CASE HISTORY

A married woman, aged 61 years, first attended the outpatient department on 13th June 1949, complaining of vaginal bleeding for the previous 6 weeks. Her normal menstrual cycle was 4 or 5 days loss every 4 weeks and this had continued until her late 40s. Since that time she had had amenorrhoea for about 2 years at a time on a few occasions, but otherwise the cycle was maintained until she was 59 years old. It changed to 3 or 4 days loss every 4 to 5 weeks until 6 weeks before she sought advice. During that time she had bled every day, though not heavily, following a "normal" period which had started at the expected time. There was no post- coital bleeding up to a year ago and she had not had intercourse since. There was nothing significant in her past medical history and her two pregnancies, 43 and 40 years ago had been normal. She had noticed some painless abdominal swelling 2 years ago but this had not increased recently. Her weight remained steady. Her breasts had not changed size since about 10 years ago when she noticed that they had become somewhat smaller. She had had a few hot flushes at that time but none since. There were no other significant complaints. She was a healthy looking, well-nourished woman.The breasts were normal for her age. The blood-pressure was 220.120mm Hg. Rising into the abdomen from the pelvis was a hard, irregular, fixed mass reaching almost to the umbilicus. Ascites was not detected. Vaginal examination showed a small cystocele and rectocele. The cervix had old tears but was otherwise normal. The mass felt abdominally, continued into the pelvis which it nearly filled. It was difficult to make out its origin. The patient was admitted to hospital on 20th June for laparatomy with the provisional diagnosis of ovarian tumour possibly with oestrogenic properties. Investigations showed a haemoglobin level of 10.9g per 100ml, normal urine tests and some radiological evidence of cardiac enlargement and peribronchial fibrosis. On 23rd June, under tubarine and cyclopropane anaethesia the abdomen was opened through a median subumbilical incision. There was no free fluid in the peritoneal cavity. The tumour was about the size of a coconut and was found to arise from the left ovary. It was of irregular consistency and parts of it were hard; it was freely mobile when disimpacted from the pelvis and there was no evidence of capsular invasion. The right ovary was atrophic and the uterus regularly enlarged to the size of a 3 months pregnancy. Although there was no evidence of peritoneal or hepatic metastasis, it was considered that the tumour might well be malignant, and as, in any case, uterine bleeding was the presenting symptom, total hysterectomy with bilateral salpingo-oophorectomy was carried out. Convalescence was uneventful and the patient was very well when last seen at the follow up clinic 7 months after operation.

PATHOLOGY

The specimen shows a pale thrombus with all the features of ante-mortem origin. It is noteworthy that although it occludes the lumen it is not being organised, although its colour indicates that it is not recent. This probably means occlusion was not complete and some marginal recanalisation of the blood was possible. The renal arteries are not involved.