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| | [[File:Mark_Hill.jpg|90px|left]] This historic 1916 textbook by Cullen describes the umbilical region. | | | [[File:Mark_Hill.jpg|90px|left]] This historic 1916 textbook by Cullen describes the umbilical region. |
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| | '''Links:''' [[Media:Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus (1916).pdf|PDF version]] | [https://archive.org/details/embryologyanatom00cull/page/n5 Internet Archive] |
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| {{Historic Disclaimer}} | | {{Historic Disclaimer}} |
| =Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus= | | =Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus= |
| | | [[File:Cullen1916 titlepage.jpg|thumb|300px]] |
| By | | By |
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| ==Contents== | | ==Contents== |
| {{Cullen1916 TOC}} | | {{Cullen1916 TOC}} |
| | | <br><br> |
| # [[Book - Umbilicus (1916) 1|Embryology of the Umbilical Region]] | | # [[Book - Umbilicus (1916) 1|Embryology of the Umbilical Region]] |
| # [[Book - Umbilicus (1916) 2|Anatomy of the Umbilical Region]] | | # [[Book - Umbilicus (1916) 2|Anatomy of the Umbilical Region]] |
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| ==List of Illustrations== | | ==List of Illustrations== |
| 1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois 2
| | [[Book - Umbilicus (1916) Figures|Figures]] |
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| 2. A More Advanced Stage in the Formation of the Umbilical Region 2
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| 3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo 3
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| 4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Show
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| ing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk ... 4
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| 5. Sagittal View of a Human Embryo 5 mm. in Length 5
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| 6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing
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| the Umbilical Region 6
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| 7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length 7
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| 8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length 8
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| 9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in
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| Length 9
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| 10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length 10
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| 11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length .. 11
| | 1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois |
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| 12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm.
| | 2. A More Advanced Stage in the Formation of the Umbilical Region |
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| Long 12
| | 3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo |
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| 13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length .. 13
| | 4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Showing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk |
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| 14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm.
| | 5. Sagittal View of a Human Embryo 5 mm. in Length |
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| in Length as Viewed from within the Abdomen 14
| | 6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing the Umbilical Region |
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| 15. Sagittal View of a Graphic Reconstruction of the Umbilical Region of a Human
| | 7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length |
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| Embryo 5.2 cm. in Length 15 | | 8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length |
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| 16. Intra-abdominal View of the Umbilical Region of a Human Embryo 6.5 cm. in
| | 9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in Length |
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| Length 17 | | 10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length |
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| 17. Intra-abdominal View of the Umbilical Region in a Human Embryo 7.5 cm. Long . . 18
| | 11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length |
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| 18. Intra-abdominal View of the Umbilical Region in a Human Embryo 9 cm. in
| | 12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm. Long |
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| Length 18 | | 13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length |
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| 19. Intra-abdominal View of the Umbilical Region in a Human Embryo 10 cm. in
| | 14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm in Length as Viewed from within the Abdomen |
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| Length 19 | | 15. Sagittal View of a Graphic Reconstruction of the Umbilical Region of a Human Embryo 5.2 cm. in Length 15 |
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| 20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long . . 19
| | 16. Intra-abdominal View of the Umbilical Region of a Human Embryo 6.5 cm. in Length |
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| 21. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in
| | 17. Intra-abdominal View of the Umbilical Region in a Human Embryo 7.5 cm. Long |
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| Length 20 | | 18. Intra-abdominal View of the Umbilical Region in a Human Embryo 9 cm. in Length |
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| 22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in
| | 19. Intra-abdominal View of the Umbilical Region in a Human Embryo 10 cm. in Length |
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| Length 21
| | 20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long |
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| 23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm.
| | 21. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in Length |
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| in Length 22 | | 22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in Length |
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| 24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long 23
| | 23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm. in Length |
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| 25. A Composite Representation of Abnormal Umbilical Structures, Based on the
| | 24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long |
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| Work of Keibel, Lowy, and Others 24 | | 25. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others |
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| 26. A Composite Representation of Abnormal Umbilical Structures, Based on the | | 26. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others |
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| Work of Keibel, Lowy, and Others 24 | | 27. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others |
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| 27. A Composite Representation of Abnormal Umbilical Structures, Based on the
| | 28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left |
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| Work of Keibel, Lowy, and Others 24
| | 29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven Months |
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| 28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left . . 25
| | 30. Three Diagrams of the Umbilical Ring and Its Significance in the Development of Ventral Hernia |
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| 29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven
| | 31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the Embryo 5.5 cm. Long |
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| Months 25
| | 32. The Umbilical Region, the Cord, and the Placenta at Term |
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| 30. Three Diagrams of the Umbilical Ring and Its Significance in the Development
| | 33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term |
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| of Ventral Hernia 27
| | 34. Normal Umbilicus according to Catteau |
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| XV
| | 35. A Type of Umbilical Region in the Adult, Viewed from Within |
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| | 36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within |
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| | 37. The Umbilical Region of an Adult, Viewed from Within |
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| XVI LIST OF ILLUSTRATIONS
| | 38. Classic Type of Umbilicus |
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| Fig. Page
| | 39. Disposition of the Vascular Cords (Usual Type) |
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| 31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the
| | 40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases |
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| Embryo 5.5 cm. Long 28
| | 41. Vascular Cord Type, Noted 5 Times in 50 Cases |
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| 32. The Umbilical Region, the Cord, and the Placenta at Term 29
| | 42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical Ring |
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| 33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term .... 32
| | 43. Vascular Cords, Noted 3 Times in 50 Cases |
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| 34. Normal Umbilicus according to Catteau 35
| | 44. Vascular Cords, Noted in 2 out of 50 Cases |
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| 35. A Type of Umbilical Region in the Adult, Viewed from Within 44
| | 45. Umbilical Fascia. Peritoneum in Place |
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| 36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within .... 44
| | 46. Umbilical Fascia and Umbilical Mesentery |
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| 37. The Umbilical Region of an Adult, Viewed from Within 45
| | 47. Reduplication of the Linea Alba. Peritoneum Removed |
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| 38. Classic Type of Umbilicus 47
| | 48. Atrophy of the Umbilical Fascia, Posterior View |
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| 39. Disposition of the Vascular Cords (Usual Type) 48
| | 49. Formation of a Mesentery. Peritoneum in Place |
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| 40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases 48
| | 50. Mesentery of the Urachus and of the Umbilical Arteries |
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| 41. Vascular Cord Type, Noted 5 Times in 50 Cases 49
| | 51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place |
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| 42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical
| | 52. Adipose Fringes in a Stout Subject. Peritoneum in Place |
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| Ring 49
| | 53. Peritoneal Diverticula. Peritoneum in Place |
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| 43. Vascular Cords, Noted 3 Times in 50 Cases 49
| | 54. Peri-umbilical Fossettes. Peritoneum in Place |
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| 44. Vascular Cords, Noted in 2 out of 50 Cases 50
| | 55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Abdominal Wall |
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| 45. Umbilical Fascia. Peritoneum in Place 52
| | 56. Extra-abdominal Multilocular Fibrocystoma of the Ovary |
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| 46. Umbilical Fascia and Umbilical Mesentery 52
| | 57. An Extra- abdominal Multilocular Fibrocystoma |
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| 47. Reduplication of the Linea Alba. Peritoneum Removed 52
| | 58. Superficial Lymphatics of the Umbilical Region |
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| 48. Atrophy of the Umbilical Fascia, Posterior View 53
| | 59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side |
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| 49. Formation of a Mesentery. Peritoneum in Place 53
| | 60. The Umbilical Vessels about the Time of Birth |
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| 50. Mesentery of the Urachus and of the Umbilical Arteries 53
| | 61. The Umbilical Vessels in the Adult |
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| 51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place 54
| | 62. 63. Method of Treating the Umbilical Stump at Birth |
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| 52. Adipose Fringes in a Stout Subject. Peritoneum in Place 54
| | 64. Nature's Method of Checking Bleeding from the Umbilical Arteries |
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| 53. Peritoneal Diverticula. Peritoneum in Place 55
| | 65. An Umbilical Granulation |
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| 54. Peri-umbilical Fossettes. Peritoneum in Place 55
| | 66. The Gradual Atrophy of the Omphalomesenteric Duct |
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| 55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Ab
| | 67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord |
| dominal Wall 57
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| 56. Extra-abdominal Multilocular Fibrocystoma of the Ovary 5S
| | 68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord |
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| 57. An Extra- abdominal Multilocular Fibrocystoma 59
| | 69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia |
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| 58. Superficial Lymphatics of the Umbilical Region 64
| | 70. A Polypoid Outgrowth from the Umbilicus |
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| 59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side 65
| | 71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70 |
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| 60. The Umbilical Vessels about the Time of Birth 72
| | 72. A Diverticular Tumor at the Umbilicus |
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| 61. The Umbilical Vessels in the Adult 72
| | 73. A Glandular Tumor from the Umbilicus |
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| 62. 63. Method of Treating the Umbilical Stump at Birth 98
| | 74. A Glandular Growth at the Umbilicus |
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| 64. Nature's Method of Checking Bleeding from the Umbilical Arteries 107
| | 75. Section in the Long Axis of a Small Umbilical Growth |
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| 65. An Umbilical Granulation 117
| | 76. Adenoma of the Umbilicus |
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| 66. The Gradual Atrophy of the Omphalomesenteric Duct 121
| | 77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord |
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| 67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord . . 121
| | 78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord |
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| 68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord 121
| | 79. An Umbilical Polyp |
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| 69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia : . . 123
| | 80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression |
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| 70. A Polypoid Outgrowth from the Umbilicus 129
| | 81. An Umbilical Polyp |
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| 71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70 129
| | 82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression |
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| 72. A Diverticular Tumor at the Umbilicus 132
| | 83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus |
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| 73. A Glandular Tumor from the Umbilicus 132
| | 84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Resembling those of the Pylorus |
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| 74. A Glandular Growth at the Umbilicus 133
| | 85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach |
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| 75. Section in the Long Axis of a Small Umbilical Growth 134
| | 86. Appearance of the Umbilical Depression in von Rosthorn's Case |
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| 76. Adenoma of the Umbilicus 135
| | 87. Gastric Mucosa at the Umbilicus |
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| 77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord. 138
| | 88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in Fig. 87 |
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| 78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord . . . 138
| | 89. Persistence of the Outer End of the Omphalomesenteric Duct |
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| 79. An Umbilical Polyp 139
| | 90. Atrophy of the Inner End of the Omphalomesenteric Duct |
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| 80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression 139
| | 91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct |
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| 81. An Umbilical Polyp 140
| | 92. Meckel's Diverticulum |
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| 82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression .... 141
| | 93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus |
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| 83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus . . . . 149
| | 94. An Abnormally Large Meckel's Diverticulum |
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| | 95. A Meckel's Diverticulum with a Lobulated Extremity |
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| | 96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface |
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| LIST OF ILLUSTRATIONS XV11
| | 97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment |
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| Fia. Fage
| | 98. An Accessory Pancreas in the Tip of Meckel's Diverticulum |
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| 84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Re
| | 99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel |
| sembling those of the Pylorus 150
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| 85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach 150
| | 100. A Diverticulum Tying Off a Loop of Small Bowel |
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| 86. Appearance of the Umbilical Depression in von Rosthorn's Case 152
| | 101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum |
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| 87. Gastric Mucosa at the Umbilicus 153
| | 102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a Hole in the Mesentery of a Meckel's Diverticulum |
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| 88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in
| | 103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel |
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| Fig. 87 154
| | 104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary |
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| 89. Persistence of the Outer End of the Omphalomesenteric Duct 156
| | 105. An Intestinal Cyst |
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| 90. Atrophy of the Inner End of the Omphalomesenteric Duct 156
| | 106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected with the Bowel |
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| 91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct 156
| | 107. Volvulus of Meckel's Diverticulum |
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| 92. Meckel's Diverticulum 159
| | 108. An Intestinal Cyst Developing from Meckel's Diverticulum |
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| 93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus. . 160
| | 109. Intestinal Cysts in the Abdominal Cavity |
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| 94. An Abnormally Large Meckel's Diverticulum 161
| | 1 10. An Intramesenteric Cyst |
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| 95. A Meckel's Diverticulum with a Lobulated Extremity 161
| | 111. A Patent Omphalomesenteric Duct |
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| 96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface 162
| | 112. A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus |
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| 97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment . . 163
| | 113. A Very Short Omphalomesenteric Duct |
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| 98. An Accessory Pancreas in the Tip of Meckel's Diverticulum 163
| | 114. A Patent Omphalomesenteric Duct with a Polyp-like Formation at the Umbilicus |
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| 99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel 164
| | 1 15. A Patent Omphalomesenteric Duct |
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| 100. A Diverticulum Tying Off a Loop of Small Bowel 165
| | 116. A Patent Omphalomesenteric Duct |
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| 101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum. . . . 166
| | 117. A Patent Omphalomesenteric Duct |
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| 102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a
| | 118. A Patent Omphalomesenteric Duct |
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| Hole in the Mesentery of a Meckel's Diverticulum .170
| | 119. A Patent Omphalomesenteric Duct |
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| 103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel 171
| | 120. A Patent Omphalomesenteric Duct |
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| 104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary 175
| | 121. A Patent Omphalomesenteric Duct |
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| 105. An Intestinal Cyst 176
| | 122. Part of a Patent Omphalomesenteric Duct |
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| 106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected
| | 123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Omphalomesenteric Duct |
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| with the Bowel 176
| | 124. An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Originally a Patent Omphalomesenteric Duct |
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| 107. Volvulus of Meckel's Diverticulum 177
| | 125. Longitudinal Section through the Entire Center of a Partially Closed Omphalomesenteric Duct |
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| 108. An Intestinal Cyst Developing from Meckel's Diverticulum 178
| | 126. A Patent Omphalomesenteric Duct |
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| 109. Intestinal Cysts in the Abdominal Cavity 182
| | 127. A Patent Omphalomesenteric Duct Opening at the Base of the Umbilical Cord |
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| 1 10. An Intramesenteric Cyst 183
| | 128. A Patent Omphalomesenteric Duct |
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| 111. A Patent Omphalomesenteric Duct 190
| | 129. A Patent Omphalomesenteric Duct as Seen from the Abdominal Cavity |
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| 112. A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus . 190
| | 130. Inversion of the Bowel through a Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord |
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| 113. A Very Short Omphalomesenteric Duct 190
| | 131. A Patent Omphalomesenteric Duct of Large Diameter |
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| 114. A Patent Omphalomesenteric Duct with a Polyp- like Formation at the Umbil
| | 132. Commencing Prolapsus of Small Bowel through a Patent Omphalomesenteric Duct |
| icus 190
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| 1 15. A Patent Omphalomesenteric Duct 192
| | 133. Partial Prolapsus of the Small Bowel through the Omphalomesenteric Duct |
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|
| 116. A Patent Omphalomesenteric Duct 193
| | 134. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct |
|
| |
|
| 1 17. A Patent Omphalomesenteric Duct 197
| | 135. Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct |
|
| |
|
| 118. A Patent Omphalomesenteric Duct 197
| | 136. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and an Umbilical Hernia between the Loops of Prolapsed Bowel |
|
| |
|
| 119. A Patent Omphalomesenteric Duct 202
| | 137. Prolapse of the Small Bowel through an Open Omphalomesenteric Duct |
|
| |
|
| 120. A Patent Omphalomesenteric Duct 205
| | 138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct |
|
| |
|
| 121. A Patent Omphalomesenteric Duct 206
| | 139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Secondary Complications |
|
| |
|
| 122. Part of a Patent Omphalomesenteric Duct 206
| | 140. Prolapsus and Inversion of the Intestine through a Patent Omphalomesenteric Duct |
|
| |
|
| 123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Om
| | 141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct |
| phalomesenteric Duct 207
| |
|
| |
|
| 124. An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Origin
| | 142. A Small Cyst of the Umbilicus Due to a Remnant of the Omphalomesenteric Duct |
| ally a Patent Omphalomesenteric Duct 209
| |
|
| |
|
| 125. Longitudinal Section through the Entire Center of a Partially Closed Om
| | 143. Small Cyst of the Abdominal Wall Due to a Remnant of the Omphalomesenteric Duct |
| phalomesenteric Duct 209
| |
|
| |
|
| 126. A Patent Omphalomesenteric Duct 211
| | 144. A Small Intestinal Cyst Lying between the Peritoneum and the Recti |
|
| |
|
| 127. A Patent Omphalomesenteric Duct Opening at the Base of the Umbilical Cord . . 216
| | 145. An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord |
|
| |
|
| 128. A Patent Omphalomesenteric Duct 216
| | 146. A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction |
|
| |
|
| 129. A Patent Omphalomesenteric Duct as Seen from the Abdominal Cavity 216
| | 147. A Small Umbilical Concretion |
|
| |
|
| 130. Inversion of the Bowel through a Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord 219
| | 148. Acute Inflammation of the Umbilicus Due to an Accumulation of Sebaceous Material |
|
| |
|
| 131. A Patent Omphalomesenteric Duct of Large Diameter 224
| | 149. Cholesteatoma from the Umbilicus in Case 1 |
|
| |
|
| 132. Commencing Prolapsus of Small Bowel through a Patent Omphalomesenteric Duct 224
| | 150. Cholesteatoma from Case 2 |
|
| |
|
| 133. Partial Prolapsus of the Small Bowel through the Omphalomesenteric Duct . . . 224
| | 151. A Connective-tissue Projection Really Representing a Small Fibroma in the Floor of the Umbilicus |
|
| |
|
| 134. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct .... 224
| | 152. Enlargement of Fig. 151 |
|
| |
|
| 135. Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 225
| | 153. Subumbilical Phlegmon |
|
| |
|
| 136. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and an Umbilical Hernia between the Loops of Prolapsed Bowel 225
| | 154. The Subumbilical Space |
|
| |
|
| 137. Prolapse of the Small Bowel through an Open Omphalomesenteric Duct 227
| | 155. Paget's Disease of the Umbilicus |
|
| |
|
| 138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct 228
| | 156. Paget's Disease of the U/mbilicus |
|
| |
|
| 139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Sec
| | 157. Paget's Disease of the Umbilicus |
| ondary Complications 229
| |
|
| |
|
| 140. Prolapsus and Inversion of the Intestine through a Patent Omphalomesenteric Duct 230
| | 158. Paget's Disease of the Umbilicus |
|
| |
|
| 141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 232
| | 159. The Appearance in a Case of Paget's Disease of the Umbilicus After Treatment with Radium |
|
| |
|
| 142. A Small Cyst of the Umbilicus Due to a Remnant of the Omphalomesenteric Duct 238
| | 160. Syphilis of the Umbilicus |
|
| |
|
| 143. Small Cyst of the Abdominal Wall Due to a Remnant of the Omphalomesenteric Duct 238
| | 161. Atrophic Tuberculid Starting at the Umbilicus |
|
| |
|
| 144. A Small Intestinal Cyst Lying between the Peritoneum and the Recti 240
| | 162. Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket |
|
| |
|
| 145. An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord 243
| | 163. The Manner in Which a Periprostatic Abscess may Occasionally Rupture at the Umbilicus |
|
| |
|
| 146. A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction 245
| | 164. Escape of Pleural Fluid from the Umbilicus |
|
| |
|
| 147. A Small Umbilical Concretion 249
| | 165. The Opening of a Broad Ligament Abscess at the Umbilicus |
|
| |
|
| 148. Acute Inflammation of the Umbilicus Due to an Accumulation of Sebaceous Material 249
| | 166. Abdominal Pregnancy with Spontaneous Escape of Liquor Amnii from the Umbilicus |
|
| |
|
| 149. Cholesteatoma from the Umbilicus in Case 1 251
| | 167. Small Papilloma in the Umbilical Depression |
|
| |
|
| 150. Cholesteatoma from Case 2 251
| | 168. A Shall Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine Mucosa |
|
| |
|
| 151. A Connective-tissue Projection Really Representing a Small Fibroma in the Floor of the Umbilicus 252
| | 169. Glands from a Small Umbilical Tumor |
|
| |
|
| 152. Enlargement of Fig. 151 252
| | 170. Typical Uterine Mucosa in a Small Umbilical Tumor. An Enlargement of Area B in Fig. 168 |
|
| |
|
| 153. Subumbilical Phlegmon 262
| | 171. Glands in a Small Umbilical Tumor |
|
| |
|
| 154. The Subumbilical Space 264
| | 172. Dilated Glands in a Small Umbilical Tumor |
|
| |
|
| 155. Paget's Disease of the Umbilicus 270
| | 173. Dichotomous Branching of Glands in a Small Umbilical Tumor |
|
| |
|
| 156. Paget's Disease of the U/mbilicus 270
| | 174. Uterine Glands in an Umbilical Tumor |
|
| |
|
| 157. Paget's Disease of the Umbilicus 271
| | 175. Gland Hypertrophy in a Small Umbilical Tumor |
|
| |
|
| 158. Paget's Disease of the Umbilicus 274
| | 176. A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands |
|
| |
|
| 159. The Appearance in a Case of Paget's Disease of the Umbilicus After Treatment with Radium 275
| | 177. Uterine Mucosa in an Umbilical Tumor |
|
| |
|
| 160. Syphilis of the Umbilicus 284
| | 178. A Small Umbilical Tumor Containing Numerous Glands |
|
| |
|
| 161. Atrophic Tuberculid Starting at the Umbilicus 286
| | 179. Glands in a Small Umbilical Tumor |
|
| |
|
| 162. Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket 288
| | 180. An Adenomyoma in the Abdominal Wall Near the Anterior Iliac Spine |
|
| |
|
| 163. The Manner in Which a Periprostatic Abscess may Occasionally Rupture at the Umbilicus 289
| | 181. A Small Umbilical Tumor Containing Glands Similar to Those of the Body of the Uterus |
|
| |
|
| 164. Escape of Pleural Fluid from the Umbilicus 289
| | 182. Adenomyoma of the Umbilicus |
|
| |
|
| 165. The Opening of a Broad Ligament Abscess at the Umbilicus 290
| | 183. A Group of Sweat-glands in an Umbilical Tumor |
|
| |
|
| 166. Abdominal Pregnancy with Spontaneous Escape of Liquor Amnii from the Umbilicus 348
| | 184. Appearance of the Carcinomatous Umbilicus After Removal |
|
| |
|
| 167. Small Papilloma in the Umbilical Depression 365
| | 185. Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries |
|
| |
|
| 168. A Shall Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine Mucosa 376
| | 186. A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth |
|
| |
|
| 169. Glands from a Small U\iisiLirALTuMOR 377
| | 187. Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth |
|
| |
|
| 170. Typical Uterine Mucosa in a Small Umbilical Tumor. An Enlargement of Area B in Fig. 168 378
| | 188. Adenocarcinoma of the Umbilicus |
|
| |
|
| 171. Glands in a Small Umbilical Tumor 379
| | 189. A Section Showing Carcinoma of the Right Inguinal Glands |
|
| |
|
| 172. Dilated Glands in a Small Umbilical Tumor 380
| | 190. Secondary Carcinoma of the Umbilicus |
|
| |
|
| 173. Dichotomous Branching of Glands in a Small Umbilical Tumor 381
| | 191. Telangiectatic Myxosarcoma of the Umbilicus |
|
| |
|
| 174. Uterine Glands in an Umbilical Tumor 381
| | 192. Appearance of the Umbilicus After Removal of the Tumor Shown in Fig. 191 |
|
| |
|
| 175. Gland Hypertrophy in a Small Umbilical Tumor 382
| | 193. Myxosarcoma of the Umbilicus |
|
| |
|
| 176. A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands 383
| | 194. Telangiectatic Myxosarcoma Projecting from the Right Side of the Umbilicus |
|
| |
|
| 177. Uterine Mucosa in an Umbilical Tumor 384
| | 195. A Telangiectatic Myxosarcoma |
|
| |
|
| 178. A Small Umbilical Tumor Containing Numerous Glands 388
| | 196. A Case of Congenital Umbilical Hernia |
|
| |
|
| 179. Glands in a Small Umbilical Tumor 389
| | 197. An Amniotic Hernia |
|
| |
|
| 180. An Adenomyoma in the Abdominal Wall Near the Anterior Iliac Spine 394
| | 198. Several Loops of Bowel Which Lay Outside the Umbilicus and were Nipped Off During Fetal Life. The Child Lived a Short Time After Birth |
|
| |
|
| 181. A Small Umbilical Tumor Containing Glands Similar to Those of the Body of the Uterus 396
| | 199. A Serous Umbilical Hernia |
|
| |
|
| 182. Adenomyoma of the Umbilicus 397
| | 200. Freeing the Umbilical Hernial Sac from the Abdomen |
|
| |
|
| 183. A Group of Sweat-glands in an Umbilical Tumor 398
| | 201. Closure of the Hernial Opening at the Umbilicus |
|
| |
|
| 184. Appearance of the Carcinomatous Umbilicus After Removal 424
| | 202. Closure of the Hernial Opening at the Umbilicus |
|
| |
|
| 185. Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries 432
| | 203. An Umbilical Hernia Associated with Marked Prolapsus of the Abdominal Wall |
|
| |
|
| 186. A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth 439
| | 204. An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds |
|
| |
|
| 187. Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth .... 440
| | 205. The Abdominal Scar After the Removal of a Very Large Area of Fat |
|
| |
|
| 188. Adenocarcinoma of the Umbilicus 441
| | 206. An Umbilical Cyst |
|
| |
|
| 189. A Section Showing Carcinoma of the Right Inguinal Glands 442
| | 207. Exstrophy of the Bladder Opening at or Near the Umbilicus |
|
| |
|
| 190. Secondary Carcinoma of the Umbilicus 443
| | 208. Exstrophy of the Bladder. A side View of the Case Depicted in Fig. 207, Showing the Relative Distance from the Symphysis to the Opening in the Abdominal Wall |
|
| |
|
| 191. Telangiectatic Myxosarcoma of the Umbilicus 450
| | 209. Exstrophy of the Bladder |
|
| |
|
| 192. Appearance of the Umbilicus After Removal of the Tumor Shown in Fig. 191. . 450
| | 210. Escape of Urine from the Umbilicus When the Inner Urethral Orifice Is Blocked by a Membrane |
|
| |
|
| 193. Myxosarcoma of the Umbilicus 451
| | 211. A Patent Urachus with a Mushroom-like Projection at the Umbilicus |
|
| |
|
| 194. Telangiectatic Myxosarcoma Projecting from the Right Side of the Umbilicus . . 452
| | 212. A Patent Urachus with a Penile Projection at the Umbilicus |
|
| |
|
| 195. A Telangiectatic Myxosarcoma 452
| | 213. The Appearance of the Umbilicus in a Case in Which both a Patent Omphalomesenteric Duct and a Patent Urachus Existed |
|
| |
|
| 196. A Case of Congenital Umbilical Hernia 460
| | 214. Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same Child |
|
| |
|
| 197. An Amniotic Hernia 462
| | 215. A Picture of the Child Three Weeks After Removal of a Patent Omphalomesenteric Duct and a Patulous Urachus |
|
| |
|
| 198. Several Loops of Bowel Which Lay Outside the Umbilicus and were Nipped Off During Fetal Life. The Child Lived a Short Time After Birth 464
| | 216. A Patent Urachus |
|
| |
|
| 199. A Serous Umbilical Hernia 469
| | 217. A Urachus Open from Bladder to Umbilicus |
|
| |
|
| 200. Freeing the Umbilical Hernial Sac from the Abdomen 472
| | 218. An Open Urachus |
|
| |
|
| 201. Closure of the Hernial Opening at the Umbilicus 473
| | 219. Escape of Urine from the Umbilicus Due to a Patent Urachus |
|
| |
|
| 202. Closure of the Hernial Opening at the Umbilicus 474
| | 220. A Patent Urachus with a Penile Projection at the Umbilicus |
|
| |
|
| 203. An Umbilical Hernia Associated with Marked Prolapsus of the Abdominal Wall 475
| | 221. A Ring-shaped Vesical Calculus with a Fine Hair in Its Axis |
|
| |
|
| 204. An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds 476
| | 222. A Partially Patent Urachus |
|
| |
|
| 205. The Abdominal Scar After the Removal of a Very Large Area of Fat 477
| | 223. A Patent Urachus |
|
| |
|
| 206. An Umbilical Cyst 478
| | 224. A Portion of a Urachus Seven Times Enlarged, with Numerous Large and Small Dilatations |
|
| |
|
| 207. Exstrophy of the Bladder Opening at or Near the Umbilicus 482
| | 225. Portion of a Urachus Ten Times Enlarged |
|
| |
|
| 208. Exstrophy of the Bladder. A side View of the Case Depicted in Fig. 207, Showing the Relative Distance from the Symphysis to the Opening in the Abdominal Wall : 483
| | 226. Cysts of the Urachus Arranged Like a String of Pearls |
|
| |
|
| 209. Exstrophy of the Bladder 483
| | 227. Spindle-Shaped Dilatations of the Urachus |
|
| |
|
| 210. Escape of Urine from the Umbilicus When the Inner Urethral Orifice Is Blocked by a Membrane 488
| | 228. A Small Cyst of the Urachus |
|
| |
|
| 211. A Patent Urachus with a Mushroom-like Projection at the Umbilicus 489
| | 229. A Patent Urachus |
|
| |
|
| 212. A Patent Urachus with a Penile Projection at the Umbilicus 489
| | 230. A Multilocular Cyst of the Urachus |
|
| |
|
| 213. The Appearance of the Umbilicus in a Case in Which both a Patent Omphalomesenteric Duct and a Patent Urachus Existed 493
| | 231. Section of a Patent Urachus |
|
| |
|
| 214. Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same Child 493
| | 232. Transverse Section of a Patent Urachus |
|
| |
|
| 215. A Picture of the Child Three Weeks After Removal of a Patent Omphalomesenteric Duct and a Patulous Urachus 494
| | 233. A Small Cyst of the Urachus |
|
| |
|
| 216. A Patent Urachus 497
| | 234. A Diffuse Neuroma of the Bladder |
|
| |
|
| 217. A Urachus Open from Bladder to Umbilicus 498
| | 235. Cut Surface of the Bladder Showing a Diffuse Neuroma of Its Walls |
|
| |
|
| 218. An Open Urachus 499
| | 236. A Diffuse Neuroma Forming a Mantle Around the Cavity of the Bladder |
|
| |
|
| 219. Escape of Urine from the Umbilicus Due to a Patent Urachus 502
| | 237. Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus |
| | |
| 220. A Patent Urachus with a Penile Projection at the Umbilicus 505
| |
| | |
| 221. A Ring-shaped Vesical Calculus with a Fine Hair in Its Axis 507
| |
| | |
| 222. A Partially Patent Urachus 515
| |
| | |
| 223. A Patent Urachus 517
| |
| | |
| 224. A Portion of a Urachus Seven Times Enlarged, with Numerous Large and Small Dilatations 518
| |
| | |
| 225. Portion of a Urachus Ten Times Enlarged 518
| |
| | |
| 226. Cysts of the Urachus Arranged Like a String of Pearls .- 520
| |
| | |
| 227. Spindle-Shaped Dilatations of the Urachus 520
| |
| | |
| 228. A Small Cyst of the Urachus 532
| |
| | |
| 229. A Patent Urachus 534
| |
| | |
| 230. A Multilocular Cyst of the Urachus 535
| |
| | |
| 231. Section of a Patent Urachus .' 536
| |
| | |
| 232. Transverse Section of a Patent Urachus 537
| |
| | |
| 233. A Small Cyst of the Urachus 538
| |
| | |
| 234. A Diffuse Neuroma of the Bladder 542
| |
| | |
| 235. Cut Surface of the Bladder Showing a Diffuse Neuroma of Its Walls 543
| |
| | |
| 236. A Diffuse Neuroma Forming a Mantle Around the Cavity of the Bladder 544
| |
| | |
| 237. Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus 551 | |
|
| |
|
| 238. Section of the Segment of Urachus Which Passed between the Bladder and the Cyst- wall, as Seen under a Low Power 552 | | 238. Section of the Segment of Urachus Which Passed between the Bladder and the Cyst- wall, as Seen under a Low Power 552 |
|
| |
|
| 239. The Abdominal Contour in a Case of Very Large Urachal Cyst 558 | | 239. The Abdominal Contour in a Case of Very Large Urachal Cyst |
|
| |
|
| 240. A Urachal Cyst Turned Inside Out and Showing Papillary Masses, Particularly in the Lower Part of the Picture 559 | | 240. A Urachal Cyst Turned Inside Out and Showing Papillary Masses, Particularly in the Lower Part of the Picture 559 |
|
| |
|
| 241. Infected Urachal Remains 568 | | 241. Infected Urachal Remains |
|
| |
|
| 242. An Infected Urachus Opening between the Umbilicus and Bladder 570 | | 242. An Infected Urachus Opening between the Umbilicus and Bladder |
|
| |
|
| 243. Urachal Cyst 576 | | 243. Urachal Cyst |
|
| |
|
| 244. A Dilated Urachus Communicating with the Bladder 579 | | 244. A Dilated Urachus Communicating with the Bladder |
|
| |
|
| 245. Large Accumulation of Urine in a Partially Patent Urachus 579 | | 245. Large Accumulation of Urine in a Partially Patent Urachus |
|
| |
|
| 246. An Infected Urachus Opening at the Umbilicus 580 | | 246. An Infected Urachus Opening at the Umbilicus |
|
| |
|
| 247. A Patent Urachus Dilated in Its Middle Portion 580 | | 247. A Patent Urachus Dilated in Its Middle Portion |
|
| |
|
| 248. Accumulation of a Large Quantity of Urine in a Urachal Pouch 581 | | 248. Accumulation of a Large Quantity of Urine in a Urachal Pouch |
|
| |
|
| 249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac 584 | | 249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac |
|
| |
|
| 250. A Phosphatic Deposit on the End of a Long Bone 585 | | 250. A Phosphatic Deposit on the End of a Long Bone |
|
| |
|
| 251. A Dilated Urachus Communicating with the Bladder 598 | | 251. A Dilated Urachus Communicating with the Bladder |
|
| |
|
| 252. Urachal Cyst 599 | | 252. Urachal Cyst |
|
| |
|
| 253. Urachal Cyst 603 | | 253. Urachal Cyst |
|
| |
|
| 254. Urachal Cyst 603 | | 254. Urachal Cyst |
|
| |
|
| 255. A Patent Urachus Containing a Vesical Calculus 625 | | 255. A Patent Urachus Containing a Vesical Calculus |
|
| |
|
| 256. Carcinoma of the Patent Urachus 632 | | 256. Carcinoma of the Patent Urachus |
|
| |
|
| 257. A Multilocular and Malignant Cyst of the Urachus 637 | | 257. A Multilocular and Malignant Cyst of the Urachus |
|
| |
|
| 258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus 638 | | 258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus |
|
| |
|
| 259. Giant-cells in the Wall of an Adenocarcinoma of the Urachus 639 | | 259. Giant-cells in the Wall of an Adenocarcinoma of the Urachus |
|
| |
|
| 260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus. . .640-641 | | 260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus |
|
| |
|
| 261. Adenocarcinoma of the Urachus 642 | | 261. Adenocarcinoma of the Urachus |
|
| |
|
| 262. A Papillary-like Area i.\ an Adkxocarcinomatous Cystofthe Urachus 643 | | 262. A Papillary-like Area in an Adkxocarcinomatous Cystofthe Urachus |
|
| |
|
| 263. Metastasis from Adenocarcinoma of the Urachus 644 | | 263. Metastasis from Adenocarcinoma of the Urachus |
|
| |
|
| 264. An Umbilical Cyst 645 | | 264. An Umbilical Cyst |
|
| |
|
| 265. \\ aj.i of an Umbilical Cyst 645 | | 265. \\ aj.i of an Umbilical Cyst |
|
| |
|
| 266. Giant-cells in the Wall of an Umbilical Cyst 646 | | 266. Giant-cells in the Wall of an Umbilical Cyst |
|
| |
|
| 267. Tuberculosis of the Urachus 652 | | 267. Tuberculosis of the Urachus |
| | |
| 268. An Area Suggesting a Tubercle 653
| |
| | |
| 269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus 654
| |
|
| |
|
| | 268. An Area Suggesting a Tubercle |
|
| |
|
| | 269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus |
|
| |
|
| ==List of Plates== | | ==List of Plates== |
| | [[Book - Umbilicus (1916) Figures#List of Plates|List of Plates]] |
|
| |
|
| I. Drawings of Normal Umbilici 40
| |
|
| |
| II. Drawings of Normal Umbilici 41
| |
|
| |
| III. Drawings of Normal Umbilici 42
| |
|
| |
| IV. Drawings of Normal Umbilici 43
| |
|
| |
| V. Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary. .434-435
| |
|
| |
| VI. Umbilical Hernia 466-467
| |
|
| |
| VII. Exstrophy of the Bladder 484-485
| |
|
| |
|
| |
| ==Chapter XXXVII. Malignant Changes in the Urachus==
| |
|
| |
| Carcinoma of the urachus.
| |
|
| |
| Historic sketch.
| |
|
| |
| Symptoms.
| |
|
| |
| Report of cases.
| |
| Sarcoma in the urachal region.
| |
| An extraperitoneal abdominal tumor.
| |
|
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| A large multilocular carcinomatous cyst of the urachus; secondary growths in the pelvis (personal observation).
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| A rare umbilical cyst.
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|
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| CARCINOMA OF THE URACHUS.
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|
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| I have been able to find three cases of carcinoma of the urachus recorded in
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| the literature.
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|
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| Sex. — All of the patients were men. Two of the patients had had congenital urinary fistula? at the umbilicus, and in each of these the discharge of urine
| |
| had ceased after the use of escharotics. The third patient also evidently had a
| |
| congenital fistula, as he gave a history of "moisture at the umbilicus" during
| |
| childhood. This had ceased without treatment.
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|
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| Age. — The patients were twenty-five, twenty-seven, and thirty-two respectively, indicating that, when carcinoma of the patent urachus develops, the malignant change occurs in early adult life.
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|
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| Hoffmann and Fischer gave very careful and full histories of their cases. Hoffmann's patient, when twenty-seven years of age, noted a raised hardening between
| |
| the umbilicus and symphysis. It was the size of a goose's egg, non-painful, and
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| movable from side to side. It gradually extended toward the symphysis and right
| |
| inguinal region.
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|
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| Shortly after the tumor was noticed the patient experienced pain on urination.
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| At times the urine was abundant, at times it came drop by drop. The man rapidly
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| grew weaker and lost 25 pounds in four months. When Hoffmann saw him. the
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| umbilicus presented a peculiar radiating appearance, while in the mid-line, just below
| |
| the umbilicus, was a roundish, nodular tumor, 8 to 10 cm. long, adherent to the umbilicus and very painful. After the patient had urinated an area of tympany could
| |
| be elicited between the tumor and the symphysis. On account of tenesmus, the
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| patient urinated every hour. The urine contained pus and aggregations of epithelial cells.
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|
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| The tumor became fluctuant, ruptured, and a large amount of purulent and
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| bloody fluid escaped, but the growth did not diminish in size. From time to time
| |
| onion-like balls escaped with the pus. These consisted of quantities of squamous
| |
| epithelial cells that had become agglutinated. Precisely similar balls escaped in
| |
| Fischer's case.
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|
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| The urethra was normal.
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|
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| 628
| |
|
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|
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|
| |
| MALIGNANT CHANGES IN THE URACHUS. 629
| |
|
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| The umbilical opening closed temporarily, but soon reopened, and in the late
| |
| stages of the disease the inguinal glands were swollen.
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|
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| As noted in the autopsy report, the cavity between the umbilicus and bladder
| |
| had walls 1 cm. thick. Its inner surface had an irregular, ulcerated, and eaten-out
| |
| appearance (Fig. 256). The bladder-wall had been involved by continuity, and also
| |
| contained secondary nodules. The growth was a squamous-cell carcinoma.
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|
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| Fischer's patient, when thirty-one years old, first noted a small, hard tumor the
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| size of a pigeon's egg below the umbilicus. Seven or eight months later he had pain
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| on micturition, and noticed a sediment in the urine. The nodule was incised on the
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| supposition that it was fluctuant, and slimy, necrotic tissue escaped. The tumor
| |
| soon grew out of the incision, bled a great deal, and finally left an ulcerated area, the
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| walls of which were raised and hard, while the floor consisted of hard nodules. From
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| the ulcerated area onion-like balls of epithelial cells escaped.
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|
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| The inguinal glands on both sides became swollen. At autopsy the bladder
| |
| mucosa showed a catarrhal swelling, but no involvement by the malignant growth.
| |
| The prostate was normal. The growth was a carcinoma, evidently of the squamouscell type, as indicated by the onion-like balls.
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|
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| Death in these cases may occur from gradual weakening as a result of the disease, or from a perforation of the growth posteriorly into the abdominal cavity,
| |
| causing a peritonitis. The occurrence of three cases of carcinoma of the urachus
| |
| is another point in favor of the early removal of the patent urachus.
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|
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| In the future cancer of the urachus, when met with, will undoubtedly be operated on early. The growth can be given a relatively wide berth, and the block dissection should include the inguinal glands on both sides.
| |
|
| |
| Cases of Carcinoma of the Urachus Developing Years After the Closure of a
| |
|
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| Congenital Patent Urachus.
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|
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| Carcinoma Evidently D e v e 1 o p i n g F r o m Remains of
| |
| the Urachus. — Fischer* saw this patient in consultation with Hanuschke in
| |
| 1874. The man, thirty-two years of age, sought treatment on account of an ulcer
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| of the umbilicus. During his childhood, when voiding, there was a moisture at the
| |
| umbilicus. Later these symptoms disappeared and there was never any trouble with
| |
| urination. Early in 1873 he casually noticed below the umbilicus a hard tumor the
| |
| size of a pigeon's egg. This gave rise to no symptoms. It gradually grew, and seven
| |
| or eight months later there were pain and a burning sensation on micturition and sediment in the urine. Toward the end of 1873 he consulted a physician. The difficulty in urination had increased, and the tumor had grown markedly. His general
| |
| condition was not satisfactory. Hanuschke thought that the tumor was soft, and
| |
| that he could make out fluctuation. Accordingly he made an incision, and purulent, slimy masses escaped — evidently pieces of necrotic tissue. The tumor mass
| |
| grew out of the incision wound ; it very soon broke down, with a good deal of bleeding, and an ulcer resulted. When Fischer saw the patient, he was pale and weak,
| |
| had difficulty in micturition, and suffered from strangury. The ulcer was situated
| |
| 2 cm. below the umbilicus, and formed a deep crater, which was heart-shaped. Its
| |
| walls were elevated, hard, and extended below the level of the skin about 4 cm. Its
| |
| greatest breadth was 8 cm. Its greatest length, 7 cm. The floor was very irregular
| |
|
| |
| * Fischer: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, n. F. No. 89 (Chir. No. 24), Leipzig, 1894, 519.
| |
|
| |
|
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|
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| 630 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| and covered with hard nodules. It reached a depth of 5 cm. below the skin surface. Surrounding the ulcer the tissue was hard. On pressure there escaped a thin,
| |
| bloody, foul-smelling pus from the ulcer, and there were also portions of the tumor
| |
| forced out as small balls suggesting onions. These were composed of quantities of
| |
| flat epithelial cells.
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|
| |
| The urine was acid, slightly cloudy, and had a purulent sediment. The inguinal
| |
| glands on both sides were swollen.
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|
| |
| Complete removal of the growth was impossible. The abdominal walls, however, were split in the mid-line as far as the symphysis, and beneath the muscle thick,
| |
| pork-like tumor masses were found adherent. As much of the tumor as possible
| |
| was removed, and the cautery was employed. The patient died fourteen days
| |
| after the operation. Microscopic examination of the tumor mass showed it to be a
| |
| carcinoma. At autopsy the inner surface of the bladder was found to show catarrhal
| |
| swelling. It was intact. There was no abnormality in the prostate. The intestines
| |
| were normal.
| |
|
| |
| A Patent Urachus, Closure; Later Carcinoma of the
| |
| Urachus.* — This case was also mentioned in the Deutsche Klinik, 1864, xvi,
| |
| 116. The patient was a man, twenty-eight years of age, who had a urachal fistula
| |
| at birth. This was healed with escharotics. Twenty-five years later a tumor
| |
| developed between the umbilicus and the symphysis. This broke and discharged
| |
| pus and later urine. The autopsy revealed a carcinoma of the mucosa of the
| |
| urachus, which had perforated into the umbilicus and into the bladder.
| |
|
| |
| A Patent Urachus Partly Closed by the Use of Escharotics; Later, Carcinoma of the Urachus. — Hoffmannf first
| |
| reports the case of Hermann R., in which there was an enormous sac formation and
| |
| accumulation of fluid outside of the abdomen. This Hoffmann attributed to a
| |
| dilated urachus.
| |
|
| |
| Hoffmann reports the case of Alexander Wanner, a postal employee, who
| |
| was born in 1841 with an opening at the umbilicus through which urine
| |
| escaped, while it also passed from the urethra. This condition lasted until
| |
| his third year, when the opening closed after the use of escharotics. The
| |
| patient had no further difficulty, and with the exception of several inflammations of the eye was perfectly well. About the middle of the year 1868
| |
| he noticed between the umbilicus and the symphysis, near the umbilicus, a
| |
| raised hardening of the abdomen about the size of a goose's egg, which was
| |
| not painful and could be pushed from side to side. This gradually grew and
| |
| extended toward the symphysis, and spread toward the right inguinal region.
| |
| Shortly after the appearance of the tumor the patient began to have pain on urination. The urine sometimes came in an abundant stream; at other times only in
| |
| drops. As a result the patient had a continuous desire to urinate. The pains
| |
| became severe and he grew weaker. He had lost weight — in the last four months,
| |
| 25 pounds. On admission to the hospital, November 10, 1868, he weighed 99
| |
| pounds, was poorly nourished, anemic, and had a peculiar radiating formation
| |
| of the umbilicus, in the folds of which no opening could be discovered. Immediately
| |
| below the umbilicus was a tumor, 8 to 10 cm. long, situated in the middle line. It
| |
|
| |
| * Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.
| |
| t Hoffmann: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch. d.
| |
| Heilkunde, 1870, xi, 373.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. 631
| |
|
| |
| was roundish, nodular, very painful, and adherent to the umbilicus, but on both
| |
| sides it was free. After urination, between the tumor and the symphysis was an
| |
| area of tympany. On account of the tenesmus the patient urinated every hour,
| |
| and the urine contained pus and aggregations of epithelial cells. The patient drank
| |
| quantities of soda-water and local applications were made. His pain diminished,
| |
| but the tumor continued to grow. The umbilicus became prominent, fluctuation
| |
| was detected, and on December 1st the swelling broke and a large quantity of
| |
| thick, purulent, bloody fluid escaped. The tumor, however, did not diminish in
| |
| size, although the pain became less and less. In the fluid numerous onion-like
| |
| balls were found. These consisted of large quantities of squamous epithelial cells
| |
| which had become agglutinated.
| |
|
| |
| Examination of the urethra with a bougie yielded nothing abnormal. The
| |
| prostate was not enlarged, the bladder-wall was thick and did not contract completely after the escape of urine. From September 4th urine and purulent fluid
| |
| often escaped from the umbilicus, and the urine passed from the bladder from
| |
| that time on was cloudy. The opening at the umbilicus gradually contracted, and
| |
| for some time only purulent fluid escaped from it. The tumor became smaller, and
| |
| toward the middle of January, 1869, the umbilicus closed completely.
| |
|
| |
| Diarrhea developed and marked emaciation. At the end of January the opening at the umbilicus reappeared, and a purulent-like material escaped. The pain
| |
| became more severe. The inguinal glands were swollen and the patient grew weaker.
| |
| On January 31st he weighed 88 pounds. He died in the middle of May, 1869.
| |
|
| |
| Only an incomplete autopsy could be obtained. The family physician who
| |
| made it said there were appearances of peritonitis. The umbilicus had a peculiar,
| |
| radiating, stellar appearance, and there was an opening 3 mm. in diameter. Through
| |
| this there was a passage going downward and backward into a canal which gradually widened. The cavity had walls 1 cm. thick. It extended from the umbilicus
| |
| to the top of the bladder. It was 10 cm. in length, and in its middle portion was
| |
| 2.5 cm. broad. The entire inner surface presented an ulcerated, irregular, much
| |
| eaten-out, reddish appearance (Fig. 256).
| |
|
| |
| At its lower part this cavity communicated with the bladder by an opening
| |
| 3.3 cm. broad, and the posterior wall of the bladder was invaded by this ulcerated
| |
| growth over an area 4 cm. in diameter. The bladder-walls, where invaded, were
| |
| 1.8 cm. thick, while the unchanged portions were 0.8 cm. thick. At the point
| |
| where the cavity communicated with the bladder posteriorly was a perforation, the
| |
| exact size of which could not be determined on account of the tearing of the specimen. The bladder mucosa, on the whole, looked normal, but at one point in the
| |
| anterior wall was a round nodule, 1 cm. in diameter; in the posterior wall were
| |
| several smaller ones.
| |
|
| |
| Microscopic examination showed that the growth of the urachus was a squamouscell carcinoma, and that the secondary nodules were also carcinomatous.
| |
|
| |
| Hoffmann says that this patient was born with a patent urachus. The opening
| |
| at the umbilicus had closed after the use of escharotics in the third year. In the
| |
| twenty-seventh year a carcinoma developed in the urachus and extended to the
| |
| bladder. The perforation caused by the cancer led to a local peritonitis.
| |
|
| |
| A Urachal Cyst and Cancer of the Bladder Occurring
| |
| Independently. — ■ Rotter's case may well be considered here. The urachus
| |
|
| |
|
| |
|
| |
| 632
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
|
| |
| J- 'ig. 256. — Carcinoma of the Patent Ubachus. (After C. E. E. Hoffmann.)
| |
| A is a partially diagrammatic picture: ", The anterior abdominal wall; b, the opening of the urachus at the umbilibe urachus, which is occupied by a carcinoma; at d the growth has broken through into the abdominal cavity;
| |
| < , the bladder. At points /, /, /, /, on the bladder mucosa are small secondary carcinomatous masses. B represents the
| |
| appearance of the umbilicus with the opening of the urachal fistula in its center.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. 633
| |
|
| |
| was the seat of a cyst and the bladder showed a carcinoma. The one was absolutely independent of the other.
| |
|
| |
| Rotter's* patient was a forty-three-year-old man, who, for nine months, had
| |
| had bleeding from the bladder. Cystoscopic examination showed a tumor in the
| |
| upper portion of the bladder. This did not grow rapidly. Above the symphysis,
| |
| and reaching to the umbilicus, was another tumor, which on aspiration yielded a
| |
| fluid containing cholesterin. This tumor was diagnosed as a urachal cyst. At
| |
| operation the upper tumor was found lying between the peritoneum and the abdominal muscles. In its upper portion it was free, but over the lower half it was so
| |
| intimately blended with the peritoneum that it was necessary to remove a portion
| |
| of the peritoneum with the tumor. The urachal tumor pressed so into the bladder
| |
| muscle that it was also necessary to open this viscus.
| |
|
| |
| The cancer of the bladder was removed, and a defect 7 by 8 cm. in the bladder
| |
| closed by layers. This patient was shown by Rotter at the Berlin Surgical Society.
| |
| Microscopic examination demonstrated carcinoma of the bladder. This had perforated at the point where the cyst was found. The cyst contained many polymorphous epithelial cells. There was no doubt that it was a urachal cyst.
| |
|
| |
| Possibly an Adenocarcinoma of the Urachus. — I am at
| |
| a loss where to place this case of Koslowski's.f The situation of the tumor suggests a urachal growth. Furthermore, the variation in the size of the glands might
| |
| very readily correspond to the cyst-like spaces we have noted where isolated segments of the urachus have persisted. The invasion of the rectus sheath and of the
| |
| rectus muscle naturally points toward malignancy. We shall accordingly leave this
| |
| case among those of carcinoma of the urachus. Whether it really belongs here or
| |
| not is problematic.
| |
|
| |
| The patient was a man, fifty-five years of age, who five weeks before had noticed
| |
| in the mid-line, between the symphysis and the umbilicus, a small, painful tumor
| |
| which grew to the size of a walnut. This man was markedly emaciated, looked to
| |
| be seventy years of age, had frequent diarrhea, and was bent over from guarding
| |
| the abdominal muscles. Between the umbilicus and symphysis, near the mid-line,
| |
| was a tumor which suggested a patella. The overlying skin was free. The tumor
| |
| was slightly movable and very painful. It felt very tense, and gradually merged
| |
| into the surrounding tissue. Passing from the tumor toward the umbilicus was a
| |
| cord the size of a goose-quill. Koslowski thought the tumor was a malignant
| |
| epithelial growth developing from remains of the urachus.
| |
|
| |
| Operation. — A median incision showed that the linea alba and sheath of the
| |
| rectus had been penetrated by the tumor. An elliptic incision encircled the umbilicus and the tumor. Removed with the tumor were portions of the sheath of the
| |
| recti and some of the rectus muscle, the transversalis fascia, and peritoneum. After
| |
| the abdomen was opened, the tumor was drawn up and brought into view fibrous
| |
| cords passing to the umbilicus. The upper cord was the size of a goose-quill, firm,
| |
| and infiltrated. The lower cord was less firm and contained veins; these passed
| |
| into the vesico-umbilical ligament. The peritoneum covering the posterior surface
| |
| of the tumor showed evidence of scar and of ulceration. The patient made a good
| |
| recovery. The tumor in form resembled a patella. The peritoneum was firmly
| |
|
| |
| * Rotter: Blasencarcinom combinirt mit Urachuscyste. Centralbl. f. Chir., 1897, xxiv, 604.
| |
| t Koslowski, B. S.: Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir.. 1903,
| |
| lxix. 469.
| |
|
| |
|
| |
|
| |
| 634 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| attached to it. The surrounding muscle was penetrated by the tumor. Microscopic examination showed that it was made up of glands of various sizes. They
| |
| varied from the size of urinary tubules to those large enough to be noted with the
| |
| naked eye. The diagnosis was fibro-adenoma submalignum. The glands resembled
| |
| intestinal glands.
| |
|
| |
| [It is difficult to establish the exact character of this tumor. — T. S. C]
| |
|
| |
|
| |
|
| |
| SARCOMA IN THE URACHAL REGION.
| |
|
| |
| Frank, in 1893, recorded a very interesting case of sarcoma probably developing
| |
| in the sheath of the urachus in a young lad. Unfortunately, the subsequent history
| |
| of the case is lacking, but the histologic picture of the growth, the invasion of the
| |
| muscles of the abdominal wall, and the secondary nodules in the omentum leave
| |
| no doubt as to its malignancy.
| |
|
| |
| Alban Doran reports a case of sarcoma developing in the wall of a cyst of the
| |
| urachus. This is so interesting that I shall also record it in detail.
| |
|
| |
| Sarcoma Probably Developing in the Sheath of the
| |
| Urachus. — Frank* gives a good resume of the literature and reports the
| |
| case of a boy eleven years of age. For several weeks he had had loss of appetite
| |
| and was losing weight. About fourteen days before the boy came under observation the father noticed a swelling in the umbilical region, and from a small opening
| |
| at the umbilicus a little pus could be pressed. There was no urinary difficulty and
| |
| no discomfort on defecation. The urine, however, had recently became cloudy and
| |
| stringy. The child's mother had died of pulmonary disease, otherwise the family
| |
| history was good.
| |
|
| |
| On examination the boy was found to be strong and well nourished. In the
| |
| umbilical region was a hard, circumscribed thickening, only slightly painful on
| |
| pressure, reaching about a fingerbreadth above the umbilicus. Here it could be
| |
| traced three fingerbreadths to the right and to the left of the linea alba. Below
| |
| it extended almost to the symphysis. The skin over the tumor was only slightly
| |
| movable. A sound introduced into the sinus passed from 4 to 6 cm. downward.
| |
| With a sharp curette friable, sanguineopurulent masses were removed. These on
| |
| examination were found to consist of pus-cells, granulation tissue, and debris.
| |
|
| |
| Operation. — An elliptic incision was made, commencing 3 cm. above the umbilicus. The recti muscles at the umbilicus were found to be infiltrated by the growth.
| |
| The incision was then carried through healthy muscle to the peritoneum. Loops
| |
| of small bowel were adherent to the peritoneal surfaces of the tumor, and nodules
| |
| were found scattered throughout the omentum. The tumor was gradually turned
| |
| out ward and was removed without much difficulty. Its lower end was intimately
| |
| adherent to the bladder, and the outer walls of this viscus were removed and
| |
| the small opening in it was closed. The omentum was removed on account of
| |
| the tumor nodules. The abdomen was closed with difficulty. The patient's
| |
| recovery was slow.
| |
|
| |
| The tumor, on section, was found to have invaded the recti in all directions.
| |
| Its chief extension was along the course of the urachus as far as the bladder. The
| |
| tumor itself, with the surrounding parts, was as large as a man's fist, and was nodular and uneven.
| |
|
| |
| * Frank, Theodor: Zur Casuistik der Urachustumoren. Inaug. Diss., Wurzburg, 1893.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. 635
| |
|
| |
| On microscopic examination the sarcomatous character of the tumor was evident. In the center of the tumor the intercellular substance was most marked, but
| |
| toward the periphery it consisted almost entirely of spindle-cells with little connective tissue. The growth of the spindle-cells into the recti and into the bladder
| |
| was especially evident. The entire picture indicated that the tumor had developed
| |
| in the connective-tissue layers of the urachus and that it had then spread out in all
| |
| directions.
| |
|
| |
| The case is perfectly clear, but there is no after-history beyond two months, and
| |
| no description of the omental nodules.
| |
|
| |
| AUniqueSpecimenofCystic Sarcomaof the Urachus.*
| |
| — Alban Doran says: "Mr. F. S. Eve has presented to the Museum of the Royal
| |
| College of Surgeons of England a unique specimen of cystic sarcoma of the urachus,
| |
| and has kindly supplied me with the following notes :
| |
|
| |
| ' ' A man, aged thirty-eight years, was admitted into the London Hospital with
| |
| a swelling in the hypogastrium noticed for several weeks and associated with pain
| |
| after micturition. A cystic tumor filled the lower part of the abdomen, especially
| |
| to the right, where it extended toward the loin. It did not dip into the pelvis.
| |
| On puncture, dark blood came away; a few days later a rigor occurred, with vomiting and a rise of temperature to 104° F. Mr. Eve then operated, exposing a large
| |
| cystic tumor; the parietal peritoneum was reflected over its anterior and superior
| |
| surfaces. Five pints of dark, bloody material were removed. The cyst adhered to
| |
| the omentum, which bore engorged veins, and to an inch and a half of small intestine which was infiltrated where adherent. The adherent portion of the wall of the
| |
| gut was excised, and the wound closed with sutures. The lower part of the cyst
| |
| was intimately connected with the bladder, the serous coat of which organ was
| |
| reflected onto its surface. This peritoneal covering was divided, and the cyst carefully dissected away from the bladder. During the process the bladder was opened,
| |
| for the vesical wall at this point was so thin that the cavities of the cyst and the
| |
| bladder were only separated by the vesical mucous membrane covered by a few
| |
| muscular fibers. The opening was sutured, but not without great difficulty, owing
| |
| to the thinness of the walls at this point. The sutures were further protected by
| |
| gauze packing. A gauze drain was passed into the pelvis, and a catheter retained
| |
| for a while in the bladder. Neither flatus nor feces could be made to pass after the
| |
| operation, and the patient died on the fourth day. There was no general peritonitis, but the pelvic peritoneum had become inflamed at the point where the
| |
| gauze had been applied.'
| |
|
| |
| "Mr. Eve examined the specimen and found that it was a large allantoic cyst
| |
| separated from the posterior superior surface of the bladder by nothing except a
| |
| very much thinned mucous membrane. Their cavities, however, did not. communicate. The inner wall of the cyst was lined at certain points with very vascular
| |
| polypoid masses, which proved to be, on microscopic examination, sarcomatous.
| |
| The most unusual feature of this cyst was its malignancy, but its peritoneal relations were of greater importance in respect to the subject of this communication."
| |
|
| |
|
| |
|
| |
| AN EXTRAPERITONEAL ABDOMINAL TUMOR.
| |
| The following interesting case, the specimen from which was exhibited by Dr.
| |
| Aveling, may be considered here, although from the description one could not say
| |
| * Doran, Alban H. G.: The Lancet, 1909, i, 1304.
| |
|
| |
|
| |
|
| |
| 636 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| that the growth was a sarcoma. It may serve, however, to form the nucleus around
| |
| which similar cases may be collected.
| |
|
| |
| Dr. Aveling* exhibited before the British Gynecological Society a subperitoneal tumor which had grown in the anterior abdominal wall and reached from two
| |
| inches above the umbilicus to the pubes. It was removed after death, the patient
| |
| having succumbed after an exploratory operation. Sir Spencer Wells, who saw the
| |
| tumor, said he had seen only two similar cases, and he classified the tumor, according to Virchow, as a fibroma molluscum cysticum abdominale. The specimen was
| |
| referred to Mr. Bland-Sutton and Dr. Aveling for further examination.
| |
|
| |
| The tumor was ovoid in shape, and measured 10 inches in length, 7 inches in
| |
| width, and weighed 4% pounds. It was surrounded by a distinct, thick, fibrous
| |
| capsule. On section the tissue was of a dirty white color, and the cut surface
| |
| looked like a sponge. The loculi were filled with gelatinous tissue, which readily
| |
| broke down on scraping the cavities with the handle of a scalpel. Inside the growth
| |
| six or seven hard nodules, of the size of walnuts, could be felt. These, when dissected out and divided, looked like small leiomyomata, such as occasionally exist
| |
| in the uterus. They presented the same whorled arrangement of the fibers, and
| |
| corresponded with them histologically. On microscopic examination of the tumor
| |
| the outer portion was found to consist of non-striped muscle-fibers, some of large
| |
| size. Internal to this the cells assumed more the shape and characters of those
| |
| seen in spindle-cell sarcomata, while the gelatinous material contained in the loculi
| |
| was the result of mucoid degeneration of the sarcomatous elements.
| |
|
| |
| Sutton and Aveling then go on to say that the specimen was of great interest
| |
| from an etiologic standpoint. "Man, in common with other mammals, possesses
| |
| a persistent pedicle of the allantois, familiar under the name of the urachus. This
| |
| structure is frequently found dilated into a cyst, usually of small size. An account
| |
| of these allantois cysts, with reference to a few recorded cases, will be found in the
| |
| Path. Soc. Trans., xxxvi, 523." They drew attention to the fact that Mr. Lawson
| |
| Tait, in his work on Diseases of the Ovaries, had described certain growths which
| |
| he regarded as probably originating in the urachus, and which attained such considerable dimensions as to require operative interference.
| |
|
| |
| They thought that, in the present case, they had to deal with an allantois cyst,
| |
| the walls of which had become sarcomatous, thus affording another illustration of
| |
| the great tendency exhibited so often by aberrant and ill-developed structures to
| |
| become the seat of morbid growths, such as sarcoma or carcinoma.
| |
|
| |
| [After a somewhat careful study of the literature on the subject of umbilical
| |
| tumors, the interpretation of Bland-Sutton and Aveling is not altogether clear. It
| |
| would rather seem as if we are dealing with a myoma. The gross description speaks
| |
| of non-striped muscle, and this the histologic picture substantiates. The gross and
| |
| histologic appearance of the nodule coincides with the appearances presented by
| |
| uterine myomata. The areas that were supposed to be sarcomatous and inclosed
| |
| cavities presenl ing a m ucoid appearance might very readily have been due to hyaline
| |
| degeneration. Without an opportunity of examining their specimen we should hesitate to express any definite opinion as to this case, further than that their interpretation does not seem to tally with the recorded cases of secondary growths attributed
| |
| to the allantois. — T. S. C]
| |
|
| |
| Doran* says that Aveling and Bland-Sutton had already reported a case of
| |
|
| |
| * Aveling: Brit. Gyn. Jour., 1886-87, ii, 56 and 187.
| |
| t Doran, Alban H. G. : The Lancet, 1909, i, 1304.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS.
| |
|
| |
|
| |
|
| |
| 637
| |
|
| |
|
| |
|
| |
| multilocular myxosarcoma of the sheath of the urachus, but it did not involve the
| |
| urachal canal, and was quite unconnected with the bladder. The specimen (No.
| |
| 417 b) in the pathologic series of the Museum of the Royal College of Surgeons of
| |
| England was supposed, when first examined, to have developed in the urachus, but
| |
| Mr. J. H. Targett considered that it was a myxosarcoma which had originated in
| |
| the connective tissue surrounding the bladder.
| |
|
| |
| After I had made my comment on Aveling and Bland-Sutton's case, Alban
| |
| Doran's note on the case came to my notice, clearly showing a lack of unanimity
| |
| of opinion among those who had examined the specimen, not only as to the exact
| |
| character of the tumor, but also as to its precise source of origin.
| |
|
| |
|
| |
|
| |
| Multilocular urachus cvsi
| |
|
| |
|
| |
|
| |
| Omentum, adherent"
| |
| to tumor
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 257. — A Multilocular and Malignant Cyst of the Urachus.
| |
| Gyn.-Path. Nos. 10368 and 1048S. The cyst lay between the abdominal muscles and the peritoneum of the
| |
| anterior abdominal wall. Below it was attached by a pedicle near the top of the bladder. Upward it extended for
| |
| a considerable distance above the umbilicus. The omentum was densely adherent to its upper surface. The cyst -wall
| |
| anteriorly was so thin that I cut it, thinking that it was peritoneum. The cyst is composed of one large and many
| |
| smaller cavities. Projecting into the large cyst are many smaller cysts, and papillary and solid growths spring from the
| |
| inner surface of the cyst. Some of the smaller cysts have smooth walls, as is well seen in the one near the pedicle of the
| |
| tumor. Cross-sections of other small cysts show that they are partially filled with secondary growths. It will be
| |
| noted that the uterus, tubes, and ovaries are absolutely independent of the cystic tumor. They are, however, partially
| |
| covered over with secondary cancerous nodules. (For the histologic appearances in this case see Figs. 261, 262, 263.)
| |
|
| |
|
| |
|
| |
| A LARGE MULTILOCULAR CARCINOMATOUS CYST OF THE URACHUS; SECONDARY
| |
|
| |
| GROWTHS IN THE PELVIS.
| |
|
| |
| I saw Mrs. W. W., aged thirty-seven, in consultation with Dr. E. S. Mann, of
| |
| Dallastown, Pa., and had her admitted to the Johns Hopkins Hospital, October 6,
| |
| 1906. This patient had never been pregnant. Her menses had commenced at
| |
| fourteen and had always been regular until the previous year. Her last period
| |
| had occurred sixteen months before admission. About two years before I saw her,
| |
|
| |
|
| |
|
| |
| 638
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| she had noticed, on moving, a sharp, sticking pain in the left lower abdomen. For
| |
| about a year and a half she had had some abdominal enlargement, and eight weeks
| |
| before admission the abdomen had commenced to swell a great deal. The feet and
| |
| legs had also been swollen. The patient gave a history of having lost 20 pounds in
| |
|
| |
|
| |
|
| |
| ■■■:■•■ H.V.?^. • •: .- -•• ■ »I ■..'■:■•• -. >-..••••.'.'• ■ ",/ .-. ■ <■«, '.. . . >? • • ■ '. .v. • • •
| |
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| |
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| |
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| |
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| |
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| |
|
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| |
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|
| |
| -VV'-^v
| |
|
| |
|
| |
|
| |
| c
| |
| Fig. 258. — Giant-cells in the Wall op an Adenocarcinomatous Cyst of the Urachus. (X 90 diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. Occupying the center of the field are slit-like spaces lined on one or both sides
| |
| with giant-colls. The most perfect picture is that seen at a. At 6 is a giant-cell lying in the stroma. From this picture
| |
| as a whole one gets the impression that these slit-like spaces may be due to the cracking of brittle giant-cells. At c
| |
| are the epithelial cells lining a gland-like space of the carcinomatous cyst. Scattered throughout the field are quantities
| |
| of small round-cells. Many of these have absorbed brown pigment, have swollen up, and at first sight look like vacuoles.
| |
| In the center of these pale round or oval spaces the small round, deeply staining nucleus is still clearly visible. At d
| |
| the stroma has undergone almost complete hyaline transformation.
| |
|
| |
|
| |
|
| |
| the past six months. She had had dysuria, and had had to void four or five times
| |
| during the night.
| |
|
| |
| On admission it was noted that she was a well-nourished woman, weighing 172
| |
| pounds. The abdomen was markedly distended. It rose rather abruptly from
| |
| the symphysis to the umbilicus, and then gradually shaded off to the xiphoid. On
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS.
| |
|
| |
|
| |
|
| |
| 639
| |
|
| |
|
| |
|
| |
| percussion fluid was evident in all parts of the abdomen. About two months
| |
| before she had noticed large and small lumps in various parts of the abdomen.
| |
| Some of these were fully an inch in diameter, and they had sharp edges.
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
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|
| |
|
| |
|
| |
|
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|
| |
|
| |
| y\i
| |
|
| |
|
| |
|
| |
| ;
| |
|
| |
|
| |
|
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|
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|
| |
|
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|
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| |
|
| |
|
| |
|
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| v.
| |
|
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|
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|
| |
| mi
| |
|
| |
|
| |
|
| |
| /**\ \
| |
|
| |
|
| |
|
| |
| Fig. 259. — Giant-cells in the Wall of an Adenocarcinoma of the Urachus. ( X 90 diam.)
| |
| Gyn.-Path. Nos. 10368 and 104SS. At a is a slit-like space lined on both sides with a large giant-cell. The nuclei
| |
| of the giant-cells are irregularly distributed and stain deeply. Extending from one end of the space to the other is a
| |
| delicate strand. This, under a higher power, was found to contain two small nuclei. At b is an irregular oblong space
| |
| with a large giant-cell in the center of its upper margin, and an irregular mass of protoplasm containing numerous nuclei
| |
| bordering its lower margin; projecting into the cavity from either end are delicate filaments of stroma devoid of nuclei.
| |
| At c is a series of parallel slits. The tissue at this point consists of hyaline material. Most of these slits have no lining
| |
| whatsoever, but both the upper and lower slit have small giant-cells attached to their margins. At d is a slit-like space
| |
| lined with giant-cells, e is a giant-cell that could be clearly focused at another level. It was irregularly triangular in
| |
| shape, and contained a quantity of oval, uniformly staining nuclei arranged chiefly at one end of the cell. There were
| |
| other giant-cells scattered throughout the field. The protoplasm of some of these was brownish in color, apparently
| |
| owing to the absorption of old blood-pigment. The stroma of the cyst-wall in this region consisted of fibrous tissue.
| |
| In the vicinity of these giant-cells and in the neighborhood of the slit-like spaces it showed a great deal of hyaline trans
| |
| formation; many of the small round-cells that still persisted were swollen and contained a yellowish or brownish pigment — undoubtedly caused by old hemorrhage.
| |
|
| |
|
| |
|
| |
| On pelvic examination the cervix was found to be perfectly normal; nothingfurther could be made out.
| |
|
| |
| Operation (October 8, 1906). — On opening the abdomen I immediately came
| |
|
| |
|
| |
|
| |
| 640
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| •
| |
|
| |
|
| |
|
| |
| >>
| |
|
| |
|
| |
|
| |
| <a
| |
|
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|
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|
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|
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|
| |
| a
| |
|
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| |
| mm ise*
| |
|
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|
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| ipm
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|
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|
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| d
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|
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| C
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| ?tvv. ;----. -/^
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| /^ -->' , -" * ' ■.."".'-' ; I-- :'_ - 1^
| |
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| \^' si
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| A
| |
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| |
| Fig. 260.
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS. G41
| |
|
| |
| in contact with the contents of a cyst. This cyst was large, multilocular, and
| |
| intimately adherent to the anterior and lateral abdominal walls (Fig. 257). At
| |
| first I thought it was impossible to remove it, but on continuing the incision upward
| |
| we entered the general peritoneal cavity. I then delivered the tumor from above
| |
| downward. Its pedicle sprang from the top of the bladder. This pedicle was 1
| |
| cm. broad and 2 mm. thick. Raw areas were left, both on the anterior and lateral
| |
| abdominal walls. The bleeding was checked by sliding over the peritoneum as far
| |
| as possible, thus bringing the raw areas together and diminishing the size of the
| |
| denuded space.
| |
|
| |
| Both ovaries were normal in size, but were somewhat glued down to the pelvic
| |
| floor. As the pedicle of the cyst sprang from the bladder, I thought it advisable
| |
| to turn it in, fearing that there might be an opening between the bladder and the
| |
| cyst. In the pelvis were metastatic deposits, some of them very minute, others
| |
| irregular, somewhat translucent, and fully 1 cm. in diameter. The appendix was
| |
| removed, and the abdomen closed. The patient was discharged November 5,
| |
| 1906. In answer to an inquiry Dr. Mann wrote me that the patient died January
| |
| 8, 1908.
| |
|
| |
| Gyn.-Path. Nos. 10368 and 10488.— The cyst-walls vary
| |
| considerably in thickness. At some points they are thin and transparent; at
| |
| others they reach the thickness of about 2 cm. These solid areas also contain cysts,
| |
| and in the small cysts is a blackish-colored fluid. The entire specimen is vascular,
| |
| and in some places friable and apparently malignant.
| |
|
| |
| On histologic examination the walls are found to consist in part of fibrous tissue,
| |
| with a definite laminated arrangement. In many places necrosis has taken place,
| |
| and the tissue presents a homogeneous appearance or takes the stain very poorly.
| |
| At other points in the walls the connective-tissue cells have taken up much brown
| |
| pigment, evidently from a long-standing hemorrhage. Here and there throughout
| |
| the walls are slit-like spaces, the smaller ones surrounded by giant-cells * (Fig. 258) .
| |
| The giant-cells really consist of large masses of protoplasm containing oval or round,
| |
| deeply staining nuclei (Fig. 260), and some of these nuclei are four or five times
| |
| the size of the surrounding ones. Where the cavities are larger, giant-cells may
| |
| be seen clinging to one side of the cavity, other portions of the cavity being devoid
| |
| of a lining (Fig. 259). At certain points are aggregations of giant-cells, and interspersed are small, slit-like spaces. One is instantly reminded of the giant-cells
| |
| and slit-like spaces noted by Bondi, and on careful examination we found here and
| |
|
| |
| * I am fully aware of the frequency with which foreign-body giant-cells are prone to occur
| |
| in the walls of certain cysts and elsewhere, but the giant-cells in this case are rather unusual,
| |
| hence I have described them more or less in detail.
| |
|
| |
|
| |
|
| |
| Fig. 260. — Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Ukachus. ( X 90 and 300 diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. A. a seems to be a large, gland-like space filled with coagulated blood and
| |
| exfoliated epithelium. It is lined with one layer of low cuboid epithelium, well seen at b. c is a large blood-vessel.
| |
| Scattered throughout the stroma of the cyst-wall are giant-cells and quite a number of slit-like spaces lined with giantcells. Traversing the slit-like spaces (d) are delicate strands, one of which contains very small nuclei.
| |
|
| |
| B. This shows an enlargement of the oblong area in A. The stroma consists of fibrous tissue. At a is a nest of
| |
| cancer-cells which has retracted from the surrounding connective tissue. 6 is a deposit of calcareous material near
| |
| the wall of a blood-vessel, c and d are slit-like spaces, c is lined with a ribbon of protoplasm showing nuclei scattered fairly evenly throughout it. It is impossible to detect any division of the protoplasm into individual cells. The
| |
| space d is lined with a wide zone of protoplasm showing many nuclei, uniform in size and staining properties, equally
| |
| distributed throughout the protoplasm, e is another slit-like space lined with a ribbon of protoplasm containing
| |
| only a single row of nuclei.
| |
| 42
| |
|
| |
|
| |
|
| |
| 642
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| there crystals lying in the cavity, such as were also found by Bondi. Other portions
| |
| of the tumor show gland-like spaces lined with one or more layers of epithelium
| |
| (Fig. 261). The nuclei of the epithelial cells are oval and vesicular, or are deeply
| |
| staining, and the epithelium itself is of the low cylindric variety. In some places
| |
| the epithelium has proliferated to a moderate extent. The gland arrangement in
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| 5r#
| |
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| |
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| |
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| |
|
| |
| «£*#"
| |
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| |
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| |
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| |
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| |
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| |
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| |
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| |
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| |
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| |
|
| |
| Fig. 261. — Adenocarcinoma op the Urachus. ( X 90diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. The growth at this point bears considerable resemblance to a papillocystoma
| |
| of the ovary; it consists of large and small irregular spaces lined almost exclusively with one layer of cuboid or low cylindric epithelium, a is a very good example of one of the spaces with a projection into it from the side. This space is
| |
| lined with one layer of cuboid epithelium containing relatively round and deeply staining nuclei. These nuclei are
| |
| particularly well seen at 6. The granular contents in the gland-spaces consist of coagulated epithelial secretion. The
| |
| epithelial elements in the left lower part of the picture have to a large extent melted away. The fibrous stroma of the
| |
| growth contains very few nuclei, c is one of the blood-vessels in the stroma. From this picture alone one could not
| |
| tell definitely whether the growth was malignant or not. That it is malignant, however, is definitely settled by a reference to Kig. I'll:',, and also by the fact that at operation metastases were found.
| |
|
| |
|
| |
|
| |
| some places suggests a papillary formation (Fig. 262), and the gland cavities are
| |
| filled with a homogeneous material that takes the eosin stain. The epithelial cells
| |
| at other points are almost flat. There does not seem to be much variation in the
| |
| size of the cells, and such a picture alone would suggest a papillocystoma. At
| |
| other points the epithelium has proliferated markedly, so that we have what
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS.
| |
|
| |
|
| |
|
| |
| 643
| |
|
| |
|
| |
|
| |
| appears to be solid nests; or the epithelium has melted away, as is noted in
| |
| colloid carcinoma.
| |
|
| |
| There is no doubt we are dealing with a multilocular cyst that has become
| |
| malignant. This cyst certainly belongs to a rare type. Of the malignancy, there
| |
| can be no doubt, because metastases in the pelvic peritoneum were noted at operation (Fig. 263). It did not spring from the ovaries, as they were perfectly normal in
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 262. — A Papillary- like Area in an Adexocarcixomatous Cyst of the Urachus. (X 90 diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. The picture is a rather confused one. At a the complex papillary mass is
| |
| seen covered with one layer of cuboid epithelium having round, uniformly staining nuclei. At b are two definite glandlike spaces. At c is a bluntish projection of the stroma into a gland-space, d indicates the stroma, consisting of spindleshaped connective-tissue cells. The gland-spaces are filled with a granular, homogeneous material seen at e. (For the
| |
| appearances of the metastases see Fig. 263.)
| |
|
| |
| size and distant from the growth. Its pedicle, as noted from the history, sprang
| |
| from the top of the bladder. It will further be noted that during the removal of
| |
| the tumor a large part of the peritoneum of the anterior and lateral abdominal walls
| |
| had to be sacrificed. This tumor evidently originated from the urachus.
| |
|
| |
| The mode of origin of the giant-cells has been of especial interest to me. It will
| |
| be noted that these giant-cells have been found almost entirelv in the outer con
| |
|
| |
|
| |
| 644
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| nective-tissue wall of the large cyst, and that the cavities that they line are slitlike. This is particularly well seen in Fig. 258. Furthermore, in the vicinity of
| |
| these slit-like spaces are well-formed giant-cells lying completely surrounded by
| |
| stroma (Fig. 258, b). On examining the space b in Fig. 259, one gathers the
| |
| impression that the tissue has been especially brittle, and that during the process
| |
| of hardening the giant-cells may have split lengthwise; this impression is still
| |
| further strengthened by examining the area c in Fig. 259. Here the protoplasm
| |
| has apparently been split up into several long strands. At the upper end of this
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 263. — Metastasis from Adenocarcinoma of the Urachus. ( X 90 diam.)
| |
| Gyn.-Path. Nos. 10368 and 10488. o and a are blood-vessels. Scattered throughout the field are nests of epithelial
| |
| cells. Although originally the growth was glandular, the metastases have tended to form solid nests. At 6, however,
| |
| two gland-like spaces can be faintly made out. During the process of hardening the cancerous tissue tended to retract
| |
| from the stroma. This is especially well seen at c. The stroma of the growth showed considerable small-round-cell
| |
| infiltration.
| |
|
| |
|
| |
|
| |
| area there is an intact giant-cell. The finer structure of the giant-cell is well seen
| |
| in Fig. 260, B, d.
| |
|
| |
| In an examination of a large number of ovarian cysts I have never seen a picture
| |
| analogous to the one here depicted. To be sure, in very young dermoid cysts of
| |
| the ovary, giant-cells are the rule, but here they are invariably lining or clinging
| |
| to the walls of small cysts — such giant-cells are the embryonic stages of squamous
| |
| epithelium.
| |
|
| |
| Dr. William H. Welch informed me that he had occasionally seen giant-cells
| |
|
| |
|
| |
|
| |
| MALIGNANT CHANGES IN THE URACHUS.
| |
|
| |
|
| |
|
| |
| 645
| |
|
| |
|
| |
|
| |
| similar to these in the walls of cysts and elsewhere, and suggested that they might
| |
| be foreign-body giant-cells. He further suggested the possibility of their developing around crystals. On careful examination of many giant-cells I found just one
| |
| crystal. This was irregular in form. Whether the giant-cells in this case are foreign-body cells or not I cannot say. This point, of course, is of interest only to the
| |
| pathologist.
| |
|
| |
| Bondi reported a small umbilical cyst of unknown origin. He found quantities
| |
| of giant-cells analogous to those here depicted (Fig. 266), and in his case some of
| |
| the giant-cells surrounded crystals. Although his
| |
| cyst was not malignant, it is of such interest in
| |
| connection with my case that I shall here report
| |
| it somewhat in detail.
| |
|
| |
|
| |
|
| |
| A RARE UMBILICAL CYST.
| |
| Bondi* reports this case from Schauta's clinic.
| |
| The patient was a woman, sixty-two years of age.
| |
| She had had three normal labors. About twenty
| |
| months before coming under observation she
| |
| noticed that the umbilicus was larger than usual,
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| **
| |
|
| |
|
| |
|
| |
| pi.
| |
|
| |
|
| |
|
| |
| :>F
| |
|
| |
|
| |
|
| |
| Fig. 264. — An Umbilical Cyst. (After Bondi.)
| |
| The original tumor was 5 cm. in diameter. The drawing has been
| |
| made from the hardened specimen, which was much contracted. Nearly
| |
| two years before operation the patient had noted an enlargement at the
| |
| umbilicus. The overlying skin was brownish in color, tense, and elastic.
| |
| It was slightly compressible. H is the skin covering the cyst; Nr, the
| |
| confines of the umbilical depression; P, a prolongation of the peritoneal
| |
| cavity into the mass. The walls of the cyst were composed of two layers
| |
| — an outer, consisting of whitish tissue, and an inner, homogeneous zone,
| |
| grayish brown in color. The cyst contents were spongy, yellowish brown,
| |
| and soft. (For the histologic picture see Figs. 265 and 266.)
| |
|
| |
|
| |
|
| |
| Fig. 26.5. — Wall of an Umbilical Cyst.
| |
| (After Bondi.)
| |
| This is a section of the cyst-wall seen
| |
| in Fig. 264. H represents the skin, with
| |
| connective tissue immediately beneath it ;
| |
| B, a dense layer of connective tissue. Rx,
| |
| granulation tissue. In this are areas containing small spaces. These spaces, as seen
| |
| in Fig. 266, are lined with giant-cells. The
| |
| cells in this layer contain blood-pigment.
| |
| The inner surface (F) consists of coarse
| |
| and fine threads of fibrin.
| |
|
| |
|
| |
|
| |
| and that the abdomen had increased in size. She had never noticed a tumor projecting outward beyond the level of the umbilicus.
| |
|
| |
| At operation, at the umbilicus was a tumor 5 cm. in diameter, the skin over it
| |
| being brownish in color. It was tense and elastic, showed no marked fluctuation,
| |
| and was slightly compressible. The abdominal enlargement was due to a multilocular ovarian cyst the size of a man's head, with torsion of the pedicle to the extent
| |
| of 180 degrees; the wall of the cyst was partially necrotic.
| |
|
| |
| * Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 190.5, xxi, 729.
| |
|
| |
|
| |
|
| |
| 646 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| In the hardened specimen the umbilical cyst was 2.5 cm. in diameter. It
| |
| lav over an outward prolongation of the abdominal cavity, much as a cap
| |
|
| |
| would fit (Fig. 264). The walls of the
| |
|
| |
| .v^^T^^- c y s ^ nac * two layers, the outer consist
| |
| ■ > .'!''' "'''•' <. j n g f whitish tissue 2 mm. thick. It
| |
|
| |
| V, ' /Sl'Vi* y&SZ?' "I "".s*' "' was adherent to the skin and to the
| |
| *." 'Mi' 1 ^,^ '' *is*» peritoneum, and the inner zone consisted
| |
| \ ii ^ v -''F~'~' u; $?l£'Z •^N;* of a broad, homogeneous, gray-brown
| |
| H%» . -, - : ^ tissue. The cyst contents were spongy,
| |
| % %\Sj ! /<?^j.- M ?^ ,; l||-: yellowish brown, and soft. Its length
| |
| } » ;f ' "^/v^C — *^^ in the hardened specimen was 2.5 cm.,
| |
| ^ l*^/j§^- '^" "<#^ : f and its greatest thickness, 1.5 cm. The
| |
| v\'%fj|&/^/; )' ^,;f.-."--^'* *£• V outer wall of the cyst consisted of fibrous
| |
| ,Ui ^ ^-^^^'v^^ tissue, which gradually passed over into
| |
| s^- •*'-'* v *|^' the inner, homogeneous lining, consist'* V *'^ ;* 'o» '"■* ing of young fibrous tissue. This gradu"*%t£ j , v-** ally merged into the granulation tissue
| |
| *" **- bx which lined the cavity. The granulation
| |
| fig. 266.— Giaxt-cells in the Wall of an u.mbili- tissue here and there contained blood-pigon i.) ment. Here and there near the inner
| |
|
| |
| Scattered throughout the inner wall of the cyst
| |
|
| |
| (Fig. 26.5) were aggregations of small, siit-iike spaces. surf ace were numerous spaces, often oc
| |
| Some of these are lined with one layer of epithelium, CU lTmg ill groups. These Were regularly
| |
|
| |
| others with giant-cells. The nuclei of the giant-cells .... ,-,-,. __ _ . o^^x
| |
|
| |
| are uniform and fairly evenly distributed throughout lmed With giailt-CellS (t lgS. 265 and 266) .
| |
|
| |
| the protoplasm. j n t nese spaces were crystals showing that
| |
|
| |
| the spaces were not artefacts. Bondi
| |
| says that it was not a dermoid, but a peritoneal cyst, into which a hemorrhage had
| |
| occurred.
| |
|
| |
| It is possible that these giant-cells were foreign-body giant-cells. As already
| |
| pointed out, they bear a marked resemblance to those noted in the malignant cyst
| |
| of the urachus I have just recorded so fully. (See Figs. 258, 259, and 260.)
| |
|
| |
|
| |
|
| |
| LITERATURE CONSULTED ON MALIGNANT GROWTHS OF THE URACHUS AND URACHAL REGION.
| |
|
| |
| Aveling: Brit. Gyn. Jour., 1886-87, ii, 56, 187.
| |
|
| |
| Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 1905, xxi, 729.
| |
|
| |
| Doran, A.: Stanley's Case of Patent Urachus with Observations on Urachal Cysts. St. Bartholomew's Hospital Reports, 1898, xxxiv, 33.
| |
|
| |
| Doran, A. H. G.: Urachal Cyst Simulating Appendicular Abscess; Arrested Development of
| |
| Genital Tract; with Notes on Recently Reported Cases of Urachal Cysts. The Lancet,
| |
| 1909, i, 1304.
| |
|
| |
| Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, N. F., No. 89 (Chir. No. 24), Leipzig, 1894, 519.
| |
|
| |
| Frank, T.: Zur Casuistik der Urachustumoren. Inaug. Diss., Wurzburg, 1893.
| |
|
| |
| Graf, F.: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.
| |
|
| |
| Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch.
| |
| der Heilkunde, 1870, xi, 373.
| |
|
| |
| Koslowski, B. S. : Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir., 1903, lxix, 469.
| |
|
| |
| Rotter: Blasencarcinom kombinirt mit Urachuscyste. Centralbl. f. Chir., 1897, xxiv, 604.
| |
|
| |
| Wolff, C. C. : Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873.
| |
|
| |
|
| |
|
| |
| ==Chapter XXXVIII. Bleeding from the Urachus into the Bladder==
| |
|
| |
| The literature on this subject is a negligible quantity. W. Ramsay Smith *
| |
| reports a case which, although somewhat obscure, may be mentioned here.
| |
|
| |
| The patient, a female infant, was born August 3d. The labor was short, and
| |
| the child brought away with forceps. The cord appeared to be normal. On the
| |
| second night, August 5th, a large quantity of bright-red blood was noticed on the
| |
| infant's binder. It appeared on that night only, and the nurse noticed that it was
| |
| coming not from the cord,- but from the umbilicus at the side of the cord. Two
| |
| days later (August 7th) the child had an attack of diarrhea, and there was a good
| |
| deal of blood in the stools, and it was noticed that this blood was coming from the
| |
| urethra. On August 8th the bleeding was very severe, there being over two teaspoonfuls at a time. The blood always appeared when the bowels moved, but it
| |
| came from the urethra. The diarrhea ceased, and the bleeding stopped on August
| |
| 9th. Smith thought that the bleeding took place from the hypogastrics, and
| |
| escaped to the bladder along the urachus. Ballantyne felt somewhat reluctant
| |
| to accept this explanation, but said that, under the circumstances, it was difficult
| |
| to suggest any that was more satisfactory.
| |
|
| |
| A few years ago, while discussing diseases of the umbilical region with Dr.
| |
| Edward Reynolds, of Boston, he mentioned the fact that on several occasions he
| |
| had noted bleeding from the urachus into the bladder. Later I wrote asking him
| |
| kindly to furnish me with the data he had bearing on the subject. His reply was as
| |
| follows :
| |
|
| |
| "With regard to my recent hematuric case, the patient was a physician about
| |
| thirty-five years old, from whom I removed the appendix about two years ago.
| |
| She came to me on the seventh of February, saying that, after very hard and long
| |
| automobiling over rough country roads a few days before, she had been seized by
| |
| a sudden urgent desire to urinate, and had passed a quantity of bloody urine.
| |
| Since then urination had been normal, but the urine was slightly blood-stained.
| |
| She informed me that she had noticed that the first part of the urine was clear and
| |
| that the blood came with the last few drops. When I first looked into her bladder
| |
| the small amount of urine was clear (she had just emptied it). I inspected the
| |
| trigonum and fundus of a normal bladder carefully in the knee-chest position, and,
| |
| on turning the point of the cystoscope forward, found that in the interval the urine
| |
| had become distinctly pink. I then emptied the bladder thoroughly with the
| |
| evacuator, and saw a small stream of blood flowing from the orifice of the urachus.
| |
| The patient has written me since that the hematuria stopped within forty-eight
| |
| hours after her visit to me, and that there was no recurrence. I told her that I
| |
| thought there was no other treatment than the removal of the urachus; that I
| |
| should not advise that unless the symptoms were persistent; that I should advise
| |
|
| |
| * Smith, W. Ramsay: Obstet. Trans., Edinburgh, 1892-93, xviii, 53.
| |
|
| |
| 647
| |
|
| |
|
| |
|
| |
| 648 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| it if the hematuria were recurrent. I asked her to keep me informed of her progress, and I think that she will do so.
| |
|
| |
| ''This is not my first case of the kind. A good many years ago, when I was
| |
| doing a large out-patient clinic and making a great many cystoscopic examinations,
| |
| I saw a number of cases, I should guess from half a dozen to a dozen, in which minor
| |
| vesical symptoms seemed to be associated with a reddened, eroded condition of the
| |
| vesical mucous membrane immediately about a small orifice in the upper and anterior part of the bladder, which, after some study, I grew to consider as the orifice
| |
| of a patent urachus, and which, on close inspection, I could recognize in a considerable proportion of bladders in which it was not making trouble. I believe that this
| |
| slight anomaly is very common, and that it is a not unimportant lurking-place for
| |
| bacteria in infected bladders. In at least two cases in these old days I saw bleeding
| |
| from this orifice; I think in more than that number, but the conditions of the
| |
| clinic made careful record keeping very difficult. I should say that the hematuria
| |
| was transient but recurrent. I do not know the ultimate outcome. The patients
| |
| in that clinic were all of a class which it is difficult to follow up afterward."
| |
|
| |
| Dr. Reynolds' observation clearly demonstrates that in some cases blood does
| |
| escape from the persistent urachus into the bladder. His suggestion that the
| |
| urachal opening is probably the lurking-place of bladder infections is fully borne
| |
| out by the cystitis frequently noted where a partially patent urachus exists.
| |
|
| |
|
| |
|
| |
| 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.
| |
|
| |
| 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)
| |
|
| |
| * Briddon, C. K., and Eliot, E.: Med. and Surg. Reports, Presbyterian Hospital, New York,
| |
| January, 1900, iv, 30.
| |
|
| |
| 649
| |
|
| |
|
| |
|
| |
| 650 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| 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.
| |
|
| |
|
| |
|
| |
| TUBERCULOSIS OF THE PATENT URACHUS. 651
| |
|
| |
| "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.
| |
|
| |
|
| |
|
| |
| 652
| |
|
| |
|
| |
|
| |
| THE UMBILICUS AND ITS DISEASES.
| |
|
| |
|
| |
|
| |
| 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
| |
|
| |
| * Eastman, Joseph Rilus: Amer. Jour, of Obstetrics, 1915, lxxii, 640.
| |
|
| |
|
| |
|
| |
| TUBERCULOSIS OF THE PATENT URACHUS.
| |
|
| |
|
| |
|
| |
| 653
| |
|
| |
|
| |
|
| |
| 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.
| |
|
| |
|
| |
|
| |
| a
| |
|
| |
| •1
| |
|
| |
|
| |
|
| |
| b
| |
|
| |
|
| |
|
| |
| x
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| d c
| |
|
| |
| Fig. 26S. — 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
| |
|
| |
|
| |
|
| |
| 654 THE UMBILICUS AND ITS DISEASES.
| |
|
| |
| 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
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
| Fig. 269. — A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus.
| |
|
| |
| This L= 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.
| |
|
| |
| symptoms of any kind relating to the genitourinary organs; there is no evidence of
| |
| return of the disease."
| |
|
| |
|
| I wrote Dr. Eastman asking if he could send me sections of the urachus. This
| | # [[:File:Cullen1916 plate01.jpg|Drawings of Normal Umbilici]] |
| he promptly did. An examination of them shows the following:
| | # [[:File:Cullen1916 plate02.jpg|Drawings of Normal Umbilici]] |
| | # [[:File:Cullen1916 plate03.jpg|Drawings of Normal Umbilici]] |
| | # [[:File:Cullen1916 plate04.jpg|Drawings of Normal Umbilici]] |
| | # [[:File:Cullen1916 plate05.jpg|Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary]] |
| | # [[:File:Cullen1916 plate06.jpg|Umbilical Hernia]] |
| | # [[:File:Cullen1916 plate07.jpg|Exstrophy of the Bladder]] |
|
| |
|
| 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
| | {{Cullen1916 footer}} |
| of tuberculosis of the urachus.
| | [[Category:Draft]] |
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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Pages where the terms "Historic" (textbooks, papers, people, recommendations) appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms, interpretations and recommendations may not reflect our current scientific understanding. (More? Embryology History | Historic Embryology Papers)
|
Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus
By
Thomas Stephen Cullen
Associate Professor of Gynecology in the Johns Hopkins University
Assistant Visiting Gynecologist to the Johns Hopkins Hospital
Illustrated By
Max Brodel
W. B. Saunders Company, Philadelphia And London, 1916
This book is affectionately dedicated to my Mother Mary Cullen
Daughter of the late Rev. Thomas and Mary Greene
Born on July 12, 1841, at Polminick, near
Penzance, Cornwall, England
Preface
During the summer of 1904 I saw a case of cancer of the umbilicus with Dr.
Jacob L. Winner. Up to that time I had thought that hernia was practically the
only lesion to be noted in this locality. The patient did well for a time, but later
large intra-abdominal tumors could be felt and finally he died. Xo autopsy was
obtained. Histologic examination of the umbilical growth showed that it was an
adenocarcinoma.
I was at a loss to explain the presence of glands in this position, and a cursory
examination of the text-books failed to elucidate the matter. I could not rid myself of the desire to find out definitely just how an adenocarcinoma could exist in the
umbilicus, and several years later, when other and more pressing problems had been
completed, I carefully searched the literature for cases of cancer of the umbilicus
and was amazed to find the records of many instances.
In the majority of the cases the umbilical growth was secondary to a cancer of
the stomach, gall-bladder, intestine, or ovary. Cases of primary adenocarcinoma
and of squamous-cell carcinoma of the umbilicus occur, but they are very rare.
During this study I encountered a wealth of material dealing with the omphalomesenteric duct. We have long been familiar with Meckel's diverticulum, but two
facts, that the omphalomesenteric duct may be patent throughout its entire extent
at birth, and that remnants of the outer end of the duct may give rise to the small
umbilical polyps sometimes noted after the cord drops off, have not been commonly
appreciated.
The literature is rich in records of devastating infections that prevailed before the
era of asepsis. These occurred generally in hospitals, and most often when an epidemic of puerperal sepsis was rampant among the mothers. The descriptions of
some of them are intensely graphic, and from the detailed reports of the individual
cases one can obtain a wonderful picture of the terminal infections occurring in these
infants.
I found a somewhat extensive literature on dermoids of the umbilicus, but on
analyzing the cases was obliged to conclude that the majority of these growths
represented nothing more than inflammations due to irritation exerted by an umbilical concretion. It was the presence of caseous material and the admixture of
wool from the patient's clothing that had led to the erroneous diagnosis.
I found records of cases of Paget's disease, diphtheria, and syphilis of the umbilicus. There is also an extensive literature on the escape of intra- and extraabdominal fluid, usually pus, through the umbilicus, and many cases of umbilical
fistula are recorded.
Many umbilical tumors have been reported, some benign, others malignant.
I was especially interested in one group of cases. These tumors were small; they
always occurred in women; they tended to swell at the menstrual period, and some urachus have been collected, the cases classified, and the appropriate methods of
treatment outlined. I trust that this work may help the general practitioner, the
pediatrician, and the surgeon to treat more satisfactorily lesions of this heretofore
relatively unknown region, unknown, although up to the daj r of birth it is on the
main highway between the mother and the child.
Thomas S. Cullen.
The Johns Hopkins Hospital, May, 1916.
Contents
- Embryology of the Umbilical Region
- Anatomy of the Umbilical Region
- Umbilical Infections in the New-born
- Umbilical Hemorrhage
- Granulation Tissue or Granuloma of the Umbilicus
- Remnants of the Omphalomesenteric Duct
- Congenital Polyps; Fistul.e or Cystic Dilatations at the Umbilicus; with a Mucosa More or Less Similar to that of the Pyloric Region of the Stomach, and Secreting an Irritating Fluid Bearing a Marked Resemblance to Gastric Juice. Persistence of the Outer Portion of the Omphalomesenteric Duct
- Meckel's Diverticulum
- Intestinal Cysts
- A Patent Omphalomesenteric Duct
- The Patent Omphalomesenteric Duct (continued)
- Prolapsus of the Bowel through a Patent Omphalomesenteric Duct
- Cysts in the Abdominal Wall Due to Remnants of the Omphalomesenteric Duct
- Persistence of the Omphalomesenteric Vessels
- Umbilical Concretions Associated with Inflammatory Changes in the Abdominal Wall
- Abscess in the Subumbilical Space
- Paget's Disease of the Umbilicus
- Diphtheria of the Umbilicus . Syphilis of the Umbilicus; Tuberculosis of the Umbilicus; Atrophic Tuberculid commencing at the Umbilicus
- The Escape of Retroperitoneal and Abdominal Fluid from the Umbilicus; the Opening of an Appendix Abscess at the Umbilicus. Abscess of the Liver Opening at the Umbilicus; Peritonitis with the Escape of Pus from the Umbilicus; the Piecemeal Removal of a Suppurating Ovarian Cyst through the Umbilicus
- Fecal Fistula at the Umbilicus
- The Escape of Round Worms from the Umbilicus
- The Escape of Various Foreign Substances from the Umbilicus
- Umbilical Tumors
- Adenomyoma of the Umbilicus
- Carcinoma of the Umbilicus
- Sarcoma of the Umbilicus
- Umbilical Hernia
- The Urachus
- Congenital Patent Urachus
- Remnants of the Urachus
- Urachal Remnants Producing Tumors between the Umbilicus and Symphysis
- Large Urachal Cysts
- Abscesses in the Anterior Abdominal Wall between the Umbilicus and Symphysis Due to Infection of Urachal Remains or of Urachal Cysts
- Urachal Cavities between the Symphysis and Umbilicus Communicating with the Bladder or Umbilicus or with Both
- Acquired Urinary Fistula at the Umbilicus
- Urachal Concretions and Urinary Calculi Associated with Urachal Remains
- Malignant Changes in the Urachus
- Bleeding from the Urachus into the Bladder
- Tuberculosis of the Patent Urachus
List of Illustrations
Figures
1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois
2. A More Advanced Stage in the Formation of the Umbilical Region
3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo
4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Showing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk
5. Sagittal View of a Human Embryo 5 mm. in Length
6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing the Umbilical Region
7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length
8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length
9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in Length
10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length
11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length
12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm. Long
13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length
14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm in Length as Viewed from within the Abdomen
15. Sagittal View of a Graphic Reconstruction of the Umbilical Region of a Human Embryo 5.2 cm. in Length 15
16. Intra-abdominal View of the Umbilical Region of a Human Embryo 6.5 cm. in Length
17. Intra-abdominal View of the Umbilical Region in a Human Embryo 7.5 cm. Long
18. Intra-abdominal View of the Umbilical Region in a Human Embryo 9 cm. in Length
19. Intra-abdominal View of the Umbilical Region in a Human Embryo 10 cm. in Length
20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long
21. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in Length
22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in Length
23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm. in Length
24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long
25. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others
26. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others
27. A Composite Representation of Abnormal Umbilical Structures, Based on the Work of Keibel, Lowy, and Others
28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left
29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven Months
30. Three Diagrams of the Umbilical Ring and Its Significance in the Development of Ventral Hernia
31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the Embryo 5.5 cm. Long
32. The Umbilical Region, the Cord, and the Placenta at Term
33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term
34. Normal Umbilicus according to Catteau
35. A Type of Umbilical Region in the Adult, Viewed from Within
36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within
37. The Umbilical Region of an Adult, Viewed from Within
38. Classic Type of Umbilicus
39. Disposition of the Vascular Cords (Usual Type)
40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases
41. Vascular Cord Type, Noted 5 Times in 50 Cases
42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical Ring
43. Vascular Cords, Noted 3 Times in 50 Cases
44. Vascular Cords, Noted in 2 out of 50 Cases
45. Umbilical Fascia. Peritoneum in Place
46. Umbilical Fascia and Umbilical Mesentery
47. Reduplication of the Linea Alba. Peritoneum Removed
48. Atrophy of the Umbilical Fascia, Posterior View
49. Formation of a Mesentery. Peritoneum in Place
50. Mesentery of the Urachus and of the Umbilical Arteries
51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place
52. Adipose Fringes in a Stout Subject. Peritoneum in Place
53. Peritoneal Diverticula. Peritoneum in Place
54. Peri-umbilical Fossettes. Peritoneum in Place
55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Abdominal Wall
56. Extra-abdominal Multilocular Fibrocystoma of the Ovary
57. An Extra- abdominal Multilocular Fibrocystoma
58. Superficial Lymphatics of the Umbilical Region
59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side
60. The Umbilical Vessels about the Time of Birth
61. The Umbilical Vessels in the Adult
62. 63. Method of Treating the Umbilical Stump at Birth
64. Nature's Method of Checking Bleeding from the Umbilical Arteries
65. An Umbilical Granulation
66. The Gradual Atrophy of the Omphalomesenteric Duct
67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord
68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord
69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia
70. A Polypoid Outgrowth from the Umbilicus
71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70
72. A Diverticular Tumor at the Umbilicus
73. A Glandular Tumor from the Umbilicus
74. A Glandular Growth at the Umbilicus
75. Section in the Long Axis of a Small Umbilical Growth
76. Adenoma of the Umbilicus
77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord
78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord
79. An Umbilical Polyp
80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression
81. An Umbilical Polyp
82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression
83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus
84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Resembling those of the Pylorus
85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach
86. Appearance of the Umbilical Depression in von Rosthorn's Case
87. Gastric Mucosa at the Umbilicus
88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in Fig. 87
89. Persistence of the Outer End of the Omphalomesenteric Duct
90. Atrophy of the Inner End of the Omphalomesenteric Duct
91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct
92. Meckel's Diverticulum
93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus
94. An Abnormally Large Meckel's Diverticulum
95. A Meckel's Diverticulum with a Lobulated Extremity
96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface
97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment
98. An Accessory Pancreas in the Tip of Meckel's Diverticulum
99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel
100. A Diverticulum Tying Off a Loop of Small Bowel
101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum
102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a Hole in the Mesentery of a Meckel's Diverticulum
103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel
104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary
105. An Intestinal Cyst
106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected with the Bowel
107. Volvulus of Meckel's Diverticulum
108. An Intestinal Cyst Developing from Meckel's Diverticulum
109. Intestinal Cysts in the Abdominal Cavity
1 10. An Intramesenteric Cyst
111. A Patent Omphalomesenteric Duct
112. A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus
113. A Very Short Omphalomesenteric Duct
114. A Patent Omphalomesenteric Duct with a Polyp-like Formation at the Umbilicus
1 15. A Patent Omphalomesenteric Duct
116. A Patent Omphalomesenteric Duct
117. A Patent Omphalomesenteric Duct
118. A Patent Omphalomesenteric Duct
119. A Patent Omphalomesenteric Duct
120. A Patent Omphalomesenteric Duct
121. A Patent Omphalomesenteric Duct
122. Part of a Patent Omphalomesenteric Duct
123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Omphalomesenteric Duct
124. An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Originally a Patent Omphalomesenteric Duct
125. Longitudinal Section through the Entire Center of a Partially Closed Omphalomesenteric Duct
126. A Patent Omphalomesenteric Duct
127. A Patent Omphalomesenteric Duct Opening at the Base of the Umbilical Cord
128. A Patent Omphalomesenteric Duct
129. A Patent Omphalomesenteric Duct as Seen from the Abdominal Cavity
130. Inversion of the Bowel through a Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord
131. A Patent Omphalomesenteric Duct of Large Diameter
132. Commencing Prolapsus of Small Bowel through a Patent Omphalomesenteric Duct
133. Partial Prolapsus of the Small Bowel through the Omphalomesenteric Duct
134. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct
135. Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct
136. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and an Umbilical Hernia between the Loops of Prolapsed Bowel
137. Prolapse of the Small Bowel through an Open Omphalomesenteric Duct
138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct
139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Secondary Complications
140. Prolapsus and Inversion of the Intestine through a Patent Omphalomesenteric Duct
141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct
142. A Small Cyst of the Umbilicus Due to a Remnant of the Omphalomesenteric Duct
143. Small Cyst of the Abdominal Wall Due to a Remnant of the Omphalomesenteric Duct
144. A Small Intestinal Cyst Lying between the Peritoneum and the Recti
145. An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord
146. A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction
147. A Small Umbilical Concretion
148. Acute Inflammation of the Umbilicus Due to an Accumulation of Sebaceous Material
149. Cholesteatoma from the Umbilicus in Case 1
150. Cholesteatoma from Case 2
151. A Connective-tissue Projection Really Representing a Small Fibroma in the Floor of the Umbilicus
152. Enlargement of Fig. 151
153. Subumbilical Phlegmon
154. The Subumbilical Space
155. Paget's Disease of the Umbilicus
156. Paget's Disease of the U/mbilicus
157. Paget's Disease of the Umbilicus
158. Paget's Disease of the Umbilicus
159. The Appearance in a Case of Paget's Disease of the Umbilicus After Treatment with Radium
160. Syphilis of the Umbilicus
161. Atrophic Tuberculid Starting at the Umbilicus
162. Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket
163. The Manner in Which a Periprostatic Abscess may Occasionally Rupture at the Umbilicus
164. Escape of Pleural Fluid from the Umbilicus
165. The Opening of a Broad Ligament Abscess at the Umbilicus
166. Abdominal Pregnancy with Spontaneous Escape of Liquor Amnii from the Umbilicus
167. Small Papilloma in the Umbilical Depression
168. A Shall Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine Mucosa
169. Glands from a Small Umbilical Tumor
170. Typical Uterine Mucosa in a Small Umbilical Tumor. An Enlargement of Area B in Fig. 168
171. Glands in a Small Umbilical Tumor
172. Dilated Glands in a Small Umbilical Tumor
173. Dichotomous Branching of Glands in a Small Umbilical Tumor
174. Uterine Glands in an Umbilical Tumor
175. Gland Hypertrophy in a Small Umbilical Tumor
176. A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands
177. Uterine Mucosa in an Umbilical Tumor
178. A Small Umbilical Tumor Containing Numerous Glands
179. Glands in a Small Umbilical Tumor
180. An Adenomyoma in the Abdominal Wall Near the Anterior Iliac Spine
181. A Small Umbilical Tumor Containing Glands Similar to Those of the Body of the Uterus
182. Adenomyoma of the Umbilicus
183. A Group of Sweat-glands in an Umbilical Tumor
184. Appearance of the Carcinomatous Umbilicus After Removal
185. Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries
186. A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth
187. Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth
188. Adenocarcinoma of the Umbilicus
189. A Section Showing Carcinoma of the Right Inguinal Glands
190. Secondary Carcinoma of the Umbilicus
191. Telangiectatic Myxosarcoma of the Umbilicus
192. Appearance of the Umbilicus After Removal of the Tumor Shown in Fig. 191
193. Myxosarcoma of the Umbilicus
194. Telangiectatic Myxosarcoma Projecting from the Right Side of the Umbilicus
195. A Telangiectatic Myxosarcoma
196. A Case of Congenital Umbilical Hernia
197. An Amniotic Hernia
198. Several Loops of Bowel Which Lay Outside the Umbilicus and were Nipped Off During Fetal Life. The Child Lived a Short Time After Birth
199. A Serous Umbilical Hernia
200. Freeing the Umbilical Hernial Sac from the Abdomen
201. Closure of the Hernial Opening at the Umbilicus
202. Closure of the Hernial Opening at the Umbilicus
203. An Umbilical Hernia Associated with Marked Prolapsus of the Abdominal Wall
204. An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds
205. The Abdominal Scar After the Removal of a Very Large Area of Fat
206. An Umbilical Cyst
207. Exstrophy of the Bladder Opening at or Near the Umbilicus
208. Exstrophy of the Bladder. A side View of the Case Depicted in Fig. 207, Showing the Relative Distance from the Symphysis to the Opening in the Abdominal Wall
209. Exstrophy of the Bladder
210. Escape of Urine from the Umbilicus When the Inner Urethral Orifice Is Blocked by a Membrane
211. A Patent Urachus with a Mushroom-like Projection at the Umbilicus
212. A Patent Urachus with a Penile Projection at the Umbilicus
213. The Appearance of the Umbilicus in a Case in Which both a Patent Omphalomesenteric Duct and a Patent Urachus Existed
214. Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same Child
215. A Picture of the Child Three Weeks After Removal of a Patent Omphalomesenteric Duct and a Patulous Urachus
216. A Patent Urachus
217. A Urachus Open from Bladder to Umbilicus
218. An Open Urachus
219. Escape of Urine from the Umbilicus Due to a Patent Urachus
220. A Patent Urachus with a Penile Projection at the Umbilicus
221. A Ring-shaped Vesical Calculus with a Fine Hair in Its Axis
222. A Partially Patent Urachus
223. A Patent Urachus
224. A Portion of a Urachus Seven Times Enlarged, with Numerous Large and Small Dilatations
225. Portion of a Urachus Ten Times Enlarged
226. Cysts of the Urachus Arranged Like a String of Pearls
227. Spindle-Shaped Dilatations of the Urachus
228. A Small Cyst of the Urachus
229. A Patent Urachus
230. A Multilocular Cyst of the Urachus
231. Section of a Patent Urachus
232. Transverse Section of a Patent Urachus
233. A Small Cyst of the Urachus
234. A Diffuse Neuroma of the Bladder
235. Cut Surface of the Bladder Showing a Diffuse Neuroma of Its Walls
236. A Diffuse Neuroma Forming a Mantle Around the Cavity of the Bladder
237. Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus
238. Section of the Segment of Urachus Which Passed between the Bladder and the Cyst- wall, as Seen under a Low Power 552
239. The Abdominal Contour in a Case of Very Large Urachal Cyst
240. A Urachal Cyst Turned Inside Out and Showing Papillary Masses, Particularly in the Lower Part of the Picture 559
241. Infected Urachal Remains
242. An Infected Urachus Opening between the Umbilicus and Bladder
243. Urachal Cyst
244. A Dilated Urachus Communicating with the Bladder
245. Large Accumulation of Urine in a Partially Patent Urachus
246. An Infected Urachus Opening at the Umbilicus
247. A Patent Urachus Dilated in Its Middle Portion
248. Accumulation of a Large Quantity of Urine in a Urachal Pouch
249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac
250. A Phosphatic Deposit on the End of a Long Bone
251. A Dilated Urachus Communicating with the Bladder
252. Urachal Cyst
253. Urachal Cyst
254. Urachal Cyst
255. A Patent Urachus Containing a Vesical Calculus
256. Carcinoma of the Patent Urachus
257. A Multilocular and Malignant Cyst of the Urachus
258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus
259. Giant-cells in the Wall of an Adenocarcinoma of the Urachus
260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus
261. Adenocarcinoma of the Urachus
262. A Papillary-like Area in an Adkxocarcinomatous Cystofthe Urachus
263. Metastasis from Adenocarcinoma of the Urachus
264. An Umbilical Cyst
265. \\ aj.i of an Umbilical Cyst
266. Giant-cells in the Wall of an Umbilical Cyst
267. Tuberculosis of the Urachus
268. An Area Suggesting a Tubercle
269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus
List of Plates
List of Plates
- Drawings of Normal Umbilici
- Drawings of Normal Umbilici
- Drawings of Normal Umbilici
- Drawings of Normal Umbilici
- Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary
- Umbilical Hernia
- Exstrophy of the Bladder
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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Cite this page: Hill, M.A. (2024, June 5) Embryology Book - Umbilicus (1916). Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_Umbilicus_(1916)
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