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• A patient underwent a left-sided hepatic lobectomy for primary hepatocellular carcinoma 13 years ago and remained symptom free. He then presented with spontaneous rupture of a large tumor in the right lobe of the liver. Although this tumor proved to be primary hepatocellular carcinoma, there were significant histological differences between the two lesions, suggesting that this was a second primary liver tumor. Bleeding from the tumor was controlled by selectively ligating the branches supplying the area of hemorrhage. (Arch Surg1986;121:726-728)

A total of 157 children with Wilms' tumors were treated at the Children's Memorial Hospital during the years 1956-1978. Fourteen (or 9%) of these children had bilateral lesions. During the early years, treatment consisted of surgical excision of one kidney with radiation to the second tumor. During the second decade of this study a more aggressive approach to bilateral tumors was used consisting of nephrectomy on the side of the large tumor, with a heminephrectomy on the contralateral side and chemotherapy. More recently, we have attempted bilateral heminephrectomy when possible, together with increasingly aggressive chemotherapy. This series of patients allows us to compare the results of various treatment modalities among our own patients as well as those reported from other pediatric surgical centers.

—At the time the patient was initially seen in 1978, the differential diagnosis of Dr Bouvet's patient's condition should have included solitary secretory myeloma and benign monoclonal gammopathy. In 1980, the patient had had moderate bone pains. At that time, she probably had multiple myeloma with relatively low tumor burden. In January 1981, the patient had clear-cut roentgenographic and bone marrow evidence of multiple myeloma. It would have been important to have verified the absence of myeloma proteins in her urine at that time. The salient feature of this patient's condition was the continued presence of two M spikes belonging to the same immunoglobulin subclass throughout the clinical course and a decrease in only one of the two M spikes in face of clinical and laboratory evidence of large tumor burden of multiple myeloma in January 1981. In this case, the decrease in one of the two M spikes was

• A 62-year-old woman with multiple neurofibromas of the lung was found to have severe hypoxemia due to right-to-left shunting within the tumors. Pulmonary angiograms demonstrated that the major area of shunting was in a large tumor mass in the right lower lobe. Pathologically the neurofibromas were vascular with hyperplastic small arteries and arterioles and large dilated veins. Multiple pulmonary neurofibromas are rare; and, to our knowledge, never previously reported in association with pulmonary arteriovenous shunting. ( Arch Intern Med 1986;146:1618-1619)

To the Editor.— The answer given by Charles W. Macenski (232:849, 1975) concerning covering of hair is irresponsible. Long loose tresses that dangle onto an aseptic field or that are clutched by an infant's hand are a means for spread of contagion by contact. Habitual grooming motions to remove offending hair from the face or to accentuate a hair style make hair a direct extension of the dirty hand. An anecdote is pertinent and more eloquent than microbiologic data. The patient had partial large bowel obstruction, resulting from a large tumor of the rectum. He was lying in the lateral Sims position. Rectal examination was demonstrated to a student, who then leaned over the patient in imitation. Long hair dangled on the patient's buttocks. As the gloved finger was withdrawn, a gush of feces soiled the glove. The student recoiled, stood erect, and reflexly wiped the hair from his face

A large tumor of the acoustic nerve was pressing on the brain stem. It could not be removed completely, but University of Chicago neurosurgeons hoped to make the few remaining years of the patient, an elderly woman, as comfortable as possible. They proposed to go directly to the tumor's center, then core out as much as possible. Operating room preparations, however, included something extra. George J. Dohrmann III, MD, PhD, and Jonathan M. Rubin, MD, PhD, set up the ultrasound equipment they've been using in neurological surgery since 1980. In this case, a neurosurgical resident wondered aloud why they were going to all that trouble, since "you can see the tumor clearly on the CT [computed tomography] scan." "Well," said Dohrmann, an assistant professor of neurosurgery at the university's Pritzker School of Medicine, "let's see what ultrasound will do for us." What ultrasound will do for all neurosurgeons, Rubin and

BRAIN TUMOR Case 1. —In December, 1887, I removed a large tumor from the brain.1It was my first case of modern cerebral surgery. The weight of the tumor was 3 ounces and 49 grains, and its size 2[unk] by 2½ by 1¾ inches, its circumference being 7¼ by 6 inches. The tumor was a fibroma arising from the dura. Dr. W. J. Taylor has stated2that the patient "lived for nearly twenty years" after the operation. This is an unintentional error, for it was 25 years last December since the operation, and the patient was still alive a few months ago. His sight is poor, but is sufficient to enable him to find his way about, though not to enable him to read. He has once in a year or so an epileptic attack in spite of his use of bromids. He is now 50 years old

A large tumor involving the lids always presents two problems: (1) the treatment of the malignant process and (2) repair of any remaining defect for the preservation of the appearance and function of the lid and the protection of the eye. A number of malignant lesions can, of course, be treated by radium and the roentgen rays, and many can be treated by removing surgically only a portion of the lid. When more than half of the lid is involved and it becomes necessary to remove the greater portion or all of the lid, a major problem in plastic surgery is presented, viz., how to build a new lower lid that will be approximately normal in appearance and function. For use when the upper lid is still intact, a satisfactory solution has been devised, as shown by the following case report and the illustrations. REPORT OF CASE History .—Mr. J.

A bride of three days consulted me on account of unendurable pain at the first attempt at sexual intercourse. She was a young woman of apparently perfect health. She said she had never been sick in her life and that she had worked constantly as a nurse for several years after taking training in a small hospital. In her girlhood she had fallen on a picket fence and injured the vagina and bladder, but she believed she had entirely recovered from that injury. At each menstrual period she bloated some but had no pain. There was always a rather long flow, sometimes lasting six or eight days. Clots were never seen. There had always been some leucorrhea. On making an examination the vagina was found closed just beyond the remnants of the hymen. A large tumor could be felt through the rectum about an inch and a half behind this

Although new growths of the mediastinum are very rare in childhood, the possibility of their occurrence should be bone in mind in the differential diagnosis of obscure intrathoracic conditions. The finding, on operation, of a large tumor mass in this region, in a child of 8 years, which had escaped recognition for more than a year, though studied very carefully, clinically as well as roentgenologically, prompted me to review the subject and present a study of the case. The literature contains many articles on mediastinal neoplasms in general, without special reference to the young. Hare 1 presented a complete review of this subject, including patients of all ages. There have been, however, only a few studies of this condition in childhood by foreign writers, notably Schubert, 2 Rosenberg, 3 Bollog, 4 and Keating. 5 Up to the present time, as far as can be ascertained from a search of the

Patient. —Mrs. W. F. M., age 29 years, a farmer's wife, who had been delivered of a female child Feb. 10, 1902, was admitted to the Southwestern Hospital, Elk City, Okla., March 12, 1902. History. —Patient's own statement: "I have always been stout and well, have given birth to three children, one aged 4, one aged two years, and the one just recently born. When my labor came on I sent for a midwife, Mrs. Hughes, my neighbor who lives near by, and when my child was born I was so nearly dead we sent for a physician, who came and said I had a large tumor, gave me some medicine and left the house." The social and family history of this patient gives no information other than that she was without constitutional taint and had always followed a plain and simple mode of living. Examination. —An

An equally large tumor, to judge by the weight of the fragments that were preserved, was successfully removed three months later from the next case. This tumor also had failed to give neighborhood symptoms beyond those of the syndrome under discussion, though the adiposity and scanty menstruation suggested a nearly hypophysial involvement. Case12.— Failing vision for eighteen months advancing to near blindness. Primary optic atrophy. Bitemporal hemianopsia advancing to unilateral blindness. Normal sella. Correct preoperative diagnosis. Operation. Total piecemeal removal of a 16 Gm. tumor. Recovery with marked improvement in vision in the left eye, stationary after two years. July 8, 1926 : Admission of Mrs. Rose B., 37 years of age, with the sole complaint of loss of vision ; referred by Dr. George de Schweinitz through Dr. Otto Lowy of Newark, N. J. History .—Until December, 1924 , the patient had never consulted a doctor. At about that time she

Mrs. A. S., 38 years old, presented herself March, 1899, with a large tumor on the right thigh. Her mothers' family were healthy, also that of the father, with the exception of one brother dying at 40 with consumption, probably contracted by exposure during the Civil War. Menstruation began when she was 15 years of age and was regular up to within the last two months, when it stopped. She has been married twice, to her first husband when she was 16, and by him had two children, one still-born and one living six years, dying of "slow fever." At 19 she married her second husband, and has had one child, now 8 years old and healthy. Her first husband died of consumption. She has been in good health up to the present illness, which began about two years ago with slight tenderness about the right thigh. Two months later

MEDICAL HISTORY BY DR. BROWN. Patient. —Miss R. M., aged 19 years and 3 months, was first seen by me June 10, 1903, in consultation with Dr. Smiley, her family physician. History. —In March, 1903, she had a bilious attack with vomiting similar to attacks that she frequently had had either from overeating or from overfatigue. She was somewhat run down at the time of this attack, which was followed by a period of indigestion. She vomited some bile, the vomiting bearing very vague relation to eating. Two weeks later a paralysis of the left external rectus was noticed and there developed slowly an apparent paralysis of the right external rectus. During the early part of the month of March she did considerable fine hemstitching out of doors while driving. This time for doing it was chosen in order to avoid its being known. During

History. —E. I., aged 35, married, came to me with a large tumor of abdomen. The patient's mother had borne eight children. The patient had always been healthy up to time of present illness. She had none of the usual diseases of childhood; her weight at 15 years of age was 180 pounds. She was the mother of four children, the eldest 16, the youngest 10 years of age. Between these children twins were born, who lived to be 8 months old. The patient had been married seventeen years. Present Illness. —This began in June, 1907, at which time the patient thought she became pregnant, as she had cessation of menstruation, nausea and fainting spells. In August, 1907, she had slight return of menses and pain in abdomen. At various times during this month pain in abdomen was quite severe. Her digestion was exceedingly poor. In November, 1907, she

The bloodless removal by electrocoagulation of a large tumor, so vascular that several attempts at surgical removal had failed because of hemorrhage, indicates the value of this method. The tumor was large. It is the only one of this size, attached to the side of the face, reported in the literature. History. —Miss A. M., an unmarried white woman, aged 33, complained of a large tumor on the right side of the face. The patient stated that instrumental delivery at birth resulted in injury to the right eye and deformity of the right orbit. At 3 months of age, the right eye was removed on account of festering of the eyeball. At 4 years of age, the late Dr. Harold Gifford, Sr., of Omaha removed a growth from the right eyelid and counseled against any future surgery to any tumorous growth of that region. At 5 years of age, multiple

A white man, aged 65, a farm laborer, entered the University Hospital because of a foul odor which complicated a large tumor mass hanging from the left gluteal region. The accompanying illustration shows the size and location of the tumor. It had been present fourteen years, beginning as a small growth just beneath the skin. Physical examination was essentially negative, the only departure from normal being the pupils, which were somewhat sluggish to light, an early senile cataract, and a soft diastolic blow heard over the aortic area. The tumor was hard and somewhat irregular and had three open ulcers on the posterior and inferior surfaces. The pedicle was soft and pliable and gave no evidence of infiltrating the deeper structures. The mass was excised with a diathermic knife, and wound healing by first intention followed. Gross examination and section showed it to be a lipoma, and that diagnosis was

Charles M., aged 52 years, musician, entered the Arapahoe County Hospital, Denver, March 9, 1898. His mother died of cancer, at the age of 70 years, and a sister of his mother died of phthisis. He had been given to dissipation, contracting syphilis when about 20 years old, and he was addicted to drink. He had contracted gonorrhea several times. During the last fifteen years he had had some rheumatism. He said his present trouble commenced four months before, with a bad cold acccompanied by a severe cough, at which time a swelling appeared in the left chest, which had gradually increased. The tumor had been tender and attended by shooting pains, moderate in character and confined chiefly to the region of the swelling. About two months before entering the hospital he became short of breath and this had increased so that he could with difficulty move

A Chinese man, aged 65, was admitted to the surgical service, Nov. 19, 1914, presenting a large tumor of the left parotid region. The patient was a farmer with no significant history. The tumor was of three years' growth. It had at no time been painful, but was a serious mechanical impediment to speech and deglutition. The pation was under average stature, and not of robust physique, but otherwise was in good health. On examination the tumor appeared nodular, with occasional areas of almost bony hardness, and others of apparently cystic degeneration. It seemed intimately connected with the parotid gland, was not tender or painful, and gave rise to no pressure symptoms except the mechanical impediments noted. Its size and location are shown in the illustration. The skin was movable over the mass except in one spot on the lower posterior aspect, where it was adherent under an ulcer the

Leiomyoma of the vagina are comparatively rare tumors. They are usually small and are located principally on the anterior vaginal wall. This case is of special interest because of the large size of the tumor.

To the Editor.— We agree with the premise of Dr. Mikhail's opening statement. However, we still believe that the case we described had a bona fide solitary plasmacytoma. 1 The entire large tumor, 3×4×6× cm, was composed of plasma cells, some of which were atypical. The presence of an inflammatory infiltrate abutting the neoplastic cells is not surprising, particularly since the tumor was over the lower buttock and subject to irritation from pressure. There was no evidence of metastatic disease up to six months postexcision of this mass, which had been present over 20 years (at which time the patient returned to Samoa). Although not recorded in the original report, Dr. Benjamin Castleman, pathologist at the Massachusetts General Hospital, corroborated our diagnosis. Serologic evidence for syphilis was absent. We appreciated learning that a postmortem of the case reported by Dr. Mikhail and colleagues 2 did not reveal myeloma.