LOCK AND COLLINS: MEIGS' SYNDROME 517

received prolonged treatments with a variety of hormones including equine gonado-

gens, chorionie gonadotropic hormones, estrogens, and progesterones. Only one of
the six advised laparotomy. Slight uterine spotting followed some of the glandular
therapy. ‘On Sept. 25, 1939, the patient returned and requested surgical treatment,
having I+ amenorrhea now for almost seven. yews amd sterility for five years.
The findings on bimanual examination were the same as noted on the initial visit.
On Sept. 27, 1939, laparotomy was performed. The uterus was found to be
hypoplastic, regular, firm, and freely movable. Both tubes were normal. Each ovary
was enlarged symmetrically to the size of the uterine corpus. The tunica albuginea
of each ovary was extremely thick and its surface studded with multiple follicle
cysts. About two-thirds of each ovary were removed by wedge-shaped resection,
and after puncturing the remaining visible cysts, the ovary was closed with fine
catgut. Appendectomy was also performed for “mechanical” reasons. The patient
left the hospital in ten days, after an uneventful convalescence. The microscopic
report of the pathologist (Dr. Otto Saphir) was “multiple simple cysts and fibrosis
of the ovary. ”
The first menstruation occurred on Oct. 21, 1939, or twenty-four days after the
operation, and lasted seven days, with moderate flow. Bimanual examination after
this period revealed a normal genital status. Menstruation occurred regularly every
twenty-eight to thirty-one days thereafter, and the patient conceived after the period
of April 25, 1940, having used no contraception for three months. At this writing
(October, 1940) she is pregnant approximately thirty-two weeks.
Multiple follicle cysts, crow)ding the ovarian cortex and causing bilateral ovarian
enlargement is not an infrequent cause of amenorrhea and sterility. These symptoms
may be explained by. an absence of ovulation due to the mechanical “blockade”
by the multiple cysts which crowd the surface. Pneumoroentgenography has been
a very important adjunct in the diagnosis of bilateral polycystic ovaries, since it is
not infrequently difficult or impossible to evaluate the true size of one or both
ovaries on bimanual examination. Rectal examination required in virgins rarely
reveals t.he ovarian swellings.
RFFFRFNCFc
2 11 AL_
(1) Stein, I. F., and Levendd, M. L.: AM. J. OBST. & GYNEC. 29: 151, 1935.
(2) Stein, I. F., and Cohen, M.: AM. J. OBST. 8~ GYNEC. 38: 465, 1939.

MEIGS’ SYNDROME
FIBROMA OF THE OVARY WITH ASCITES AND HYDROTHORAX
FRANK R. LOCK, B.A., M.D., AND
CONRAD G. COLLINS, MS., M.D., F.A.C.S., NEW ORLEANS, LA.
(From the Department of Gynecology, Tulane University and Charity Hospital)

F IBROMA
to the attention
of the ovary associated
of the medical
with ascites and hydrothorax
profession by Meigs
was first called
and Cassl in 1937. At that
time they were able to collect 7 cases. In 1939, Meigsa brought the literature up
to date with an additional 8 eases. Bomze and Kirshbauma have added two cases
since the appearance of Meigs last publication. The importance of accurate diag-
nosis of this benign neoplasm is obvious when it is noted that of the 17 cases in
the literature 15 patients were treated by surgical removal of the tumor and survived.
One of the remaining 2 patients was not given the benefit of a laparotomy, and
died as a result of the syndrome. The other reported by Bomze and Kirshbaum
presented numerous complicating factors and died two days following laparotomy.
These authors considered 3 possible mechanisms as the cause of death. First, the
presence of a large ovarian tumor interfering with the progress of gestation and
causing abortion, combined with the effects of toxemia and exploratory laparotomy.
Second, acute glomerulonephritis which was observed on microscopic examination
of necropsy material, and third, death as a result of an untreated Meigs’ syndrome.
 518 AMERICAN JOURNAL OF OBSTETRICS AXD GYNECOLOGY

Clinically, the condition may closely simulate advanced pelvic malignancy with
peritoneal, and pleural or pulmonary metastases. Caehexia is not uncommon. The
patient usually has known of the presence of an abdominal mass for a long time
prior to consulting a physician. The ascitic fluid may be so marked that the
patient is incapacitated, and the abdominal mass obscured hy the distended
abdomen. Attention is called to the co-existing hydrothorax by dyspnea which
may have been present for months. Sufficient fluid is usually present to gi\-e
ample physical findings. The diagnosis of Me&s syndrome is relatively simple
if the condition is considered.
The rarity of this condition has prompted us to report a case which has re-
cently come under our observation, and in which the diagnosis was made pre-
operatively.
V. V., aged 31 years, colored, was admitted to the Charity Hospital March 31,
1940, complaining that her stomach was swollen. Two weeks prior to admission,
she began to have generalized cramping pains in her abdomen, which became
progressively worse during an interval of approximately six hours. The pains
subsided somewhat, and she noticed that her abdomen had become greatly dis-
tended. She had no nausea or vomiting. She ate dinner as usual, but the inges-
tion of food caused a recurrence of the pains. There was little or no increase in
the size of the patient’s abdomen from the acute onset until admission to the
hospital. She had more or less constant cramping pains of varying intensity
during the two-week interval. Her bowt>l function haul been unchange~l, and no
nausea or vomiting occurred at any time.
She had noticed a lumpy mass in the lower abdomen for a year. She had
dyspnea on climbing steps for the year prior to admission, which had become
progressively more severe and was noticeable on slight exertion during the past
month. Occasional palpitation was present, associated with the periods of dyspnea.
She was not confined to bed during the two weeks of her illness, but. experi-
enced discomfort on walking. She had uo swelling of her feet, ankles, or hands.
The patient had a slight product.ivc cough for one month. There were no
hemoptysis, night sweats or chest pain.
Menstrual and Xurital History.-The patient reached menarche at. l:! years of
age. Her periods occurred at a twenty-eight-day interval, lasting five to six days
throughout her menstrual life. There was no dysmenorrhea. Her last menstrual
period began Feh. 17, 1940. The present menstrual period began afar& 12, 1940.
One pregnancy occurred terminating in a normal full-term delivery when the
patient was 13 years of age.
Hiisfory.-The past and family hist.ory revealed nothing of signiiieanc3r.
Physiwl Emminntion.-She was a slightly undernourished colored female with
a tense protuberant abdomen. Flatness and impaired breath sounds were noted
over the right base posterior and lateral to the level of the seventh rib. No rales
were noted. Tactile fremites were absent. No abnormalities were noted on ex-
amination of the left hemithorax. The heart was within normal limits on per-
cussion and no anscultatory abnormalities were noted. Her blood pressure was
101/78.
Marked symmetrical enlargement of the patient’s abdomen was present. The
skin was tense. No enlarged veins were noted. A tympanitic percussion note was
present in superior portion of abdomen. IMluess to flatness was noted in de-
pendent port,ions of the abdomen. Bhifting dullness and fluid vvaves were demon-
strable. When the patient was in the supine position, a ballotable mass was
present in the lower abdomen that extended up to the umbilicus. The mass was
very hard and nodular on palpation. The mass shifted from one side of the
abdomen to the other as the patient was turned from side to side. The liver and
spleen were not palpable. No sacral edema was present.
Genital examination revealed a multiparous introitus with 3 slight cystocele
and rectocele. Bartholin’s glands were not palpable. No exudate could be ex-
pressed from Skene’s glands. The cervix was normal in size and color. A healed
laceration was present on the right side. The external OS was slightly dilated;
the cervix was a little softer than normal in consistency. The uterus was en-
larged to the size of an eight weeks’ pregnancy with a single fibroid palpable
 LOCK AND COLLINS: MEIGS’ SYNDROME 519

on the anterosuperior surface. The fibroid was approximately 4 cm. in diameter.

The uterus was anteflexed and freely movable. The mass present in the lower
abdomen extended into the pelvis, was freely movable, and was discrete from the
uterus; it was noted on the left side. Slight fixation of the right adnexa was
noted.
The extremities presented no gross abnormalities. No pitting edema was
present.
Laboratory examination revealed no abnormalities.
Diagnosis.-Fibroma of the left ovary and uterine fibroids associated with
ascites and hydrothorax.
X-ray examination of the chest on March 16, 1940, showed increased density
in lower third of right hemithorax with slight displacement of the heart to the
opposite side. Diagnosis: Fluid in the right pleural cavity.
Laparotomy on March 21, 1940, revealed a large solid tumor of the left ovary
approximately 12 cm. in diameter. It was very hard and glary white in appear-
ance. The surface was irregular. A long pedicle was present. Approximately
four liters of clear fluid escaped from the abdomen when the peritoneum was
opened. Uterine fibroids, chronic infiammatory disease of the right tube and
ovary, and chronic appendicitis were also present. A total hysterectomy, bilateral
salpingo-oophorectomy and appendectomy were done.
The pathologic report showed a large tumor mass of the left ovary, 14 cm. in
diameter, slightly lobulated and very firm in consistency. On cut section the
surface was yellowish white in color and contained a cystic portion 3 cm. in
diameter. The tumor was largely covered by peritoneum and several dilated
vessels were noted on its outer surface.
The uterus and cervix measured 10 by 9 by 3.5 cm. The cervix was lacerated
unilaterally. The mucosa was smooth and pale yellow. A subserosal tumor mass
was present which measured 3 cm. in diameter, well encapsulated, and firm in
consistency. The endometrium measured 3 cm. in thickness and was pale yellow
and soft in consistency. The right ovary was adherent to the tube and the
fimbriated end was closed. The ovary contained a cyst filled with hemorrhagic
5uid, other cysts present contained clear yellow duid.
Final Microscopic Diccgnosis.-Fibroma of the ovary, leiomyoma of the uterus,
follicular cysts of the ovary, chronic salpingitis, and chronic appendicitis.
The patient’s convalescence was particularly uneventful, and she left the hos-
pital April 3, 1940. The patient was entirely free of symptoms during her
convalescence
X-ray examination of the chest on April 1, 1940, the 12th postoperative day,
showed clearing of the opacity previously seen in the lower portion of the right
chest.
Fo,lbw-Up Exam&,&o%-The patient was seen on Sept. 19, 1940. She had been
entirely well since operation, had gained weight and had been able to resume her
full duties about the household.
This patient presents the classical Meigs’ syndrome. We agree with Meigs’
recommendation that paracentesis, be done, if necessary, for accurate diagnosis
of the pelvic mass. However, when paracentesis and thoracentesis are done,
rapid reaccumulation of the fluid occurs. There is the danger of secondary in-
fection of the affected serous cavities, which occurred in one of the reported
cases. We were fortunate that the fibroma of the left ovary was readily palpable
in spite of a relatively massive ascites and that the patient was not sufficiently
embarrassed by the pleural transudate to require its removal.
There is little doubt that many cases of Meigs’ syndrome have been overlooked
in the past.
REFERENCES

(1) Meigs, J. V., and Cass, J. W.: AM. J. OBST. & GYNEC. 33: 249, 1937. (2)
Mei’gs, J. V. : Ann. Surg. 110: 731, 1939. (3) Bomze, E. J., and Ekshbaum, J. D.:
-1lnr.J. OBST.& G~x~c.40: 281,194O.