was impossible to introduce a sound far, an excision of the upper portion of the cord was undertaken. The umbilicus was dissected free, and the fistulous tract about 2 cm. below this point was opened. Here there was a small lumen into which a sound could be introduced without difficulty and carried toward the bladder region. The farther dissection of the cord was easily accomplished without injury to the peritoneum. Midway between the umbilicus and symphysis, however, it was impossible to avoid entering the abdominal cavity. From the opening in the peritoneum one could see the relation of the bladder very well. This cord spread out and passed without any definite margin gradually into the upper portion of the bladder, just as is the case in the embryo. Care was taken not to injure the general peritoneal cavity. The urachus was freed to the point where it entered the bladder. It was then cut across transversely, so that the entire tract from the umbilicus to the bladder was excised. A funnel-like opening, 1.5 cm. wide, was left in the bladder. Examination of the inner surface of the bladder showed that this organ was a long, thick-walled tube, similar to that noted in Bramann's case. The opening in the bladder was closed, and a drain laid into the incision. The wound had healed completely in four weeks.

At the end of two and a half years there was no evidence of any fistula, and the patient was completely cured, the only discomfort being frequent urination.

A Case of Patent Urachus Over One Inch in Diameter Forming a Tubular Prolongation of the Bladder. — Marshall* reports the case of a woman, aged forty-three, who had complete procidentia. On opening the abdomen to suspend the uterus, and while making a short incision midway between the pubes and umbilicus, he found the subperitoneal fat very abundant. On dividing this he could see what appeared to be peritoneum. A nick having been made into it, a pair of scissors was passed upward and then downward to enlarge the incision.

On lifting the retroflexed uterus up to the abdominal opening and thus compressing the bladder, Marshall noted an escape of some clear fluid into the lower part of the wound. This aroused his suspicions. A bougie introduced into the bladder through the urethra entered the abdominal incision through a large opening. What was at first thought to be peritoneum was in reality the anterior wall of a patent urachus. The first cut upward had slit through the upper blind end in the peritoneum into the abdominal cavity. The downward cut had opened the peritoneum and both walls of the urachus.

The urachal opening was V/i inches in diameter and formed a large opening in the conic-shaped bladder. The bladder was closed with a double layer of continuous catgut sutures and a catheter was kept in for one week. The patient made a good recovery.

Suppuration of the Persistent Urachus With Rupture into the Bladder and the Abdominal Wall.f — In November, 1901, a forty-eight-year-old man came to Mikulicz's clinic. He had had a gonococcal

• Marshall: Jour, of Obst. and Gyn. of the Brit. Empire, 1907, xi, 259.

t Matthias, F. : Vereiterung des persistierenden Urachus mit Durchbruch in die Blase und in die Bauchdecken. Beitrage z. khn. Chir.; herausg. von Paul Bruns, Tubingen, 190-1, xlii, 339. 39

594 THE UMBILICUS AND ITS DISEASES.

infection ten years before, which had not been promptly treated. For the last few years he had had an abundant discharge from the urethra. Apart from this the patient had been well. Six months before admission, he began to have a pressure in the lower abdominal region and suffered from a general feeling of malaise. The urine was cloudy and contained whitish threads and flocculi. There was a cramp-like, sticking pain in the urethra. During the three months following this the patient lost weight and the urine was cloudy. Two months later there was again pain in the lower abdomen, and a tumor could be felt above the top of the bladder. Mikulicz found a firm, ill-defined tumor lying below the umbilicus. This occupied the mid-line and extended a little more to the right. It commenced three fingerbreadths below the umbilicus, and ended 5 cm. above the symphysis. There was a cord passing from the tumor to the umbilicus. The umbilicus itself appeared normal. , Mikulicz thought that he was dealing with an abscess of the abdominal wall, and one that communicated with the bladder, and that its origin was due to the extension of a cystitis by way of a persistent urachus. Bladder irrigations were employed. When there was a large quantity of pus in the urine, the tumor became smaller and the patient felt better. The reverse was the case when the urine contained but little pus. The difference in the size of the tumor was manifested in its transverse diameter. When a large amount of pus escaped in the urine and the tumor had diminished to half its volume, a cystoscopic examination was made. In the anterior bladder-wall, in the neighborhood of the top of the bladder and in the mid-line, was a transverse oval opening passing into a funnelshaped diverticulum. The walls of this could be seen for some distance, but the point ended in darkness.

Operation. — A median incision was made. The skin was dissected free from the tumor, which was covered with thick and edematous fascia, and on the left side the peritoneal cavity was opened. From this point the tumor was separated from the abdominal wall, and in the lower angle of the incision the bladder was recognized by means of a metal catheter which had been introduced from below. The tumor sat on the top of the bladder, and on the right and on the left, between the tumor and bladder, was a loop of small bowel which was separated without injury. The tumor was the size of a billiard ball, and sat as a cap on the top of the bladder. The muscular covering of the bladder extended over on it, particularly on the posterior surface. The peritoneal cavity was well walled off and the tumor opened. Its walls were 12 mm. thick, and the cavity was the size of a walnut. From it escaped an old clot mixed with pus. An attempt was made, by filling the bladder with 300 c.c. of salt solution, to find a communication with the abscess cavity. In this the operator was unsuccessful ; no fluid escaped, but a sound could be passed from the cavity into the bladder. The tumor was separated from the bladder. The small opening in the bladder-wall was closed with catgut, and the muscularis, which formed two flaps over the tumor, was brought together. A retention catheter was introduced into the bladder and kept in place for ten days. The urine then came away spontaneously, and the pus disappeared almost completely. The extirpated tumor was the size of an apple and irregularly round. Its walls varied from 2 to 20 mm. in thickness, and there were irregular dilatations in the interior. It consisted of striated, dense connective tissue. Here and there were citron-yellow portions, undoubtedly fatty tissue. The inner surface of the sac, apart from dilatations, was uneven; no mucosa was visible.

URACHAL CAVITIES AND INFECTIONS. 595

Microscopic Examination. — Sections showed that the wall was made up of smooth muscle-fibers, connective tissue, and an inner zone consisting of old connective tissue containing many round-cells and small blood-vessels. There were hemorrhages, and here and there the tissue was necrotic. There was no evidence of epithelium. Mikulicz found a small opening in the wall of the tumor. This was lined with epithelium. It could be traced for a distance of 2 mm. in serial sections, and had a breadth of 1 mm. The epithelium lining the canal was several layers thick; only in a few places did it consist of a single layer.

In conclusion Mikulicz said that very probably the normal dilatation of the opening of the urachus in the bladder, being funnel-shaped, had allowed the cystitis to extend to the urachus, and through breaking of the wall there had resulted abscess formation in the musculature of the bladder-wall and of the abdominal wall to the umbilicus. Since the abscess originally lay within the bladder musculature, its rupture into the interior of the bladder near the actual opening of the urachus was not exceptional.

[There is no doubt in this case that there was an abscess between the bladder and the umbilicus. It was probably of urachal origin, but Matthias's description is not particularly clear. — T. S. C]

Escape of a Calculus From the Umbilicus.* — This case had been reported by Gennaro in 1890. After a mucopurulent discharge from the umbilicus had lasted several days, a calculus escaped from the umbilical opening. It consisted of urate of soda, phosphate of lime, and magnesia. The urachus was a diverticulum of the bladder. Gennaro thought that the calculus was due to fermentation of the stagnant ammoniacal urine.

A Case of Dilated Urachus Accidentally Opened During an Abdominal Section for Peritonitis. Recovery. f — A boy, aged five, was brought to the Children's Hospital, Brighton, on February 18, 1896. There was a history of vomiting and diarrhea for two days. On admission he was suffering with severe abdominal pain, but there was no marked tenderness. His temperature was 102° F. The next day he was much worse, and lay on his left side, with his thighs fully flexed. The distention, tenderness, and pain were more severe. There was no localized swelling. His diarrhea was almost constant. His temperature was 103.6° F., his pulse, 108. In the next five days there was some improvement in his general condition. The abdomen was still distended, but the vomiting and diarrhea were improved. On the ninth day, in the region of the bladder and extending nearly to the umbilicus, there could be made out a certain amount of resistance that was fairly sharply defined. Micturition was frequent, but there was no dribbling. On the suspicion that the swelling might be the bladder, a catheter was passed, but only about half an ounce of urine was drawn off. This did not affect the size or position of the hypogastric fulness. On February 27th the general condition was better, except that he was passing a large quantity of mucus by bowel. The distention and hypogastric fulness were less marked. On the evening of the next day, twelve days after the first symptoms, the boy was much worse, his vomiting had returned, and the distention was

• Monod, Jean: Des fistules urinaires ombilicales dues a. la persistance de l'ouraque. These

de Paris, 1899 (obs. 47), 168.

t Morgan, G.: The Lancet, 1896, ii, 1154.

596 THE UMBILICUS AND ITS DISEASES.

very severe. His temperature was 103° F. and his condition so critical that it was decided to operate at once.

An incision was made extending from the umbilicus to a point near the pubes. The deeper abdominal layers were divided carefully over a director. An incision was made into what was taken for the subperitoneal fat and peritoneum, and there was a gush of about one ounce of clear urine. The wound was at once clamped and a catheter was passed. The bladder was found to be quite empty and lying in the pelvis, but the catheter could be passed up into the wound in the cyst where the clamp was. After carefully dissecting around the cyst, Morgan opened the abdominal cavity and found signs of recent peritonitis, with flakes of lymph, but no pus. The abdominal cavity was flushed with hot water, and the intestines were carefully sponged. The boy was too ill to have a prolonged examination or have the mass dissected out, but it was certain that the cyst was in the mid-line, running up to the umbilicus and communicating with the bladder. After the bladder and cyst had been washed out with boric acid solution, the wound in the bladder was closed with a double row of silk sutures, the stitches not penetrating to the mucous membrane. The abdominal wall was also carefully closed. On the following day the boy was much better, but on the fourth day pus began to well up from the suture line. Three stitches were taken out and the pus cavity was irrigated. For ten days after this there was some escape of urine from the abdominal wound, but this became less and less, and the boy's general condition improved. Twentysix days after operation the wound was closed and the boy was quite well.

A Rare Variety of Cyst of the Urinary Bladder, Probably Arising From the Urachus, Cured by Operation.* — A. M'V., a miner, aged thirty-nine, was admitted to the Glasgow Royal Infirmary on October 21, 1895. He complained of severe pain in the hypogastric region. This had commenced four days before, and had continued ever since. Coincident with the onset of the pain he found that he was unable to micturate, and his doctor had to pass a catheter. When the urine was drawn off, it contained a large quantity of blood. Vomiting came on soon after the onset of the pain and was followed by attacks of diarrhea.

On admission he was suffering considerable pain, had an anxious expression and walked with difficulty. The skin over the region of the bladder was red and blistered from the use of hot fomentations and applications of mustard. The abdomen was considerably swollen, very tense over the region of the bladder, and from the umbilicus to the pubes it was absolutely dull on percussion. After admission a catheter was passed and 20 ounces of urine, containing a large quantity of blood, were drawn off. This gave the patient considerable relief, but even after the bladder had been completely emptied, the dulness in the hypogastric region did not disappear. From the 1st until the 8th of November the patient's condition steadily improved, and at the latter date he was able to pass his urine without difficulty. On examination the abdomen still showed a considerable amount of swelling in the hypogastric region. The swelling in appearance greatly resembled a distended bladder.

Operation. — A free incision was made in the mid-line, midway between the pubes

• Newman, D.: Throe Renal Cases, a Case of Cyst of the Urachus, and a Case of Strangulated Hernia, Treated in the Surgical Wards of the Glasgow Royal Infirmary. Glasgow Med.

Jour., 1896, xlvi, 20.

URACHAL CAVITIES AND INFECTIONS. 597

and the umbilicus. On incision into the transversalis fascia, a large quantity of gelatinous fluid escaped which had a strongly ammoniacal odor. The cyst-wall was thin and smooth, and its anterior wall was not covered with peritoneum. The cyst extended from the apex of the bladder to the umbilicus. After evacuation of the contents the cyst was washed out with carbolic acid solution, and a drainagetube inserted. In the evening the dressing was found to be soiled with urine which had a strongly ammoniacal odor.

On November 16th the greater part of the urine was passing through the abdominal wound and a retention catheter was now introduced into the urethra. Notwithstanding this the urine continued to escape from the wound, and not until December 16th did the cyst become completely obliterated and the wound in the abdomen close. On careful inquiry into the history of the patient it was found that he had noticed a swelling in the hypogastric region as long as he could remember, but until this occasion it had never given him any trouble.

Probably a Partially Patent Urachus with Infection.* — This patient was observed by Chopart. She was pregnant, and had suffered from retention of urine for some time. The abdomen became tender and painful. Fluctuation was felt, and was specially marked in the region of the umbilicus. An incision was made between the right rectus muscle and the umbilicus, and much pus escaped. On the following clay the bed and the apparel of the patient were soaked with urine. This escaped for some time by the umbilicus until, after repeated catheterization, the urine commenced to pass through the urethra and the umbilicus closed.

Dilatation of the Urachus; Communication with the Bladder. — Patel'sf patient was a child three years of age who, from birth, had incontinence of urine both day and night. The urine did not escape drop by drop, but at frequent intervals and involuntarily. There were no malformations.

Below the umbilicus was a voluminous tumefaction, fusiform, and prominent in its central portion. In its middle portion it was the size of two fists. It was exactly in the median line; above it reached the umbilicus, and below passed into the pelvis, although its termination could not be felt. It was movable. Catheterization yielded a small glass of clear urine. There was evidently a tumor lying behind the abdominal walls, adherent to the umbilicus, and clinically independent of the bladder.

A median incision was made below the umbilicus. The tumor was found adherent to the umbilicus. Half a liter of pale-yellow fluid escaped, which contained large quantities of albumin. The sac was lined with an irregularly wrinkled muscular layer. Above the finger impinged on the umbilicus. The inferior end was very narrow and was dilated with difficulty. It led to a small circular cavity in which the vesical trigonum was recognized. Removal of the diverticulum was not undertaken on account of the size of the tumor and of its probable adhesion to the peritoneum, and on account of the patient's age. The walls of the sac were sutured much in the way that cavities resulting from removal of hydatids of the liver are obliterated. The walls were brought together and a catheter was left in the blad

• Xicaise: Ombilic. Diet, encycloped. des sci. med., Paris, 1881, 2. ser., xv, 140.

| Patel: Malformation congenitale de 1'ouraque. Dilatation kystique de la partie interieure de 1'ouraque demeure en communication avec la vessie; incontinence d'urine symptornatique. Capitonnage de la poche. Rev. mens, des maladies de l'enfance, Paris, 1904, xxii, 77.

598

THE UMBILICUS AND ITS DISEASES.

der. During the five days that the catheter remained in place there was some discharge from the abdominal wall. When the child left the hospital, the abdomen was soft. The bladder was large enough and the child urinated about every three hours. There was no incontinence. Recovery was permanent. This case was also reported by Gabriel Renard.*

The Diagnosis and Treatment of a Case of Patent Urachus. f — The patient was a woman twenty-five years of age. Six months previously she had begun to have pain in the umbilical region. Two weeks later a swelling had appeared at the umbilicus. This had ruptured, and since then pus had been discharging, except during occasional intervals of a week. A probe was

passed through the umbilicus into the bladder, and the end emerged at the external urinary meatus.

The urachus was opened on a director about two inches above the symphysis. It showed a dilatation in the middle, with a constriction above, and below, where it connected with the bladder. The actual cautery was used to destroy about one inch of the lower portion of the urachus. The portion above was packed, a piece of iodoform gauze being passed through the fistula to the umbilicus. The bladder was accidentally opened, but at once closed with catgut. The patient made a good recovery.

Urachal Cyst Communicating with the Bladder. — Robinson+ says: " I worked several years in the dissecting room, paying special attention to visceral and pelvic anatomy, but did not see any urachal cyst in but one autopsy (Fig. 251)." In this case the urachus was dilated, forming a fusiform tumor. It opened into the bladder and extended upward as far as the umbilicus. . . . "I understand from veterinarians that the horse is one of the most typical animals to show urachal cysts, and that quite late in horse fetal life the urachus is found often quite a distance above the bladder."

A Urachal Cyst Communicating With the Bladder. — In Roser's § case the urachal cyst had a small opening into the bladder (Fig. 252) . When the patient wished to void, the contraction of the bladder muscles forced the

• Etenard, Gabriel: Sur un kyste de l'ouraque. These de Lyon, 1905, No. 89.

fReid, \Y. L.: Glasgow Hosp. Reports, 1899, ii, 76. % Robinson, F. Byron: Annals of Surg., 1891, xiv, 336.

§ Roser, W '.: Ueber Operation der Urachuscysten. Langenbeck's Arch. f. klin. Chir., 1877, xx, 47:;.

Fig. 251. — A Dilated Urachus Communicating With the Bladder. (After F. Byron Robinson.) The urachus (6) is patent from the bladder (a) almost to the umbilicus. It is markedly dilated, and its cavity communicates directly with the bladder. It resembles a secondary bladder.

URACHAL CAVITIES AND INFECTIONS.

599

urine into the cyst more easily than through the urethra. The cyst, therefore, became more and more distended, until three or four liters of urine accumulated. When it was desired to empty the bladder, a catheter had to be introduced into it and the cyst was then pressed upon. In order to keep the patient free from trouble catheterization several times a day was necessary.

The patient had what appeared to be a greatly distended bladder when she was three months pregnant. A puncture was made in the linea alba above, and a large amount of urine removed. The pregnancy went to term. Four years later she had a similar attack when she was again pregnant. The old cyst had refilled. It was tapped from above, and the patient miscarried. The cyst again filled, and operation became necessary. The urine was ammoniacal, owing to stasis in the sac. There was foul urine in the cyst, which at that time had reached the umbilicus.

An extraperitoneal opening, about 3 cm. long, was made in the mid-line, and two chambers full of stinking ammoniacal purulent fluid escaped. There was temporary relief. A retention catheter failed to bring about closure of the bladder, and when last seen, the patient still had the urachal cyst opening into the bladder.

Polypus of the Urinary Bladder with the Development of a Urinary Fistula at the Umbilicus. — ■ Savory's* patient was a male, thirteen months old and sickly. Immediately beneath and partly surrounding the umbilicus was a firm, tense swelling, two or three inches in diameter. Its limits were not well defined. It was very tender, and pain was increased by attempts to void. The urine merely dribbled away. The child had been ill eight weeks. The first thing noticed was that micturition caused pain in the lower abdomen, followed by an almost constant desire to void rupted temporarily and then started again.

The umbilical induration was incised and pus escaped; later urine appeared, and nearly all came this way Autopsy. — On section of the abdomen an abscess was found between the posterior surface of the abdominal parietes and the peritoneum and extending from the umbilicus almost to the symphysis. The omentum was adherent to the abdominal wall. The growth in the bladder stretched across behind the ureteral orifices, which were dilated. This mass was attached at each side, but was free in the center, and could block the urethra. It was a polyp. It was impossible to find the opening between the bladder and the abscess by which the urine escaped from the umbilicus.

A Partially Patent Urachus.t — Simon reports the case of a

• Savory, W. S.: Med. Times, London, 1852, N. S., v, 106.

t Simon, Charles: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. SO (obs. 12), 26.

Fig. 252. — Urachal Cyst. (Redrawn by August Horn after W. Roser.) The bladder itself looks normal, except that at the upper part anteriorly there is a small opening which communicates with a large cyst extending as high as the umbilicus.

The stream was often inter

600 THE UMBILICUS AND ITS DISEASES.

patient of Portal, a man forty-five years of age, who died shortly after a fall on the abdomen resulting in a severe injur}' to the bladder. Some time after the accident he had noticed that the urine was escaping at the umbilicus. Portal says: "On opening the bod}' I found a tube which extended from the umbilicus to the bladder. This was cone-shaped. Its diameter toward the umbilicus was ^4 inch and 1^2 inches at the bladder. The thickness was unequal. The volume of the bladder did not exceed that of a small apple."

An Infected Urachal Cyst Communicating With the Bladder.* — This patient, a man sixty-six years of age, came under Trendelenburg's observation on July 3, 1887. For a year or more he had had frequent urination. The urine was cloudy, and often much pressure was necessary to start it. Six months before he had noticed a swelling in the lower abdomen, above the symphysis. For three or four days he had had pain in this region, and soon after a spontaneous opening had appeared at the umbilicus from which a purulent fluid had escaped. Recently he had become weaker.

On admission to the hospital he showed, in the hypogastric region, a marked swelling about the size of a head. This began just above the symphysis and reached to the umbilicus. Rectal examination revealed an enlarged prostate, especially on the right, and above this a distended bladder. A very fine sound was passed from the umbilicus and entered into a large cavity. The fluid from the umbilicus showed round-cells undergoing fatty change. After catheterization with the removal of 1500 c.c. of cloudy urine the swelling to a large extent disappeared, but there persisted a long tumor reaching from the umbilicus to the symphysis.

Operation. — An incision was made between the umbilicus and the symphysis. Immediately behind the fascia was a sac containing about a liter of urine mixed with pus. A piece of the wall was removed, and the wound closed with drainage. A purulent fluid continued to escape from the sac. Microscopic examination of the wall showed it to be lined with one layer of squamous epithelium resembling that of the bladder. There was no muscle in the wall. The connective tissue contained many round-cells.

A Dilated Urachus Communicating With the Bladder . f — The patient was a very frail woman, weighing probably 85 pounds. At labor she had had a bad tear and developed a fever, from 100° to 101.5° F., for nearly six weeks. In the following spring she entered the hospital for operation, but later developed pain and swelling in the right side.

A median incision, 2^ inches long, was made. The peritoneum was exposed and cut, but the bladder was opened. The patient had just voided before the operation. The wound was closed, but the operator, in attempting to enter the peritoneum, got into the same cavity again. It proved to be an accessory bladder — really a dilated urachus — and contained l}/£ to 2 pints of urine. A catheter introduced into the urethra could be passed into this cavity. It was closed and the patient recovered.

Escape of Urine From the Umbilicus. — UnterbergerJ reporter! the case of a woman, twenty-three years of age. She was supposed to have

Schnellenbach: [Jeber die (Jrachuscysten. Inaug. Diss., Bonn, 1888. f Timmerman, C. F.: Trans. Med. Soc. State of New York, 1904, 331.

tTJnterberger: Retroversio-flexio uteri gravidi partialis incarcerata. Urachus-fistel. Monatssohr. f. Geb. u. Gyn., 1900, xi, 657.

URACHAL CAVITIES AND INFECTIONS. 601

had an ovarian cyst that had ruptured through the umbilicus, and for three weeks clear fluid had continued to escape from the navel.

The trouble had begun with pain in the lower abdomen. This had become so severe that the patient had been forced to remain in bed and local applications had been applied. Urination and defecation at this time were normal.

The patient had fever and gradually became weaker. One month before her admission to the hospital urinary disturbances developed, and after a time the urine commenced to escape through the umbilicus and the pain disappeared. Pus sometimes escaped from the umbilicus with the urine.

For fourteen days before the patient entered the hospital no urine had been passed from the urethra. The umbilical opening had the caliber of a hair, and was surrounded by a small red zone. The abdominal walls were somewhat infiltrated. A catheter passed into the bladder entered for its entire length and about 2000 c.c. of urine mixed with pus were removed. The uterus, which contained a pregnancy, was retroverted and partially incarcerated. No operation was performed, but Unterberger regarded the case as one of patent urachus.

A Dilated and Infected Urachus Communicating With the Bladder and Umbilicus.* — A. W., white, male, aged forty, was admitted to the Georgetown University Hospital, June 21, 1904. When twenty years old he had gonorrhea, from which he made a good recovery. His present trouble began when he was seventeen years of age, with pain in the suprapubic region extending to the umbilicus. There was induration and tenderness of the parts on pressure. These symptoms grew worse; poultices were applied, and two weeks later an opening appeared at the umbilicus through which was discharged a moderate amount of pus. From this time the fistula remained patulous almost constantly, with a discharge of pus and urine. Occasionally it would close — never longer than for two days, during which time there would be considerable pain, especially on urination. When the opening closed, the area around and below the navel would become inflamed, and when it was reestablished, spontaneously or by the patient, there would be immediate relief from pain and the escape of a large quantity of dark, offensive-smelling fluid. The odor was worse after the fistula had been closed a day or two than when it was discharging freely, but at all times it was offensive, to a great extent barring the patient from the society of his friends. The discharge had always been most profuse during urination, and in the morning, when the patient would begin to move about, but there was at all times enough to keep his clothing soiled. At thirty-four years of age he had an attack of pain in the region of the right kidney, with nausea, vomiting, and elevation of temperature, and he had to keep to his bed for three weeks. Since then he had had other attacks of less severity, usually beginning with pain in the loin and extending to the testicle, sometimes accompanied by vomiting and the passage of blood through the urethra. The attacks had always been most severe after exertion.

Examination showed a large, robust, well-nourished man, with good color and apparently in excellent health. At the umbilicus was a flat area of scar tissue of a bluish color, containing a small opening through which a probe could be passed

• Vaughan, George T. : Patent Urachus. Review of the Cases Reported. Operation on a

Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus. Trans. Amer. Surg. Assoc, 1905, xxiii, 273.

602 THE UMBILICUS AND ITS DISEASES.

downward and slightly backward for a distance of three and one-half inches into a pouch which lay in front of the bladder.

The urine from the bladder contained urates and epithelial cells. A diagnosis of patent urachus with dilatation into a pouch and infection of its contents was made, and operation was advised.

Operation (June 25, 1904). — The bladder was distended with water through the urethra, and a grooved director was passed through the umbilical fistula to the bottom. The cavity was opened, and a considerable amount of bloody pus, with an offensive urinary odor, was evacuated. The sac was pyriform in shape, with the small end above: it lay in front of the peritoneum, and above and in front of the bladder, with which it communicated through a very small opening. The sac was about three inches in length, and had a capacity of about three ounces; it contained many laminated clots and resembled very much a small urinary bladder, the walls containing muscular and fibrous tissue and being lined with mucous membrane. The sac was carefully dissected out, the peritoneum being opened in two places accidentally, and the walls were brought together. Recovery was without incident except for the high temperature that occurred on the day after operation (107° F. in the axilla), and he was well three weeks after the operation.

On August 13, 1904, just a month after leaving the hospital, the patient had a severe attack of renal colic on the right side, with chills, vomiting, blood}^ urine, dehrium, and swelling of the face and extremities. His pulse was 140, the temperature 104° F. On August 21st the right kidney was incised, and a round stone, half an inch in diameter, was removed. After this the patient had no further trouble until February, 1905, when he had an attack of renal colic on the left side, with the passage of several small, pea-sized calculi from the bladder. A month later he had another attack, which was much more severe and was complicated with almost complete suppression of urine for forty-eight hours, delirium, chills, and a temperature of 106° F. On May 1, 1905, the left kidney was incised and two stones were removed. Up to June 27, 1905, the patient had had no further trouble with his bladder, but had had an attack of appendicitis which he managed to pass through without operation.

Under date of May 12, 1915, Dr. Vaughan writes: "After an operation on both kidneys for stone the patient got along pretty well until December 6, 1906, when I had to operate on the left kidney again, removing a large oval stone. Patient recovered, but had trouble again during the summer of 1914 (during my absence), and Dr. Fowler removed stones from the right kidney. He is in pretty good condition now, but evidently has stones, probably in both kidneys. Since June 25, 1904, patient has had five operations — excision of urachus and two operations on each kidney.'"

Suppuration of a Urachal Cyst. — In Weiser's* Case 3 the patient was a man aged seventy-three, who had always been well except for an attack of orchitis four months before the present sickness. For six months he had suffered with pain and soreness in the abdomen, but had noticed no tumor. Two weeks before Weiser's visit the abdominal wall had opened spontaneously two inches below the umbilicus, and discharged urine. There had never been any pus. When the patient was lying down quietly, the urine did not escape, but as soon as he assumed an upright position, there was a constant discharge. The old gentleman

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

URACHAL CAVITIES AND INFECTIONS.

603

OOTteo LINE REPRESENTS UVACHUS *-* CYST WALLS

appeared perfectly well aside from this urinary sinus, which in caliber was about

the size of a pencil, and entered immediately into a large sac, the lower limit

of which Weiser could not reach with an eightinch probe.

Weiser entered the peritoneal cavity above the

sinus, and found the sac anterior to the parietal

peritoneum. The sac extended to within one inch

of the umbilicus, above which the urachus was not

patulous (Fig. 253), and downward into the pelvis.

It was intimately connected with the bladder at the

point of urachal attachment, and was densely adherent to the posterior bladder-wall as well as to

the intestines, the greater part of the sac being made

up of abdominal viscera. After freeing the anterior

wall of the cyst sufficiently, he made a plastic closure

of the original point of rupture through the abdominal wall. A catheter was placed in the bladder through the urethra and allowed to remain for several days. The abdominal wound was closed without drainage. The patient made a good recovery, and was about the house on the fourteenth

day. Two months later Dr. Stowell, under whose care the patient had been originally, told Dr. Weiser that the abdominal wall had given way again a trifle lower down toward the symphysis, and urine was again discharging through a small sinus. Later the opening closed spontaneously.

A Very Large Abscess-sac Extending into the Pelvis, Opening a t t h e Umbilicus, and Containing a Calculus. — This case in many respects suggests an umbilical abscess that reaches very large proportions and contains a concretion. On the other hand, it makes one think of certain cases of abscess of the urachus. I wrote Dr. Weiser* as to the character of the calculus. From his reply it was evidently of urinary origin, and probably made up largely of oxalates. A woman, seventy-five years of age, had for fifteen years suffered inconvenience

from a discharge of pus from the umbilicus. The discharge was constant and at

• Weiser, W. R.: Annals of Surg., 1906, xliv, 531.

Fig. 253. — Urachal Cyst. (After W. R. Weiser, Case 3, Fig. 3.) Male, aged seventy-three. The abdominal wall opened spontaneously two inches below the umbilicus and urine was discharged. The sac extended upward to within an inch of the umbilicus ; downward into the pelvis. It was intimately attached to the fundus of the bladder.

Fig. 254.

(After

-Urachal Cyst. W. R. Weiser.)

Revised from Case 1. At the operation Weiser tapped the cyst, evacuating five ounces of horribly fetid pus, followed by a calculus weighing 70 grains. The cyst had a thick and indurated wall and dipped well down into the pelvis. It was extraperitoneal. [Dr. Weiser tells me that in his article two of his pictures were not properly placed, hence the "revision."— T. S. C.l

604 THE UMBILICUS AXD ITS DISEASES.

times profuse. At various times she had consulted a physician in reference to the condition, but, aside from prescribing various washes and ointments, no treatment or diagnosis was offered.

She finally consulted Dr. Weiser. The patient at this time was well nourished and active for her age. The abdomen was very fat, and a tumor the size of a cocoanut presented in the median line, between the umbilicus and the symphysis. The mass could be raised with the abdominal wall and was apparently attached thereto.

There was a copious discharge of foul-smelling pus from the umbilicus, and an eight-inch probe, passed into the sinus, failed to reach the lower wall of the sac. The temperature was 101° F., her pulse, 100. She volunteered the information that the condition was no worse than usual, but that she was not feeling well generally, and during the past month there had been very frequent micturition.

Under ether Weiser excised the umbilicus and unhealthy skin surrounding it, and cutting down through two inches of fat, came upon a bulging mass extending from the umbilicus as far down as he could feel toward the symphysis (Fig. 254). This he tapped, and evacuated about five ounces of horribly fetid pus, followed by a calculus weighing 70 grains. Exploration with the finger demonstrated the fact that the cyst had a thick and indurated wall, and dipped well down into the pelvis. Up to this point in the operation he had not opened the peritoneal cavity. He now washed out the sac. packed it with gauze, and entered the peritoneal cavity, above the location of the tumor. To his surprise he found the mass densely adherent to the intestine posteriorly, and on passing his hand down into the pelvis on the outside of the cyst, discovered it to be closely associated with the bladder. He now concluded that he was dealing with a urachal cyst, and, as the posterior wall was almost entirely made up of intestines, he concluded to cut away such portions of the sac as seemed safe. He left the posterior wall intact, as well as that portion which dipped down into the pelvis. The wound was closed as- far as the peritoneum, and the rest was walled off with a coffer-dam drain of iodoform gauze. Her recovery was uneventful, but it required three months for the sinus to close.

March 11, 1912. My Dear Dr. Cullen: Replying to your letter of the eighth inst. and referring to the urachal calculus: The stone was quite hard, and the surface was dark brown, resembling in color a type of gall-stone. Upon cutting open, the substance of the stone resembled a hard bladder stone in color and general appearance.

Unfortunately, this stone was lost before reaching the laboratory, but I think it was probably made up largely of oxalates. My opinion was that this was a urinary calculus which became discolored on its outer strata by lying in a bed of foul pus and being exposed through the discharging sinus at the umbilicus.

Cordially yours,

Walter R. Weiser.

Case of Vesico-umbilical Fistula of FourteenYears' Standing. — Wbrster* reports the case of Miss H., aged twenty-one. She had good health until a severe attack of diphtheria when eight years old. Following this she had incontinence of urine and cystitis. From about this time she could not straighten herself up properly and had a habit of standing with the body bent forward at an angle of 45 degrees. She was also incapable of stooping to pick up any

• Worster, Joseph: Med. Record, 1877, xii, 196.

URACHAL CAVITIES AND INFECTIONS. 605

thing. Two years after the diphtheria she suffered from a cystitis, accompanied by a copious flow of purulent matter from the urethra, and shortly afterward a swelling was noted in the umbilical region, the appearance of which was followed by large and repeated discharges of pus from the umbilical opening, and subsequently of urineThe umbilical inflammation subsided, but pus escaped from time to time, and the urine continually. In her eleventh year, as a result of a contusion, an opening occurred below the umbilicus, from which urine escaped. Extending from the bladder to the umbilicus was a hard, cord-like mass, two inches in diameter and uniform in size.

Operation (April 14, 1875). — Two elliptic incisions were made and the umbilical area removed. Eight days after the operation urine escaped from the wound. A second operation was undertaken at once, with good results.

LITERATURE CONSULTED ON URACHAL CAVITIES COMMUNICATING WITH THE BLADDER OR UMBILICUS OR WITH BOTH.

Ball, C. B. : A Case of Pervious Urachus with Remarkable Disease of Bladder. Trans. Acad.

Med. Ireland, 1883-84, Dublin, 1884, ii, 376. Bourgeois: Jour. gen. de med., 1821, lxxvi, 219. Bramann, F. : Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., 1887,

xxxvi, 996. Freer, J. A. : Abnormalities of the Urachus. Annals of Surg., 1887, v, 107. Garrigues, H. J.: Persistent Urachus in an Adult Woman. Med. Record, New York, 1899, lvi,

720. Graf, F. : Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896. Hastings, C: A Singular Case of Ischuria. London Med. and Phys. Jour., 1829, N. S., vi,

515. Hind, W. : Diseases of the Urachus and Umbilicus. Brit. Med. Jour., 1902, ii, 242. Ill, E. J.: Tumors of the Urachus. Trans. Amer. Assoc. Obst. and Gyn., 1892, v, 238. Amer.

Jour. Obst., 1897, xxxvi, 568. Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. Marshall, G. B. : Case of Patent Urachus over One Inch in diameter, forming a Tubular Prolongation of the Bladder. Jour. Obst. and Gyn. of the Brit. Empire, 1907, xi, 259. Matthias, F. : Vereiterung des persistierenden Urachus mit Durchbruch in die Blase und in die

Bauchdecken. Beitriige z. klin. Chir.; herausg. von Paul Bruns, Tubingen, 1904, xlii, 339. Monod, J. : Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,

1899, No. 62. Morgan, G. : A Case of Dilated Urachus Accidentally Opened Whilst Performing Abdominal

Section for Peritonitis; Recovery. The Lancet, 1896, ii, 1154. Newman, D.: Three Renal Cases, a Case of Cyst of the Urachus, and a Case of Strangulated

Hernia, Treated in the Surgical Wards of the Glasgow Royal Infirmary. Glasgow Med.

Jour., 1896, xlvi, 20. Nicaise: Ombilic. Diet, encycloped. des sci. med., Paris, 1881, 2. ser., xv, 140. Patel, M.: Malformation congenitale de l'ouraque; dilatation kystique de la partie interieure de

l'ouraque demeure en communication avec la vessie; incontinence d'urine symptomatique.

Capitonnage de la poche. Rev. mensuelle des mal. de l'enfance, Paris, 1904, xxii, 77. Reid, W. L.: On the Diagnosis and Treatment of a Case of Patent Urachus. Glasgow Hosp.

Rep., 1899, ii, 76. Renard, Gabriel: Sur un kyste de l'ouraque. These de Lyon, 1905, No. 89. Robinson, F. B.: Cysts of the Urachus (Congenital Cysts, Extraperitoneal Cysts, or Dilatation

of Functionless Ducts). Annals of Surg., 1891, xiv, 336. Roser, W.: Ueber Operation der Urachuscysten. Langenbeck's Arch. f. klin. Chir., 1877, xx,

473. Savory, W. S.: Polypus of the Urinary Bladder. Med. Times, London, 1852, N. S., v, 106.

606 THE UMBILICUS AND ITS DISEASES.

Schnellenbach: TJeber die Urachuscysten. Inaug. Diss., Bonn, 1888.

Simon, C: Quels sont les phenoinenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. 80.

Timnierman, C. F. : Dilated Urachus. Trans. Med. Soc. State of New York, 1904, 331.

Unterberger: Retro versio-flexio uteri gravidi partialis incarcerata. Urachus-fistel. Monatsschr. f. Geb. u. Gyn., 1900, xi, 657.

Vaughan, G. T.: Patent Urachus. Review of the Cases Reported. Operation on a Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus. Trans. Arner. Surg. Assoc, 1905, xxiii, 273.

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

Worster, J.: Case of Vesico-abdominal Fistula of Fourteen Years' Standing. Med. Record, 1877, xii, 196.

Reference

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

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