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

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

Small urachal cysts; Historic sketch; Report of cases. Personal observations on small cysts of the urachus.

Remnants of the urachus may become distended, producing small or large cysts, which may or may not become infected. Some of them are directly connected with the bladder or with the umbilicus or with both. For convenience I have made the following tentative classification. Some overlapping, of course, is inevitable.


(1) Small urachal cysts.

(2) Large urachal cysts.


Non-infected. Infected.

(3) Urachal cavities lying between the symphysis and umbilicus and communicating with the bladder or umbilicus or both.


SMALL URACHAL CYSTS.

Small urachal cysts naturally give rise to no clinical symptoms, hence they are recognized only when the abdomen is opened for some intra-abdominal lesion or at autopsy. It is not to be wondered at, therefore, that the literature on the subject is very meager.

As has been said before, Luschka concludes that large cystic tumors of the anterior abdominal wall needing surgical interference develop, and that these tumors originate from the urachus.

Veiel, in 1862, in his dissertation on the Metamorphosis of the Urachus, cites the findings in the body of a man forty-five years of age. Passing downward from the umbilicus was a delicate cord 1 mm. broad. About 3 cm. above the bladder it grew larger, so that at the top of the viscus it was 1.2 cm. thick. At this point it was covered with a thick layer of bladder muscle. The urachus could be divided into four sections — the lowest (part 1), which was open, was 14 mm. long. In the middle it was somewhat smaller, but at each end it was 2 mm. thick. Part 2 was 7 mm. long and was closed and thread-like. Part 3 was 8 mm. long, was open, and about 1 mm. thick. Part 4 was closed and thread-like. On microscopic examination the upper open portion showed moisture and had a lining of so-called transitional epithelium. After the specimen had been treated with acetic acid, three dilatations of the canal were found. These contained yellowish concretions.

Wutz, in 1883, after reporting his Case 22, in which the urachal cyst contained a firm, stony, hard, yellowish brown, glistening body, described the following case in detail :

Case 24. — The specimen was from a man twenty years old, dead of peri 526


SMALL URACHAL CYSTS. 527

tonitis following a perforated appendix. The distance from the umbilicus to the top of the bladder was 16 cm. The bladder mucosa in the vicinity of the trigonum was diffusely reddened, and on its surface were a few blood and pus corpuscles. The bladder was small and drawn out to a point. It was 7.5 cm. in length. In the mucosa of the vertex the opening of the urachal canal had a diameter of 2 mm. ; 2.5 cm. above the bladder was a cyst 1.5 cm. long, 0.8 cm. broad, and attached to the side of the urachus; into it a sound could be passed from the urachus. About 3 mm. above this cyst were several smaller ones, some reaching the size of a pin-head. Wutz said that a probe could be passed into the urachal canal for a distance of 4.3 cm. The large cyst was filled with clear yellow fluid, which contained albumin and mucin. Microscopic examination showed polymorphous epithelium, pus-cells, and red blood-corpuscles. In the smaller cyst the epithelium was normal and there was no evidence of pus-cells.

Wutz (p. 404) sums up the results of his observations of the urachus and urachal cysts as follows:

1. All the observed cysts have been located in the lower fourth or lower third of the distance from the urachus to the top of the bladder, and originated from the normally persistent portion of the urachus.

2. In the majority of the cases they were lined with several layers of flat epithelium.

3. The cysts had a more or less strongly developed covering of smooth musclefibers.

4. The size of the cysts varied from that of microscopic objects to that of a large bean.

5. Laminated bodies contained in the cyst fluid did not stain blue with iodin, but yellow, and they did not consist of amyloid substance.

6. Concretions in the canal of the urachus or in the urachal cysts were of rare occurrence, and then reached only a small size.

7. Urachal cysts were sometimes the seat of inflammatory changes.

Morestin, in 1900, reported a case in which two small urachal cysts were discovered between the muscle and peritoneum during an abdominal operation for a left pus-tube. They were too small to be recognized before operation. They were arranged one above the other, but were independent. The cord of the urachus passed from the summit of the bladder and disappeared in the lower cyst. It was again recognized above the upper cyst, and could be followed to the umbilicus. The peritoneum was loosely attached to the cysts. The cysts were globular, smooth, transparent, of a bluish tinge, and contained a limpid, colorless fluid. Their inner surfaces were smooth and presented a serous aspect. There was an outer covering of connective tissue and an inner lining of flattened epithelium. These cysts manifestly had originated from the urachus.

Wyss, in 1870, under the title of "A Cyst Near the Umbilicus," reported his findings at autopsy. Between the peritoneum and muscle, a little to the side of the linea alba, and about one inch above the umbilicus, was a cyst the size of a bean. It contained turbid, tenacious mucus, grayish yellow in color. It was lined with cylindric epithelium. Wyss thought that the cyst had resulted from embryonic remains.

The location of the cyst, the changes in the epithelium, and the cyst contents strongly suggest that it had originated from remnants of the omphalomesenteric duct.


528 THE UMBILICUS AND ITS DISEASES.

Opitz. in his article on Urachal Cysts published in 1905, referred to a cyst of the abdominal wall and said that it looked like an appendix; that it was lined with one layer of low epithelium, and was surrounded by a circular layer of muscle, outside of which was a longitudinal muscular layer. From the description it is impossible to get a clear idea of the case.

Caruso, when operating on a woman forty-two years old for removal of a myoma, noted a small cyst at the level of the umbilicus. This was lined with cuboid epithelium. He also noted tubular glands and non-striped muscle. The location of this cyst would throw some doubt upon its urachal origin, and the presence of tubular glands suggests that it may have originated from remains of the omphalomesenteric duct or from uterine glands at the umbilicus.

Weiser, in his article, says that he received personal letters from Wm. J. Mayo, Nicholas Senn, Edwin Martin, W. A. Smith, Roswell Park, J. F. Erdmann, Howard A. Kelly, DeForest Willard, and from E. Wyllys Andrews, saying that they had personally encountered instances of cysts of the urachus.

From the foregoing it is seen that small urachal cysts are found between the bladder and umbilicus, and that they lie between the muscles and peritoneum of the anterior abdominal wall. There ma3 r be only one cyst or several in a row. They may be minute or reach a centimeter or more in diameter. They have thin walls, and may be transparent or translucent. Their inner surfaces are smooth. They are lined with transitional or cylindric epithelium. The cyst fluid contains albumin, mucin, and exfoliated epithelium, and sometimes polymorphonuclear leukocytes and red blood-cells. They are merely dilatations.

Wutz's observations on small urachal cysts are the most complete that we possess. It will be of interest to glance through the 22 cases that he has recorded.

Case 1 . — A nineteen-j^ear-old boy had had a right-sided otitis media. The urachus was the seat of several small cystic dilatations, some of which communicated with one another.

Case 2 . — A girl, twenty years of age, died of tuberculous peritonitis. The distance of the umbilicus from the vertex of the bladder was 20 cm. The length of the epithelial tube was 3.6 cm. The latter terminated in five transparent cysts the size of pin-heads.

Case 3"" — A twenty-three-year-old man died of pulmonary tuberculosis. The distance from the umbilicus to the vertex of the bladder was 17 cm., and the length of the epithelial tube, 4 cm.

The latter ran straight, could be sounded, and terminated in three cysts the size of millet-seeds.

Case 4 . — A woman, twenty-four years of age, died of pulmonary tuberculosis. The distance from the umbilicus to the top of the bladder was 26.5 cm. At a point 3.7 cm. from the bladder, lying on the left side and communicating with the canal,' was a cyst the size of a pea.

fas e 5 . — The woman, twenty-seven years of age, was suffering with "sarcomatous struma." The distance from the umbilicus to the vertex of the bladder was 20.8 fin. About 0.5 cm. above the vertex, on the side, was a transparent cyst the size of a millet-seed.

Case 6 . — The patient was a woman, thirty-one years of age, with pulmonary tuberculosis. The distance from the vesical vertex to the umbilicus was 17 cm. The epithelial tube could he sounded, the probe passing directly upward. In the


SMALL URACHAL CYSTS. 529

middle of its course the tube was obstructed, but the canal again appeared and terminated in a small cyst, conic in form, and almost 1 mm. long.

Case 7 . — The patient was a man, thirty-six years of age, who had pulmonary tuberculosis. The distance from the umbilicus to the vertex of the bladder 1 was 15.5 cm. The length of the epithelial tube was 4.4 cm. At a point 0.75 mm. from the top of the bladder was a spindle-like dilatation, 0.71 mm. long and 0.1 mm. broad.

Case 8 . — A man, thirty-eight years of age, died of tuberculosis. The distance from the umbilicus to the vertex was 25 cm. The length of the epithelial tube was 0.7 cm. At a point 3 mm. from the vertex of the bladder was a spindlelike dilatation varying from 1.5 to 0.42 mm. in diameter. About 1 mm. from this was a second, 2 mm. long, 0.67 mm. broad.

Case 9 . — The subject was a woman, thirty-nine years of age, dead of cerebral hemorrhage. The distance from the umbilicus to the vertex was 20.5 cm. The length of the epithelial tube was 4.3 cm. At a point 2.5 cm. above the vertex of the bladder was a dilatation 3.5 x 1.5 mm., filled with a yellowish, crumbly material.

Case 10. — The subject was a woman forty years of age, dead of tuberculous cerebrospinal meningitis. The distance from the umbilicus to the vertex of the bladder was 18.8 cm., and the length of the epithelial tube was 1.9 cm. About 1 cm. above the vertex of the bladder were two cysts attached to the left side of the tube. The first was roundish and measured 0.54 x 0.3 mm. The second was 0.63 x 0.49 mm. Scattered throughout the entire length of the tube were numerous small dilatations. These were somewhat pedunculated, and were situated on all sides of the tube.

Case 11. — The man, forty-three years of age, had died of delirium tremens. The distance from the umbilicus to the vertex of the bladder was 20 cm. The length of the epithelial tube was 5.6 cm. In the bladder mucosa there was a distinct groove. At a point 3.5 cm. above the bladder were three nipped-off cysts the size of millet-seeds. A short distance from the bladder the tube contained an oval body, 0.17 x 0.1 mm. This was brownish in color and homogeneous in consistence. In the further course of the tube were several diverticula and nipped-off cysts of various forms, filled with firm brown contents.

Case 12. — The man, forty-three years of age, had died of pachymeningitis. The distance from the umbilicus to the vertex of the bladder was 12 cm. Projecting from the top of the bladder were two small cystic dilatations.

Case 13. — A woman, forty-three years old, had died from degeneration of the heart. The distance from the umbilicus to the base of the bladder was 15 cm. The epithelial tube was 5.4 cm. long. The tube showed four spindle-shaped cysts; the largest was 1.5 cm. above the vertex of the bladder and measured 6x2 mm.

Case 14. — The man, forty-five years of age, had died of pulmonary tuberculosis. The distance from the umbilicus to the vertex of the bladder was 16 cm. The length of the epithelial tube was 5 cm. At a point 3 mm. above the top of the bladder was a cyst the size of a millet-seed, with a second the size of a pin-head on the top of it. The tube passed for a distance of 3 cm. and terminated with three cysts resembling a string of pearls. Besides these were numerous round, oval cysts, recognized microscopically.

Case 15. — The man, sixty-five years of age, had died of typhoid fever. 35


530 THE UMBILICUS AND ITS DISEASES.

The distance from the umbilicus to the vertex of the bladder was 26 cm. The length of the epithelial tube was 5.5 cm. From the top of the bladder the tube passed directly upward and formed at the junction of the lower middle third a beautifully spindle-shaped cyst, not nipped off. This was 1.6 mm. long and 0.4 mm. broad. Above this point the tube showed numerous diverticula extending as far up as 3 cm. Here there was a broad-based cyst projecting from the right side. It was oval and measured 2.16 x 1.62 mm. These cysts were filled with lumps of brownish yellow material.

Case 16. — The man, sixty-one years of age, had died of pachymeningitis with hemorrhage. The distance from the umbilicus to the vertex was 19 cm. The length of the epithelial tube was 3.1 cm. It showed diverticula and cysts. They were arranged in groups around the canal, and at first sight suggested acinous glands.

Case 17. — The woman, sixty-six years old, had died of an incarcerated hernia. The distance from the umbilicus to the vertex of the bladder was 22.5 cm. The length of the epithelial tube was 7.7 cm. Commencing 1 mm. above the top of the bladder were five pearl-like cysts, almost round and transparent. The first, third, and fifth were the size of small peas, while the two between them were as large as millet-seeds. The dilatations opened into one another, and the tube for several centimeters further admitted a fine bristle (Fig. 226, p. 520). The contents were yellowish-white and friable. Commencing 4.8 cm. above the bladder were six cysts of the size of pin-heads containing transparent fluid.

Case 18. — The man, sixty-seven years of age, had died of bronchopneumonia. The distance from the umbilicus to the vertex of the bladder was 16 cm. The epithelial tube was 4.8 cm. long. Situated 4.6 cm. above the bladder was a spindle-shaped cyst, 2x1 mm., with brownish-yellow contents.

Case 19. — The man, sixty-nine years of age, had died of cardiac degeneration. The distance from the umbilicus to the vertex of the bladder was 22.5 cm. The epithelial tube at the bladder had a diameter of 0.3 mm. Beyond this point were three cysts, the largest 10 mm. in diameter. The cysts communicated with one another.

Case 20. — The subject was a man, sixty-five years old, who had had softening of the brain due to an embolus. The distance from the umbilicus to the vertex of the bladder was 21.5 cm. The epithelial tube was 6 cm. long. The mucosa of the bladder at the vertex showed a definite, tent-like depression. Then there was a canal 1.6 cm. long and irregularly dilated. Situated 3 mm. above this was a spindle-shaped dilatation, 2 cm. x 4.5 mm.

Case 21. — The man, seventy-three years old, had died of carcinoma of the esophagus. The distance from the umbilicus to the vertex of the bladder was 19.5 cm. The epithelial tube was 0.6 cm. long. Situated 2 mm. from the vertex were two pin-head-sized, transparent cysts.

Case 22. — The man, seventy-three years old, had died of bronchopneumonia. The distance from the umbilicus to the vertex of the bladder was 16 cm. The epithelial tube was 6.7 cm. long. About 1 cm. from the top of the bladder was a spindle-shaped cyst, 0.7 cm. long and 0.3 cm. broad. Situated 0.3 cm. above this was a second cyst, nearly 2 cm. in length and 4.5 mm. broad (Fig. 227, p. 520).

Wutz in discussing these cysts says that the epithelium taken from the inner surface of the fresh cysts consisted of cells of various forms and sizes. A transverse


SMALL URACHAL CYSTS. 531

section through the cysts showed that they had an epithelial lining, then a structureless membrane, then a delicate connective tissue, and numerous smooth musclefibers were arranged chiefly longitudinally. In the walls were a small number of blood-vessels. The acinous glands described by Luschka were not observed by Wutz. He saw, however, quite frequently the lateral dilatations that gave a picture of a grape-like formation. The cysts contained partly transparent, partly yellowish or yellowish-brown or brownish-red masses. In the first case the contents were fluid, in several of the later ones they were firm. There were numerous fat-crystals, fat-droplets, and free fat, large fat-cells, brownish-yellow amorphous masses, isolated cholesterin crystals, and small, round, strongly glistening bodies.


LITERATURE CONSULTED ON SMALL URACHAL CYSTS. Caruso, F. : Contributo alio studio anatomo-patologico dei tumori cistici dell' ombelico. Atti

della Soc. Italiana di Ost. e Gin., 1901, viii, 293. Luschka, H.: Leber den Bau des menschlichen Harnstranges. Arch. f. pathologische Anat.

und Physiol, u. f. klin. Medicin, 1862, xxiii, 1. Morestin, H.: Kystes de l'ouraque. Bull, de la Soc. anat. de Paris, 1900, lxxv, 1040. Opitz: Verhandl. Deutsche Gesellsch. f. Gyn., Kiel, 1905, xi, 545. Veiel, E.: Die Metamorphose des Urachus. Diss., Tubingen, 1862. Weiser, W. R.: Cysts of the Urachus. Annals of Surg., 1906, xliv, 529. Wutz, J. B.: LTeber Urachus und Urachuscysten. Virchows Arch., 1883, xcii, 387. Wyss, H.: Zur Kenntnis der heterologen Flimmercysten. Virchows Arch., 1870, li, 143.

Personal Observations on Small Cysts of the Urachus.

As far back as 1895 Dr. Kelly was much interested in small urachal remains that from time to time were noted during abdominal operations; and for a year or two he removed portions of the urachus where any thickening was noted. All these I examined histologically. Sometimes the cord itself would show a uniform thickening, as in Case 6902 (Path. No. 3144). Here it varied from 3 to 8 mm. in diameter, and yet on histologic examination there was no evidence of a lumen. The center was composed of longitudinal bundles of non-striated muscle. Surrounding this was fibrous tissue, and external to the latter was a circular muscular layer. This case shows that a large urachal cord does not necessarily mean that the urachus is patent.

A survey of the accompanying cases will show that the cysts varied from some very minute ones to others measuring 1 x 0.9 cm. From our experience it seems that where the urachus appears as a single dilated tube, the duct is usually lined with several layers of transitional epithelium, as in Fig. 229 (Gyn. No. 6792) and Fig. 232 (Path. No. 17025). It may, however, have only a single layer of cylindric epithelium, as seen in Fig. 228 (Gyn. No. 3802).

Occasionally the remnants of the urachus appear as a small multilocular cyst, as noted in Fig. 230 (Gyn. No. 8250). The loculi are lined with cuboid epithelium. It is probable that such small multilocular cysts represent remnants of the acini described by various authors as projecting from the sides of the urachus.

The urachal remains were in every case surrounded by non-striped muscle.

Our experience leads us to believe that remnants of the urachus in the adult are by no means rare.

The small cysts may be filled with colorless fluid. Frequently they contain


532


THE UMBILICUS AND ITS DISEASES.


granular debris which has a yellowish-brown tinge, and swollen and granular exfoliated cells containing brown pigment.

Small Cyst of the U r a c h u s . — Gyn. No. 3802. A. P., aged twenty-five. Admitted November 19, 1895. At operation the uterus was suspended, the perineum repaired, an adherent ovary freed, and a cyst of the urachus removed (Fig. 228).

Path. No. 887. The specimen consists of fat containing a small cord 3 mm. in diameter, 1 cm. long. This ends at the upper end in an oval cyst, 1 x 0.9 cm., which has thin walls and contains clear fluid. This cyst is lined with one layer of cuboid cells, showing oval, uniformly staining nuclei parallel with the cyst-wall. In many places the epithelium appears to be two or three layers in thickness where



Fig. 228. — A Small Cyst of the Urachus. Gyn. No. 3802. Path. No. 887. This cyst measured 1 x 0.9 cm., had thin walls, and contained clear fluid. In the handling, the cyst has been somewhat flattened. It is embedded in adipose tissue, and at either end is seen a fibrous CO rd — the obliterated urachus. The definite cyst-wall is composed of fibrous tissue and non-striped muscle. The cyst was lined with one layer of cuboid cells.


cut on the bias. It is surrounded by fibrous tissue, and a moderate amount of muscle separates it from the surrounding adipose tissue.

Diagnosis: Small cyst of the urachus.

Cyst of Urachus. — Gyn. No. 6722. E. G., aged forty-six. Admitted to the Johns Hopkins Hospital February 27, 1899, with a diagnosis of uterine myoma. Operation: Hysteromyomectomy, excision of a small urachal cyst found lying between the obliterated hypogastric arteries.

Path. No. 2947. The cyst is 8 mm. in diameter. Its walls average 1 mm. in thickness. On histologic examination the little growth is found to consist of clusters of alveoli embedded in connective-tissue stroma, the entire area being surrounded by fat and fibrous tissue. The alveoli vary from a pin-point to 1 mm. in diameter. Some of them undoubtedly communicated with one another. They are lined with cuboid epithelium which is one layer in thickness.

Diagnosis: Cyst of the urachus.


SMALL URACHAL CYSTS. 533

A Partially Patent Urachus. — Gyn. No. 6739. C, aged fortynine. Admitted to Ward B, Johns Hopkins Hospital, March 6, 1899. Operation: Dilatation of the cervix and suspension of the uterus. A portion of the urachus was excised.

Path. No. 2961. The piece removed was 1.8 cm. long and varied from 2 to 3 mm. in thickness. On histologic examination the lumen of the urachus was found to be 1 mm. in diameter. It was lined with transitional epithelium two or three layers in thickness. The nuclei of the epithelial cells were round or oval, and stained uniformly. External to the epithelial lining was a varying amount of muscular and connective tissue, and surrounding the whole was adipose tissue.

A Partially Patulous Urachus. — Gyn. 6778. Mrs. S., admitted to Ward B, Johns Hopkins Hospital, March 2, 1899. During the course of the abdominal operation a portion of the urachus was removed. This piece was 1 cm. long and varied from 2 to 4 mm. in thickness.

Path. No. 3023. The small cord at first suggests a tube. It is tortuous, shows little projections into it; it is lined with one or sometimes two or three layers of epithelium and completely surrounded by non-striped muscle. Situated near the lumen is a small, gland-like space lined with cylinclric cells. Scattered throughout the muscle are quantities of blood-vessels. In many respects it resembles the Fallopian tube more than it does a urachus, but at other points the similarity is not so marked.

A Partially Patent U r a c h u s . — Gyn. No. 6792. G., Ward B. Operation: Hysteromyomectomy, drainage of gall-bladder, excision of a portion of the urachus.

Path. No. 3049. The portion of the urachus removed is in two pieces. The first (a) is 2.5 cm. long, 0.5 cm. in diameter, and removed from a point about 7 cm. above the summit of the bladder, b, the intervening part, is 7 cm. long and 1 mm. in diameter. In the first specimen there is a definite lumen 0.5 mm. in diameter, lined with two or three layers of cells of the transitional type (Fig. 229) . The nuclei are oval or round and stain uniformly. Surrounding the lumen is fibrous tissue, a small number of non-stripecl muscle-fibers, and external to this adipose tissue. There is no doubt that we have here remains of the lumen of the urachus. In the portion near the bladder the lumen has been completely obliterated.

Urachal Remains. — Gyn. No. 6902. M., nineteen years old. Admitted to Ward B, Johns Hopkins Hospital, May 8, 1899. The operation consisted of hysterotomy, curettage, and resection of an ovary, together with excision of a portion of the urachus. The part of the urachus removed was 3.5 cm. long and from 3 to 8 mm. in diameter. These measurements included some of the surrounding adipose tissue.

Path. No. 3144. Microscopically, no trace of the lumen could be made out. In the center was a stroma consisting of bundles of non-striped muscle arranged longitudinally and surrounded by fibrous tissue; external to this again was a circular layer of muscle. In other words, this cord was made up entirely of muscular and fibrous tissue without any sign of a lumen.

A Very Small Multilocular Urachal Cyst. — Gyn. No. 8250. J. W., married, aged twenty-seven. Admitted October 24, 1900. The uterus was suspended for a retroflexion, and a cyst, supposedly of the urachus, was


534


THE UMBILICUS AND ITS DISEASES.


removed. The cyst of the urachus was 3x5 mm. It was translucent and showed irregular, tiny, projections into the cavity, Fig. 230.

Path. No. 4441. The specimen was found to be a multilocular cyst, the loculi being large and small and apparently opening into one another. The epithelium in some places was cuboid. The nuclei of the epithelial cells were oval; they stained uniformly and were arranged parallel with the cyst-wall. Where the tissue was cut on the bevel, the epithelium appeared to be several layers in thickness and suggested squamous epithelium. The stroma between the cysts consisted essentially of non-striped muscle-fibers separating the cyst proper from the sur


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Fig. 229. — A Patent Urachus. Gyn. No. 6792. Path. No. 3049. This portion of the urachus was in the mid-line, about 7 cm. above the bladder. The lumen is slightly irregular and contains some granular detritus. Lining the cavity is transitional epithelium, in some places only as a single layer, but at most points two or three layers thick. Surrounding the lumen is fibrous tissue in which some non-striped muscle was recognized.


rounding fibrous and adipose tissue. This cyst was a remnant of the urachus. Whether the loculi all communicated with one channel or not it is difficult to say.

A Partially Patent Urachus. — Path. No. 3012. This patient was admitted to Dr. Kelly's sanitarium March 7, 1899. The operation consisted of an abdominal myomectomy and excision of the urachus.

Histologic Examination. — The lumen is found narrow and lined with two or three layers of columnar epithelium. External to the epithelium are bundles of longitudinal and circular muscle-fibers. The urachus is pervious.

Probable Cyst of the Urachus. — Gyn. No. 6815. Path. No. 3062. B., twenty-five years old. Admitted to Ward B, Johns Hopkins Hospital, April 8, 1899.


SMALL URACHAL CYSTS.


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Fig. 230. — A Multilocular Cyst of the Urachus. Gyn. No. 8250. Path. No. 4441. This cyst was 3x5 mm. and was translucent. As seen from the upper, lowpower picture, it was composed of numerous loculi. Many of these seemed to communicate with one another. Surrounding the cyst, and separating it from the adipose tissue, is a definite wall. This consisted of fibrous tissue and nonstriped muscle. The small area of the cyst-wall, blocked off and indicated by the arrow, has been enlarged and is seen in the lower picture. The cyst is lined with one layer of cuboid cells.


536


THE UMBILICUS AND ITS DISEASES.


Operation. — Exploratory laparotomy; excision of a small cyst from the anterior abdominal wall just above the symphysis. This cyst contained two small lumina, which appeared to be convolutions of the same tube. Each was lined with two or more layers of transitional epithelium. The nuclei of the epithelial cells were oval and stained uniformly, and the lumen was surrounded b} r nonstriped muscle-fibers arranged circularly. External to these were parallel bundles of non-striped muscle-fibers embedded in fibrous tissue. It seems practically certain that they were remains of the urachus.

A Partially Patent Urachus. — Gyn. Path. No. 17025. While



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Fig. 231. — Section of a Patent Urachus. Gyn. Path. No. 17025. A longitudinal section of a portion of the urachal cord. The tube has evidently been tortuous, thus accounting for the longitudinal and transverse sections of the lumen. (For the high-power picture see Fig. 232.)


collecting the literature on the urachus I found, when operating on Mrs. M. E. at the Church Home and Infirmary, February 28, 1912, a urachal cord that seemed unusually large. Longitudinal sections of this showed elongate, irregular, and round cavities embedded in non-striped muscle and fat. The low-power picture is well shown in Fig. 231. One gathers the impression that the urachus consists of one tortuous and probably slightly branching tube. It will be noted that these spaces have a distinct lining and that some of them are filled with a definite substance. From Fig. 232 we learn that the spaces are lined with transitional epithelium. The contents of the cavities were in the main brownish yellow. The


SMALL URACHAL CYSTS.


537


small oval or spheric masses are swollen, exfoliated cells, which have taken up pigment granules. This was without a doubt a patent and slightly cystic urachus.

A Small Urachal Cyst. — Gyn. No. 21255. N. D., aged twentythree, white, was admitted to the Johns Hopkins Hospital on June 4, 1915, complaining of severe abdominal pain and of backache. She was married and had had one child.



Gyn. Path. No. 1702.5.


Fig. 232. — Transverse Section of a Patent Urachus. The cavity is lined with several layers of transitional epithelium, amount of debris. Surrounding the urachus is non-striped muscle.


It contains a certain


After a careful examination it was found that she had a relaxed vaginal outlet and a retroposed uterus, chronic appendicitis, and gall-stones.

At operation Dr. J. Craig Neel, the resident gynecologist, repaired the perineum, brought up the uterus, removed the appendix, and emptied the gall-bladder of its stones. While making the median abdominal incision to bring up the uterus, he found a small cyst of the urachus in the mid-line (Fig. 233). This cyst was about


538


THE UMBILICUS AND ITS DISEASES.


1 x 1.5 cm. in diameter, and seemed to be filled with clear fluid. The cyst and about 1 cm. of the urachus on each end of it were removed.

Gyn.-Path. No. 21256. Sections from the cyst wall show that it is composed in a large measure of connective tissue with here and there a little non-striped


Obliterated urachus

Josten'or surface of Urachus cyst

faterct urachus



Fig. 233. — A Small Cyst of the Urachus. Gyn. Path. No. 212.56. This cyst was accidentally discovered when a median abdominal incision was being made. The cyst was located at a point midway between the umbilicus and symphysis. It was thin-walled, and above and below was directly continuous with the urachal cord. In the urachus just below the cyst were three slit-like openings — points at which the urachus was apparently still patent. The small drawing in the right upper corner of the picture shows the cyst after removal. The urachus above was obliterated; below, it was patent for a short distance.


muscle. The cyst is lined with one layer of almost flat epithelium. The wall in most places is smooth but here and there is slightly wavy.

The solid cord above the cyst consists almost entirely of connective tissue. The urachal cord is composed in part of connective tissue, but contains many bundles of non-striped muscle. The slit-like spaces noted macroscopically are devoid of any epithelium. There is no doubt that this cyst is of urachal origin.



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

Reference

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

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