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The patient was a married woman, aged sixty-two, who had had nine children, and who had ceased to menstruate ten years previously. She was brought to me on November 18, 1899, by the late Mr. Rudge, of Bristol, who informed me that she had been seen by several consultants in Bristol, and that they, considering the case to be one of malignant disease, had, on that ground, advised against any operation. Mr. Rudge himself disagreed with this view, and had therefore brought his patient up to London for another opinion. She had been in failing health for several months, and looked seriously ill.
I found a cystic tumour occupying the lower half of the abdomen, and, in the hollow of the sacrum, apparently continuous with the abdominal tumour, a soft swelling in which, though it was elastic, I could not satisfy myself that there was evidence of fluctuation. This intra-pelvic swelling pushed the uterus upwards and forwards, and encroached both upon the vagina and upon the rectum.
On the ground that there was no evidence that the tumour, whatever its nature, was irremovable, I agreed with Mr. Rudge as to the desirability of at least an exploratory operation, and we advised the patient and her friends accordingly. After returning home to Bristol and considering the matter, the patient, at the entreaty of her husband and children, decided to give her consent, and on November 29, 1899, the operation was performed. Two tumours were removed-one abdominal, one pelvic. The former was partly cystic (2 pints, 7 fluid ounces being removed by tapping before removal) and partly solid, and grew from the left ovary. The latter was solid, with cavities in its substance due to softening, and was adherent to surrounding parts. It grew from the right ovary, and was equal in size to an ostrich's egg. There was some ascites. The uterus was healthy.
On examination, the tumours proved to be soft, columnarcelled carcinomata of the ovary.
The patient made a good recovery, her temperature never exceeding 100 degrees Fah. She was able to return home to Bristol within three weeks.
On the 31st of January, 1903, rather more than three years after the operation, Mr. Rudge reported that there was no evidence of recurrence, and that the patient was, in fact, quite well. But, not long after that, her health began to fail, and she complained of pain and tenderness in the left iliac region. These symptoms increased, and gastro-intestinal disturbances followed, with cramp and ædema of both lower extremities; and, though no actual growth was discovered throughout the illness, the emaciation and loss of strength became very pronounced, and death occurred on the 19th of August, 1903.
As I began by saying, I do not put this case forward as being a signal instance of success. I include it rather because I feel it only fair to speak of the less successful cases as well as the more successful. But even here, was it not worth while for the patient to undergo the operation? As a result of it, she had three years of comparative health and comfort; without it she must, I think, have died, under circumstances of great and increasing misery, within almost as many months. That is the case as stated from the patient's point of view. But there are the relatives and friends to be considered, and it is certain that they would declare the prolongation of so highly valued a life for nearly four years to be well worth the risk and ordeal of an operation.
In the next case to which I will ask your attention, I was myself in some doubt at first as to the desirability of operating. A single lady of thirty-four, acting as her father's secretary, was sent to me from Gloucestershire on the 28th of January, 1902, with the statement that she had a rapidly increasing abdominal tumour, and that she had also sumë duiness at the lower part of the chest on the right side, which the doctor thought might be due to old pleurisy and not to the presence of fluid. The account the patient gave me was that some increase in size had first been noticed in May, 1901, but that no attention had been paid to it until October, when she began to suffer from severe attacks of abdominal pain, which were thought to be due to indigestion. No examination had been made until Christmas Eve, when the doctor had discovered a tumour. Three days later she saw a consulting physician in Gloucester, who regarded the tumour as
uterine and did not consider that an operation was at present advisable. The patient had, however, become rapidly worse, and during the last fortnight had been incapacitated from following her usual occupation and had been unable to lie down at night.
I found the abdomen enlarged and tense from the presence of a fixed, tender, cystic tumour, equal in size to the six months pregnant uterus. On vaginal examination the uterus was found to be lying forward and to the left of the middle line. It was of normal length and immovable. Behind it there was a fixed, hard swelling, extending across the back of the pelvis. Otherwise no part of the tumour extended into the pelvis. The patient had a dry cough and dyspnea, with dulness over the posterior and lower part of the right lung and exaggerated resonance below it. My opinion was that the abdominal tumour was either a malignant ovarian cyst or an ordinary ovarian cyst with a twisted pedicle and secondary inflammation around it.
The patient went into St. Thomas's Home the following day in order to be under my observation. Being in some doubt as to the precise condition of things in the chest, I suggested a consultation, and on January 31 Dr. Sharkey, the senior physician to St. Thomas's Hospital, saw her with me and examined the chest very carefully. He would not give a positive opinion, but was inclined to the view that the abnormal chest signs were due to the displacement upwards of the liver and intestine. The next day—as she had, in the meantime, had another attack of pain-Dr. Sharkey saw the patient again. He found extension of the dulness, and now considered that mere displacement would scarcely account for the phenomena, and that there must be some fluid. He suggested the introduction of a trocar to settle the point, and in the meantime thought an operation under the circumstances scarcely to be advised. However, whilst approving the suggestion as to the exploratory puncture of the chest, I came to the conclusion that an abdominal incision ought to be made quickly and the nature of the abdominal tumour definitely ascertained. To this the patient and her sister agreed.
Arrangements were accordingly made for the operation to take place on the morning of the 3rd of February, and for the chest to be aspirated in the meantime. On February 2 the acting resident medical officer aspirated the chest, and drew off i pint and 16 fluid oz. of clear fluid. The following day I opened the abdomen. There was a considerable amount of ascitic fluid. The tumour was multi-locular and cystic with thin, easily lacerable walls and with no adhesions. tained much thick, mucoid material, and many parts consisted of either a very close aggregation of minute cysts or of a loosely-composed solid growth. A part that much resembled brain tissue in colour, appearance, and consistence, was sent to the Clinical Research Association for examination and report (see below). The growth filled up the back of the pelvis, and, in an upward direction, had extended beneath the liver and pushed it up. It had originated from the right ovary. The Fallopian tube, much elongated, was spread out over the tumour and removed with it. The pedicle was broad. The left appendages were normal and were not removed. There had been a considerable amount of intra-cystic hæmorrhage, especially into the lowermost loculus. The whole tumour, after removal, peeled readily out of its capsule. The patient made a rapid and uneventful recovery, and left the Home on the 5th of March, feeling very well. The improvement in the general condition, indeed, was very marked.
The following report, signed by “J. H. Targett,” was received from the Clinical Research Association on the 15th of February :-“The general structure of this growth corresponds with that of a multi-locular adenoma, and there is no definite evidence of malignancy. At the same time, the epithelial proliferation is rapid and, in places, irregular, forming masses of cells within the loculi. Hence the tumour is of a suspicious character, and a guarded prognosis should be given.”
Two years after the operation I received from the patient a most grateful letter, in which she told me she was so well that people could scarcely believe there had ever been anything seriously wrong with her. About three months later,
whilst preparing this lecture, I wrote to the local doctor in order to have the latest possible information about her. He told me in reply that he had visited the patient and that she complained of some indefinite discomfort in the abdomen to which he himself, however, was not inclined to attach much importance. In face of the very rapid growth and suspicious appearance of the tumour removed, and of the very guarded report I received as to its pathological nature, I cannot but regard even the indefinite symptoms now complained of with some little apprehension. Nevertheless, there remains the fact that for at any rate two years the patient has enjoyed excellent health, and that seems to me to be ample justification for the operation, even though there should, ultimately, be a recurrence of the disease, of which, however, at present there is no actual evidence.
I pass on now to two cases that come within an entirely different category from those of which I have been speaking. I had not at first thought of including them, or I should have somewhat modified the title of my lectures so as to have brought them more directly within its scope. But though the suspicion of malignancy in these two cases did not arise until the tumours had been removed and came to be examined microscopically, the lesson they inculcate is very much the same, and it is on that account that I have decided to relate them. Both were examples of solid tumour of the ovary, which eminent pathological authorities pronounced to be sarcomatous, but which, after the lapse of many years— thirteen years in one case and nearly eight in the other—show no sign of recurrence. One of these cases I have mentioned occasionally in the course of discussions at the Obstetrical Society of London, but I have not hitherto described either of them in detail, because it seemed to me that their value largely depended upon the length of time they could be kept under observation. The present occasion appeared to offer a suitable opportunity to place them on record. I will take them in the order of their occurrence.
The first case, then, was that of a girl of nineteen, in a situation as nursemaid, who was sent up from the country to