PERSISTENCE OF THE URACHUS. 509 



Finally, in other cases the urachus simply persists while no lesion 

 exists on the side of the urethra. 



Whatever the original cause, escape of urine by the umbilicus pro- 

 duces irritation, which may end in complications, infection of the 

 unhealed umbilical wound, infection of the canal of the urachus itself 

 and the bladder, or even infection of the peritoneum. 



Symptoms. At first, persistence of the urachus is shown by per- 

 manent or intermittent discharge of urine through the umbilicus. 

 Usually this discharge is only seen from five to eight days after 

 birth, when the necrosed cord is detached ; in most cases it is con- 

 tinuous, for the opening is abnormal and has no sphincter. 



Contact with the air and the wound causes the urine to undergo 

 a kind of ammoniacal fermentation and to irritate neighbouring tissues, 

 such as the stumps of the umbilical vessels, the interstitial connective 

 tissue, and even the skin. The wound constitutes an excellent culture 

 medium for microbes. The umbilicus becomes swollen and cedematous, 

 and soon exhibits a saccular swelling, 2 to 4 inches in diameter, which, 

 on palpation, proves to be hot and painful ; its centre is occupied 

 by the opening of the urinary fistula. A probe passed into this 

 fistula travels upwards and backwards (see Fig. 183). 



At a later stage other complications, including omphalitis and 

 omphalo-phlebitis, may set in. The most frequent of the delayed com- 

 plications is purulent cystitis, with the formation of purulent concre- 

 tions in the bladder, which may occur even after the fistula of the 

 urachus has healed. In other cases the canal of the urachus con- 

 tracts and becomes obliterated towards the bladder. A blind fistula 

 then persists, with an opening at the umbilicus, or, the parts having 

 healed externally, all that remains is a phlegmonous swelling with 

 the characteristic symptoms. 



Diagnosis. A thorough examination will invariably allow of urinary 

 fistula being distinguished from other diseases of the umbilicus, the 

 escape of urine at this point being so suggestive. 



Prognosis. The prognosis is rather grave, on account of the com- 

 plications, which are possible, and, in fact, usual, unless the disease 

 is promptly diagnosed. 



Treatment. Formerly as a preventive measure a ligature was ap- 

 plied to the whole mass of the cord at birth, but this ligature in no 

 way prevents the canal of the urachus persisting after the atrophied 

 portion separates. Cauterisation of the urinary fistula with Eabel's 

 fluid or tincture of iodine can have no good result, unless the 

 urethra is permeable. 



If the urethra is obstructed it is evidently from that side that treat- 

 ment should be attempted, either by displacing the muco-albuminous 



