Successful Removal of a Solid Uterine Fibroma Weighing Seventy Pounds
BMJ (Clinical Research Edition)
ON February 4th, I878, in consultation with Mr. Symonds of Oxford, I saw a single lady, thirty-six years of age. Her abdomen was enormously enlarged by a solid tumour, which extended upwards behind the lower ribs orn both sides, pressing them outwards, and passed downwards into the pelvis, filling up the hollow of the sacrum, and causing prolapse of the posterior wall of thc vagina. This sketch, although made of another patient, gives an excellent idea of the appearance of the lady, except that
... e lady, except that it hardly shows how much the tumour encroached on the thorax, and there was considerable cedema of the feet and legs, which was said to disappear for a time after the cessation of each monthly period. The cervix uteri could not be reached, and it was impossible to ascertain where the uterus was situated. The catamenia were regular in time and normal in quantity. Mr. Symonds had advised removal of the tumour in 1876, when it was much smaller; but the patient and her friends steadily objected. The first symptom of illness was in i868, when backache became troublesome; and, early in I869, Mir. Barker of Wisbech Ifound a small hard swelling in the left side of the abdomen. This gradually enlarged; and Mr. Barker informs me that in June 1871, " in consultation with Dr. Protheroe Smith, the question of removing the tumour was canvassed, and it was then decided by us that, taking into account the low vital power of the patient and the fact that several forms of struma had shown themselves in several members of the family, it was decided that operative measures were not justifiable". After this consultation, increase went on, at first slowly, but much more rapidly during the year I877. As the tumour w%as quite solid, not fluctuating anywhere, and as the uterus could not be found, I expressed my opinion to AMr. Symonds that an accurate diaanosis was impossible; that I thought the tumour more likely to be uterine than ovarian ; but that it might be some such rare form of abdominal fibroma as I had once removed in Germany, and which had been described by Virchow as fibronca mtolltuscztmto, not necessarily connected with either uterus or ovaries. I also said that only an exploratory incision could determine if the tumour could be removed or not; and, that if the attempt were made, it should rather be at the wish of the patient than by the advice of the surgeon. At first, she decided against operation; but suffering became daily greater, and it was arranged that I should make an exploratory incision on Mlarch 7th, four days after the cessation of the catamenia. Accordingly, on that day, chloro-methyl being administered by Dr. Day, and Dr. Bantock, Mr. Thornton, and Dr. W. Webb assisting me, Mr. Symonds and Mr. Hill also being present, I made an incision in the median line between the umbilicus and pubes and cut into the substance of a solid fibroid tumour, which was closely adherent to the abdominal wall. After separating some adhesions, I passed my hand into the peritoneal cavity, and found the tumour to be free from adhesions on the left side, also behind and above, but to be closely bound down on the right side. In front, the bladder was so high that the incision could not be carried within about four to five inches of the pubes, so it was extended upwards about five or six inches above the umbilicus, as soon as I had convinced myself that it would be possible to remove the tumour. A large piece of adhering omentum was detached from the upper part and behind. Towards the left side, a broad mesenteric attachment was divided by the krnife, large blood-vessels being temporarily secured by torsion-forceps. I was then able to shell the tumour out from a sort of vascular capsule formed by the two layers of the right broad ligament, and separate it, but only by the knife, from the posterior surface of a uterus of normal size, after forcibly pulling the tumour up out of the pelvis and separating it from the rectum, to which it adhered closely. The right ovary (although normal) was cut away, because the Fallopian tube had been divided and the broad ligament was much torn. The left ovary and Fallopian tube were not disturbed. Several silk ligatures were applied to the right of the uterus, and also to open vessels on its posterior surface when the tumour had been cut away. Two large pieces of omentum were cut off, after securing them by ligature. I then found that the two opposite sides of the remnant of the capsule of broad ligament (out of which I had enucleated the tumour) could be brought together behind the uterus, so as to complete the union of the divided peritoneum from the lower angle of the opening in the abdominal wall, the elevated bladder and the fundus uteri, all down the back of the uterus to the rectum. I did this by an uninterrupted suture of fine silk, making about twenty points of suture, and finishing close to the vagina and rectum. In this way, the perito. neal sac was completely shut off from the torn cellular tissue of the pelvis. A good deal of sponging was necessary to remove clots of blood from the peritoneal cavity; but very little blood was lost considering the great size of the tumour and the extent of its attachments. The opening in the abdominal wall was closed by twenty-five silk sutures. The patient was placed in bed exactly an hour from the minute when she began to inhale methylene. She was faint and vecy chilly, a spray of a solution of thymol (I in I,OOO of water) having played upon the abdomen all through the operation; and, although sponges moistened by warm thymol solution protected the intestires and abdominal cavity to some extent, the chilling effect of the spray was manifest. On examining the tumour, it was found that about two pounds of blood had drained from the vessels divided in its capsule and at its line of separation from the uterus. Its circumference in three different directions was 52 inches at the smallest, 57 inches at the largest, and 53 inches in a third. A small piece was cut out for microscopic examination, and the tumour was then weighed in the Museum of the Mliddlesex Hospital, and found to be 68 lbs. 6 oz. The tumour was "chiefly composed of cells with relatively large nuclei, many corntaining several nucleoli, of the type difficult to distinguish as distinctly muscular; but in some parts of the tumour unstriped musclecells were manifest" (J. K. Thornton). I have very little to add as to the progress after operation, except that the temperature seldom rose above 99 deg., only reaching IOI.2 deg. (the highest noted) once. Only four opiates were given. There was never any distension of the abdomen. Six days after operation, the bandage and dressing were removed for the first time. The four or five layers of thymol gauze next the skin were damp with serum; the outer layers were quite dry. The wound was united from top to bottom. All the twenty-five sutures were removed, and the line of union was almost imperceptible. The dressing was only changed twice after this; and, except a few drops of pus from one of the central stitch-holes, union was perfect by first intention. For a few days in the second and third week after operation, the patient occasionally vomited, and was weak and low-spirited, and there was a considerable swelling in the pelvis, as if from a hoematocele in the front of the rectum, to such an extent that the uterus could not be felt. There were frequent, very offensive, watery motions, but never any purulent discharge. When the swelling in the pelvis began to subside, and after washing out the rectum with thymol solution, rapid amendment set in and went on. Two days before she left London by rail for Oxford, on April 8th, just a month after operation, I carefully examined the pelvis by vagina and rectum, and really could not find any trace of an operation having been performed. The uterus was in its normal position, was movable, and of ordinary size and weight. Mr. Symonds wrote that he was surprised to see her looking so well after the journey; and I received a letter, dated April i6th, saying that she was gaining her strength, could walk downstairs, and that her appetite was good. She wrote herself on May 4th, saying, " I mab o w -ad am able to walk a little, and get out in the air as much as possible. "