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Endometriosis of an abdominal scar following cesarean section
102
TRE
AMERICAN
JOURNAL
OF
ORSTETRICS
AND
GYNECOLOGY
REFERENCES
(1) Cushn~l: Textbook of Pharmacology, Philadelphia, Lea and Febiger. (2: Sollmann: Manual of Pharmacology, Philadelphia, W. B. Saunders Co. (3) Jun.o and Cook: Proc. See. Erper. B:ol. and Med., 1927, xiv, 586. (4) Laaurd, Irwin, and Pruwinlc: AM. JOUR. OBST. AKD GYNEC.. 1926, xii, 104. (5) Ikmett: -4x. JOUR. OBST. AP;D GYNEC., 1926, xi, 227. 626
MEDICAL
ARTS
BUILDIW.
ENDOMETRIOSIS
OF AN
ABDOMIXAL
CESAREAN BY PERCY
T
11.
SCAR
FOLLOWING
SECTION” M.D., NEW YORK, N. Y.
WILLIAMS,
HE case I wish to report is one of endometriosis of an abdominal scar following a second classical cesarean operation.
The patient, a woman of thirty-five, was admitted to Lenox Hill Hospital with a diagnosis of movable retroversion and an inflamed painful scar following two eesarean sections which were done respectively nine and seven years before. She admitted that the scar was somewhat changeable in color, but she had not noticed that the variation had any relation to the menstrual cycle. Physical examination was otherwise negative except for a third degree movable retroversion which was giving her no symptoms. The cicatrix measured 8 cm. in length and involved the umbilicus at about the junction of the upper and middle thirds. It. was firm, thickened, irregular, and Its surface was moist and rather sticky to the rather heaped up in appearanee. touch, she said it was constantly “perspiring.” It was dull pink and had the appearance of chronically inflamed cicatricial tissue. No hernial ring could be made out because of the brawny tissues, but a slight impulse on coughing made one suspicious of an underlying hernia. A diagnosis of a chronically inflamed cicatrix overlying a hernia was made but a possible sarcoma could not be ruled out. Endometriosis was thought of but dismissed, because there was no history of variation of color wit,h the phases of the menstrual cycle. Operation took place the day after admission. The scar was excised by a narrow elliptical incision; the hernia repaired by muscular overlapping, and the excised portion sent for microscopic examination. Convalescence was uneventful; patient left the hospital in seventeen days. Microscopic examination of the various parts of the specimen showed diffuse involvement of the cicatrix by adenomyoma with all the characteristics of typical endometrial tissue. The tumor was poorly outlined and extended from beneath the epidermis to the peritoneal surface and laterally to the margins of the scar. The peritoneum was not involved. The bulk of the tumor was composed of smooth muscle cells disposed in bundles running in all directions. Imbedded in this tissue were small islands of fat and epithelial tubules or cysts, either single or in groups, sometimes reating directly on the muscle but more often separated from it by zones of cellular tissue resembling the endometrial stroma. The tubules were lined with a single layer of noneiliated euboidal or cylindrical epitbelial cells. Morphologically they were identical with uterine glands. In a few tubules the epithelium was degenerated and the lumma *pead
at
a
meeting
of
the
New
York
Obstetrical
Society,
May
8. 1928
WILLIAMS filled with granular usually infiltrated
:
ENDOMETRIOSIS
OF
d6bris. The tissue surrounding with inflammatory cells.
AN
ABDOMINAL the tubules
SCAR was
edematous
lo:? and
Whatever opinion one may hold as to the origin of the endometrial implants so ably described by Sampson,j when found in other sites, this case seems undoubtedly one of transplantation to an open scar by the dragging over it of the contents of the gravid uterus during cesarean section. Heaney,z in 1925, in describing a similar case found in the literature, Schwartz,6 reports 29 instances of endometriosis in abdominal scars. of St. Louis, added 2 more cases, and this case is the thirty-second. In analyzing these 32 cases, 14, or nearly 44 per cent, followed ventral fixation. It is difficult to understand why this condition should occur so frequently after fixation when we take into consideration the comparative rarity of this operation compared to the frequency of the classical cesarean section. Is it that the sutures are often passed entirely through the muscle wall into the uterine cavity and out again through the abdominal wall, carrying grafts of endometrium with them? If so, it should warn us to pass our sutures less deeply. However, in some of these cases as the two reported by Sampson, excision or resection of the tubes was performed. Two cases, or 6.2 per cent, followed hysterectomy; whether subtotal or complete I was unable to determine, but presumably supravaginal. Three cases, or 9.3 per cent, followed unspecified pelvic operations. Two cases, 6.2 per cent, followed appendectomy and one oophorectomy. Ten cases, or 31.2 per cent, followed either cesarean section or some operation involving the opening of the cavity of a pregnant uterus, that is, rupture of the uterus during attempted abortion, 2; hysterotomy during an operation on a pregnant uterus, 1, and cesarean section on the full-term uterus in ‘7. Dr. Sampson, in kindly writing to us about this ease says among other things : “I have never encountered such a case in my own practice following cesarean section. On the other hand, I have had two cases of endometriosis in the rectus muscle following fixation of the uterus to the abdominal wall. There have been cases reported of endometriosis of the abdominal scar following operation in which the uterus has not been opened and for this reason some believe that the endometriosis in these cases results from the transplantation of bits of peritoneal serosa included in the wound rather than the transplanting of uterine mucosa by the surgeon.” Nicholson3 in England and Novak4 in this country hold this view. If it is difficult to understand how the miillerian mucosa can be transplanted in cases not involving the opening of the uterus or section of the tubes, it is equally difficult to understand why, if these growths result from the implantation of bits of peritoneal serosa, they have never been found except in females.
104
THE
AMERICAN
JOKRXAL
OF
ORSTETRI(‘S
.\XD
QYNECOLOtGX
REFERENCES
(1) Heaaey,
0.
&WL~OV~~, hi. J.
8. : Obst.
w.
C.:
AM. OBST.
AM. J. 65 Gynaec.
w.: OBST. 8; GYNEC. 10: ii: 6&&?:, :;l;. (6) 3. 429 PAI& AVENTTE.
5.
OBST'. C% GYP;EC.
Brit.
802,
192.5.
Schwartz,
J.
Emp.
i 10: 33:
UYNIC. 10: 630.32, F2R-30, 730, 1925. 62-33,
(5) Sampson, dokn 0. H., md Paddock, (For
1026.
A. : X.:
730,
1925.
(3)
Sbholsm,
(21
(4) Novak, E.: Av. AX. J. OBST. & GYNEC. Ax. J. OBST. &Z GYNEC.
SCP page
discussiom,
l.20.)
RECIPROCAL RELATIONS I3ETWEE:N DISEASES OF THE ALIMENTARY AND FEMALE GENITAL SYSTEMS BY
r
A.
J.
WALSCIIEID,
M.D.,
NEW
YORK,
iT.
Y.
HE digestive system can be influenced by the female genitals and r their diseases in a reflex manner through the sympathetic and parasympathetic nervous systems. This causal relationship is in evidence especially at the critical periods of puberty and the menopause, and in connection with the functions of menstruation, gestation, parturition, lactation, etc. A strong predisposition is supplied by the state of the female organs at the time, and especially at the time of the menopause, when t,he uterus and ovaries are undergoing regressive changes. The organs are no longer able to produce their peculiar hormones. and this deficiency disturbs the entire equilibrium of the hormonal system, which in turn is felt in the distnrbed innervation of Lhe autonomous system, manifested respectivchly as vagotonia or sympatheticotonia. Without any immediate .attempt, to fix the primary responsibilit;v attention may be called to the transitory spastic states which are apt 180supervene at the menopausal period in the alimentary canal from the esophagus to the colon. This spasticit? may be multiple and aEect different levels of the canal, and the symptom picture may not onl) be very complicated and varied but the frequent spastic contractions Spasticitg ma3 may contribute to the development of peptic ulcer. of course be sufficient per se to cause ileus or incomplete stasis and map also be a factor in stasis of mechanical origin. As a result, while intestinal obstruction is rare from this cause, we may readily surmise the development of general st,asis and autoint.oxication. The waman at the menopause may suffer from suppurative foci in the teeth or elsewhere in the digestive tract and the physiologic state at that epoch may possibly light up focal infection; however, the teeth should be put in order even if there is no actual evidence of focal infection. In speaking of the disequilibrium of the hormonal system induced at the menopause, the question of high blood pressure comes up. If this were a common phenomenon, a relationship would be suspected; but in my own experience high blood pressure at the menopause is dne to some special cause not related to t.he Iatt.ey. Hence, if 1 find
TRE
AMERICAN
JOURNAL
OF
ORSTETRICS
AND
GYNECOLOGY
REFERENCES
(1) Cushn~l: Textbook of Pharmacology, Philadelphia, Lea and Febiger. (2: Sollmann: Manual of Pharmacology, Philadelphia, W. B. Saunders Co. (3) Jun.o and Cook: Proc. See. Erper. B:ol. and Med., 1927, xiv, 586. (4) Laaurd, Irwin, and Pruwinlc: AM. JOUR. OBST. AKD GYNEC.. 1926, xii, 104. (5) Ikmett: -4x. JOUR. OBST. AP;D GYNEC., 1926, xi, 227. 626
MEDICAL
ARTS
BUILDIW.
ENDOMETRIOSIS
OF AN
ABDOMIXAL
CESAREAN BY PERCY
T
11.
SCAR
FOLLOWING
SECTION” M.D., NEW YORK, N. Y.
WILLIAMS,
HE case I wish to report is one of endometriosis of an abdominal scar following a second classical cesarean operation.
The patient, a woman of thirty-five, was admitted to Lenox Hill Hospital with a diagnosis of movable retroversion and an inflamed painful scar following two eesarean sections which were done respectively nine and seven years before. She admitted that the scar was somewhat changeable in color, but she had not noticed that the variation had any relation to the menstrual cycle. Physical examination was otherwise negative except for a third degree movable retroversion which was giving her no symptoms. The cicatrix measured 8 cm. in length and involved the umbilicus at about the junction of the upper and middle thirds. It. was firm, thickened, irregular, and Its surface was moist and rather sticky to the rather heaped up in appearanee. touch, she said it was constantly “perspiring.” It was dull pink and had the appearance of chronically inflamed cicatricial tissue. No hernial ring could be made out because of the brawny tissues, but a slight impulse on coughing made one suspicious of an underlying hernia. A diagnosis of a chronically inflamed cicatrix overlying a hernia was made but a possible sarcoma could not be ruled out. Endometriosis was thought of but dismissed, because there was no history of variation of color wit,h the phases of the menstrual cycle. Operation took place the day after admission. The scar was excised by a narrow elliptical incision; the hernia repaired by muscular overlapping, and the excised portion sent for microscopic examination. Convalescence was uneventful; patient left the hospital in seventeen days. Microscopic examination of the various parts of the specimen showed diffuse involvement of the cicatrix by adenomyoma with all the characteristics of typical endometrial tissue. The tumor was poorly outlined and extended from beneath the epidermis to the peritoneal surface and laterally to the margins of the scar. The peritoneum was not involved. The bulk of the tumor was composed of smooth muscle cells disposed in bundles running in all directions. Imbedded in this tissue were small islands of fat and epithelial tubules or cysts, either single or in groups, sometimes reating directly on the muscle but more often separated from it by zones of cellular tissue resembling the endometrial stroma. The tubules were lined with a single layer of noneiliated euboidal or cylindrical epitbelial cells. Morphologically they were identical with uterine glands. In a few tubules the epithelium was degenerated and the lumma *pead
at
a
meeting
of
the
New
York
Obstetrical
Society,
May
8. 1928
WILLIAMS filled with granular usually infiltrated
:
ENDOMETRIOSIS
OF
d6bris. The tissue surrounding with inflammatory cells.
AN
ABDOMINAL the tubules
SCAR was
edematous
lo:? and
Whatever opinion one may hold as to the origin of the endometrial implants so ably described by Sampson,j when found in other sites, this case seems undoubtedly one of transplantation to an open scar by the dragging over it of the contents of the gravid uterus during cesarean section. Heaney,z in 1925, in describing a similar case found in the literature, Schwartz,6 reports 29 instances of endometriosis in abdominal scars. of St. Louis, added 2 more cases, and this case is the thirty-second. In analyzing these 32 cases, 14, or nearly 44 per cent, followed ventral fixation. It is difficult to understand why this condition should occur so frequently after fixation when we take into consideration the comparative rarity of this operation compared to the frequency of the classical cesarean section. Is it that the sutures are often passed entirely through the muscle wall into the uterine cavity and out again through the abdominal wall, carrying grafts of endometrium with them? If so, it should warn us to pass our sutures less deeply. However, in some of these cases as the two reported by Sampson, excision or resection of the tubes was performed. Two cases, or 6.2 per cent, followed hysterectomy; whether subtotal or complete I was unable to determine, but presumably supravaginal. Three cases, or 9.3 per cent, followed unspecified pelvic operations. Two cases, 6.2 per cent, followed appendectomy and one oophorectomy. Ten cases, or 31.2 per cent, followed either cesarean section or some operation involving the opening of the cavity of a pregnant uterus, that is, rupture of the uterus during attempted abortion, 2; hysterotomy during an operation on a pregnant uterus, 1, and cesarean section on the full-term uterus in ‘7. Dr. Sampson, in kindly writing to us about this ease says among other things : “I have never encountered such a case in my own practice following cesarean section. On the other hand, I have had two cases of endometriosis in the rectus muscle following fixation of the uterus to the abdominal wall. There have been cases reported of endometriosis of the abdominal scar following operation in which the uterus has not been opened and for this reason some believe that the endometriosis in these cases results from the transplantation of bits of peritoneal serosa included in the wound rather than the transplanting of uterine mucosa by the surgeon.” Nicholson3 in England and Novak4 in this country hold this view. If it is difficult to understand how the miillerian mucosa can be transplanted in cases not involving the opening of the uterus or section of the tubes, it is equally difficult to understand why, if these growths result from the implantation of bits of peritoneal serosa, they have never been found except in females.
104
THE
AMERICAN
JOKRXAL
OF
ORSTETRI(‘S
.\XD
QYNECOLOtGX
REFERENCES
(1) Heaaey,
0.
&WL~OV~~, hi. J.
8. : Obst.
w.
C.:
AM. OBST.
AM. J. 65 Gynaec.
w.: OBST. 8; GYNEC. 10: ii: 6&&?:, :;l;. (6) 3. 429 PAI& AVENTTE.
5.
OBST'. C% GYP;EC.
Brit.
802,
192.5.
Schwartz,
J.
Emp.
i 10: 33:
UYNIC. 10: 630.32, F2R-30, 730, 1925. 62-33,
(5) Sampson, dokn 0. H., md Paddock, (For
1026.
A. : X.:
730,
1925.
(3)
Sbholsm,
(21
(4) Novak, E.: Av. AX. J. OBST. & GYNEC. Ax. J. OBST. &Z GYNEC.
SCP page
discussiom,
l.20.)
RECIPROCAL RELATIONS I3ETWEE:N DISEASES OF THE ALIMENTARY AND FEMALE GENITAL SYSTEMS BY
r
A.
J.
WALSCIIEID,
M.D.,
NEW
YORK,
iT.
Y.
HE digestive system can be influenced by the female genitals and r their diseases in a reflex manner through the sympathetic and parasympathetic nervous systems. This causal relationship is in evidence especially at the critical periods of puberty and the menopause, and in connection with the functions of menstruation, gestation, parturition, lactation, etc. A strong predisposition is supplied by the state of the female organs at the time, and especially at the time of the menopause, when t,he uterus and ovaries are undergoing regressive changes. The organs are no longer able to produce their peculiar hormones. and this deficiency disturbs the entire equilibrium of the hormonal system, which in turn is felt in the distnrbed innervation of Lhe autonomous system, manifested respectivchly as vagotonia or sympatheticotonia. Without any immediate .attempt, to fix the primary responsibilit;v attention may be called to the transitory spastic states which are apt 180supervene at the menopausal period in the alimentary canal from the esophagus to the colon. This spasticit? may be multiple and aEect different levels of the canal, and the symptom picture may not onl) be very complicated and varied but the frequent spastic contractions Spasticitg ma3 may contribute to the development of peptic ulcer. of course be sufficient per se to cause ileus or incomplete stasis and map also be a factor in stasis of mechanical origin. As a result, while intestinal obstruction is rare from this cause, we may readily surmise the development of general st,asis and autoint.oxication. The waman at the menopause may suffer from suppurative foci in the teeth or elsewhere in the digestive tract and the physiologic state at that epoch may possibly light up focal infection; however, the teeth should be put in order even if there is no actual evidence of focal infection. In speaking of the disequilibrium of the hormonal system induced at the menopause, the question of high blood pressure comes up. If this were a common phenomenon, a relationship would be suspected; but in my own experience high blood pressure at the menopause is dne to some special cause not related to t.he Iatt.ey. Hence, if 1 find