Maech 1,

A MIRROR OE HOSPITAL PRACTICE.

1873.]

A MIRROR OF HOSPITAL PRACTICE. MEDICAL COLLEQE HOSPITAL.

W

CASE OP ENCEPFIALOID DISEASE OF TIIE INGUINAL GLANDS; SIMULATING ANEURISM OF THE EXTERNAL ILIAC A LITE LI Y.

By Surgeon J. A. Puuefoy Colle3,M.D., F.R.C.S.I., Officiating Second Surgeon, Medical College Hospital. Harho Chandra., aged 30, a Bengali fisherman, was admitted into the second Surgeon's ward, Medical College Hospital, Calcutta, on the evening of the 1st August 1872. Ilia story,

which from his weak state was told with great difficulty, was that about a year ago he observed a small tumour in the right groin, near the anterior superior spine of the ilium. This increased slowly for nine, but very rapidly for the last three months, especially for the last few weeks; and latterly became intensely painful: for the last five months he has been unable IIo can assign no cause for it; he never received to walk. any injury or sprain in the right groin, nor had he ever felt anything give way there. About ten days ag,>, a barber made two incisions into the tumour, but only a little blood escaped. Present State.?The right iliac fossa is occupied by a huge tumour, the lower edge of which lies a little below Poupart's ligament. The upper edge reaches from the anterior superior spinous process of the ilium to a little to the loft of the umbilicus, and the inner edge runs down close to the mesial line. The tumour is the size, and very much the shape of a good sized cocoanut; its most prominent part projects four inches from the surface of the abdomen. Its anterior surface is partly occupied by a sloughy patch measuring about seven inches from side to side, and from two to three inches from above downwards: an irregularly wavy line of demarcation is forming along the upper and lower edges. The skin involved in the slough is of a deep crimson, witli a slightly greenish hue in some places : the areolar tissue under it, and also that in the inguinal region, is emphysematous. The two small cuts made by the barber lie one at the outer, the other at the inner end of the slough; a plug of coagulated blood protrudes for half an inch from each. The tumour has a soft, elastic, spongy feel, nearly resembling fluctuation ; it does not, and never did, pulsate, and no " bruit" Pulsation can be felt in the anterior and ean be heard in it. posterior tibial arteries, but not in the femoral. There is tenderness over the liver, and the conjunctivas are yellow. Patient's countenance is anxious and sunken. August 2nd.?Pulse 108; temperature 98*6; respirations 30. Tongue dry and parched; teeth covered with sordes; jaundice decidedly more marked. Urine free from albumen; acid; specific gravity 1011?. A very foetid smell proceeds from the Patient complains much of thirst; he talks at random, tumour. and is evidently sinking. My colleagues, Dr. 1). T5. Smith and Mr. II. C. Cutcliffe, saw the caso with me. Opinions wero divided as to whether the tumour

was

simply

an

encephaloid growth,

or was

complicated

the rupture of an artery, leading to the effusion of blood into the morbid structures, and the consequent formation of " diffused false aneurism," which was now on the a so-called point of bursting. Practically, the point at issue was, whether the disease was to be considered merely as encephaloid, or as a "diffused false" (so-called) aneurism. It was evident that in the latter case an immediate operation on tho old system gave tho patient a feeble chance of recovery, and was also tho only means of securing him from the sudden death to which the yielding of the slough might exposo him. The patient was so evidently sinking that no operation could make matters worse. An exploratory puncture was first made into the tumour with No. 2 trocar of Dieulafoy's aspirator, through which about $ of grumous bloody fluid, of a dirty crimson colour, escaped. This was looked on as almost conclusive of the aneurismal nature of the disease. It was thought most improbable by my colleagues that an encephaloid tumour should so rapidly have attained this size, and have produced such extensive sloughing, without having ulccrated and fungated long before. 10-45 a.m.?The patient was now so low that there was some question as to tho propriety of operating. He rallied a little under chloroform, and we proceeded. I mado an incision about three quarters of an inch long into the most prominent part of the tumour, and passed my finger through it into a large .cavity full of coagulated blood. No fluid blood eseaped when my finger was withdrawn, aud it was only by firm pressure on the

by

05

tumour that some clots could be forced out. The incision was then enlarged to a length of six inches, including the opening made by the barber on the inside, but not reaching that on the outside. Living tissues were divided for about half an inch on tlie inside; otherwise the incision ran only through dead or dying structures. The parts divided were so altered and stained with blood that it was hard to recognise them ; they seemed however to be only the skin, fat and superficial fascia. This cut opened a large cavity with ragged walls. The iliac spine could be felt at the upper and outer angle of this cavity, and the ramus of the pubis below and internally; and to the inside, the external iliac artery could be felt and seen pulsating. The abdominal muscles and their tendons, so shreddy in some places, matted together in others, and everywhere infiltrated with blood as to be hardly recognisable, lay partly behind, but mainly above the cavity; a part of the tendon of the external oblique lay in front of it, but from the state of the parts their exact relations could not be made out. Owing to the lacerated and anfractuous character of its walls the cavity presented a number of loculi,* running backwards into the iliac fossa, all of which, as well as the general cavity, were filled with coagula, partly decolorised and imperfectly laminated, but mainly recent. On removing all the coagula, slight oozing of blood was found from the walls in one or two places, but no bleeding vessel could be detected. The tumour, when emptied of its contents, The cavity was reduced to about a third of its original size. was washed out with a solution of chloride of zinc, and filled with strips of lint dipped in the same ; and a spica bandage was applied so as to keep up moderate pressure. Not more than f. 3iij of blood, if so much, were lost during the operation. The cavity laid open was so like that resulting from rupture of an artery that we came to the conclusion that it was a diffused false aneurism, caused by the rupture of a branch of the external iliac, which had subsequently become occluded. 1 p.m.?Pulse 102 ; patient extremely restless, talking in an excited manner, and tossing to and fro ; never remaining for ten seconds in one position. Pupils moderately dilated. 2 p.m.?Pulse at the wrist barely perceptible; skin cold and clammy; pupils dilated; respiration spasmodic, gasping; is sinking fast. lie died at 2-15 p.m. Scctio Cudaveris, 10 a.m., August 3rd, 20 hours after death. Brain and membranes healthy; Pleura healthy; Lungs pale, crepitant throughout, thickly set all over with cancerous nodules varying from the size of a pea to that of a walnut. Those on the surface of the lung projected considerably above the pleura. These nodules, when cut into, were either soft and creamy or firm and lardaceous, never cheesy. Under the microscope they showed innumerable caudate, pyriform or triangular cells, with large nuclei, often multiple, but hardly a trace of stroma. Pericardium healthy. Heart fatty: slight atheromatous deposits along the attached edges of the aortic valves : no fibrinous coagula. Peritoneum, stomach, and intestines, healthy. Liver shrunken, weighing 2 lbs. |oz., and deeply stained with bile; Gall bladder empty. Kidneys fatty. The cavity in the iliac region has been already described; it passed down into the thigh, in front of Poupart's ligament for about 1^ inch. Inguinal glands enlarged, softened. The source of the blood found in the cavity was not discovered: common, external and internal iliacs and abdominal aorta healthy. A second tumour, the size of a hen's egg, lay to the inside of the first on the right external iliac artery with which its long axis coincided ; it was covered in front and at the inner sides by peritoneum and pelvic fascia, and was adherent above to some of the appendices epiploic? of the sigmoid flexure. Its lower margin touched the origin of the deep epigastric artery?and the deep circumflex ilii artery wound round its posterior and lower part to the large cavity in the groin, in the posterior wall of which it was lost among the matted ana infiltrated tissues. Both these arteries were healthy, and neither of them opened into the tumour lying on the external iliac artery. On opening this tumour (the walls of which towards the abdominal cavity were very thin), it was found full of dark coagulated blood, mixed with some yellow matter of a creamy consistence, which under the microscope shewed cells exactly like those found in the nodules on the lungs, mixed with pus cells and granules. Its cavity, when cleared of its contents, was found to be loculated, somewhat like the pelvis of a kidney whose ureter It was lined by a perfectly smooth has been obstructed. membrane, and had no communication whatever with ^

glistening

? This description is from my notes written immediately after the operation. I did not then suspect the exi-teneo of another tumour, similarly 0:1 the external iliac artery, and with perfectly smooth, instead of "anfractuous and lacerated" wails.

loeuiated, lyinj

66

THE INDIAN MEDICAL GAZETTE.

either the iliac artery, any of its branches, or the cavity of the tumour in the iliac fo3sa, from which it was only separated, in several places, by a very thin septum. Water injected forcibly into the external iliac artery did not escape either into the cavity of this tumour or into that in the groin, either from the main artery or from the epigastric or circumflex ilii. Several lymphatic glands, lying along the brim of the pelvis to the inner side of the iliac vessels, were slightly enlarged, and on section were found full of creamy material, presenting the same microscopic characters as those of the creamy matter found in the tumour over the external iliac artery, and in the nodules scattered through the lungs. Kemarks.?There can be doubt that this was a case of encephaloid cancer affecting (probably originating in) the inguinal glands, and accompanied by the formation of cvsts (Paget. Surgical Pathology, ed. 1870, pp. GSO, 778). The source of the yellow creamy matter contained in the smaller tumour (and which appeared to be essentially encephaloid) is open to some doubt. The cyst in this case was perfectly smooth (although loculated) throughout, and shewed no traca of any endogenous growth, which by breaking down could have furnished the matter in question. The tumour opened in the operation, was so altered by inflammation, sloughing, and infiltration with blood, that its From the loculated exact nature could not bo ascertained. appearance of its walls, in those places where they were least it was a cyst, resembling that originally altered, it is probable the smaller tumour; and that in the prosress of the disease it had taken on destructive inflammation, leading, among other consequences, to ulceration, which opened some branch of the circumflex ilii artery, and thus converted the cavity into an aneurism; for such it virtually was. The extensive sloughing which afterwards set in was doubtless preceded by plugging of the opened artery, which could not therefore be detected after death.

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[Makch 1,

1873.

Case of Encephaloid Disease of the Inguinal Glands; Simulating Aneurism of the External Iliac Artery.

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