ART. I.-CASE OF ABDOMINAL TUMOUR (FIBRO-SCIRRHOUS) CONNECTED WITH THE UTERUS-AUTOPSY AND REMARKS.

BY C. W. PENNOCK, M. D.

Physician to the Philadelphia Hospital, Blockley, (with a lithographic plate.) Eliza Hyson (black), aged 36, married at 19, has never had children, has miscarried four times; in the three first instances between the sixth and seventh months, without any known cause; in a fourth pregnancy, fourteen years since, in the fifth month of gestation, was, severely beaten and kicked in the lumbar region, which was followed by abortion the next morning. Since this event she has not been pregnant; the menstrual function, however, has continued until the last three months; no pain was experienced at the usual menstrual period, and the appearance of the secretion was natural. Twelve years since (two years after the beating) a distension of the right lumbar region was observed, which was mistaken for pregnancy; this tumour has gradually increased in size, and now presents an enormous enlargement. It has never been attended with pain, and she came into the hospital in consequence of the weight and inconvenience of the tumour, rather than for any other cause. Transient ædema of the limbs occurred in 1838. In the autumn of 1838 she entered the hospital, and was placed in the wards of Dr. Dunglison, where she remained some months. Being somewhat relieved, she requested her discharge, and, after a short absence, returned the size of the tumour being much augmented. A few days after her re-entrance, the patient presented the following symptoms:

February 14th, present state.-Slight emaciation; nothing peculiar in the expression of the countenance ; intelligence perfect; no cellular infiltration; skin natural; decubitus dorsal, or on the left side; position in bed slightly elevated. Chest well formed. Percussion preternaturally resonant, and respiration feeble beneath right clavicle, elsewhere normal. Percussion of heart shows it dilated; rhythm of heart nearly normal; slight bellows sound accompanies the first, heard beneath the cartilage of left third rib, and beneath cartilages of second and third ribs on the right side near the sternum. Pulse 80, easily excited, somewhat tense.

Abdomen enormously distended by an internal tumour; the measurement from the symphyses of pubis to the ensiform cartilage, three feet; circumference round the umbilicus four feet eight inches. Percussion is flat, with the exception of right lumbar region near the spine, where it is resonant. In the epigastric and upper part of umbilical region, abdomen soft, elsewhere hard; hard globular masses, resisting pressure, felt in different portions of abdomen, particularly in the hypogastric, right iliac, and lumbar, extending up to right hypochondriac; fluctuation caused by palpation on left side of

tumour, none anteriorly, imperfectly felt on right side. Appetite good; constipation; some difficulty in urining. Pulsation of femoral arteries distinct, but feeble.

In examination per vaginam, the finger is introduced with difficulty, from pressure of tumour filling the greater part of the cavity of the pelvis; the os tincæ found towards the right iliac crista, soft, and unchanged-neck not obliterated the tumour, by strong pressure, may be raised, but upon withdrawing the hand, it sinks heavily downwards.

(Treatment palliative-mild cathartics, simple nutritious diet, hip baths, fomentations to abdomen, &c.)

On the 20th, fluctuation was observed in the upper and lateral portions of the abdomen, conveying the sensation of the existence of a slight effusion of fluid between the external parietes and tumour; no pain on pressure; pulse rather more tense, 90 per minute; skin of natural heat. Patient was directed to drink an infusion of juniper berries. . bacc. juniperi 3j. bitart. potassæ 3ij. aquæ Oj. in the day, and pulv. Doveri grs. viij. at night. The fluid diminished very sensibly in a few days. No marked fever was at any time observed; patient remained almost constantly in a recumbent posture, not, as she frequently stated, from pain, but in consequence of the weight and sense of distension when sitting. Emaciation and debility rapidly increased.

Absence from the city prevented my seeing the patient during the last week of her life. My friend, Dr. Barnes, resident physician, reports, that on the 1st of March she had a severe chill, followed by fever, pain in the abdomen, great dyspnoea, and the physical signs of peritonitis and pneumonia. All means of relief proved unavailing, and this acute attack caused death in less than thirty-six hours from its commencement.

Autopsy fifty hours after death.-Frame, medium size; much emaciation; no effusion into cellular tissue.

Abdomen-Greatly enlarged, of an irregular globular form, measuring thirty-one inches and a half from pubes to ensiform cartilage; circumference over umbilicus, where distension is greatest, fifty-one inches. Percussion of abdomen flat, except in epigastric region, where it is resonant. Abdomen soft, except in hypogastric and right lumbar regions, where a hard, irregular, semicircular mass is felt, resembling a fœtus at term; a globular mass is also felt to the left of umbilicus; fluctuation by palpitation in umbilical region.

Opening the abdomen two quarts of fetid bistre-coloured fluid escaped. Peritoneum and omentum thickened, covered with numerous bright scarlet patches, and are firmly united by bands to contiguous organs. Raising the omentum, a large globular tumour is seen, by which the intestines are displaced and forced into epigastric region; this tumour, sixteen by fourteen inches, occupies the whole of the hypogastric, umbilical, and greater part of lumbar regions, is anterior to the uterus, to the body of which it is firmly connected. United to this large tumour, at its inferior and left lateral margin, is another tumour, which projects into the cavity of the pelvis, and rests principally in the left iliac fossa. The tumours are firmly attached to the parietes of the abdomen and pelvis by membranous bands, and are covered externally by the peritoneum, which is much thickened, of a dark red colour, and interspersed with patches of minute arterial vessels. The large tumour on its right lateral margin is united in an extent of two inches with the cellular coat of the fundus and body of the uterus. Cellular tissue connects the peritoneal coat with the proper capsule of the tumours, which is of a pearl colour, hard, fibro-cellular, and a line in thickness. Near the connection of the tumour with the uterus cellular tissue is very abundant; it contains numerous meshes of blood-vessels, principally veins, is deeply injected, and resembles muscular fibre. The tumour, somewhat irregular and lobulated, is of unequal firmness, in some spots soft to the touch, in others, hard and resisting; evident fluctuation exists over the softer portions

corresponding with that observed during life. Incision being made into the large tumour, it is found to be filled with more than six gallons of fetid yellow brown (café-au-lait), thick, and viscid fluid, in which float yellow flocculi and small fibrous masses. The walls of the tumour from three lines to three inches thick, are of variable consistence, which in some parts resemble that of cartilage, and grating under the scalpel, in others the firmness of pork. General aspect of its surface when cut, is of a light blue passing into French gray, interspersed with pale pink, and is intersected with striæ of pearly whiteness; these bands divide it into small masses which are smooth when first cut, but soon rise in slight elevations. The internal surface of the tumour is very irregular; in its walls are cells filled with a yellow deposit, of the consistence of cheese, and numerous pendant masses of the fibrous character and appearance above mentioned are attached to its parietes. Some portions of the internal surfaces are much injected, of a bright arterial hue. The tumour in the left iliac fossa is five inches by four; shape ovoid; very firm; scalpel cutting it with difficulty; solid, with the exception of a small central canal by which it communicates with the large tumour; around this canal the substance is softened, of a yellowish brown colour. The tumour is fibro-scirrhous, and resembles in structure the walls of the large tumour.

Uterus-Displaced, lying towards the right crista of the ileum, irregular in shape, three inches long, two wide, hardened, and scirrhous; its walls present a very evident muscular structure, the fibres of which interlace with the capsules of the tumours; when cut, the parietes present a marbled appearance from pale blue and straw-coloured nodules intersected by white striæ; the neck is much elongated, five inches in length, and lies between the two large tumours first described. Os tincæ natural, soft to the touch. Ovaries-right ovary slightly enlarged, containing an ounce of thick glutinous, and dark fluid; left ovary normal. In the broad ligament, near its fimbriated extremity, are numerous deposits in the cellular tissue, of small, flat, and circular carcinomatous masses.

Near the fundus of the uterus, connected with its cellular coat, and covered by its peritoneal, are three sessile, unsoftened, fibro-scirrhous tumours, from the size of a hazel-nut to that of a walnut. A fourth tumour, fibro-cartilaginous externally, and containing a thick, yellow, gelatinous fluid, similar to that of the largest tumour, is embedded in the cellular tissue. A pedunculated tumour, two inches in diameter, is connected with the neck of the uterus by a slender stem four inches long.

Stomach-Contracted; mucous membrane very pale ; cellular and muscular coats thickened, particularly near pylorus; pyloric orifice contracted and

hardened.

Small intestines-Throughout very pale; mucous coat normal; absence of red vessels in mucous tissue, but numerous vessels containing globules of yellow substance seen in the jejunum. Mucous coat of colon dark gray, consistence normal; cellular coat much thickened and opaline.

Mesenteric glands-Generally normal; meso-colic hardened and scirrhous, slightly enlarged.

Liver-Slate colour, not congested, somewhat enlarged, consistence natural; gall-bladder distended by bile of thin consistence, and of bright lemon hue.

Kidneys.-Left, atrophied, pale, bossellated; cortical substance granulated; attached to it are several hydatids of the size of a hazel-nut. The right kidney enlarged, displaced, resting on the bodies of the vertebra; cortical substance buff-coloured, slightly granulated.

Spleen-Enlarged, six by four inches, soft, friable, no carcinomatous

deposit.

Bladder.-Parietes thinner than natural, otherwise healthy.

Ureters-Pass on either side around the semi-circumference of the large

tumour.

Thorax-lungs.-The right, normal, except along the upper margin of the upper lobe, where it is emphysematous. Left, congested, friable, not hepatised.

Heart.-Pericardium adherent to left pleura; upon its surface are raised opaline patches. No adhesion of pericardium to the heart. Right cavities of the heart are dilated; valves of the aorta are thickened; ossific deposit on the edges; mitral valve thickened with cartilaginous deposit; parietes of right ventricle three and a half lines. Left, normal. Brain not examined. Remarks.-From the colour of the serous membrane, and from that of the fluid found in the cavity of the abdomen exterior to the tumour, it is evident that chronic peritonitis and ascites must have existed for some time. The symptoms occurring in the last days of life, the vivid arterial redness in patches on the peritoneum, and the engorgement of the left lung, prove the immediate cause of death to have been an attack of acute peritonitis with commencing pneumonia. All the tumours were evidently of the same character-the identity of the structure of the walls, and the internal pendant masses of the large tumour with the formation of the others, show, that originally it must have been solid throughout. The colour, pale blue, passing into gray, the granulated appearance and hardness of the surface when cut, are indications of scirrhous; whilst the unusual development of the fibrous deposit, and the osseous and cartilaginous changes, indicate the character of the formation to be mixed, fibro-scirrhous.

Several points of interest, in addition to its great size, are connected with the history of this tumour. During the long continuance of its formation, twelve years, the patient does not seem to have suffered the violent pain so frequently attendant upon this class of affections; only slight oedema of the limbs resulted from the pressure of the tumour upon the abdominal arteries; the menstrual function continued unaffected until a short time before death, and although the softening of the large tumour and the formation of the purulent secretion were very great, yet no marked hectic was observed.

The singular character of these heterologous formations has engaged much of the attention of pathologists, and the cause of their production is yet but imperfectly understood. It would seem that the most satisfactory theory is, that the deposite is formed in the capillary system, intermediate to the arteries and veins. In the present instance we have seen that the carcinomatous formation was observed in the cellular tissue of the broad ligament, unconnected with any secreting glands. A question of great interest is presented respecting the circulation in these tumours; by many it is thought that the small quantity of blood which permeates them must be from the veins. This theory Bérard, in some very happy experiments on encephaloid formation, (detailed in Dictionnaire de Médecine, article, Cancer,) disproves, showing it to be exclusively arterial, and that the veins become obliterated by the new formation obstructing their caliber. Anxious to ascertain whether any vessels entered into the scirrhous masses, repeated attempts at injecting them were made, in which I was very kindly and skilfully assisted by Dr. McKee, of North Carolina, resident physician. Unfortunately for a satisfactory result, the tumours had been removed some time from the body previous to the attempt; every precaution, however, was taken to ensure success, but we could not force a minute injection into the arteries further than a short distance beyond the capsule of the tumours, whilst the vein seemed effectually closed by that tunic. The problem respecting the circulation through these formations is extremely interesting, and it is hoped it will soon be satisfactorily elucidated.

Great pains were taken to inject the pedunculated tumour, supposing that its pedicle must contain blood vessels for its nutrition. In this we were entirely unsuccessful, and examining the stem by a microscope, we were convinced that it was a duplicature of the peritoneum, containing merely capillary vessels. We were induced, therefore, to regard the pedunculated tumours as resulting from a deposit in the cellular tissue, beneath the