1910 BMJ (Clinical Research Edition)  
Six months ago she was 241 in. in circumference, and now she -s more than 32 in. She had been losing flesh rapidly, was constipated, and the left foot and ankle had been swelling. She *tad been married twice, but had had no children nor any mis-.carriages. Menopause four years ago. She had never had an *illnessof any moment. The patient was a little, slight woman, with a dark and sallow complexion. The abdomen was enlarged -and protuberant, especially the lower part. A large, firm tumour could
more » ... firm tumour could be felt, the bulk of which was on the right side, tbut it spread right across the abdomen. It extended upwards -nto the right hypochondrium and downwards into the pelvis. It was moderately regular in outline, but rounded lumps could 'be felt. One on the extreme right was very tender on pressure. Free fluid was present in the left flank, which was thought to be localized by adhesions, as there was no shifting dullness on change of positin Dilated veins were visible on the surface, running upwards from the right groin. Per vaginam: The vagina itself was quite soft. In its roof ,anteriorly could be felt two lumps and posteriorly another lump pushing down towards Douglas's pouch. These were ,solid but not hard. On pressing firmly upwards movement was communicated to the tumour. The cervix could not be identified. The edge of the tumour was well defined. Percussion over it was absolutely dull. Below the umbilicus it was almost in 'contact with the abdominal wall, but above, the elastic -stretehed wall had to be depressed by the fingers before the upper edge could be felt. The heart was normal, but there were signs in the lungs. -Bronchial breathing right side in front, dullness at both bases, absolute over the left base with absence of vocal resonance ,and breath sounds, and very definite crepitations. There were also crepitations at the right base, but less distinct. The -pulse averaged 100, and the temperature, which was occasion--ally slightly raised, about 98.80. Subsequent Course.-She had some difficulty with the bowels, -,but passed urine normally, quantity between 30oz. and 400z. daily, the speific gravity being moderately low, but containing nothing abnormal. Her chief complaint was pain, which was very severe at times, especially at night, and usually on the right side of the abdomen, but there were intervals when she was quite free from pain. The abdo-'men increased in size, and the superficial veins became more apparent. The diagnosis was easy, except as to the exact nature and origin of the tumour; it was malignant growth of right appendage with secondary deposits in lungs. The bad nights became more frequent, anddyspnoea began. The patient begged that something might be done to relieve her of the weight of the tumour, and prayed that she might -die on the operating table rather than continue as she was. 'It was on this account that operation was agreed upon, and -also on the slender chance that the tumour mightDrove to be innocent and the condition of the lungs due to luid at the abases, an extension from the abdomen. She was operated upon three and a half weeks after admission. Operation.-The bladder was sounded, the sound passing 31 in. An incision was then made midway between umbilicus and pubes. On opening the peritoneum there was an escape of *eark, clear, blood-stained fluid; then the tumour presented itself. It was smooth, solid, and with rounded nodules on the -surfce; it was softening in parts. The hand was introduced, "but it could not pass right around the tumour on account of a 'aarge adhesion on the left side. The wound was now enlarged -upwards almost to the xiphisternum and downwards to the pubes, and the hand passed around the tumour above. Even then considerable retraction of the lax abdominal wall was necessary before the large diameter of the tumour -could be got out over it. Adhesions on the right were then separated piece by piece after ligaturing, and adhesions -and large entering vessels on the left. One very large thick ..adhesion united the tumour to the sigmoid colon. An 4 encirclinlg incision was then made through. the peritoilefim above the thick pedicle of the tumonr, the centre of which came from the right broad ligament near its junction with the uterus, and with some difficulty the peritoneum was stripped downwards, and the pedicle ligated in sections and snipped across with scissors. This was a very difficult procedure, since the tumour was practically sessile, and owing to its great size it overhung, and interfered with the work going on beneath. The haemorrbage was only moderate, but owing to the patient's condition, and on the advice of the anaesthetist, it was found necessary to accelerate matters. The peritoneum was accordingly drawn over the stump, and a large drainage tube having been inserted, the abdomen was rapidly closed by through-andthrough stitehes of silkworm gut. It was noticed during the operation that the ovaries were enlarged, and that there were, smaal miliary growths like sago grains along the small intestine. Also that there were purple patches of congestion in the parietal peritoneum. The tumour weighed 121 lb., but this does not convey a fair impression of its size. On section a number of rounded areas were observable of a darker colour than the rest, and slightly raisedabove its surface, and there was amedium-sizedcavity ful of gelatinous semifluid material. A portion was senttothe Government pathologist, who examined it microscopically, and reported it to be a spindle-celled sarcoma. For the first two days after the operation there was little complaint of pain and only a little clear blood-stained fluid came from the tube; then atony and distension of the small intestine took place, and patient had at times alarming dyspnoeic attacks. She died in one of these on the fourth day after. Post-mortem Examination.-Pedicle wound in good condition; very little free fluid in abdominal cavity; recent adhesions of small intestine. Uterus and ovaries adherent to surrounding structures behind and at the sides of the pelvis, so that the fingers could not be pushed down into the pouch of Douglas. The right ovary was about three times its normal size, and on section was white and firm, without any trace of normal glandular tissue. There were small lumps in the broad ligaments and at the back of the uterus. Smallsago graindeposits in small intestine. Liver small, pale, and firm, but no growths. The right lung had recent adhesions. The left' lung was consolidated near the base, and the pleura coarse, rough, and thickened. CASEII. Adeno-carcinoma of Uterus. Margaret W., a married woman aged 42, and a nullipara, was admitted as an urgent case for profuse haemorrhage from the uterus. She said that she had been losing blood at timesbetween the periods-for over a year. She had been treated medically with some success and had menstruated regularly until two weeks ago. Since then she had been bleeding slightly until 4 o'clock in the morning of admission, when she had a considerable haemorrhage. She had been married fourteen years, without children or miscarriages. She was a well nourished woman, pale, but not very anaemic. Her pulse was 64 and of good tension, but soon quickened up to 106. Shortly after admission she vomited copiously. On examination blood was oozing from the vagina,which was full of clot. The vagina was narrow and short, and in its roof a, rounded smooth firm tumour could be felt, which filled up the hollow of the sacrum. The finger could be just swept around. it, and it had very much the same feel as the presenting occiput; at full term. The external os could notbe defined. The continuity of the tumour with the uterus was made out bimanually. By abdominal examination the uterus was found to be enlarged to about half-way between umbilicus and pubes, with a small firm lump on the right side. The bleeding was much lessened by hot douching with a solution containing tinct. hamamelidis and calcium chloride. The vagina was then plugged with iodoform gauze and ergotinin citrate gr. A injected hypodermically. This checked the bleeding completely, but next day the mucous membranes were very pale and the pulse moderately accelerated, and some permanent measure had to be considered. It was thought most probable that fibroids were present and it was decided to operate. She was first examined in the lithotomy position. The vagina was so small that it would only admit one finger, and a small dilatable speculum was inserted and the vagina dilated before anything could be seen. No external os was then visible, but a rounded tumour which appeared to form part of an enlarged cervix. Manipulation started the bleeding, and on swabbing the bleeding point could be identifted on the front aspect of the tumour, which was apparently breaking down. This was plugged again and the patient laid on the table in the Trendelenburg position. Thn skin of the abdomen had already been well prepared. A 3-in. incision was made in the middle line between umbilicus and pubis, the peritoneum opened, and the small intestine pushed. up and packed off with gauze. The uterus was then examined. The fundus was little larger than the normal size except for a, small firm round subperitoneal growth on the right side. The lower pole was uniformly enlarged and blocked up the pelvio canal. It measured 31 in. in diameter and was solid. The uterus had the shape of a pear with the head hanging downwards. It was decided to remove it. There was also a single smooth-walled cyst about the size of an orange attached to the right broad ligament close to the right ovary., The wall was thin, moderately tense, and it fluctuated freely. The broad ligaments were clamped and the ovarian and uterine arteries ligatured on each side in the usual way, except that, owing to the inverted pear shape of the uterus, the clamps I
doi:10.1136/bmj.1.2570.809 fatcat:jhtvequk6zhvlmdfnoua3v6cp4