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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.

Online Editor

This historic 1916 textbook by Cullen describes the umbilical region.

Modern Notes: placenta

Historic Embryology - Placenta
1883 Embryonic Membranes \| 1907 Development Atlas \| 1909 \| 1910 Textbook \| 1917 Textbook \| 1921 Textbook \| 1921 Foetal Membranes \|1921 human \| 1921 Pig implantation \| 1922 Single placental artery \| 1923 Placenta Review \| 1939 umbilical cord \| 1943 human and monkey \| 1944 chorionic villus and decidua parietalis \| 1946 placenta ageing \| 1960 first trimester placenta \| 1960 monkey \| 1972 Placental circulation \| Historic Disclaimer

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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.

List of Illustrations

1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois 2

2. A More Advanced Stage in the Formation of the Umbilical Region 2

3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo 3

4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Show ing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk ... 4

5. Sagittal View of a Human Embryo 5 mm. in Length 5

6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing

the Umbilical Region 6

7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length 7

8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length 8

9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in

Length 9

10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length 10

11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length .. 11

12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm.

Long 12

13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length .. 13

14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm.

in Length as Viewed from within the Abdomen 14

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

17. Intra-abdominal View of the Umbilical Region in a Human Embryo 7.5 cm. Long . . 18

18. Intra-abdominal View of the Umbilical Region in a Human Embryo 9 cm. in

Length 18

19. Intra-abdominal View of the Umbilical Region in a Human Embryo 10 cm. in

Length 19

20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long . . 19

21. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in

Length 20

22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in

Length 21

23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm.

in Length 22

24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long 23

25. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

26. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

27. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left . . 25

29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven

Months 25

30. Three Diagrams of the Umbilical Ring and Its Significance in the Development

of Ventral Hernia 27

XV

XVI LIST OF ILLUSTRATIONS

Fig. Page

31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the

Embryo 5.5 cm. Long 28

32. The Umbilical Region, the Cord, and the Placenta at Term 29

33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term .... 32

34. Normal Umbilicus according to Catteau 35

35. A Type of Umbilical Region in the Adult, Viewed from Within 44

36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within .... 44

37. The Umbilical Region of an Adult, Viewed from Within 45

38. Classic Type of Umbilicus 47

39. Disposition of the Vascular Cords (Usual Type) 48

40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases 48

41. Vascular Cord Type, Noted 5 Times in 50 Cases 49

42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical

Ring 49

43. Vascular Cords, Noted 3 Times in 50 Cases 49

44. Vascular Cords, Noted in 2 out of 50 Cases 50

45. Umbilical Fascia. Peritoneum in Place 52

46. Umbilical Fascia and Umbilical Mesentery 52

47. Reduplication of the Linea Alba. Peritoneum Removed 52

48. Atrophy of the Umbilical Fascia, Posterior View 53

49. Formation of a Mesentery. Peritoneum in Place 53

50. Mesentery of the Urachus and of the Umbilical Arteries 53

51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place 54

52. Adipose Fringes in a Stout Subject. Peritoneum in Place 54

53. Peritoneal Diverticula. Peritoneum in Place 55

54. Peri-umbilical Fossettes. Peritoneum in Place 55

55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Ab dominal Wall 57

56. Extra-abdominal Multilocular Fibrocystoma of the Ovary 5S

57. An Extra- abdominal Multilocular Fibrocystoma 59

58. Superficial Lymphatics of the Umbilical Region 64

59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side 65

60. The Umbilical Vessels about the Time of Birth 72

61. The Umbilical Vessels in the Adult 72

62. 63. Method of Treating the Umbilical Stump at Birth 98

64. Nature's Method of Checking Bleeding from the Umbilical Arteries 107

65. An Umbilical Granulation 117

66. The Gradual Atrophy of the Omphalomesenteric Duct 121

67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord . . 121

68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord 121

69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia : . . 123

70. A Polypoid Outgrowth from the Umbilicus 129

71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70 129

72. A Diverticular Tumor at the Umbilicus 132

73. A Glandular Tumor from the Umbilicus 132

74. A Glandular Growth at the Umbilicus 133

75. Section in the Long Axis of a Small Umbilical Growth 134

76. Adenoma of the Umbilicus 135

77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord. 138

78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord . . . 138

79. An Umbilical Polyp 139

80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression 139

81. An Umbilical Polyp 140

82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression .... 141

83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus . . . . 149

LIST OF ILLUSTRATIONS XV11

Fia. Fage

84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Re sembling those of the Pylorus 150

85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach 150

86. Appearance of the Umbilical Depression in von Rosthorn's Case 152

87. Gastric Mucosa at the Umbilicus 153

88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in

Fig. 87 154

89. Persistence of the Outer End of the Omphalomesenteric Duct 156

90. Atrophy of the Inner End of the Omphalomesenteric Duct 156

91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct 156

92. Meckel's Diverticulum 159

93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus. . 160

94. An Abnormally Large Meckel's Diverticulum 161

95. A Meckel's Diverticulum with a Lobulated Extremity 161

96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface 162

97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment . . 163

98. An Accessory Pancreas in the Tip of Meckel's Diverticulum 163

99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel 164

100. A Diverticulum Tying Off a Loop of Small Bowel 165

101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum. . . . 166

102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a

Hole in the Mesentery of a Meckel's Diverticulum .170

103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel 171

104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary 175

105. An Intestinal Cyst 176

106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected

with the Bowel 176

107. Volvulus of Meckel's Diverticulum 177

108. An Intestinal Cyst Developing from Meckel's Diverticulum 178

109. Intestinal Cysts in the Abdominal Cavity 182

1 10. An Intramesenteric Cyst 183

111. A Patent Omphalomesenteric Duct 190

112. A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus . 190

113. A Very Short Omphalomesenteric Duct 190

114. A Patent Omphalomesenteric Duct with a Polyp- like Formation at the Umbil icus 190

1 15. A Patent Omphalomesenteric Duct 192

116. A Patent Omphalomesenteric Duct 193

1 17. A Patent Omphalomesenteric Duct 197

118. A Patent Omphalomesenteric Duct 197

119. A Patent Omphalomesenteric Duct 202

120. A Patent Omphalomesenteric Duct 205

121. A Patent Omphalomesenteric Duct 206

122. Part of a Patent Omphalomesenteric Duct 206

123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Om phalomesenteric Duct 207

124. An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Origin ally a Patent Omphalomesenteric Duct 209

125. Longitudinal Section through the Entire Center of a Partially Closed Om phalomesenteric Duct 209

126. A Patent Omphalomesenteric Duct 211

127. A Patent Omphalomesenteric Duct Opening at the Base of the Umbilical Cord . . 216

128. A Patent Omphalomesenteric Duct 216

129. A Patent Omphalomesenteric Duct as Seen from the Abdominal Cavity 216

130. Inversion of the Bowel through a Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord 219

131. A Patent Omphalomesenteric Duct of Large Diameter 224

132. Commencing Prolapsus of Small Bowel through a Patent Omphalomesenteric Duct 224

133. Partial Prolapsus of the Small Bowel through the Omphalomesenteric Duct . . . 224

134. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct .... 224

135. Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 225

136. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and an Umbilical Hernia between the Loops of Prolapsed Bowel 225

137. Prolapse of the Small Bowel through an Open Omphalomesenteric Duct 227

138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct 228

139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Sec ondary Complications 229

140. Prolapsus and Inversion of the Intestine through a Patent Omphalomesenteric Duct 230

141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 232

142. A Small Cyst of the Umbilicus Due to a Remnant of the Omphalomesenteric Duct 238

143. Small Cyst of the Abdominal Wall Due to a Remnant of the Omphalomesenteric Duct 238

144. A Small Intestinal Cyst Lying between the Peritoneum and the Recti 240

145. An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord 243

146. A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction 245

147. A Small Umbilical Concretion 249

148. Acute Inflammation of the Umbilicus Due to an Accumulation of Sebaceous Material 249

149. Cholesteatoma from the Umbilicus in Case 1 251

150. Cholesteatoma from Case 2 251

151. A Connective-tissue Projection Really Representing a Small Fibroma in the Floor of the Umbilicus 252

152. Enlargement of Fig. 151 252

153. Subumbilical Phlegmon 262

154. The Subumbilical Space 264

155. Paget's Disease of the Umbilicus 270

156. Paget's Disease of the U/mbilicus 270

157. Paget's Disease of the Umbilicus 271

158. Paget's Disease of the Umbilicus 274

159. The Appearance in a Case of Paget's Disease of the Umbilicus After Treatment with Radium 275

160. Syphilis of the Umbilicus 284

161. Atrophic Tuberculid Starting at the Umbilicus 286

162. Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket 288

163. The Manner in Which a Periprostatic Abscess may Occasionally Rupture at the Umbilicus 289

164. Escape of Pleural Fluid from the Umbilicus 289

165. The Opening of a Broad Ligament Abscess at the Umbilicus 290

166. Abdominal Pregnancy with Spontaneous Escape of Liquor Amnii from the Umbilicus 348

167. Small Papilloma in the Umbilical Depression 365

168. A Shall Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine Mucosa 376

169. Glands from a Small U\iisiLirALTuMOR 377

170. Typical Uterine Mucosa in a Small Umbilical Tumor. An Enlargement of Area B in Fig. 168 378

171. Glands in a Small Umbilical Tumor 379

172. Dilated Glands in a Small Umbilical Tumor 380

173. Dichotomous Branching of Glands in a Small Umbilical Tumor 381

174. Uterine Glands in an Umbilical Tumor 381

175. Gland Hypertrophy in a Small Umbilical Tumor 382

176. A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands 383

177. Uterine Mucosa in an Umbilical Tumor 384

178. A Small Umbilical Tumor Containing Numerous Glands 388

179. Glands in a Small Umbilical Tumor 389

180. An Adenomyoma in the Abdominal Wall Near the Anterior Iliac Spine 394

181. A Small Umbilical Tumor Containing Glands Similar to Those of the Body of the Uterus 396

182. Adenomyoma of the Umbilicus 397

183. A Group of Sweat-glands in an Umbilical Tumor 398

184. Appearance of the Carcinomatous Umbilicus After Removal 424

185. Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries 432

186. A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth 439

187. Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth .... 440

188. Adenocarcinoma of the Umbilicus 441

189. A Section Showing Carcinoma of the Right Inguinal Glands 442

190. Secondary Carcinoma of the Umbilicus 443

191. Telangiectatic Myxosarcoma of the Umbilicus 450

192. Appearance of the Umbilicus After Removal of the Tumor Shown in Fig. 191. . 450

193. Myxosarcoma of the Umbilicus 451

194. Telangiectatic Myxosarcoma Projecting from the Right Side of the Umbilicus . . 452

195. A Telangiectatic Myxosarcoma 452

196. A Case of Congenital Umbilical Hernia 460

197. An Amniotic Hernia 462

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

199. A Serous Umbilical Hernia 469

200. Freeing the Umbilical Hernial Sac from the Abdomen 472

201. Closure of the Hernial Opening at the Umbilicus 473

202. Closure of the Hernial Opening at the Umbilicus 474

203. An Umbilical Hernia Associated with Marked Prolapsus of the Abdominal Wall 475

204. An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds 476

205. The Abdominal Scar After the Removal of a Very Large Area of Fat 477

206. An Umbilical Cyst 478

207. Exstrophy of the Bladder Opening at or Near the Umbilicus 482

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

209. Exstrophy of the Bladder 483

210. Escape of Urine from the Umbilicus When the Inner Urethral Orifice Is Blocked by a Membrane 488

211. A Patent Urachus with a Mushroom-like Projection at the Umbilicus 489

212. A Patent Urachus with a Penile Projection at the Umbilicus 489

213. The Appearance of the Umbilicus in a Case in Which both a Patent Omphalomesenteric Duct and a Patent Urachus Existed 493

214. Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same Child 493

215. A Picture of the Child Three Weeks After Removal of a Patent Omphalomesenteric Duct and a Patulous Urachus 494

216. A Patent Urachus 497

217. A Urachus Open from Bladder to Umbilicus 498

218. An Open Urachus 499

219. Escape of Urine from the Umbilicus Due to a Patent Urachus 502

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

239. The Abdominal Contour in a Case of Very Large Urachal Cyst 558

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

242. An Infected Urachus Opening between the Umbilicus and Bladder 570

243. Urachal Cyst 576

244. A Dilated Urachus Communicating with the Bladder 579

245. Large Accumulation of Urine in a Partially Patent Urachus 579

246. An Infected Urachus Opening at the Umbilicus 580

247. A Patent Urachus Dilated in Its Middle Portion 580

248. Accumulation of a Large Quantity of Urine in a Urachal Pouch 581

249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac 584

250. A Phosphatic Deposit on the End of a Long Bone 585

251. A Dilated Urachus Communicating with the Bladder 598

252. Urachal Cyst 599

253. Urachal Cyst 603

254. Urachal Cyst 603

255. A Patent Urachus Containing a Vesical Calculus 625

256. Carcinoma of the Patent Urachus 632

257. A Multilocular and Malignant Cyst of the Urachus 637

258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus 638

259. Giant-cells in the Wall of an Adenocarcinoma of the Urachus 639

260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus. . .640-641

261. Adenocarcinoma of the Urachus 642

262. A Papillary-like Area i.\ an Adkxocarcinomatous Cystofthe Urachus 643

263. Metastasis from Adenocarcinoma of the Urachus 644

264. An Umbilical Cyst 645

265. \\ aj.i of an Umbilical Cyst 645

266. Giant-cells in the Wall of an Umbilical Cyst 646

267. Tuberculosis of the Urachus 652

268. An Area Suggesting a Tubercle 653

269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus 654

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 XXXVI. Urachal Concretions and Urinary Calculi associated with Urachal Remains

Historic sketch.

Urachal stones or concretions.

Urinary calculi in the urachus.

Removal of vesical stones through the umbilical opening.

Other calculi in the umbilical region.

Phillips, in an article in Todd's Cyclopaedia of Anatomy and Physiology (1835), said that in January, 1787, Boyer exhibited a bladder taken from a man thirty-six years of age. The urachus formed a canal 1^2 inches long, and contained 12 urinary calculi each the size of a millet-seed. It was demonstrated that this canal was not a vesical sac or a prolongation of the vesical mucous membrane.

In 1838 Civiale, in his treatise on calculous affections, called attention to the fact that the anatomist Colombus had observed calculi at the umbilicus. Civiale refers to the case of a woman coming under Hagendorn's care, who had a very painful abdominal abscess which contained two calculi. He also refers to Vallisnieri, who spoke of stones escaping from the umbilicus. In Helwig's case, cited by the same author, a woman seventy years old had an umbilical abscess; it broke, and several stones escaped, one of which weighed 15 grains. In another case a man discharged from the umbilicus a calculus which weighed about an ounce and was as large as a pigeon's egg. Civiale also referred to cases observed by Tolet, Rhodius, and Roesler. The stones varied from the size of the kernel of an olive to that of a hazelnut. They escaped from the umbilicus.

Simon, in 1843, mentioned the fact that calcareous concretions had been found along the course of the urachus and had also escaped through the umbilical ring. He said that Colombus, Donatus, Harder, Bartholin, and Cruveilhier had reported such cases. '

Simon said that Rhodius and Helwig had reported cases similar in character. In the case of Helwig's patient, a man, the stone was the size of a pigeon's egg.

Concretions or calculi escaping from the umbilicus may originate from several sources. They may be formed in the bladder or in the urachus, which communicates with the bladder, and where, consequently, urinary salts can become concentrated, or, again, in a urachus, that is completely isolated from the bladder. Finally we have umbilical concretions. The escape of gall-stones from the umbilicus has been considered elsewhere.

Calculi developing in a urachus communicating with the bladder are identical in their composition with vesical stones. Those developing in the urachus, when no connection exists between it and the bladder, are very small; umbilical concretions are cheesy in character. These last have been considered in detail in Chapter XV (p. 247).

The majority of the cases mentioned in the historic sketch just given are not

620

CALCULI ASSOCIATED WITH URACHAL REMAINS. 621

sufficiently clear to enable one to determine with any degree of accuracy to which group they belong.

URACHAL STONES OR CONCRETIONS.

The careful and painstaking investigations of Luschka, published in 1862, give us a very comprehensive knowledge of the urachus. He says the urachal contents are not all alike. The fluid is usually pale yellow, thin, and translucent. It may, however, be cloudy, and brown or reddish in color. It contains a large number of cells, numerous fat-globules, and not infrequently corpora amylacea. In the dilatations and in the isolated cysts the contents are frequently sticky and of a dirty brown color, and scattered throughout the field are bodies which have a marked resemblance to prostatic concretions.

Urachal concretions were also described by Hoffmann in 1870.

Suchannek, in 1879, when describing the contents of a patent portion of the urachus, discussed the granular bodies. These, he said, judging from their reaction to acetic acid, are due to a degeneration of the epithelium, which is probably colloid or amyloid in character.

Wutz briefly details his findings in the cyst contents of the many cases he examined.

In Case 11 he noted that, a short distance from the bladder, the urachus contained an oval body 0.17 x 0.1 mm. It was brownish in color and homogeneous in consistence. In the further course of the tube were several diverticula and nippedoff cysts of various shapes. They contained firm brownish contents.

In Case 15 Wutz says that the cysts were filled with lumps of brownish and yellow material.

In Case 17 the cyst contents were yellowish white and friable.

In Case 18 Wutz found a spindle-shaped urachal cyst, 2x1 mm. Its contents were brownish yellow in color.

Wutz, in summing up his observations on cyst-contents, said that they consisted of fat-crystals, fat-droplets, free fat, large flat epithelial cells, brownish-yellow amorphous masses, isolated cholesterin crystals, and small, round, very glistening bodies. In one of the cysts in Case 22 he found a small, firm, stony hard, yellowish-brown, glistening body. Under the microscope this was irregular, nodular,\ and partly transparent. It was 0.37 x 0.36 mm. in diameter. On the addition of hydrochloric acid free carbonic acid escaped.

Ledderhose referred briefly to urachal concretions in 1890.

In Boyer's case, which we have already considered and In which 12 millet-seedsized stones were found in the urachus, these bodies were urinary stones.

Rokitansky (1861) referred to a case in which 21 calculi the size of linseeds were found in a urachal dilatation 0.6 mm. above the top of the bladder.

Veiel, one of Luschka's pupils, in his dissertation on the urachus published in 1862, described his findings in the body of a man forty-five years old. "Passing downward in the mid-line from the umbilicus was a delicate cord 1 mm. broad. Three centimeters above the bladder it commenced to get thicker, and at the bladder was 1.2 cm. broad. The urachus could be divided into four sections. The lowest section, situated nearest the bladder, was 14 mm. long and patent. The next was 7 mm. long, solid, and thread-like. The third was 8 mm. long and was also patent. The fourth section— nearest the umbilicus— was solid. After the urachus had been

622 THE UMBILICUS AND ITS DISEASES.

treated with acetic acid, three dilatations of the canal could be seen. They contained yellowish concretions.

Arrou, in 1910, in an article entitled A Suppurating Cyst of the Urachus, reported a case in which an abscess contained a stone or concretion the size of an olive; it was like a piece of incompletely dried mortar. [I should be inclined to look upon it as a simple umbilical concretion accompanied by inflammation, were it not for the fact that the lower end of the sac bore a definite relation to the urachus. — T. S. C]

Suppurating Cyst of the Urachus. — Arrou* reports the case of a patient operated upon by Tricot. A soldier with absolutely no history of bladder trouble complained of vague pain in the umbilical region. The pain became acute, and the patient when marching had to bend forward. There was no nausea and no intestinal disturbance. Urination was normal; there was no fever.

Examination revealed a painful plaque, as large as the palm of the hand, a little below the umbilicus. There was no edema or redness. Gradually a little swelling was noted over the painful area; this was accompanied by some fever.

Operation. — An exploratory incision was made under the supposition that there was an abscess in the abdominal wall, but when the patient was in the operatingroom, there was an escape of a small amount of pus from the lower margin of the umbilicus. A probe introduced into the small orifice passed downward and backward into a cavity, measuring 6 cm. in its vertical direction. The patient was at once anesthetized and the cavity incised. It proved to be the size of a mandarin orange. It contained a calculus the size of an olive, that was like a piece of incompletely dried mortar. The cyst lining resembled an inflamed mucosa. Unfortunately, both sac and calculus were lost.

The upper end of the sac ended at the bottom of the umbilicus. The lower extremity terminated in a closed cul-de-sac. Attached to the lower portion of the sac was a large cord, the size of the little finger, which became smaller and terminated in the fundus of the bladder. Arrou was sure that it was the urachus. The peritoneum was opened above and laterally. The intestines were protected and the urachus was cut across with the cautery at a point several millimeters above the bladder. The sac was completely removed and the wound closed. The patient made a good recovery.

From the data at hand it is evident that urachal concretions or stones are very rare. They are usually no larger than linseed grains or millet-seeds. They are usually yellowish brown or brown in color, and may resemble corpora amylacea. They are too small to be a surgical factor, and are of interest only to the pathologist.

URINARY CALCULI IN THE URACHUS. In 1877 Vosburgh reported his observations on a man aged fifty, who had been complaining of a soreness and constant pain at the navel. Examination showed redness, tenderness, and a hard swelling around the umbilicus. The tumor was incised, and at the depth of half an inch a stone, the size of a hickory-nut, was felt and at once removed. The stone was phosphatic in character and had a strong urinary odor. The wound healed. The patient stated that, about twenty years before, a stone had been removed in a similar manner from this location.

Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832.

CALCULI ASSOCIATED WITH URACHAL REMAINS. 623

Monod, in 1899, referred to the stagnation of urine in the interior of the urachus as giving rise to calculi. He said that Colombus, Marcellus, Donatus, Harder, and Bartholin had cited examples of this kind. He added that the calculi may be eliminated through the umbilicus, as was noted by Hagendorn, Rhodius, and Hehvig.

The same author mentions a case recorded by Peyer in 1721, in which a calculus escaped from the umbilicus after retention of urine. In the chapter on Urachal Infections I have referred to a case reported by Weiser (p. 603). The patient, a woman seventy-five years of age, had had a purulent discharge from the umbilicus for fifteen years. When Weiser saw her she had a tumor the size of a cocoanut situated in the mid-line, between the umbilicus and symphysis. When this was opened, five ounces of very fetid pus escaped, and also a calculus weighing 70 grains. The wound healed in three months. Wishing to find out the character of this stone, I wrote Dr. Weiser, and from his reply it appears probable that it closely resembled a vesical calculus, but, as noted from the history, there was no opening into the bladder and no urine escaped from the incision during the patient's convalescence.

Probably one of the most interesting cases is the one recorded by Dykes. It might be claimed that the extravesical portion of the stone developed in a diverticulum of the bladder, but the location of the opening in the top of the bladder and in the median line leaves little doubt that the cavity was a dilated portion of the urachus, especially as the probe in the cavity could be carried up to within two inches of the umbilicus.

Patent Urachus and Encysted Urinary Calculi.* — "This case, which both in its clinical and pathologic bearings I believe to be of some interest, came under observation on January 27, 1908, at Rae Bareli Oudh:

"The patient was a Hindu male, aged about thirty years, apparently healthy apart from his urinary complaint, which dated back some five years or more. Owing to pressure of work I had not seen him until he was on the operating table, prepared for litholapaxy. The urine, I was informed, was acid and free from albumin. Several small concretions lay free on the base of the bladder, but on commencing to crush the first, the beak of the lithotrite impinged upon what appeared to be a much larger calculus, occupying a position at the apex of the half -distended bladder. After the first stone had been crushed the projecting portion of this larger calculus was easily seized between the blades of the lithotrite, but was found to be fixed to the bladder- wall.

"To crush this calculus in situ appeared dangerous, if not impossible, so lateral lithotomy was performed and the forefinger passed into the bladder. The calculus was now found j ust within reach of the finger. With the forefinger on the tip of the calculus and the other hand on the abdominal wall, it was estimated to be of considerable size, and its upper portion seemed very close under the examining hand beneath the abdominal wall in the middle line. It was evidently an 'hour-glass' stone, the deeper half being considerably larger than the projecting portion felt by the finger. The projecting portion being steadied in the grasp of the lithotomy forceps, the perforated end of a long probe was insinuated alongside the neck, and gradually manceuvered around the whole circumference, loosening the retaining tissue, until, by gentle traction and rotation of the forceps, an 'hour-glass' calculus was safely delivered. A second calculus immediately dropped from the same pocket into the bladder cavity. It, together with the three small concretions, the presence

Dykes, Campbell: The Lancet, 1910, i, 566.

624 THE UMBILICUS AND ITS DISEASES.

of which, on the bladder floor, had already been detected, was now removed, and the debris of the small stone, first crushed, washed out. In case other concretions might still be lying in the pocket its recesses were explored with a probe. Nothing further was found, but the probe passed up in the middle line, easily palpable through the abdominal wall, to a point two inches below the umbilicus. At the upper end the pocket seemed to be contracted to a mere sinus. Convalescence was rapid and uncomplicated.

"The ' hour-glass ' calculus weighed over l^ ounces. Its neck was of about the thickness of a cedar pencil, but somewhat flattened. The deeper lobe was larger than the projecting head, which was capped by a pea-sized, rough, dark-colored concretion, easily broken off, when drj", from the head proper. This terminal concretion resembled exactly, in color and approximately in size, the four small concretions which had been found free in the bladder, differing only in being rough and not polished or faceted by attrition. This resemblance strongly suggested that these four also owned the same source, from the head of the ' hour-glass ' calculus. Each weighed about 10 or 12 grains. The second encysted calculus showed a large oval facet corresponding to a like facet on the base of the 'hour-glass' calculus. Its longer axis had lain at right angles to that of the diverticulum in which it lay. It weighed just over half an ounce.

Neither in recorded cases nor in museum specimens have I come across any instance in which an encj^sted calculus had occupied the apex of the bladder. All the records I have found refer to basal or lateral sacculi, such as are commonly associated with enlarged prostate and chronic cystitis. This is so, for instance, in all the cases of encysted calculus included in the late Sir Henry Thompson's series of over 800 cases, the specimens of which are now in the museum of the Royal College of Surgeons of England. From the position and relations of the diverticulum this case appears to be an example of persistent patency of the lower end of the urachus, with calculus formation following, presumably on the accidental lodgment of a small concretion in it.

"While urachal cysts are much commoner in the female than in the male, a patent condition of the urachus leading to urinary umbilical fistula is much commoner in the male."

A Patent Urachus; Vesical Calculi; Sac-like Dilatations in the Urachus Containing Urinary Calculi; Removal of All the Calculi; Recovery. — During the meeting of the Southern Surgical and Gynecological Association held in Cincinnati on December 13, 1915, the President, Dr. Bacon Saunders, of Fort Worth, Texas, told me of the following interesting case that came under his care several years ago.

The patient was a boy about eleven years of age. He had had all the classic symptoms of stone in the bladder since infancy. Examination disclosed a fistulous opening at the umbilicus through which escaped quantities of foul-smelling urine. On a line from the umbilicus to the pubic region were five nodules ranging in size from a hazelnut to an almond.

A number of small calculi, resembling prostatic stones were removed from the bladder. An incision was made over each of the nodules in the mid-line below the umbilicus and a stone removed from each. These stones were of the same character as those found in the bladder. Urine escaped from the multiple openings for a while, but these openings eventually all closed, and the boy made a satisfactory recovery.

CALCULI ASSOCIATED WITH URACHAL REMAINS.

625

REMOVAL OF VESICAL STONES THROUGH THE UMBILICAL OPENING.

In the chapter on Congenital Umbilical Urinary Fistula (p. 507) I have quoted the well-known case of Paget and Bowman. The patient, John Conquest, an iron founder, forty years old, had had a urinary fistula at the umbilicus since birth. Paget detected a stone in the bladder. The umbilical opening being rather large, he introduced a finger, engaged the stone in the urachus, and brought it out through the umbilicus. This stone was irregularly ring-shaped, having developed around a curled-up hair (Fig. 221, p. 507). It was by getting the tip of his finger into the central hole in the stone that he was enabled to remove it by this route.

Nicaise refers to a case published by Faivre in the Journal de mecl. et chir., 1786. The patient, a small girl of twelve, had for four years passed her urine from the umbilicus. The urethra was obstructed by a calculus. Finally there was considerable engorgement of the surface of the abdomen, due to the urine escaping into the cellular tissue. Faivre entered the bladder through the umbilicus and removed the stone. A sound was introduced into the urethra, and the child made a complete recovery.

If urinary calculi develop in the urachus, they will naturally be found near the bladder, as indicated in Fig. 255.

Fig. 255. — A Patent Urachus Containing a Vesical Calculus. (Schematic.) The urachus is recognized as an open channel from the upper part of the bladder to the umbilicus. Just above the bladder it contains a spheric and rough vesical calculus. In the upper part of the umbilicus is a small umbilical hernia.

OTHER CALCULI IN THE UMBILICAL REGION.

On p. 337 we have discussed at length the escape of gall-stones at the umbilicus. The following cases, reported by Kostlin and by Bramann, while not strictly germane to the subject, are of considerable interest.

Communication Between the Gall-bladder and the Urinary Bladder, With Escape of Gall-stones Through the Urinary Tract. — Kostlin* cites the case of a patient whose history Faber had already reported in an inaugural dissertation. This woman first had

Kostlin, O.: Verbindung zwischen Gallenblase und Harnblase, mit Abgang von Gallensteinen durch die Harnwege. Deutsche Klinik, 1864, xvi, 116.

41

626 THE UMBILICUS AND ITS DISEASES.

trouble when thirty-five yea,vs of age. In the autumn of 1834 she had signs of peritonitis, with pains in the umbilical region. Later the pain was more marked above the symphysis. In October, 1835, she was again ill, this time with bronchopneumonia. On the fourth day there was pain over the symphysis, and the urine was blackish green (bile). The patient soon passed gall-stones, large and small, by the urethra. The gall-stones were examined chemically. The patient was kept under observation for years. She died, at sixty-three, with symptoms of bronchial catarrh and asthma.

Autopsy. — The liver was normal, but the entire organ was situated lower than usual. From the middle of the lower edge a rounded cord extended to the base of the bladder, passing in front of the intestine and pushing the transverse colon downward and to the left. The cord consisted of two portions — the lower and larger half was 1" 7.6"' (about one and three-fourth inches long) and was composed of the urachus. The upper, shorter half belonged to the lower portion of the gall-bladder. The entire length of this was 3" 1.5"' (about 3}4 inches long). The route which the bile and gall-stones traveled was from the gall-bladder through the urachus to the urinary bladder.

Kostlin mentions a similar case, reported by Pelletan.* In this case there was no autopsy.

Probably a Distended Gall-bladder Opening at the Umbilicus.! — The patient was a single woman, sixty-three years of age. She had had typhoid when thirteen. At the age of forty-five she had had sudden abdominal pain, accompanied by high fever, and there was much discomfort in the gall-bladder region. There was a tendency to vomit, and the abdomen was somewhat swollen. A tumor could be made out above and to the right of the umbilicus. It was the size of a fist and painful. The tumor persisted, grew slowly, and tended to pass more and more downward toward the symphysis.

Two years later a large quantity of foul pus escaped from the umbilicus. Pus continued to be discharged in varying amounts from the umbilicus for about sixteen years. The patient was otherwise in good condition.

On admission the abdomen was found to be slightly distended. The skin surrounding the umbilicus was covered with crusts, exfoliated epithelium, and small cysts. The umbilicus was drawn in, and in its center was a small discharging fistula. The escaping pus was foul-smelling. On palpation exactly in the mid-line a long, egg-shaped tumor was noted. At the umbilicus this was 5 cm. broad. It extended almost to the symphysis, and in its lower portion it was 7 to 8 cm. wide. The tumor lay distinctly behind the abdominal wall, and only in the neighborhood of the umbilicus was it intimately attached. In the lower part it was somewhat movable. On pressure it was found to be of dense consistence. A sound could be passed 12 cm. toward the symphysis and the cavity widened out. Calculi were detected at the bottom. Urination was always normal.

Operation. — The abdominal wall was incised for 8 cm. from the umbilicus downward. Four faceted calculi the size of pigeon's eggs were removed, and the tract was curetted out. Healing occurred after three months, but in the mean time it was necessary to curet the cavity several times. After several vain attempts Bramann found in some places many layers of squamous epithelium.

Pelletan: Jour, de chimie med., 2. ser., ii, Nos. 11 et 12.

t Bramann, F.: Arch. f. klin. Chir., 1887, xxxvi, 996.

CALCULI ASSOCIATED WITH URACHAL REMAINS. 627

Microscopic examination of the calculi yielded cholesterin and bile-pigment ; no urinary salts.

[The condition might well be explained by a gall-bladder extending into the pelvis and at the same time becoming adherent to the umbilicus. Everything points to this explanation, although Bramann considered the case to be one of open urachus. — T. S. C]

LITERATURE CONSULTED ON URACHAL CONCRETIONS AND URINARY CALCULI

ASSOCIATED WITH URACHAL REMAINS. Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832. Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., 1887,

xxxvi, 996. Civiale, J.: Traite de l'affection calculeuse, Paris, 1838, 257.

Dykes, C: Patent Urachus and Encj r sted Urinary Calculi. The Lancet, 1910, i, 566. Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch, der

Heilkunde, 1870, xi, 373. Kostlin, O.: Verbindung zwischen Gallenblase und Harnblase, mit Abgang von Gahensteinen

durch die Harnwege. Deutsche Klinik, 1864, xvi, 116. Ledderhose, G.: Chir. Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Luschka, H.: Ueber den Bau des menschlichen Harnstranges. Arch. f. pathologische Anatoniie

u. Physiologie u. f. klin. Med., 1862, xxiii, 1. Monod, J.: Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,

1899, No. 62. Nicaise: Ombilic. Diet, encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv, 140. Phillips, B.: Persistence of the Urachus. Todd's Cyclopaedia of Anatomy and Physiology,

1835, i, 393. Rokitansky, C: Pathologische Anatomie. 3. Aufl., Wien, 1861, hi, 372. Simon, C: Quels sont les phenomenes et le trait ement des fistules urinaires ombilicales. These

de Paris, 1843, No. 80. Suchannek, H.: Beitrage zur Kenntnis des Urachus. Inaug. Diss., Konigsberg, 1879. Veiel, E. : Die Metamorphose des Urachus. Diss., Tubingen, 1862. Vosburgh, H. D. : Patent Urachus with Calculus. Medical Record, New York, 1877, 606. Weiser, W. R.: Cysts of Urachus. Annals of Surg., 1906, xliv, 529. Worster, J.: Case of Vesico-abdominal Fistula of Fourteen Years' Standing. Medical Record.

1877, xii, 196. Wutz, J. B.: Ueber Urachus und Urachuscysten. Virchows Arch., 1883, xch, 387.

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.

A large multilocular carcinomatous cyst of the urachus; secondary growths in the pelvis (personal observation). A rare umbilical cyst.

CARCINOMA OF THE URACHUS.

I have been able to find three cases of carcinoma of the urachus recorded in the literature.

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.

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.

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 movable from side to side. It gradually extended toward the symphysis and right inguinal region.

Shortly after the tumor was noticed the patient experienced pain on urination. At times the urine was abundant, at times it came drop by drop. The man rapidly grew weaker and lost 25 pounds in four months. When Hoffmann saw him. the 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 patient urinated every hour. The urine contained pus and aggregations of epithelial cells.

The tumor became fluctuant, ruptured, and a large amount of purulent and 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.

The urethra was normal.

628

MALIGNANT CHANGES IN THE URACHUS. 629

The umbilical opening closed temporarily, but soon reopened, and in the late stages of the disease the inguinal glands were swollen.

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.

Fischer's patient, when thirty-one years old, first noted a small, hard tumor the size of a pigeon's egg below the umbilicus. Seven or eight months later he had pain on micturition, and noticed a sediment in the urine. The nodule was incised on the 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 walls of which were raised and hard, while the floor consisted of hard nodules. From the ulcerated area onion-like balls of epithelial cells escaped.

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.

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.

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

Congenital Patent Urachus.

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 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.

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.

The urine was acid, slightly cloudy, and had a purulent sediment. The inguinal glands on both sides were swollen.

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.

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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

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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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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

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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

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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 he promptly did. An examination of them shows the following:

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

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

Book - Umbilicus (1916)

Contents

Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus

Preface

Contents

List of Illustrations

List of Plates

Chapter XXXVI. Urachal Concretions and Urinary Calculi associated with Urachal Remains

Chapter XXXVII. Malignant Changes in the Urachus

Chapter XXXVIII. Bleeding from the Urachus into the Bladder