Pelvic transplantation metastasis as a means of recognition of hopeless abdominal carcinoma / by Dudley W. Palmer.

  • Palmer, Dudley W.
Date:
1910
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Licence: In copyright

Credit: Pelvic transplantation metastasis as a means of recognition of hopeless abdominal carcinoma / by Dudley W. Palmer. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    [TETRrdy&ebr \ 26 OCT 11 Reprint from SURGERY, GYNECOLOGY AND PELVIC TRANSPLANTATION METAS OGNITION OL HOPELESS ABD 1910, pages 154-156 1EANS OF REC- imii>;^RCINOMA By DUDLEY W. PALMER, M. D., Cincinnati, Ohio Formerly Surgical Assistant to St. Mary’s Hospital, Rochester, Minnesota IN the treatment of all carcinomata it is quite as necessary to have definite rules for guidance against operation as for operation. It is important to lay stress upon every warning point, as the present lecessity for exploration only emphasizes our more or less limited knowledge, and it is our duty to save as many patients as possible from the shock of even so slight an operation as a simple exploration, when by a more thorough examination some of them might at once be definitely classified as hopeless. It is to routine digital examination of the rectum with the patient in the knee-elbow position, and bimanually with the patient in the lithotomy position, to which we wish to call particular attention in this paper; and no case of abdominal tumor should be operated upon without its being done. By this means alone we have been able to prove over six and one-half per cent of upper abdominal carci- noma to be hopeless. While reviewing the histories of some four hundred and thirty-five cases of upper abdom- inal carcinoma seen in the last twenty months at the Mayo clinic, Rochester, Minnesota, we were surprised to find so large a percentage of them showing the following positive con- traindication to operation. For example, upon examination a small, hard, nodular tumor is found with the clinical history and laboratory findings of carcinoma of the stomach. It is freely movable and apparently mechanically removable. On rectal examination at a point about three to five inches from the anus along the anterior rectal wall (on what has been termed by Dr. George Blumer the “rectal shelf”), above the prostate in the male, and above and behind the uterus in the female, we may find a hard nodular mass distinctly orig- inating within the peritoneal cavity. These may be single or multiple and may vary in size from a small bean to an orange. Sigmoido- scopic examination shows the rectal mucosa uninvolved. This may remain as a distinct neoplasm or may, through a process of infil- tration, begin the formation of a cresent- shaped > area of cartilaginous hardness that partially surrounds the bowel. We have not seen a case that produced any stricture-like symptoms, nor have we seen one that gave symptoms suggestive of rectal carcinoma. The presence of free fluid in the abdomen often indicates a hopeless condition because it is indicative of a considerable peritoneal irrita- tion and usually actual involvement, but implantation carcinomata are often found before free fluid can be distinguished clinically and before secondary masses can be distin- guished through the abdominal wall. It must be borne in mind, however, that negative findings are of no value. One must also be guarded against mistaking for this condition, faecal concretions higher up in the sigmoid, and old inflammatory deposits in the pelvis. Tuber- culous peritonitis can be differentiated by the “feel” of the mass, its location being more diffuse, taken together with the history of the patient. Dr. Blumer cites a case where a small subperitoneal myoma projecting into Douglas’ pouch caused some confusion. He also calls attention to the fact that Houston’s fold of the rectum is sometimes thickened. Once the peritoneal covering of the pri- mary growth has been broken through, the carcinoma cells are spread in more or less numbers throughout the serous cavity by gravitation, intestinal movements, or the nor- mal circulation of the intraperitoneal fluid. We believe that a fair percentage of these cells will early find their way to the lower part of the cavity, and because of the position of the rectum acting as a shelf, they will in many in- stances lodge thereon. The tendency to gravi- tate to the pelvis is more pronounced because most of the patients with upper abdominal carcinoma are able to be about and often do light work.1 1 This is contrary to those experiments where shot have been in- troduced within the peritoneal cavity and are found not to gravitate to the pelvis; nevertheless, the qlinical evidence seems to warrant this assumption. /j