A woman forty years old, who had had one child fifteen years before, was attacked by violent pain in the lower abdomen, three days before her expected menstruation. The courses when they appeared were accom panied by great pain, and lasted in a moderate 'degree for three weeks. She was then examined at the clinic, there being no fever, but pain in the abdomen, and vomiting. When the plessimetre was pressed deep down into the abdomen, the percussion note a few finger-breadths above the pubis was dull. Deep palpation revealed the existence in either ilio meal region of a doughy, somewhat painful tumor; the left was somewhat harder than the right. Between the two tumors was a median less promi nent swelling, which was easily recognized to be the uterine body; it was to be felt three finger-breadths above the symphysis. The lateral tumors were immovable, smooth, and about the size of a fist. The median one was half that size. Some blood still flowed from the vagina, the introitus was not livid, and there was slight prolapse of the anterior vaginal wall.
Internal examination showed that the vaginal portion was displaced entirely forward; it was thin and tapering, the os being felt as a slight depression. The anterior vaginal vault had almost disappeared; there was no tumor above it; and the body of the uterus could not be felt. The posterior vaginal vault was deeply depressed, and was filled with a tumor about the size of two fists, not very tender and not everywhere of equal resistance to the touch. Its general feeling was doughy, though it was harder in spots. Fluctuation was nowhere perceptible.
Bi-manual examination showed that the swelling felt externally was completely connected with the tumor discovered in the posterior vaginal vault; and the latter was proved to be attached to the uterus. The worn ) lay in front of the tumor, and was curved back over it; hence the forward projection of the cervical portion. Pregnancy could already be excluded.
The sound could not be passed with its normal curvature, but had to be introduced almost straight, and with its point directed backwards. Uterus 4.4 inches long. The womb was fixed immovably to the anterior wall of the tumor, and elongated by it.
Br manual rectal examination gave no further information, and it was not deemed advisable to introduce the whole hand.
The patient died seven days later after puncture of the left vaginal vault had been done for symptoms indicating perforation of the tumor into the abdominal cavity.
The necropsy was done nine hours after death, and showed peritonitis and the presence of about five ounces of a reddish brown, foul-smelling fluid iu the right ovarian region. The pelvic entrance was filled with a mass (vide Fig. 31), formed of the uterus, at the back of which was an
elastic tumor (c). From this tumor projected two distinctly separated lateral swellings, which occupied the region of the broad ligaments (b. and d). The tumor in the right broad ligament was not adherent to the posterior pelvic wall; it was formed by a dilatation of the posterior peri toneal layer of the right broad ligament, the blood accumulation having taken place between the anterior and the posterior layers.
The posterior layer was much more tense than the anterior one. In some places it was extremely thin; and where it was attached to the ovary and the tube was an opening, the edges of which were as thin as paper. Here the blood had poured into the abdomen, and had caused peritonitis.
While the posterior layer was formed almost entirely of peritoneum alone, the anterior one contained the vessels and the muscular tissue of the broad ligament.
The right ovary lay against the posterior layer; up to its hilus, or up to the region of the ala vespertilionis, the division of the layers was com plete; it contained a large corpus luteum. The right tube was normal, though displaced somewhat forward; the fimbriated extremity was adherent to the dilated broad ligament; so that though the fimbriae could be re cognized, the ostium abdominale could not be found. At the place where the peritoneum passed from the right broad ligament to the uterus there were occasional adhesions to the posterior wall of Douglas's The hemorrhage had loosened the peritoneum from the uterus in a peculiar way, so that the cavities formed communicated with the cavities in the broad ligaments.
In the left broad ligament the conditions were somewhat different. It posterior surface was mostly adherent to the pelvic peritoneum; and the entire peritoneum of the floor of Douglas's and even of the posterior bladder wall, was detached by the effusion of blood. The posterior wall of the sac was formed by the muscular layer and connective tissue of the broad ligament. The effusion filled not only Douglas's sac, but also the left and even the right sacro-uterine ligaments had been denuded of peritoneal covering by it. The entire floor of the pelvis was lifted up; but there was no trace of pus.
A second swelling (e) lay just in front of this left-sided tumor. Its wall was formed by the anterior layer of the broad ligament, and not by the floor of the pelvis. There were no adhesions to the lateral pelvic peritoneum. Both tumors had for a common basis the thickened muscular layer of the left mesometrium with its vessels. Through a small opening in this common basis these tumors communicated with the other cavity.