MISCELLANEOUS SURGICAL ANOMALIES. 8 page

she was burned over her breasts by running against a shovelful of hot

coals, and several months later small tumors appeared, which never

suppurated. When a young girl a tumor was removed from the front of her

neck by operation, and cicatricial tumors then spread like a band

encircling one-half her neck. There were keloids over her scapulae,

which followed the application of blisters. On her back, over, and

following the direction of the ribs, were growths attributed to the

wounds caused by a flogging. This case was quite remarkable for the

predisposition shown to keloid at an early age, and the variety of

factors in causation.

About 1867 Duhring had under his observation at the Philadelphia

Hospital a negro whose neck was encircled by enormous keloids, which,

although black, otherwise resembled tomatoes. A photograph of this

remarkable case was published in Philadelphia in 1870.

A lipoma is a tumor consisting of adipose tissue. When there is much

fibrous tissue in the tumor it is much firmer, and is known as a

fibro-lipoma. Brander describes a young native of Manchuria, North

China, from whom he removed a fibro-lipoma weighing 50 pounds. The

growth had progressively enlarged for eleven years, and at the time of

extirpation hung as an enormous mass from beneath the left scapula. In

operating the tumor had to be swung on a beam. The hemorrhage was

slight and the patient was discharged in five days.

The true lipoma must be distinguished from diffuse accumulations of fat

in different parts of the body in the same way that fibroma is

distinguished from elephantiasis. Circumscribed lipoma appears as a

lobulated soft tumor, more or less movable, lying beneath the skin. It

sometimes reaches enormous size and assumes the shape of a pendulous

tumor.

Diffuse lipoma, occurring in the neck, often gives the patient a

grotesque and peculiar appearance. It is generally found in men

addicted to the use of alcohol, and occurs between thirty-five and

forty-five years of age; in no case has general obesity been described.

In one of Madelung's cases a large lobe extended downward over the

clavicle. The growth has been found between the larynx and the pharynx.

Black reports a remarkable case of fatty tumor in a child one year and

five months old which filled the whole abdominal cavity, weighing nine

pounds and two ounces. Chipault mentions a case of lipoma of the

parietal region, observed by Rotter. This monstrous growth was three

feet three inches long, descending to the knees. It had its origin in

the left parietal region, and was covered by the skin of the whole left

side of the face and forehead. The left ear was plainly visible in the

upper third of the growth.

Chondroma, or enchondroma, is a cartilaginous tumor occurring

principally where cartilage is normally found, but sometimes in regions

containing no cartilage. Enchondroma may be composed of osteoid tissue,

such as is found in the ossifying callous between the bone and the

periosteum, and, according to Virchow, then takes the name of

osteochondroma. Virchow has divided chondromata into two forms--those

which he calls ecchondromata, which grow from cartilage, and those that

grow independently from cartilage, or the enchondromata, which latter

are in the great majority. Enchondroma is often found on the long

bones, and very frequently upon the bones of the hands or on the

metatarsal bones.

Figure 244 represents an enchondroma of the thumb. Multiple

enchondromata are most peculiar, and may attain enormous sizes.

Whittaker describes a farmer of forty who exhibited peculiar tumors of

the fingers, which he calls multiple osteoecchondromata. His family

history was negative. He stated that at an early age he received a

stroke of lightning, which rendered him unconscious for some time. He

knows of nothing else that could be in possible relation with his

present condition. Nine months after this accident there was noticed

an enlargement of the middle joint of the little finger, and about the

same time an enlargement on the middle finger. Gradually all the joints

of the right hand became involved. The enlargement increased so that at

the age of twelve they were of the size of walnuts, and at this time

the patient began to notice the same process developing in the left

hand. The growths continued to develop, new nodules appearing, until

the fingers presented the appearance of nodulated potatoes.

One of the most frequent of the fibro-cartilaginous tumors is the

"mixed cartilaginous" tumor of Paget, which grows in the interstitial

tissues of the parotid gland, and sometimes attains enormous size.

Matas presented the photograph of a negress having an enormous fibroma

growing from the left parotid region; and there is a photograph of a

similar case in the Mutter Museum of the College of Physicians,

Philadelphia.

The hyaline enchondroma is of slow growth, but may at times assume

immense proportions, as is shown in the accompanying illustration,

given by Warren, of a patient in whom the growth was in the scapula.

In 1824 there is quoted the description of a peculiar growth which,

though not definitely described, may be spoken of here. It was an

enormous encysted tumor, springing from the clavicle of a Veronese

nobleman. Contrary to general expectations it was successfully removed

by Portalupi, a surgeon of Venice. It weighed 57 pounds, being 20 1/2

inches long and 30 inches in circumference. It is said this tumor

followed the reception of a wound.

Among the benign bone tumors are exostoses--homologous outgrowths

differing from hypertrophies, as they only involve a limited part of

the circumference. When developmental, originating in childhood, the

outgrowths may be found on any part of the skeleton, and upon many and

generally symmetric parts at the same time, as is shown in Figure 248.

Barwell had a case of a girl with 38 exostoses. Erichsen mentions a

young man of twenty-one with 15 groups of symmetric exostoses in

various portions of the body; they were spongy or cancellous in nature.

Hartmann shows two cases of multiple exostoses, both in males, and

universally distributed over the body.

Macland of the French navy describes an affection of the bones of the

face known as anakhre or goundron (gros-nez). It is so common that

about one per cent of the natives of certain villages on the Ivory

Coast, West Africa, are subject to it. As a rule the earliest symptoms

in childhood are: more or less persistent headache, particularly

frontal, sanguineous and purulent discharge from the nostrils, and the

formation of symmetric swellings the size of an almond in the region of

the nasal processes of the superior maxilla. The cartilage does not

seem to be involved, and, although it is not so stated, the nasal duct

appears to remain intact.

The headache and discharge continue for a year, and the swelling

continually increases through life, although the symptoms gradually

disappear, the skin not becoming involved, and no pain being present.

It has been noticed in young chimpanzees. The illustration represents a

man of forty who suffered from the disease since puberty. Pressure on

the eyeball had started and the native said he expected that in two

years he would lose his sight. Figure 251 shows an analogous condition,

called by Hutchinson symmetric osteomata of the nasal processes of the

maxilla. His patient was a native of Great Britain.

Among neuromata, multiple neurofibroma is of considerable interest,

chiefly for the extent of general involvement. According to Senn,

Heusinger records the case of a sailor of twenty-three in whom all the

nerves were affected by numerous nodular enlargements. Not a nerve in

the entire body was found normal. The enlargement was caused by

increase in the connective tissue, the axis-cylinders being normal. In

this case there was neither pain nor tenderness.

Prudden reports the case of a girl of twenty-five who, during

convalescence from variola, became paraplegic, and during this time

multiple neuromata appeared. At the postmortem more than a thousand

tumors were found affecting not only the peripheral branches and the

sympathetic, but also the cranial nerves and the pneumogastric. Under

the microscope these tumors showed an increase in the interfascicular

as well as perivascular fibers, but the nerve-fibers were not increased

in size or number. Virchow collected 30 cases of multiple

neurofibromata. In one case he found 500, in another from 800 to 1000

tumors.

Plexiform neuroma is always congenital, and is found most frequently in

the temporal region, the neck, and the sides of the face, but almost

any part of the body may be affected. Christot reports two cases in

which the tumors were located upon the cheek and the neck. Czerny

observed a case in which the tumor involved the lumbar plexus. Quoted

by Senn, Campbell de Morgan met with a plexiform neuroma of the

musculo-spiral nerve and its branches. The patient was a young lady,

and the tumor, which was not painful, had undergone myxomatous

degeneration.

Neuroma of the vulva is a pathologic curiosity. Simpson reports a case

in which the tumor was a painful nodule situated near the urinary

meatus. Kennedy mentions an instance in which the tumor appeared as

extremely tender tubercles.

Tietze describes a woman of twenty-seven who exhibited a marked type of

plexiform neurofibroma. The growth was simply excised and recovery was

promptly effected.

Carcinomatous growths, if left to themselves, make formidable

devastations of the parts which they affect. Warren pictures a case of

noli-me-tangere, a destructive type of epithelial carcinoma. The

patient suffered no enlargement of the lymphatic glands. The same

absence of glandular involvement was observed in another individual, in

whom there was extensive ulceration. The disease had in this case

originated in the scar of a gunshot wound received during the Civil

War, and had destroyed the side of the nose, the eye, the ear, the

cheek, including the corresponding half of the upper and lower lips.

Harlan reports a most extraordinary epithelioma of the orbit in a boy

of about five years. It followed enucleation, and attained the size

depicted in a few months.

Sarcomata, if allowed full progress, may attain great size. Plate 10

shows an enormous sarcoma of the buttocks in an adult negro. Fascial

sarcomata are often seen of immense size. Senn shows a tumor of this

variety which was situated between the scapulae.

Schwimmer records a curious case of universal small sarcomata over the

whole body of a teacher of the age of twenty-one, in the Hungarian

lowlands. The author called the disease sarcomata pigmentosum diffusum

multiplex.

The bones are a common seat of sarcomatous growths, the tumor in this

instance being called osteosarcoma. It may affect any bone, but rarely

involves an articulation; at times it skips the joint and goes to the

neighboring bone.

A case of nasal sarcoma is shown by Moore. The tumor was located in the

nasal septum, and caused a frightful deformity. In this case pain was

absent, the sense of smell was lost, and the sight of the right eye

impaired. Moore attempted to remove the tumor, but in consequence of

some interference of respiration the patient died on the table.

Tiffany reports several interesting instances of sarcoma, one in a

white female of nineteen following a contusion of tibia. The growth had

all the clinical history of an osteosarcoma of the tibia, and was

amputated and photographed after removal. In another case, in a white

male of thirty, the same author successfully performed a hip-amputation

for a large sarcoma of the left femur. The removed member was sent

entire to the Army Medical Museum at Washington.

The fatality and incurability of malignant growths has done much to

stimulate daring and marvelous operations in surgery. The utter

hopelessness of the case justifies almost any means of relief, and many

of the visceral operations, resections of functional organs, and

extraordinary amputations that were never dreamed of in the early

history of medicine are to-day not only feasible and justifiable, but

even peremptorily demanded.

Varicose veins sometimes become so enlarged and distorted as to

simulate the appearance of one varicose tumor. Adams describes a

curious case of congenital dilatation of the arteries and veins in the

right lower limb, accompanied by an anastomosis with the interior of

the os calcis. The affected thigh exceeded the other in size by

one-third, all the veins being immensely swelled and distorted. The

arteries were also distorted and could be felt pulsating all over the

limb. The patient died at thirty from rupture of the aneurysm.

Abbe shows a peculiar aneurysmal varix of the finger in a boy of nine.

When a babe the patient had, on the dorsum of the little finger, a

small nevus, which was quiescent for many years. He received a deep cut

at the base of the thumb, and immediately after this accident the nevus

began to enlarge rapidly. But for the local aneurysmal thrill at the

point of the scar the condition would have been diagnosed as angioma,

but as a bruit could be heard over the entire mass it was called an

aneurysmal varix, because it was believed there was a connection

between a rather large artery and a vein close to the mass. There is a

curious case reported of cirsoid tumor of the ear of a boy of thirteen.

Figure 259 shows the appearance before and after operation.

Jessop records a remarkable case of multiple aneurysm. This case was

particularly interesting as it was accompanied by a postmortem

examination. Pye-Smith reports an extremely interesting case in which

death occurred from traumatic aneurysm of an aberrant subclavian

artery. The patient fell from a height of 28 feet, lost consciousness

for a few minutes, but soon recovered it. There was no evidence of any

fracture, but the man suffered greatly from dyspnea, pain between the

shoulders, and collapse. The breath-sounds on auscultation and the

difficulty in swallowing led to the belief that one of the bronchi was

blocked by the pressure of a hematoma. Dyspnea continued to increase,

and eighteen days after admission the man was in great distress, very

little air entering the chest. He had no pulse at the right wrist, and

Pye-Smith was unable to feel either the temporal or carotid beats on

the right side, although these vessels were felt pulsating on the left

side. Laryngotomy was done with the hope of removing a foreign body,

but the man died on the tenth day. A postmortem examination disclosed

the existence of an aberrant right subclavian artery in the posterior

mediastinum, and this was the seat of a traumatic aneurysm that had

ruptured into the esophagus.

Relative to the size of an aneurysm, Warren reported a case of the

abdominal aorta which commenced at the origin of the celiac axis and

passed on to the surfaces of the psoas and iliac muscles, descending to

the middle of the thigh The total length of the aneurysm was 19 inches,

and it measured 18 inches in circumference.

A peculiar sequence of an aortic aneurysm is perforation of the sternum

or rib. Webb mentions an Irish woman who died of aneurysm of the aorta,

which had perforated the sternum, the orifice being plugged by a large

clot. He quotes 17 similar cases which he has collected as occurring

from 1749 to 1874, and notes that one of the patients lived seven weeks

after the rupture of the aneurysmal sac.

Large Uterine Tumors.--Before the meeting of the American Medical

Association held in Washington, D.C., 1891, McIntyre a reported a case

of great interest. The patient, a woman of thirty-eight, five feet 5

1/2 inches in height, coarse, with masculine features, having hair on

her upper lip and chin, and weighing 199 1/2 pounds, was found in a

poor-house in Trenton, Missouri, on November 26, 1890, suffering from a

colossal growth of the abdomen. The accompanying illustration is from a

photograph which was taken at the time of the first interview. The

measurements made at the time were as follows: circumference at the

largest part, just below the umbilicus, 50 inches; circumference just

below the mammae, 35 inches; from the xiphoid cartilage to the

symphysis pubis, 32 inches, not including the appendum, which is shown

in the picture. Percussion suggested a fluid within a sac. The uterus

was drawn up to the extent of from 12 to 14 inches. The woman walked

with great difficulty and with a waddling gait, bending far backward

the better to keep "the center of gravity within the base," and to

enable her to sustain the enormous weight of the abdomen. She was

compelled to pass her urine while standing. Attempts had been made six

and two years before to tap this woman, but only a few drops of blood

followed several thrusts of a large trocar. A diagnosis was made of

multilocular ovarian cyst or edematous myoma of the uterus, and on the

morning of December 7, 1890, an operation was performed. An incision 14

inches in length was first made in the linea alba, below the umbilicus,

and afterward extended up to the xiphoid cartilage. The hemorrhage

from the abdominal wall was very free, and the enormously distended

vessels required the application of a large number of pressure-forceps.

Adhesions were found almost everywhere the most difficult to manage

being those of the liver and diaphragm. The broad ligaments and

Fallopian tubes were ligated on either side, the tumor turned out, the

thick, heavy pedicle transfixed and ligated, and the enormous growth

cut away. After operation the woman was immediately placed on platform

scales, and it was found that she had lost 93 1/2 pounds.

Unfortunately the patient developed symptoms of septicemia and died on

the fifth day. In looking over the literature on this subject McIntyre

found no mention of any solid tumor of this size having been removed.

On April 18, 1881, Keith, late of Edinburgh, now of London,

successfully removed an edematous myoma, together with the uterus,

which was 42 pounds in weight. In a recent work Tait remarks that the

largest uterine myoma which he ever removed weighed 68 pounds, and adds

that it grew after the menopause. McIntyre believes that his tumor,

weighing 93 1/2 pounds, is the largest yet reported. Eastman reports

the removal of a fibroid tumor of the uterus weighing 60 pounds. The

patient recovered from the operation.

It is quite possible for a fibrocyst of the uterus to attain an

enormous size, equaling the ovarian cysts. Stockard describes an

instance of this nature in a negress of fifty, the mother of several

children. About twelve years before a cyst in the right iliac region

was tapped. The woman presented the following appearance: The navel

hung below her knees, and the skin near the umbilicus resembled that of

an elephant. The abdomen in its largest circumference measured 68

inches, and 27 inches from the ensiform cartilage to the umbilicus. The

umbilicus was five inches in diameter and three inches in length. Eight

gallons and seven pints of fluid were removed by tapping, much

remaining. The whole tumor weighed 135 pounds. Death from exhaustion

followed on the sixth day after the tapping.

Ovarian cysts, of which by far the greater number are of the glandular

variety, form extremely large tumors; ovarian dropsies of enormous

dimensions are recorded repeatedly throughout medical literature. Among

the older writers Ford mentions an instance of ovarian dropsy from

which, by repeated operations, 2786 pints of water were drawn.

Martineau describes a remarkable case of twenty-five years' duration,

in which 80 paracenteses were performed and 6630 pints of fluid were

withdrawn. In one year alone 495 pints were withdrawn. Tozzetti

mentions an ovarian tumor weighing 150 pounds. Morand speaks of an

ovarian cyst from which, in ten months, 427 pounds of fluid were

withdrawn. There are old records of tubal cysts weighing over 100

pounds. Normand speaks of an ovary degenerating into a scirrhous mass

weighing 55 pounds. Among recent operations Briddon describes the

removal of an ovarian cyst which weighed 152 pounds, death resulting.

Helmuth mentions an ovarian cyst from which, in 12 tappings, 559 pounds

of fluid were withdrawn. Delivery was effected by instrumental aid. The

tumor of 70 pounds was removed and death followed. McGillicuddy

mentions a case of ovarian cyst containing 132 pounds of fluid. The

patient was a woman of twenty-eight whose abdomen at the umbilicus

measured 69 inches in circumference and 47 inches from the sternum to

the pubes. Before the operation the great tumor hung down as far as the

knees, the abdominal wall chafing the thighs. Figure 263 shows the

appearance of a large ovarian cyst weighing 149 pounds. The emaciation

of the subject is particularly noticeable. Reifsnyder describes a

native Chinese woman affected with an ovarian tumor seen at the

Margaret Williamson Hospital at Shanghai. She was four feet eight

inches in height, and twenty-five years of age. The tumor had been

growing for six years until the circumference at the umbilicus measured

five feet 7 3/4 inches; 88 quarts of fluid were drawn off and the woman

recovered. In the College of Physicians, Philadelphia, there are

photographs of this case, with an inscription saying that the patient

was a young Chinese woman who measured but four feet eight inches in

height, while her girth was increased by an ovarian cyst to five feet 9

1/8 inches. The tumor was removed and weighed 182 1/2 pounds; it

contained 22 gallons of fluid. Figure 265 shows the appearance of the

woman two months after the operation, when the girth was reduced to

normal. Stone performed ovariotomy on a girl of fifteen, removing a

tumor weighing 81 1/2 pounds. Ranney speaks of the successful removal

of a unilocular tumor weighing 95 pounds; and Wall tells of a death

after removal of an ovarian tumor of the same weight. Rodenstein

portrays the appearance of a patient of forty-five after death from an

enormous glandular ovarian cystoma. The tumor was three feet high,

covered the breasts, extended to the knees, and weighed 146 pounds.

Kelly speaks of a cyst weighing 116 pounds; Keith one of 89 1/2 pounds;

Gregory, 80 pounds; Boerstler, 65 pounds; Bixby, 70 pounds; and Alston

a tumor of 70 pounds removed in the second operation of ovariotomy.

Dayot reports the removal of an enormous ovarian cyst from a girl of

seventeen. The tumor had been present three years, but the patient and

her family refused an operation until the size of the tumor alarmed

them. Its largest circumference was five feet 11 inches. The distance

from the xiphoid to the symphysis pubis was three feet. The tumor was

covered with veins the size of the little finger. The apex of the heart

was pushed to the 3d interspace and the umbilicus had disappeared.

There were 65 quarts of a thick, brown fluid in the tumor. The patient

recovered in twenty-five days.

Cullingworth of St. Thomas Hospital, London, successfully removed from

a girl of sixteen an ovarian cyst weighing over 80 pounds. The patient

was admitted to the hospital April 30, 1895. She gave a history of a

single menstruation, which took place in March or April, 1893, and said

that in the latter month she noticed that she was growing large. She

was tapped at Christmas, 1893, when a large quantity of fluid was

removed, and again in February, 1894, and a third time in May, 1894,

but without useful results. For the previous six months she had been

almost entirely bedridden because of the great size of the tumor. There

were no symptoms referring to the bladder and rectum. At the time she

entered the hospital she was much emaciated, the eyes were sunken, and

her cheeks had a livid hue. The chest was thin and the lower ribs were

everted; dulness began at the lower border of the 3d cartilage, and the

apex-beat was best felt in the third space. Liver-dulness began at the

4th rib cartilage in the nipple line. The abdomen was enormously

distended, and covered by large veins running from below upward to the

thorax. About 3 1/2 inches above the umbilicus there was a sulcus with

its convexity downward. There was dulness over the whole abdomen,

except at the sides parallel with the lumbar spines, and a resonant

band over the stomach. The greatest girth was 54 1/2 inches. By vaginal

examination the cervix was found to be pulled up and obliterated; the

anterior vaginal wall was bulged downward by the tumor. On May 3d

abdominal section was performed. An incision eight inches long was made

in the mid-line of the abdomen. A cystic tumor, formed of small cysts

in its upper part and of somewhat larger ones in the lower part, was

revealed. It was adherent to the abdominal wall, liver, spleen, and

omentum. The adhesions were separated and the cyst tapped with a large

trocar, and then the septa between the cysts were broken down with the

fingers. The pedicle was rather small and was tied in the usual way,

and the tumor was removed. Its seat of origin was the left ovary. The

right ovary and the uterus were healthy, but poorly developed. The

tumor weighed between 80 and 90 pounds,--the patient having weighed 170

pounds on the night before the operation and 79 1/2 pounds a week after

the operation. Alarming symptoms of collapse were present during the

night after the operation, but the patient responded to stimulation by

hypodermic injections of 1/20 grain of strychnin and of brandy, and

after the first twenty-four hours the recovery was uninterrupted.

Cullingworth thinks that the most interesting points in the case are:

the age of the patient, the enormous size of the tumor, and the advice

given by the surgeon who first attended the patient (insisting that no

operation should be performed). This case shows anew the uselessness of

tapping ovarian cysts.

In the records of enormous dropsies much material of interest is to be

found, and a few of the most interesting cases on record will be cited.

In the older times, when the knowledge of the etiology and pathology of

dropsies was obscure, we find the records of the most extraordinary

cases. Before the Royal Society, in 1746, Glass of Oxford read the

report of a case of preternatural size of the abdomen, and stated that

the dropsy was due to the absence of one kidney. The circumference of

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