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The os was very large, and its lateral dimensions so greatly increased as to be capable of admitting two fingers. On examination by the vagina it was impossible to ascertain the superior extent of the growth, but by introducing the finger into the rectum (which was considerably compressed) it could be felt to turn forwards rather abruptly about four inches from the orifice of the intes. tine. No enlargement or fulness could be discovered in the supra pubic or iliac regions, or indeed any other indication that could lead to the supposition of a tumour or hypertrophy of the body of the uterus.
The tumour felt of equal consistence throughout. It bled when disturbed, and the blood, as far as was ascertained, came from the region of the os. The diameter of its base, i.e., between the os and the posterior reflection of the vagina was not less than three inches; the measurement from side to side, at the same level, was still greater.
The diagram Fig. 1 represents an imaginary view of the pelvic viscera in section, showing the enormous development of the posterior lip of the uterus; the supposed condition of the body of the same organ, and also the rectum considerably compressed. It was drawn simply from the in. formation ascertained by digital examination before any surgical interference was resorted to, and although I have since had an opportunity of inspecting all the parts, I am unable to make any alteration in the outline that could resemble the real condition more absolutely. The dotted lines mark the seats of the first and second operation,
After mature deliberation and repeated examinations, assisted by my friend Mr Grimsdale, we determined to attempt the removal of the tumour. We proposed, by continued traction, to draw down the tumour as far as to enable us to pass ligatures through its base, and then to tie or cut it off as appeared best. Accordingly, on the 2d of July, she was placed under the influence of chloroform, and strong hooks and forceps passed into the substance of the tumour at different parts. With these forcible traction was exerted for a considerable time, but with only slight effect on the tumour, for it was impossible to pull it outwards to any extent. Under these circumstances all that was done was to pass a strong needle armed with a double ligature of whip cord, from the posterior reflection of the vagina to a little below the orfice of the os. Each half
was then secured with the ordinary polypus tubes, and by tightening the ligatures occasionally a large slough was separated at the end of a week.
Very little constitutional disturbance followed this operation, and although the tumour was not much reduced in size, the poor woman felt better and more comfortable than for long before it. The hemorrhagic discharge, from which she had so long suffered, ceased and did not again return.
The tumour rapidly regained its former dimensions, and three weeks after the operation was even larger than before. Her distress returned, and she suffered in addition from occasional partial prolapse of the growth attended with retention of urine. The introduction of the catheter, and observance of the horizontal position for a few hours, sufficed to relieve her until the recurrence of a similar attack.
I did not see her for a week previous to the 25th of September. On that morning Mr Lewis was called up at an early hour to relieve her from retention. She had not passed water for several hours, and on examination he found an enormous mass, as large as a child's head, protruding from the vulvæ, and laying on the bed between her thighs. After emptying the bladder by means of a catheter he attempted for some time to return the prolapse, but without success. Shortly afterwards I saw the patient with him. It was evident that the entire tumour and part of the uterus itself were prolapsed, and that to return it, even if desirable, would be impossible. It was deeply congested, of a dark colour, hot, and dry. She suffered terribly from pain in the back and across the loins, and called loudly for relief. Her pulse was about 100 and of tolerable strength. She had no sickness or hiccough. In other respects she did not present any immediately alarming symptoms. By supporting the tumour on a pillow to prevent its dragging, and enveloping it in a poultice, she was rendered somewhat more comfortable.
On inquiry I found that for several days previously the tumour had protruded more than usually, but that as she did not suffer from retention she had neglected to attend to it. On the evening before when trying to pass water it had come down en masse suddenly. At the same time she suffered violent pain.
In the afternoon I was again assisted by Mr Grimsdale to a more complete examination of the prolapsed mass, and our preconceived ideas of its form and attachments were thereby completely verified. Not only the tumour, but a portion of the uterus itself, were protruded, so that we could now see the os laying on the surface of the tumour, and by introducing a sound we were able to ascertain that the cavity of the uterus was not more than two and a half inches in extent. The tumour had also a tolerably distinct neck, it being at this part not more than three inches in diameter, while the body of the growth was nearly twice as wide in every direction. She was suffering most severely from symptoms of strangulation; had occasional hiccough and feeling of sickness; the pulse small and frequent; the countenance anxious. Mortification of the protruded portion was evidently commencing. It was black and turgid with blood. There appeared very little prospect of her surviving a spontaneous separation of so large a mass, and we determined, on the following morning, should her condition be favourable, to remove the entire tumour.
September 26.-She passed a sleepless night in great pain, but did not appear in any respect worse than on the preceding day. Superficial gangrene had fairly commenced, and an indistinct line of demarcation formed round the neck of the tumour.
A strong ligature of whip cord was first tied as tightly as possible round the neck of the tumour, about an inch above the anterior lip of the uterus, and then, as an additional security, and also to ensure the patency of the cervical canal, it was transfixed from behind forwards at the same level with a double ligature, the needle being carried directly through the centre of the os, and each half firmly tied. Having done this the bistoury was carried round the tumour, and it was cut off close below the ligature. There was no bleeding. The uterus immediately returned to its normal position. After two hours she expressed great relief and thankfulness that the operation had been performed. The same
Figs 2 and 3.
day she was able to pass water without assistance; the symptoms of strangulation disappeared, and she was in every respect comfortable within a few hours.
It had been intended to remove the ligatures surrounding the neck of the uterus at the end of twenty-four hours, but as she continued perfectly easy and free from pain, with good pulse and returning appetite, this proceeding was put off from day to day until, on the sixth day, we cut the knots and took them away. On the eighth day she was able to sit up, and on the tenth she went down stairs, feeling well but weaker than before the operation. She was down stairs each afternoon for some hours for several days, and appeared to be slowly regaining her strength.
About a fortnight after the operation she complained of pain down the left thigh. There was nothing to be seen, but on vaginal examination I found a small soft tumour in the neighbourhood of the os. On pressing it firmly it broke down, and about a couple of ounces of clear pus passed by the vagina ; the next day she was easier, but shortly the pains returned and became more severe, extending to the knee and calf of the leg. Nothing could be felt per vaginam beyond an irregular soft mass such as might be expected after an operation of the kind. Her health at the same time began to fail, and her pulse became quicker, being seldom under 100 and frequently 120 per minute. She had occasional slight rigors, and these shortly became more severe and more frequent. The tongue got dry and she complained of constant thirst. Pain attacked the right knee also, and was so severe in the left leg and thigh as to prevent sleep. Anasarca of the left leg then commenced and extended up the thigh, which became enormously swelled. It was evident that the poor woman was suffering from pyemia in a chronic form, and that a short time must terminate her existence. She became much emaciated, and died on the 31st of October, having survived the operation five weeks.
On examination of the body on the following day, all the abdominal viscera were found in a perfectly healthy condition. There were no abscesses, and no traces of inflammation of the peritoneum. The uterus and its appendages were of the normal size, weighing together not more than four ounces (see Fig. 2), while the tumour (Fig. 3) was seventeen ounces in weight. The accompanying wood-cuts are from drawings made by myself; they represent the uterus and tumour very accurately, and both are drawn in exact relative proportion. The posterior wall of the uterus was not thicker than is natural. Its structure on section was healthy. Its sinuses were large, but did not contain any deposits. Around the cervix uteri, which was not larger or thicker than in the healthy condition, was a deep furrow, evidently formed by the ligatures, and below this, attached by a slender neck to the inferior surface of the posterior lip, was a hardened and irregular slough, the size of a walnut, containing purulent depositions. (A Fig. 2). It was manifest the ligatures had failed to strangulate the entire thickness of the hypertrophied posterior lip; that a small portion in its centre had retained a certain degree of vitality, and that in it the purulent depositions had taken place. The circumstance of my having felt, a fortnight after the operation, a soft tumour which broke down under my finger and discharged pus was at once explained. All the veins about the rectum, vagina, and bladder were gorged with dark blood, and many of them contained partly decolorized clots. I traced several directly to the slough described, and one in particular, opening into the inferior iliac vein, was completely choked up for some inches. Both the external and internal iliac veins contained large firm decolourised clots, and at the junction of the former with the vena cava was a solid mass nearly as large as a dried date. On section it presented a small cavity in its interior filled with thick brownish pus.
The bladder was slightly thickened, and its mucous membrane injected. The thorax was not examined. The tumour weighed, after removal, 17 oz. It was of an irregular oval form, somewhat flattened from before backwards. (See Fig. 3). The large circular space upon its anterior and upper part (B) represents the flat surface, as it was cut off through the neck of the uterus. It measures from three and a half to three inches in diameter. The smaller rounded patch below, and to the right (C), is the uterine os, while, between the two is scen the narrow band which constituted the attenuated margin of the
anterior lip of the os. A pen-holder is placed under this to display more distinctly the portion of the cervical canal removed along with the tumour. The greatest transverse diameter of the tumour is obliquely across, from the left to the right side, and from before backwards. In this direction it measures six and a half inches; crossing it in the opposite direction, on the same level, it is four and a half inches. Its extreme length, from base to apex, is eight inches. Its surface is nearly regular, except at the lower and anterior portions, where it presents some slight nodulated projections. Previous to the commencement of the gangrene its exterior was smooth and shining, but now it is ash-coloured, and disorganized to the depth of one or two lines. The substance of the tumour is uniformly dense at every part. It is composed throughout of firm fibro-nucleated tissue. On section it has a pale rose-coloured appearance, and thick white bands of firm fibrous structure are seen to traverse it in every direction. The vessels running through its substance are small and round, and do not bear any analogy to uterine sinuses."
The extreme rarity of tumours occupying this portion of the uterus is well known to all pathologists ; but what is specially remarkable in the case is, the extraordinary size it had attained without destroying life by hemorrhage, or irrecoverably involving the essential structure of the uterus itself. Although the posterior wall of the uterus was three inches in thickness at the time of the operation, it had diminished to its normal size in five weeks ; a new os, not larger than is usual, had formed, and every part had so completely regained its natural condition, that it was with difficulty conceived that a tumour of the magnitude described, and of so extensive an attachment, had been recently removed. The subsequent examination has shown, that the operation was not only practicable, but that it was physiologically and pathologically correct, and that but for the unfortunate occurrence of phlebitis, the poor woman would have recovered, and would probably not have been liable to a return of the disease.
On reviewing the case, I cannot help thinking it would have been better to have cut the ligatures within a few hours after the operation, and to have trusted to check bleeding by plugging the vagina. Or if this plan bad not been adopted, the polypus tubes might have been introduced, and the ligatures tightened day by day, so as at last to bring away the entire slough. No half-strangulated and inflamed substance would then remain to serve as a nidus for purulent depositions, and the risk of phlebitis would be proportionably less.
ARTICLE V.- Case of Excision of the Knee Joint. By WILLIAM
KEITH, M.D., M.R.C.S. Eng., Senior Surgeon to the Royal
Infirmary, Aberdeen, and Lecturer on Clinical Surgery. In the present state of the question, Ilow far excision of a diseased knee joint is a useful or a warrantable operation ? no apology is deemed necessary for giving publicity to the annexed case,
| This remarkable tumour is preserved, together with the uterus, in my private inuseum, where I shall be happy to show it to those interested in the subject