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Endometriosis of the Abdominal Scar
NEWTON:
ENDOMETRIOSIS OF ABDOMINAL SCAR
561
tion. At operation several small areas of endometriosis were found, however, rather high on the rectum; this was confirmed by biopsy of the lesions and study of the ovaries which were both removed along with the uterus. The patient was followed in the gynecologic dispensary without incident. Early in June, 1942, she complained of severe hot flushes and stilbestrol was given. She took the stilbestrol for a few days and on June 13, 1942, fainted, became nauseated, and vomited twice. She came at once to the Emergency Room where it was discovered that she was again having r,~ctal bleeding. The red blood count was 2,270,000 and the hemoglobin was 44 per cent (Sahli). By inquiry from the patient it was ascertained that she had taken between ten and fifteen 1 mg. enteric coated diethylstilbestrol tablets in as many days. Gastrointestinal work-up was again negative, the patient was transfused seven times, stilbestrol therapy was discontinued, and she was discharged from the hospital on the twentysixth hospital day. Since June, 1942, the patient has been followed in the outpatient department and remained entirely well, flushes being fairly well controlled by sedatives.
ha~
Summary A patient with severe periodic bleeding from endometriosis of the bowel, requiring in all over seventy partial or whole tral1'3fusions, is reported. She was finally treated by surgical castration and was well until given diethylstilbestrol for menopausal symptoms when severe recurrence of the bleeding took place. Permanent recovery followed discontinuance of this therapy.
References 1. Scott, Roger B.: AM. J. 0BST. & GYNEC. 47: 608, 1944. ~l. Sanders, R. L.: Surgery 13: 239, 1943. B. Jenkinson, E. L., and Brown, W. H.: J. A. M. A. 122: 349, 1943. 4. Greenhill, J. P.: The 1943 Year Book of Obstetrics and Gynecology, Chicago, The Year Book Publishers, p. 419 (Comment).
ENDOMETRIOSIS OF THE ABDOMINAL SOAR Loms NEwToN,
M.D.,
BRIDGEPORT, CoNN.
MRS. M. R., 27 years old, a white patient, while in service with the Women's Army Corps, · on Dec. 26, 1943, developed a sudden urinary retention. This condition cleared up after a few days of catheterization. Thorough urologic investigation did not reveal any pathology in the urinary tract. Another sudden retention occurred on July 13, 1944. At this time she was sent to the Woodrow Wilson General Hospital where another complete urologic investiga· tion was again negative. She was told that ''probably a tumor of the womb pressed on the bladder'' and received her medical discharge papers. Careful questioning revealed a perfectly normal menstrual history; the past history contained the significant fact that on Sept. 3, 1934 (at the age of 17 years), she was op· erated on for a ruptured tubal pregnancy (left side) at the Sydenham Hospital, New York City. On pelvic examination the fundus of the uterus was found to be somewhat enlarged and irregular, slightly movable, and tender. Another cystoscopic examination revealed normal findings. A diagnosis of subserous fibromyoma of the uterus was made, and at the operation on Aug. 12, 1944, the following were the significant findings: While excising the abdominal scar of the previous operation, an irregular mass of walnut size and of cartilagenous nature was encountered 2 inches below the umbilicus. Its growth extended into the rectus muscle down to the peritoneum. This entire mass was excised and it contained several small, pea-sized cysts of dark blue color. These upon punct~re revealed dark, thick :fluid.
562
AMERICAN JOURNAIJ OF OBSTETRICS AND GYNECOLOGY
When the peritoneal cavity was opened, both the fundus of the uterus and bladder were found to be attached by a thick, irregular band of omental and inflammatory adhesions to the lower angle of the undersurface of the previous abdominal Rear. When these a
Summary 1. A case of endometriosis of the laparotomy scar is presented. In view of the history of ruptured tubal pregnancy, it can be as.sumed that "soiling" of the abdominal wound occurred at that time during the operative procedure. The histogenesis cannot be proved definitely by this theory. '!'here are various other theories whieh may explain the occurrence of this comparatively rare condition.
2. The true nature of the pathology •·ould hardly be sus[weted because the lesion itself was entirely without symptoms. 3. Adhesions of the uterus to the undersurface of the sear containing the area of endometriosis account for the erroneous diagnosis of fibromyoma by three differ~nt observers. 4. The urinary retention which occurred on two different occasions may have been neurogenic, but it cannot be adequately explained. Six months later patient was well and will be observed further. 881 LAFAYETTE STREET.
PREGNANCY IN A DIVJtB'l!CULUM: FBOif· T1IZ U'PB&US M.
c. HAWKINS, JR., B.S., M.D., F.A.C.S.,
SEARCY, ARK.
(From the Hawkins Clinic Hospital)
M
RS. E. C. W., Case No. 45·45, white, aged 29 years, was admitted to the Hawkins Clinic Hospital on January 23, 1945, because of a painful and tender mass in the right lower abdomen. She stated that the onset of pain had been two weeks before and at that time she had discovered a mass in the abdomen. The pain had progressively become more severe and the mass larger. There was no history of fever, nausea, or vomiting. She had been married for eight years, and had had no pregnancies. Menstruation was normal up until Sept. 10, 1944, since which· time she had not menstruated. Her past history waH essentially negative, with no surgery.
Physical Examination.-Patient appeared anxious and rather disturbed and suffering moderate pain; blood pressure 118/70, pulse rate 80, temperature 98.4 o F.; head, neck, eyes, ears, nose, and throat, negative; heart and lungs, negative; breasts, moderately tense, otherwise negative; abdomen, soft, not distended. There was a round, smooth, palpable mass between the umbilicus and the symphysis, to the right of the midline, extending upward from within the pelvis to within 2 inches of the level of the umbilicus. The mass was tender, slightly movable, and firm. Genitalia: Perineum, normal; vaginal mucosa, bluish discoloration; cervix, softened but otherwise normal. Bimanual: Uterus slightly enlarged and softened and apparently pushed to the left by a tense, sausage-shaped mass of elastic consistency attached to the right superior-lateral portion of the fundus of the uterus, extending from high in the right pelvis to within 2 inches of the level of the umbilicus and movable with the uterus. Tentative Diagnosis.-Pregnancy complicated by pelvic tumor. Operation was advised, and on Jan. 2S, 1945, the patient was operated upQn under cyclopropane and oxygen anesthesia. Through a low midline incision the ·abdomen was opened, revealing a tense semifluctuant sausage-shaped diverticulum from the uterus, 6 inches in length and 3 inches in diameter, \vith bluish discoloration at its free end, and apparent tflinning of its wall at this area. The diverticulum was a continuation from the fundus of the uterus at. its right cornu with fl. pedir.le-like nttachment. 'f'hf' right ronnil
ENDOMETRIOSIS OF ABDOMINAL SCAR
561
tion. At operation several small areas of endometriosis were found, however, rather high on the rectum; this was confirmed by biopsy of the lesions and study of the ovaries which were both removed along with the uterus. The patient was followed in the gynecologic dispensary without incident. Early in June, 1942, she complained of severe hot flushes and stilbestrol was given. She took the stilbestrol for a few days and on June 13, 1942, fainted, became nauseated, and vomited twice. She came at once to the Emergency Room where it was discovered that she was again having r,~ctal bleeding. The red blood count was 2,270,000 and the hemoglobin was 44 per cent (Sahli). By inquiry from the patient it was ascertained that she had taken between ten and fifteen 1 mg. enteric coated diethylstilbestrol tablets in as many days. Gastrointestinal work-up was again negative, the patient was transfused seven times, stilbestrol therapy was discontinued, and she was discharged from the hospital on the twentysixth hospital day. Since June, 1942, the patient has been followed in the outpatient department and remained entirely well, flushes being fairly well controlled by sedatives.
ha~
Summary A patient with severe periodic bleeding from endometriosis of the bowel, requiring in all over seventy partial or whole tral1'3fusions, is reported. She was finally treated by surgical castration and was well until given diethylstilbestrol for menopausal symptoms when severe recurrence of the bleeding took place. Permanent recovery followed discontinuance of this therapy.
References 1. Scott, Roger B.: AM. J. 0BST. & GYNEC. 47: 608, 1944. ~l. Sanders, R. L.: Surgery 13: 239, 1943. B. Jenkinson, E. L., and Brown, W. H.: J. A. M. A. 122: 349, 1943. 4. Greenhill, J. P.: The 1943 Year Book of Obstetrics and Gynecology, Chicago, The Year Book Publishers, p. 419 (Comment).
ENDOMETRIOSIS OF THE ABDOMINAL SOAR Loms NEwToN,
M.D.,
BRIDGEPORT, CoNN.
MRS. M. R., 27 years old, a white patient, while in service with the Women's Army Corps, · on Dec. 26, 1943, developed a sudden urinary retention. This condition cleared up after a few days of catheterization. Thorough urologic investigation did not reveal any pathology in the urinary tract. Another sudden retention occurred on July 13, 1944. At this time she was sent to the Woodrow Wilson General Hospital where another complete urologic investiga· tion was again negative. She was told that ''probably a tumor of the womb pressed on the bladder'' and received her medical discharge papers. Careful questioning revealed a perfectly normal menstrual history; the past history contained the significant fact that on Sept. 3, 1934 (at the age of 17 years), she was op· erated on for a ruptured tubal pregnancy (left side) at the Sydenham Hospital, New York City. On pelvic examination the fundus of the uterus was found to be somewhat enlarged and irregular, slightly movable, and tender. Another cystoscopic examination revealed normal findings. A diagnosis of subserous fibromyoma of the uterus was made, and at the operation on Aug. 12, 1944, the following were the significant findings: While excising the abdominal scar of the previous operation, an irregular mass of walnut size and of cartilagenous nature was encountered 2 inches below the umbilicus. Its growth extended into the rectus muscle down to the peritoneum. This entire mass was excised and it contained several small, pea-sized cysts of dark blue color. These upon punct~re revealed dark, thick :fluid.
562
AMERICAN JOURNAIJ OF OBSTETRICS AND GYNECOLOGY
When the peritoneal cavity was opened, both the fundus of the uterus and bladder were found to be attached by a thick, irregular band of omental and inflammatory adhesions to the lower angle of the undersurface of the previous abdominal Rear. When these a
Summary 1. A case of endometriosis of the laparotomy scar is presented. In view of the history of ruptured tubal pregnancy, it can be as.sumed that "soiling" of the abdominal wound occurred at that time during the operative procedure. The histogenesis cannot be proved definitely by this theory. '!'here are various other theories whieh may explain the occurrence of this comparatively rare condition.
2. The true nature of the pathology •·ould hardly be sus[weted because the lesion itself was entirely without symptoms. 3. Adhesions of the uterus to the undersurface of the sear containing the area of endometriosis account for the erroneous diagnosis of fibromyoma by three differ~nt observers. 4. The urinary retention which occurred on two different occasions may have been neurogenic, but it cannot be adequately explained. Six months later patient was well and will be observed further. 881 LAFAYETTE STREET.
PREGNANCY IN A DIVJtB'l!CULUM: FBOif· T1IZ U'PB&US M.
c. HAWKINS, JR., B.S., M.D., F.A.C.S.,
SEARCY, ARK.
(From the Hawkins Clinic Hospital)
M
RS. E. C. W., Case No. 45·45, white, aged 29 years, was admitted to the Hawkins Clinic Hospital on January 23, 1945, because of a painful and tender mass in the right lower abdomen. She stated that the onset of pain had been two weeks before and at that time she had discovered a mass in the abdomen. The pain had progressively become more severe and the mass larger. There was no history of fever, nausea, or vomiting. She had been married for eight years, and had had no pregnancies. Menstruation was normal up until Sept. 10, 1944, since which· time she had not menstruated. Her past history waH essentially negative, with no surgery.
Physical Examination.-Patient appeared anxious and rather disturbed and suffering moderate pain; blood pressure 118/70, pulse rate 80, temperature 98.4 o F.; head, neck, eyes, ears, nose, and throat, negative; heart and lungs, negative; breasts, moderately tense, otherwise negative; abdomen, soft, not distended. There was a round, smooth, palpable mass between the umbilicus and the symphysis, to the right of the midline, extending upward from within the pelvis to within 2 inches of the level of the umbilicus. The mass was tender, slightly movable, and firm. Genitalia: Perineum, normal; vaginal mucosa, bluish discoloration; cervix, softened but otherwise normal. Bimanual: Uterus slightly enlarged and softened and apparently pushed to the left by a tense, sausage-shaped mass of elastic consistency attached to the right superior-lateral portion of the fundus of the uterus, extending from high in the right pelvis to within 2 inches of the level of the umbilicus and movable with the uterus. Tentative Diagnosis.-Pregnancy complicated by pelvic tumor. Operation was advised, and on Jan. 2S, 1945, the patient was operated upQn under cyclopropane and oxygen anesthesia. Through a low midline incision the ·abdomen was opened, revealing a tense semifluctuant sausage-shaped diverticulum from the uterus, 6 inches in length and 3 inches in diameter, \vith bluish discoloration at its free end, and apparent tflinning of its wall at this area. The diverticulum was a continuation from the fundus of the uterus at. its right cornu with fl. pedir.le-like nttachment. 'f'hf' right ronnil