Book - Umbilicus (1916) 39

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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.

Umbilicus (1916): 1 Umbilical Region Embryology | 2 Umbilical Region Anatomy | 3 Umbilical New-born Infections | 4 Umbilical Hemorrhage | 5 Umbilicus Granuloma | 6 Omphalomesenteric Duct Remnants | 7 Umbilicus Abnormalities | 8 Meckel's Diverticulum | 9 Intestinal Cysts | 10 Patent Omphalomesenteric Duct 1 | 11 Patent Omphalomesenteric Duct 2 | 12 Bowel Prolapsus at Patent Omphalomesenteric Duct | 13 Abdominal Wall Cysts by Omphalomesenteric Duct Remnants | 14 Omphalomesenteric Vessels Persistence | 15 Umbilical Inflammatory Changes | 16 Subumbilical Space Abscess | 17 Umbilicus Paget's Disease | 18 Umbilicus Infections | 19 Umbilicus Abnormalities 2 | 20 Umbilicus Fecal Fistula | 21 Umbilicus Round Worms | 22 Umbilicus Foreign Substance Escape | 23 Umbilical Tumors | 24 Umbilicus Adenomyoma | 25 Umbilicus Carcinoma | 26 Umbilicus Sarcoma | 27 Umbilical Hernia | 28 The Urachus | 29 Congenital Patent Urachus | 30 Urachus Remnants | 31 Urachal Remnants Producing Tumors | 32 Large Urachal Cysts | 33 Anterior Abdominal Wall Abscesses | 34 Urachal Cavities | 35 Umbilicus Acquired Urinary Fistula | 36 Urachal Concretions and Urinary Calculi | 37 Urachus Malignant Changes | 38 Urachus Bleeding into the Bladder | 39 Patent Urachus Tuberculosis | Figures
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Chapter XXXIX. Tuberculosis of the Patent Urachus

I have been able to find only two cases of this character in the literature. The first case was recorded by Briddon and Eliot, the second by Eastman.

  • Briddon, C. K., and Eliot, E.: Med. and Surg. Reports, Presbyterian Hospital, New York, January, 1900, iv, 30.

Dr. Thacher, who made the pathologic report on the extirpated urachus in Briddon and Eliot's case, after giving a very careful and guarded description, decided that the condition was probably tuberculous. Dr. Eastman sent us his specimen and we have been able to demonstrate tubercle bacilli in the urachus.

"Tubercular Degeneration of the Patent Urachus in the Adult.* — R. M., aged nineteen, Roumanian; married. Admitted July 17, 1899. No tubercular family or personal history. The patient has always been well until five weeks ago, when she began to have slight pain, with heat, redness', and swelling in the region of the umbilicus, the navel having previously been always normal in appearance. The symptoms increased for two weeks, at the end of which time there was a small red tumor, the size of a pea, in the region of the umbilicus. During this time the patient suffered intensely from severe, sharp pain, almost constantly present, in the hypogastric region, with well-marked vesical tenesmus, increased frequency of micturition (often voiding urine every hour), and occasionally a small amount of blood in the urine. At the end of the two weeks the swelling opened spontaneously, discharging some cloudy fluid with a uriniferous and foul odor, the pain and swelling soon subsiding. About four days after the discharge of fluid at the umbilicus, she ceased to pass water normally, and since then she has had a constant discharge of cloudy fluid of a uriniferous odor, at times slightly blood-stained, through the opening at the umbilicus. She has lost considerable flesh and strength during the period of five weeks.

"Physical Examination. — The patient is markedly anemic and is apathetic. The facies is flushed; the tongue is moist and not heavily coated. The superficial glands are not enlarged. In the heart there is a hemic murmur over the pulmonic area, systolic in time. Percussion of the lungs is normal, but the breathing is rather poor. The abdomen is soft, retracted, and no masses can be felt. At the inferior portion of the umbilicus is a small sinus with everted and ulcerated edges, which discharges a seropurulent fluid of uriniferous odor. A probe introduced into the sinus goes downward and extends evidently as far as the bladder. The bladder does not percuss high, but there is some tenderness on pressure over the suprapubic region. Urine analysis at the time of admission showed very turbid and cloudy urine, with specific gravity of 1014, 15 per cent of sediment, reaction strongly alkaline, and odor foul and ammoniacal. There was 10 per cent of albumin, no blood, a large amount of mucus, much pus, and many vesical cells, with many crystals of triple phosphate. No casts were found. She was placed upon bladder irrigations twice daily, with warm 0.5 per cent, boric-acid solution, and salol (gr. v) three times a day. There was no improvement under this treatment, either in the character of the urine or in the patient's general condition, except that she had slightly less pain. At the end of a week the bladder irrigation was changed to carbolic acid, in strength of 1 : 120. This also seemed to have no effect upon the urine, frequent examinations up to the time of operation giving about the same result. As at the first analysis, the specific gravity never rose above 1014; the urine always remained alkaline and was full of pus and mucus. The temperature course was irregular, varying between 99.5° F. and 102° F., and did not seem to be influenced in any way by the bladder washing. During a period of several days of fairly constant low temperature the patient gave a moderately characteristic tuberculin reaction. The average daily amount of urine voided by the urachus varied from 15 to 20 ounces. At intervals of several days she voided a few drams or an ounce of urine per urethram.


" Owing to the obstinate, unyielding cystitis, it was thought advisable to do a suprapubic cystotomy for purposes of drainage.

" Operation (August 25th) . — Dr. Eliot. Nitrous oxid and ether; asepsis; dorsal position. A catheter was introduced through the urethra into the bladder and urine was withdrawn. Four ounces of warm 1 per cent boric-acid solution were then gently thrown into the bladder by a fountain syringe, six ounces of water, injected into a Barnes dilator, having been previously inserted into the rectum. A 23^-inch median incision was then made above the pubis and deepened down to the space of Retzius. The soft cellular tissue here being pushed aside and the bladder presenting, two silk sutures were passed in a longitudinal fashion through its wall, separated by a distance of one inch, these sutures being placed for purposes of traction. The bladder was then opened between the silk sutures, the boricacid fluid pouring out into the wound. The incision in the bladder-wall being subsequently enlarged upward, disclosed the urachus opening into the fundus of the bladder. There were several small areas of ulceration on the posterior wall of the bladder, and parts of the ulcers, together with a portion of the urachus, were secured for microscopic examination. The ulcerated areas upon the bladder-wall were cauterized with a thermocautery. The lumen of the urachus was packed with a strip of iodoform gauze, the cavity of the bladder being drained through the suprapubic wound in the usual way by means of a tube.

"Report by J. S. Thacher, Pathologist.- — A. Minute fragment of tissue from urachus. Microscopic examination shows a mass of smooth muscle and connective tissue. The muscle-cells vary somewhat in size and shape, and are irregular in arrangement.

"B. Minute fragments from base of bladder. The epithelium is partly destroyed, and the tissues are much inflamed. The inflammation appears to be of some standing.

"The bladder was drained very satisfactorily for ten days by the siphon drainage apparatus, the suprapubic wound remaining comparatively clean and dry. The patient's temperature was increased for six days following the operation. Recovery was uneventful. Bladder irrigation with carbolic acid, 1:40, was employed, when the drainage apparatus was dispensed with, the urine clearing up slightly and the pain becoming much less severe. She seemed to improve in general health to a moderate degree. Urine was not voided normally after the suprapubic operation had been performed.


"September 25th: Urine, for about one week, has had much less pus and mucus in it, and hypogastric pain has been much less severe. It was then decided to attempt an extirpation of the patent urachus, leaving the suprapubic wound unmolested.

"Operation (September 27th). — Dr. Briddon; nitrous oxid and ether; asepsis; dorsal position. A median incision was made from the umbilicus down to the suprapubic wound of the previous operation, exposing the linea alba, which was split up in the line of the incision, exposing granulation tissue forming the wall of the patent urachus. By blunt dissection this tissue was then dissected free from the underlying thickened peritoneum, during which process the urachus was opened longitudinally through a portion of its extent. The walls of the urachus were nearly a quarter of an inch thick, and their diameter was about half an inch. At its point of junction with the bladder it was cut transversely and removed, the general cavity of the peritoneum not being opened. A clean surface was thus left, whose floor was formed by the thickened peritoneum, and its sides by the divided portion of the linea alba. This tract was closed by eight interrupted chromic catgut sutures, passing from one side to the other through the skin and linea alba, thus approximating the raw edges of the tract. A sterile dressing was placed on the sutured wound, a rubber drainage-tube and iodoform gauze being left in the suprapubic wound.

" Report of J. S. Thacher, Pathologist. — Extirpation of patent urachus. Microscopic examination : Granulation tissue ; spots of marked infiltration by leukocytes; several small necrotic spots; many giant-cells; some tissue resembling tubercle tissue — probably tubercular.

" Recovery from the operation was uneventful. The bladder was drained satisfactorily for ten days, the wound for urachus extirpation healing by primary union without complication. Her general health rapidly improved, and she had gradually less hypogastric pain and discomfort. For a few weeks the patient voided no urine normally, all being discharged through the suprapubic wound. Since then she has passed almost every day one or more ounces of urine per urethram, in gradually increasing quantity. Her general condition is very much improved, the suprapubic wound is steadily closing, and urinary analysis now gives but 3 per cent, of albumin, with much less pus and mucus.

"Repeated examination of urine failed to discover any tubercle bacilli, and careful physical examination by G. A. Tuttle failed to detect any evidence of pulmonary or other visceral tuberculosis.

"Examination conducted by Dr. Tuttle, in the pathologic laboratory, of the small ulcers which were excised from the wall of the bladder at the time of the first operation, failed to yield positive indications of tuberculosis; conclusive evidence at last was furnished by the examination by Dr. Thacher of the urachus itself, removed by Dr. Briddon at the time of the second operation. Inferences are always uncertain, and although the statement that the tubercular process originated in the patent remnant of the duct itself is not entirely justifiable, nevertheless, the fact remains that examination of its wall after removal showed much more abundant evidence of tuberculosis than did the portion of the bladder-wall removed earlier by suprapubic cystotomy."

In the case under discussion the removal of the urachus was accomplished without opening the general peritoneal cavity.


I was particularly anxious to see a section from this case, and accordingly wrote Dr. Thacher. In his reply, dated New York, April 8, 1914, he gave me the results of his examination, but said the original slide could not be located.

Tuberculosis of the Urachus.* ■ — Dr. Eastman has just recorded a very interesting case of tuberculosis of the urachus in a girl aged nineteen.

"Family History. — Father died of cancer of the stomach at the age of fifty-one; one brother died during infancy of meningitis; history otherwise negative, particularly as relates to tuberculosis or neoplasms.



Fig. 267. — Tuberculosis of the Urachus.

This is a low-power photomicrograph from Dr. J. R. Eastman's case. At a is an area of caseation surrounded by tissue closely resembling that found in tuberculosis. The outer walls are composed of non-striped muscle and fibrous tissue. Scattered throughout this tissue are localized foci more or less characteristic of those noted in tuberculosis. The areas b and c are very suggestive of tubercles.

The high-power picture of the area b is shown in Fig. 268; that of the area c, in Fig. 269.


"Personal History. — Typhoid at seventeen with good recovery; history otherwise negative; patient married two years and four months; one pregnancy, child living and well; at no time night-sweats or protracted cough; no characteristic temperature history; no other evidences of tuberculosis.

"Menstrual History. — Menstruation began at twelve; regular; duration five days and free; no change in type since marriage or labor.

"Urination. — No increase in frequency, no nocturnal urination. Three diurnal urinations; never any blood or burning or stinging.

"History of illness for which patient entered hospital. — This trouble began ten months before entrance. While working in the garden, pain was felt at a point in the mid-line of the abdomen between the symphysis pubis and the umbilicus. At this time patient noticed a lump at the point designated, the size of a small apple. There was not much actual pain nor soreness. The mass did not increase in size but the tenderness remained. This condition persisted for three months when a pin-point opening appeared in the mid-line of the anterior abdominal wall, half-way between the symphysis pubis and the umbilicus. This opening discharged a clear watery fluid for about a week. Then a serous crust closed the opening. The opening again discharged after about a week, continuing to do so for one week and again the crust was formed. This process of closing and opening continued for several months. The size of the tumor did not change. The tenderness still persisted. There had never been any disturbance of the bladder, intestines or uterus.

Eastman, Joseph Rilus: Amer. Jour, of Obstetrics, 1915, lxxii, 640.




Fig. 268. — An Area Suggesting a Tubercle. This picture is a high-power magnification of the area b in Fig. 267. Its confines are indicated by x and x. Scattered throughout this area are spindle cells and round cells. At a and b are giant-cells. At c the cells are so arranged as to suggest a small gland. At d is a large cell bearing a strong resemblance to a squamous cell.


The discharge had always been free from odor. She is positive that the discharge never had a urinous odor.

"Status Prsesens. — The patient's general health was unimpaired. Urinalysis and physical examination of the chest and abdomen were negative. There were no evidences of pulmonary tuberculosis nor of tuberculosis elsewhere. Through the discharging sinus below the umbilicus a small sound could be passed downward behind the symphysis pubis.


"Operation. — The fistulous tract, upon being dissected free, was found to pass downward from the discharging orifice, coursing in front of the peritoneum, crossing the space of Retzius and terminating in a thin cord attached to the anterior bladder wall in the median line and near to the vesico-urethral junction. Upon being split open the definite tube-like structure was found to be thin-walled, showing no evidence of inflammation or other pathological condition except near the external discharging orifice, where an ulcerated mass about 2 cm. in width was situate upon the dorsal wall of the tube.


"Cystoscopic Examination. — Bladder distended with 8 ounces of water for examination: vesical sphincter normal in outline; trigone normal; both ureteral openings and the mucosa surrounding them were normal as to contractility and rhythm. There were no ulcers, tubercles, or any other abnormalities upon the floor of the bladder. The vesical roof was examined carefully and this portion of the bladder was found to be absolutely devoid of any ulcer, tubercles, opening, or any other abnormality of the vesical mucous membrane; and there was not the slightest hint of any communication with the patent urachus.


  • Chemical and Microscopic Urinalysis. — After operation as before the urine was normal.

• Clinical Course since Operation. — "Wound closed slowly; there have been no symptoms of any kind relating to the genitourinary organs; there is no evidence of return of the disease."






Fig. 269. — A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus. This a high-power picture made by Mr. H. Schapiro from Fig. 267 at c.

The tubercle is oval in form and is fairly well differentiated from the surrounding stroma. The cells of the tubercle are spindle-shaped, oval, round, or irregular. In the lower part of the tubercle is a large giant cell containing a large number of nuclei arranged chiefly in its center. The grouping of the nuclei in this giant cell resembles to some extent that usually found in foreign-body giant cells, but the picture as a whole is strongly suggestive of tuberculosis.


I wrote Dr. Eastman asking if he could send me sections of the urachus. This he promptly did. An examination of them shows the following:


The central portion of the specimen consists of granular tissue containing a few cells. It looks very much like caseous tissue (Fig. 267a). External to this is a tissue made up of young connective-tissue cells and fairly large round cells with small round nuclei, and beneath this a zone containing a few giant cells. The outer wall apparently consists of non-striped muscle and connective tissue infiltrated with small round cells. In this are round or oval areas containing aggregations of epithelioid cells with giant cells scattered here and there throughout them [Figs. 208 and 269;. External to this zone is the surrounding adipose tissue. The entire picture strongly indicates tuberculosis of the urachus.


Dr. Benjamin O. McCleary and Dr. George L. Stickney have each independently demonstrated tubercle bacilli in the sections; consequently this is a definite of tuberculosis of the urachus.


Umbilicus (1916): 1 Umbilical Region Embryology | 2 Umbilical Region Anatomy | 3 Umbilical New-born Infections | 4 Umbilical Hemorrhage | 5 Umbilicus Granuloma | 6 Omphalomesenteric Duct Remnants | 7 Umbilicus Abnormalities | 8 Meckel's Diverticulum | 9 Intestinal Cysts | 10 Patent Omphalomesenteric Duct 1 | 11 Patent Omphalomesenteric Duct 2 | 12 Bowel Prolapsus at Patent Omphalomesenteric Duct | 13 Abdominal Wall Cysts by Omphalomesenteric Duct Remnants | 14 Omphalomesenteric Vessels Persistence | 15 Umbilical Inflammatory Changes | 16 Subumbilical Space Abscess | 17 Umbilicus Paget's Disease | 18 Umbilicus Infections | 19 Umbilicus Abnormalities 2 | 20 Umbilicus Fecal Fistula | 21 Umbilicus Round Worms | 22 Umbilicus Foreign Substance Escape | 23 Umbilical Tumors | 24 Umbilicus Adenomyoma | 25 Umbilicus Carcinoma | 26 Umbilicus Sarcoma | 27 Umbilical Hernia | 28 The Urachus | 29 Congenital Patent Urachus | 30 Urachus Remnants | 31 Urachal Remnants Producing Tumors | 32 Large Urachal Cysts | 33 Anterior Abdominal Wall Abscesses | 34 Urachal Cavities | 35 Umbilicus Acquired Urinary Fistula | 36 Urachal Concretions and Urinary Calculi | 37 Urachus Malignant Changes | 38 Urachus Bleeding into the Bladder | 39 Patent Urachus Tuberculosis | Figures

Reference

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

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

Cite this page: Hill, M.A. (2019, October 18) Embryology Book - Umbilicus (1916) 39. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_Umbilicus_(1916)_39

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