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Endometrioma of the Umbilicus
CHICAGO GYNECOLOGICAL
129
SOCIETY
This points to the presence in the she has an air meniscus under the diaphragm. pelvis of adhesions which captivate the gas for a while and from which it liberates itself a little later rising to the diaphragm. That Ieads me to another point that Dr. Duncan raised. He said he saw free air under the diaphragm by fluoroscope and yet the tubes were closed. You must be careful to determine whether the air is on the left side or on the right side. An air bubble is almost constantly present in the stomach and may be confusing. When the gas is on the right side it is absolutely pathognomonic. In case of doubt when the gas is on the left side and is scanty in amount I place the patient on the left side and make pressure on the right costal margin which forces the gas to the right side. By fluoroscopy you can then see a meniscus of gas under the diaphragm on the right side. The method of introducing water into the vagina as Dr. Furniss first recommended, with the patient in the .tilted position, is very useful. I have not felt the need of that because with the ear rather close to the vagina one cannot fail to detect cervical regurgitation. When one is not experienced in distinguishing cervical leaks, this is perhaps a wise thing to do. In the majority of casts I think it suffices simply to hold the rubber acorn very firmly in the cervix against the bullet forceps which grasps the anterior cervical lip. I do not feel that the self-retaining instruments which are devised for absolute air-tightness of the cervix need be used. Dr. Cary stated that with his fingers he can feel certain differences in pressure. There is no doubt but that with increasing experience one can distinguish between various pressures, but still if you test it against a kymograph and see the kind of With the kymograph and a uniform prescurves you get, you will be surprised. sure and rate flow, you can make more accurate observations and interpretations. I prefer not to rely upon my subjective sensations. Dr. Miles referred to strictures being found at Iaparotomy. Passing a Pollitzer bulb through the fimbriated end will demonstrate the nearest stricture. If this is impassable the other intrinsic strictures can only be guessed at. Insufllating through the uterus with the cannula in situ can show the stricture nearest the uterine ostium.
CHICAGO
GYNECOLOGICAL
MEEPING
DR. F. IJEJE STONE
Patency,
presented
OF
JANUARY
an
SOCIETY 17, 1930
Instrument
for Determining
which was described in the January,
Tubal
1930, issue of this
JOURNAL. DR. A. F. LASH presented a specimen of Ectopic
ciated with Ruptured
Corpus Luteum
Asso-
Tubal’ Pregnancy.
This specimen was obtained from a white woman thirty-eight years of age who admitted to the County Hospital with a clinical picture of ruptured ectopic pregnancy. The specimen was presented as a pathologic rarity, if one were to accept what recent’ investigators (Dolgopol) say about ectopic corpus luteum, in that there are only twenty-four such reports in the literature up to 1920.
waa
DR. NORBERT ENZER, of Milwaukee,
reported a case of Endometrioma
of the Umbilicus. had
A tumor of the umbilicus been present for six
was removed from a girl 18 years of age. months and was not painful. A few days
The tumor before the
130
AMERICAN
JOURNAL
OF
OBSTETRICS
AXD
GYNECOLOGY
removal it discharged some blood, which was ten days after the last menstrual The tumor was a nodular growth with an apparently intact skin surface. period. The cut section showed a diffuse fatty and connective tissue tumor. Microscopic section revealed a thin layer of squamous epithelium, with the main portion of the tumor made up of connective tissue cells and smooth muscle fibers. Imbedded in these were numerous glands lined by columnar epithclium, some of them quite small, others dilated, occasionally single but more often multiple. They were surrounded by a dense cellular stromn, many of them containing blood and being surrounded by blood. Desquxmated epithrlium was occasionally present. The peritoneal surface of the tumor was particularly interesting because of a deep in dentation, sections through which revealed nurncrous prolongations of the peritoneum into the tumor and several gland structures which could be traced directly to the peritoneum. Thcsc latter were lined by low cuboidal epithelium of t.hc goblet type, surrounded by loose connective tissue stromn. The appearance of the glands, the stroma, tllc hemorrhage, the connective tissue led to a diagnosis of endometrioma. There were several points of interest in this tumor. The patient was younger than any that were encountered in the literature. The finding of glands directly continuous with the peritoneum strongly supported the serosal origin of these endometriomas. The presence of the gland lined by mucus-secreting cells lends some support to the origin of this tumor being from the omphalomesenteric duct. The smooth muscle was likewise of importance. If one interprets an endometrioma on the basis of Rampsou’s theory, it is a little difficult to understand how smooth muscle occurred in these tumors. At the umbilicus there was an embryologic basis for the occurreuce of smoot,h muscle. This case will be published later in more detail, with a survey of the Iitcratme. DISCUSSION DR. SIDNEY that endometrium to prove definitely would be to get In other words, endometrioma.
SCHOCHET.-I believe more firmly than ever Sampson’s v&v arises from the mullerian tissues. The only way we will be able that these endometriomas are similar in character to endometrium a very fresh specimen, have it properly fixed and study the cells. the growth morphology is no criterion as to whether it is an
DR. CAREY CULBERTSON.-While this tumor of the umbilicus was a glandular type, it is a mixed one. Even though it may be shown that some of the glands are endometrial in type, there are others that are different, in part like an adenomyoma. Aside from this difference, I agree with Dr. Sehochet that it will require further cytologic study to prove that even some of those glands are endometrial in origin. DR,.
E. D.
PLASS,
Trichomonas, sons, Evans, DRS.
CARL
H.
OF IOWA
CITY,
which was and Davis. DAVIS
AND
IOWA,
discussed G. W.
(by
invitation)
by Drs.
STEVENS
Cron,
presented
read
a paper
Reis, Lash, a paper
on
Par-
entitled
Value of Routine Radiographic Examinations of the Newborn, witi a, Study of 702 Consecutive CM. (For original article see page 73.) DISCUSSION DR. A. H. PARMELEE.-During we have studied many newborn study was in regard to congenital
the last infants syphilis
few
years at the Cook County Hospital, with the x-ray. Ou P particular but a lot of interesting things have
129
SOCIETY
This points to the presence in the she has an air meniscus under the diaphragm. pelvis of adhesions which captivate the gas for a while and from which it liberates itself a little later rising to the diaphragm. That Ieads me to another point that Dr. Duncan raised. He said he saw free air under the diaphragm by fluoroscope and yet the tubes were closed. You must be careful to determine whether the air is on the left side or on the right side. An air bubble is almost constantly present in the stomach and may be confusing. When the gas is on the right side it is absolutely pathognomonic. In case of doubt when the gas is on the left side and is scanty in amount I place the patient on the left side and make pressure on the right costal margin which forces the gas to the right side. By fluoroscopy you can then see a meniscus of gas under the diaphragm on the right side. The method of introducing water into the vagina as Dr. Furniss first recommended, with the patient in the .tilted position, is very useful. I have not felt the need of that because with the ear rather close to the vagina one cannot fail to detect cervical regurgitation. When one is not experienced in distinguishing cervical leaks, this is perhaps a wise thing to do. In the majority of casts I think it suffices simply to hold the rubber acorn very firmly in the cervix against the bullet forceps which grasps the anterior cervical lip. I do not feel that the self-retaining instruments which are devised for absolute air-tightness of the cervix need be used. Dr. Cary stated that with his fingers he can feel certain differences in pressure. There is no doubt but that with increasing experience one can distinguish between various pressures, but still if you test it against a kymograph and see the kind of With the kymograph and a uniform prescurves you get, you will be surprised. sure and rate flow, you can make more accurate observations and interpretations. I prefer not to rely upon my subjective sensations. Dr. Miles referred to strictures being found at Iaparotomy. Passing a Pollitzer bulb through the fimbriated end will demonstrate the nearest stricture. If this is impassable the other intrinsic strictures can only be guessed at. Insufllating through the uterus with the cannula in situ can show the stricture nearest the uterine ostium.
CHICAGO
GYNECOLOGICAL
MEEPING
DR. F. IJEJE STONE
Patency,
presented
OF
JANUARY
an
SOCIETY 17, 1930
Instrument
for Determining
which was described in the January,
Tubal
1930, issue of this
JOURNAL. DR. A. F. LASH presented a specimen of Ectopic
ciated with Ruptured
Corpus Luteum
Asso-
Tubal’ Pregnancy.
This specimen was obtained from a white woman thirty-eight years of age who admitted to the County Hospital with a clinical picture of ruptured ectopic pregnancy. The specimen was presented as a pathologic rarity, if one were to accept what recent’ investigators (Dolgopol) say about ectopic corpus luteum, in that there are only twenty-four such reports in the literature up to 1920.
waa
DR. NORBERT ENZER, of Milwaukee,
reported a case of Endometrioma
of the Umbilicus. had
A tumor of the umbilicus been present for six
was removed from a girl 18 years of age. months and was not painful. A few days
The tumor before the
130
AMERICAN
JOURNAL
OF
OBSTETRICS
AXD
GYNECOLOGY
removal it discharged some blood, which was ten days after the last menstrual The tumor was a nodular growth with an apparently intact skin surface. period. The cut section showed a diffuse fatty and connective tissue tumor. Microscopic section revealed a thin layer of squamous epithelium, with the main portion of the tumor made up of connective tissue cells and smooth muscle fibers. Imbedded in these were numerous glands lined by columnar epithclium, some of them quite small, others dilated, occasionally single but more often multiple. They were surrounded by a dense cellular stromn, many of them containing blood and being surrounded by blood. Desquxmated epithrlium was occasionally present. The peritoneal surface of the tumor was particularly interesting because of a deep in dentation, sections through which revealed nurncrous prolongations of the peritoneum into the tumor and several gland structures which could be traced directly to the peritoneum. Thcsc latter were lined by low cuboidal epithelium of t.hc goblet type, surrounded by loose connective tissue stromn. The appearance of the glands, the stroma, tllc hemorrhage, the connective tissue led to a diagnosis of endometrioma. There were several points of interest in this tumor. The patient was younger than any that were encountered in the literature. The finding of glands directly continuous with the peritoneum strongly supported the serosal origin of these endometriomas. The presence of the gland lined by mucus-secreting cells lends some support to the origin of this tumor being from the omphalomesenteric duct. The smooth muscle was likewise of importance. If one interprets an endometrioma on the basis of Rampsou’s theory, it is a little difficult to understand how smooth muscle occurred in these tumors. At the umbilicus there was an embryologic basis for the occurreuce of smoot,h muscle. This case will be published later in more detail, with a survey of the Iitcratme. DISCUSSION DR. SIDNEY that endometrium to prove definitely would be to get In other words, endometrioma.
SCHOCHET.-I believe more firmly than ever Sampson’s v&v arises from the mullerian tissues. The only way we will be able that these endometriomas are similar in character to endometrium a very fresh specimen, have it properly fixed and study the cells. the growth morphology is no criterion as to whether it is an
DR. CAREY CULBERTSON.-While this tumor of the umbilicus was a glandular type, it is a mixed one. Even though it may be shown that some of the glands are endometrial in type, there are others that are different, in part like an adenomyoma. Aside from this difference, I agree with Dr. Sehochet that it will require further cytologic study to prove that even some of those glands are endometrial in origin. DR,.
E. D.
PLASS,
Trichomonas, sons, Evans, DRS.
CARL
H.
OF IOWA
CITY,
which was and Davis. DAVIS
AND
IOWA,
discussed G. W.
(by
invitation)
by Drs.
STEVENS
Cron,
presented
read
a paper
Reis, Lash, a paper
on
Par-
entitled
Value of Routine Radiographic Examinations of the Newborn, witi a, Study of 702 Consecutive CM. (For original article see page 73.) DISCUSSION DR. A. H. PARMELEE.-During we have studied many newborn study was in regard to congenital
the last infants syphilis
few
years at the Cook County Hospital, with the x-ray. Ou P particular but a lot of interesting things have