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Mapa, plataa, charta, etc., may h« filmed at different reduction ratioa. Thoaa too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, aa many framea aa required. The following diagrama illuatrata the method: Lea cartae, planchee, tableaux, etc., peuvent Atre filmAe A dea taux da riductlon diff Grants. Loraqua la document eat trop grand pour Atra raproduit en un seul clichi, 11 est film* A partir de I'angie aupAriaur gauche, de gauche i droite, et de haut en baa, an prenant la nombre d'imagea nAcaaaaira. Lea diagrammea auivants illustrent la mithoda. 1 2 3 1 2 3 4 S 6 \t /t azi> >T7 / ^ u, (-r. Q ' "' • ]' ON RETROPERITONEAL AND PERIRENAL LIPOMATA BY A- ■t> J: GEORGE ADAMI, M.A., M.D.. Professor of pathology, mcGill university. Reprinted from the Montreal Medical Journal, January and February, 189?. , ON RETROPERITONEAL AND PERIRENAL LIPOMATA. BY • J. Georoe Adami, M.A., M.D. Professor of Pathology, McGill University. Montreal. The fat which is normally present around the kidney is liable as is well known to great overgrowth when those organs are diseased, as, for instance, in cases of hydronephrosis, of renal calculus and in many foi'ms of chronic renal disturbance ; more especially when the organ has undergone atrophic change is this overgrowth apt to present itself and under these conditions it would seem to have originated as a compensatory development. To this form of hyperplasia Virchow has called special attention. There is however a condition of exces- sive hyperplasia leading to the development of enormous neoplasms concerning which, so far as I can find out, Virchow makes no men- tion in his great work on tumours ; a form in which the kidneys primarily would seem to be unaffected and in which the develop- ment of new fatty tissue is so enormous that growths from 40 to 60 lbs. in weight develop in the course of a few months or, more fre- quently, of from one to three years. That Virchow should make no mention of these or of retro-periton- eal lipomata in general is evidence of their rarity, indeed after a care- ful study of the literature of the subject I have been unable to collect descriptions either complete or partial of more than about twenty- four cases ; nor again have I come across any genei'al article on the subject in our language. Nevertheless where the condition is present the clinical histories and the appearances found at the autopsy present so uniform a character and one so clearly marked off in many respects from other abdominal overgi-owths that it is well worth while to collate what has been written upon the subject and to indicate the special points which characterise this form of tumour. My attention has been more especially called to the subject from the fact that within a few weeks two very well marked cases of this condition came under my notice. For the history of one of these cases together with the tumour I am indebted to Di-. Hanna, of Perth, Ont. ; for the history and notes in connection with the other I have to express my sincere gratitude to Dr. Billings, Dr. Lamb, and the authorities of the Army Medical Museum at Washington. This last case I am informed has never been fully recorded and is of especial interest to me in that in almost every point it is identical with the former. 2 It will be well before discussing the subject as a whole to give fts briefly and as clearly as possible the facts in connection with these two cases. Dr. Hanna's patient was John McK., aged 45 years at the time of death, by trade a harness maker. His mother had died of cancer at the age of 50. The father was still alive in 1893, aged 75, a brother and a sister were living and healthy. He had been strong and in excellent health until January, 1892, when he noticed that he was growing rather stout in the abdomen, while at the same time other parts of the body were becoming emaciated. There were no other symptoms : he ate well, slept well and felt well, and not until March of tht^t year did he consider his condition sufficiently unsatisfactory to make it necessary for him to consult his local physician, who pres- cribed diuretics. The abdominal swelling continued to increase steadily and with it the emaciation, so that in Apinl he came to Dr. Hanna who found the general condition of the patient good in every particular save for the presence of a large tense abdomen revealing fluctuation from side to side, moi*e enlarged to the left ; the girth at the level of the umbilicus was 37 inches. Aspiration yielded not a drop of fluid, hence a diagnosis of abdominal tumour was made and the patient was persuaded to enter the Montreal General Hospital. There Dr, Shepherd (to whom I am indebted for the accompanj'ing illustration) made an exploratory incision on May 2nd, 1892, and found a solid uniform growth occupying the whole abdominal cavity. The relations of the tumour were found to be such that it was decided not to venture upon removal. The patient recovered well from the operation and in a fortnight returned honie. From the date of his return until his death on February 9th, 1893, Dr. Hanna saw him at intervals of a fortnight. The course was one of continual growth of the tumour and steady emaciation of body, without throughout a single moment of pain or failure of appetite ; the bowels and kidneys never failed to perform their functions. In October the measurement at the level of the umbilicus had increased to 47 inches, and in the middle of this month his physician noticed an apparent softening about the size of a saucer in the umbilical region, aspirated and drew off nine pints of sweet pus. From this date aspiration was practised every week or ten days, and in all close upon 60 pints were removed. Six weeks before death the patient presented slight signs of septicaj- mia and from this time onwards the pus aspirated was extremely offensive, while towards the end slight anasarca of the legs up to the knees manifested itself. The patient became weaker and weaker, icspiration was impeded and he died on February 9th, 1893. To the 3 very end there was absence of pain and of any disturbance in the bowels or kidneys. The necropsy on the following day revealed no disturbance of other regions, save great emaciation (»f face, extremities and chest and slight o'dema of the lower lobes of the lungs. Upon opening the abdomen the bowels were found to be behind and to the right side of the tumour, with the exception of the descending colon which was stretched over the growth and which during life could be felt passing across towards the right side and the front of the tumour. This was covered by the expanded mesentery and peritoneum. There were a few slight attachments which were readily removed by the finger, and the tumour came away readily. With it came the left kidney and the spleen. The former was firmly adherent to and, in fact, imbedded in the growth, its lower extremity was atrophied by pressure and flattened, the ureter passed down along the back of the tumour to the bladder and was pervious ; the spleen was partially imbedded in the tumour but not deeply, and it came away with comparative ease ; the right kidney was healthy and unati'ected : the liver had been pressed upwards and its measurement from above downwards was diminished. Oh section it presented the normal appearance. There was a loose adhesion of the pancreas to the growth. The tumour when it reached me the next morning weighed 41 lbs., and that, after three pints or more of pus had been removed. Taking this into account togothei- with the lo.ss of fluid during transit, 44 or 45 lbs. would seem to have been the weight ao the time of the necropsy. The kidney and a portion of the colon were still adherent, and the tumour presented a coarsely lobate appearance, the lobes being bound down and covered by several iivegular and thin layers of fibrous tissue. Upon cutting into the tumour well-marked bands c'. v-inect- ive tissue could be seen passing between the large lobes, whic \ aried in size from that of a man's fist to that of a man's head ; upon the upper and anterior surface were three or four lenticular lobes that appeared to be composed exclusively of fatty ti.ssue and were com- pletely cut otf" from the main mass by loose connective tissue ; these in fact were capable of being moved to a slight extent over the sur- face of the rest of the grow^th. Within the lower and anterior por- tion of the tumour was a large cavity of which the front wall had fallen in. This still contained grayish-green pus and the tissue around was extensively broken down, of greenish colour, with here and there thrombosed vessels and patches of old heemorrhage which had assumeil a dark green tinge. • Sections from various regions showed that the tumour was in the main composed of pure and typical fatty tissue. In many parts this was underling a mucoid change or degeneration ; in some the fat had almost wholly disappeared or had more properly degenerated, the characteristic myxomatous cells being very well seen. On the surface where the growth appeared to bo advancing, this appearance was wanting, hence I am inclined to regard the more mucoid regions as tending to be degenerated, and not, as one author to be presently cited would hold it to be, the primary condition. Well-marked con- nective tissue as a rule separated the fatty lobes, but in one region near the lower end of the tumour and not far removed from the ab- scess cavity an oat-shaped cell growth replaced well-formed connect- ive tissue, so that sections from this ai-ea presented a markedly sarco- matous appearance. There was no cartilage or deposit of calcareous salts or osseous development present. Here, then we are dealing with a huge retroperitoneal lipoma, which by some would, from its tendency to undergo mucoid degener- ation be termed a lipoma myxomatodes, and which in parts would almost seem to have taken on more marked sarcomatous characteris- tics. I am inclined to consider, however, that the rapid cell growth referred to was largely due to the neighbouring inflammatory distur- bance, although in some parts of the sections the sarcomatous appear- ance was so typical that the case may well be cited as one of chronic inflammation in a loose connective tissue resulting in overgrowth of embryonic tissue, that is to say leading to malignancy. The Army Medical Museum at Washington received the material connected with the second case from Dr. W. W. Brown, of Brooklyn, who supplied the following details : J. McN., aged 60, had been a temperate hard working man enjoying always good health. A tumour was first noticed in February, 1869; and then was about the size and shape of an ostrich egg, somewhat movable and painless. During the next two years it increased steadily in size, without, however, affecting the general health of the patient. Although latterly the liver became compressed upwards by the enormous size of the tumour, there was no dyspn(jea. As an indi- cation of his general condition it may be added that the patient was a regular attendant at church up to a fortnight before his death. Three weeks before death he walked a long distance to attend the funeral of a friend ; the day was stormy and he caught a cold, which increasing in severity led to death from exhaustion in February, 1871. The autopsy, performed by Dr. G. E. Smith, of Brooklyn, revealed the following conditions : tho anterior abcloniinal wall was infiltrated with and distended by seruin, the muscles being atrophied. A tumour weighing 41.5 lbs., of irregular Hattened shape was everywhere adher- ent to tho wall. The liver and intestines were pushed well upwards diminishing the thoracic cavity. The stomach was compressed and adherent to the diaphragm b}- old ailhesions, the right kidney con- tained one large and some smaller cysts, the left kidney was atrophied and Hattened by the tuniour to which it was adherent and in which it was partly imbedded. It contained a cyst the size of a walnut upon its convex border. These kidneys together with portions of the tumour and the plaster cast form specimens 8533 to 8536 in the Army Medical Museum. The casts shows above the descending colon passed over the growth. Examined microscopically the tumour was found to consist " largely of adipose tissue in a voluminous stroma of embryonic connective tissue with abundant nuclei between the fat cells." » '■'I,' It is seen that both these cases present a similar history, of long duration and slow growth, accompanied by very little general distur- bance. There is the same history of lack of pain and of disturbance of the general functions of the body till towards the last few days of life. Along with this lack of active disturbance of functions it is noticeable that both patients became extremely emaciated. In both the tumour consists of fatty tissue in which is imbedded a kidney showing little change beyon# what would seem to be mainly the results of pressure of the tumour, both are retro-peritoneal and over both there passes a length of the large intestine. Enormous retroperitoneal lipomata, while not unrecorded in litera- ture would not seem to be very frequent. As will be seen from the accompanying chart, I have been able to meet with altogether forty- two recorded cases including my own here published and excluding one or two mere statements of observed retroperitoneal lipomata. description of these is often imperfect in one or more important parti- culars, nevertheless taken all-in-all, thei'e is a remarkable similarity in the histories given. The greatest number have been recorded in France (9) ; England Germany and Scandinavia have each supplied half a dozen ; America five ; Switzerland four ; Austria three ; Belgium two. The fullest studies made so far have been by Terrillon in France who collected fifteen cases, and by Josephson and Vestberg in Sweden, who in a very full paper have analysed thirty cases (including Terrillon's fifteen. Salzer of Vienna has contributed a thoughtful article on the 6 subject and \n the only one, I bt'lievo, who has (hawn especial atten- tion to the perirenal dcvelopuient of many of these growths. For the benefit of future workers upon this subject I have tabulated all the cases of retroperitoneal lipoma that I have been able to tind recorded, dividing them into those which appear to me to have been definitely of perirenal origin, those in which the origin is doubtful, those which appear to have developed either in the mesentery or the radix niesenterii, and those which judging from the descriptions given seem to have developed in the lower half of the abdomen. The classification is not wholly satisfactory, for in too many in- stances only the vaguest idea seems to have ruled as to the primary seat of origin. Neverthele.ss th«! attempt to make such a classification may draw the attention of future observers to the need for more exact description of the position of the tumours when first recognised, and the relationship of parts found at the operation or autopsy. It is clear that all these huge lipomata do not have a like origin ; a large number undoubtedly originate in the neighbourhood of one or other kidney, others undoubtedly originate lower down ;but it is not a little curious that whei'e observers have recorded more than one case, those cases are with rare exceptions all of the same category. Solzer's three cases and my two are all perirenal. P(!!an's are all mesenteric ; Homans does not venture to ascribe a starting point for his cases but they present parallel features. This may, of course, be but a coinci- dence. If it be not, then probably all are recording like conditions with diflferent preconceived notions. 1 Nor again can I feel .satisfied that every important fact in connec- tion with each case is contained in these tables. I have recorded all those which are commonest in connection with this form of growth, together with important points of departure from the usual history, and again the results of operative interference. Most of the cases, I am glad to note, I have found on the shelves of our medical library at McGill ; for the more out-of-the-way articles in French and Swed- ish' literature I have had recourse to the College of Surgeons' Library in London and the Surgeon Geneivil's Library at Washington. I would especially acknowledge my indel>tedness to this last great library. In the bibliography I note those cases not consulted at first hand. It will be seen that about one third of the cases may reasonably be described as having a pei-irenal origin and that very possibly some of those classed as doubtful belong to the same category. The largest collection of retroperitoneal fat occurs physiologically around the kidney and here, consequently, is a most likely place for retroperi- i ^ tont'nl lipoinata tu (>ri<;inat(>. On tlio otliur liaiul it iiiUHt Ito calliMl to mind that fatty tunioui'H Ib.s., or almost tt third of the total weight of the child after its removal (20 lbs). The rate of growth is very slow. Upon an average between two and three years elapsed between the first i-ecognition of tlu; tumour and removal, or deatli of the patient. Three cases were ob.served for 4 years ; Bruntzel's ca.se for 5 (jr 8 ; Lauwers and Lundin and Hedbom's for 7 ; Terrier and Guillemain's for 7 if not 12 years. In other words, the growth for long causes so little general disturbance that the patient does not readily submit to operation until the tumour has ' With regard 'o tlu' Swedish cases let me say that I would ask future writers on this subjec-t coiivensant with the language to verify my epitomes. Where I have epitomised Swedish references to French and other cases and have later abstracted tlie original articles I have been surprised at the correctness of my epitomes ; for my translations have been conilucted niiims a dictionary, by the light of elementary conjparative philology and vague memories of consultations of my Baedeker during a few weeks spent many years ago in Scandinavia, —mainly in Norway and Denmark. '^ Meredith, Lancet. ■' Roberts, Medical Nncs. * Peyrot, BuUetina et Mevioireslde la Soc, de Chirug. de Paris. 8 assumed enormous proportions. The size attained by the fjrowth is shown by the fact that the majority are recorded as being more than 20 lbs. (English) in weight ; one (Waldeyer) was 63 lbs. ; five above 50 lbs ; four above 40 lbs. ; six between 30 and 40 lbs. How little general disturbance is caused will be seen by following the epitome given of the general symptoms. In case after case there is the record of absence of pain and absence of any marked distur- bance of the intestinal and urinary functions. Only towards the end may there be pain passing down one or both extremities with oedema of the legs. The common history of all the cases is the ex- treme emaciation that may develop, coupled with dyspnoea. But in about fifteen per cent, of the cases there is some history of more extensive disturbance. In Madelung's thei*e was a tendency to vomit, in Plan's third case " functional troubles" of the abdominal and thoracic viscera, in one of Roux's, periodic crises of intestinal obstruction, in Josephson and Vestberg's slight digestive disturbances, in Belkowsky's dysuria, in Cooper Foster's frequent micturition, and in Lundin and Hedbom's irritability with flatulence and colic. In only one (Pickering Pick,) is there the history of general pain and severe abdominal disturbance. It is interesting to note how frequently the definite presence of fluctuation has led to erroneous diagnosis. Even when the tumour has been exposed, as in Bruntzel's case, trocars have been inserted in the expectation that fluid could be drawn off. Nothing could better emphasise the fluid nature of fat in the living body than the frequent history of false diagnosis of ascites, multilocular ovarian cyst, or, as in two cases, of echinococcus cysts. Where there is a fluctuating tumour of the abdomen from which, upon repeated puncture, no fluid is obtain- able, it is clear that the existence of a lipoma (or a myxoma) must be seriously considered. One such case occurred recently in Dr. Stewart's wards at the Royal Victoria Hospital. There, had been slow progres- sive, painless and somewhat unilateral development of the abdominal tumour, with accompanying progressive emaciation and dyspnoea. A length of the intestine could be felt passing across the timiour. Un- fortunately the patient, a young Jewess, would not be operated upon and her friends removed her to die at home. The only slight contra- indication in this case was the age ; if I remember aright, she was scarcely twenty years old. The apparent development of secondaiy growths elsewhere was not against the diagnosis, although it was against operation, for we possess other instances of these large lipo- mata progressing to a sarcomatous termination, (e.g. Waldeyer's and my first case). ■■0\ i 9 1 1 i " : .1' That a length of the intestine should pass in front of the growth is readily explained. When the growth develops in the mesentery or behind the colon, it must be covered in front by the intestine with, on either side of it, the separated luminee of the mesenteric peritoneum. That in a very large number of cuses the portion of intestine crossing in front is recognized as being portion of either the ascending or descending colon, supports the view that the lipoma in these cases has developed in the neighbourhood of the kidney. In Waldeyer's case the transverse colon passed across the tumour, and this fact led to the opinion that the growth originated in the radix mesenterii, but at the same time the right kidney was involved in the mass, hence this might be included among the perirenal cases. For while a growth developing evenly around the kidney must inevitably push forward the colon (ascending or descending), these growths are not necessarily regular, and we have examples (Spencer Wells and Bruntzel) in which the colon has been pushed to one side. It is thus possible that an irregular growth originating around the kidney should be crossed by portions of transverse rather than by the other portions of the colon. But I would not appear to urge too strongly this contention that, whenever the kidney is involved, there the growth has originated in its neighbourhood. My own case shows very clearly that these large tumours are composed of numerous dis- tinct lobes, some of which upon the surface may be separate and freely movable over the main mass. These, it is true, were in my case small and from the absence of any degenerative changes would appear to have been more recent than the other portions of the growth. Still their existence indicates that there may be a development of multiple retroperitoneal lipomata which eventually fuse, and Dreschfeld's case is stroEgly in support of this view, as are also those of Balkowsky, Schiller and Spencer Wells. One symptom mentioned in a large number of the reports needs but to be referred to in passing, namely, the eventual (pdema of the lower extremities, due to the venous obstruction in the abdomen. It is noted more than once that this did not show itself coincidently in both legs, but appeared first in the side upon which the tumour originated. Passing now to the histology of the tumours, the divergent descrip- tions are easily reconciled when we remember that every member of the group of connective tissue tumours may pass into or show areas of conversion into other members of the group. There are instances of enormous perirenal fibromata (Lathuraz,' D'Antona,* Bauby and ' Lathuraz. Lyon Med., 1895. p. 32W (fibroma 40 lbs. i mesenteric). " D'Antona, Atti. della R. Accad. Mtd. Chir. dl Napoli, 1895, p. 142 (perirenal fibrosarcoma) . 10 Daunic'), and myxoinata (Elben,^ Gould,'' Witzel,^ and (?) Guyot*) while tumours mainly fatty may show more or less extensive conversion into fibroid, cartilaginous, osteoid, mucoid or embryonic (sarcomatous) tissue. We have thus cases of pure lipoma, fibro-lipoma, fibro- chondro-osteo-lipomata, lipoma myxomatodes, and lipo-sarcomata. On the whole when we are dealing with such large slow-growing tissues one must hold the view that originally they were overgrowths of highly developed tissue, and that where upon extirpation more embryonic tissue is found this is of relatively recent appearance. Thus I cannot agree with Wigglesworth who regarded his case as one of primary myxoma which had undergone later fatty change. Not only may there be deposits of calcareous salts and osteoid appearances in older and degenerated portions of the growth (Pean, Alsberg,) but as Dreschfeld fii-st pointed out there may be true oa,seous development. In Josephson and Vestberg's first case similar true osteomatous areas were recognized. In this same case, as in Waldeyer's and Dr. Hanna's cases, were also evidences of sarcomatous develop- ment, but in one of these only (Waldeyer's) were secondary growths found elsewhere. How benign are these growths is further shown by the fact that in only one instance (Tillmann) was there recurrence ( ? sarcomatous) after removal, and that in another (Roux) the woman gave birth to a healthy child 6 months after its removal. On the whole the tendency is for these massive tumours to be of the nature of myxolipoma, or as some term it, of lipoma myxomatodes. One of the fullest descriptions of such a growth is by Bruntzel, under the misleading title of fibroma of the capsule of the kidney. There can be no doubt, however, in reading Dr. Bruntzel's very clear de- scription of his case and the naked-eye appearance of the tumour that he was really dealing with a growth of this nature : there was the same gradual though very slow enlargement of the abdomen and pro- gressive emaciation, unaccompanied for years by any disturbance of the general health, the same perfect fluctuation leading to numerous fi'uitless attempts to tap the enlargement. Even when the tumour was exposfid upon the operating table, the surgeon was so deceived by its appearance and fluctuation that he employed a trocar in the hope of lessening its bulk prior to removal, a feature that speaks powerfully against its having been mainly fibromatous. And indeed • Bauby & Daunlc, Le Midi. MM., II., 189;), p. .t;)2, (' pararenal' flbro-myoma). ■i Elben, Wurttemb. Med. Corresp, bl., I8H0, No. 14 (hu'tnorrhagic perirenal myxoma). ■' Gould, Lancet, 1888, II., p. 518 (iia-inorrhagic " perirenal my.xonia"). ■» Witzel, D. Zeitachr. f. Chirurg., XXIV., 1886, p. :{26. " Guyot, Gaz. dc Hopt., 1870, p. 300 (myxo-chondro-tibroma). 11 the description given in the article is that the tumour was composed of a number of masses from the size of a child's head to that of a man's head, in the fibrous tissue of whicii lay large quantities of loose fatty tissue ; at the back, in a kind of hilum, lay partially imbedded the left kidney. Clearly from this description the growth was a lipoma myxomatodes identical with my own case. Passing now to the results of operative interference the results obtained were perhaps only what might be expected to follow the removal of enormous masses tilling the greater portion of the abdomen and composed of a tissue which, contrary to what is frequently taught, has a peculiarly rich vascular supply. Of the 42 cases, in 26 the tumour was removed, wholly or almost wholly. In twelve cases the operation was successful, or 46.1 per cent. (Alsberg, Buckner, Bruntzel, Belkowsky, Lundin and Hedbom, Lauwers, Madelung, Monod, Pean, Pernice, Roux and Tillman) though as above stated in Tillman's there was recurrence. In general there is little sign of surrounding inflammatory disturbance and the layer of peritoneum covering the growth is described as being smooth and glistening. In general also the huge mass peels out with fair ease from its surround- ings, though there are often accessory fatty lobules that have to be removed after the evisceration of the main mass. The greatest danger lies in the fact that in its growth forward the tumour carries before it the portion of the intestine and of necessity the mesenteric vessels supplying this. As a consequence, unless great care be taken in the removal, the blood supply of this portion of the intestine is cut off, and gangrene or necrotic inflammation ensues. This seems to have been the history in most of the fatal cases and in some of those which were successful (Madelung, Alsberg, Bruntzel, Lundin and Hedbom). There are thus it would seem two courses to be recommended to the surgeon operating in such cases. Whenever possible the tumour should be approached by a lateral or lumbar and not by any anterior incision, for by this means it may be removed without excessive injury to the covering peritoneum and the vascular supply of the gut which crosses it. Failing the adoption of this course there must be free resection of this portion of intestine. Alsberg removed seven inches of the transverse colon, Madelung, eiglit inches of the small intestine which had been injured, liUndin (light inches of the transverse colon with repeated subsequent enterotomies, while Roux removed four feet of the small intestine. Exploratory incision without removal seems in one ca&e (Terrier 12 and Ouillemain) to have led to arrest of growth and recovery of health during the next three years. To recapitulate — a retroperitoneal lipoma may be suspected where there is a very slowly growing tumour situated most often more to one side than the other, accompanied by little disturbance of general health save progressive emaciation and eventual dyspnoea ; which is crossed by a length of intestine, and gives a sense of fluctuation ; from which, further, repeated puncture fails to draw any fluid. The sense of fluctuation distinguishes this from a flbroma, the rate of growth from a sarcoma and to some extent from a myxoma. The diagnosis from this latter, rarer condition is difficult. The results of puncture exclude ovarian or other cystic formations and ascites. Removal is possible even when such a tumour has attained enor- mous dimensions. For the operation to be successful the main precaution to take is to see that the gut crossing the tumour is not deprived of its blood supply or if so deprived is freely removed, with resection. BIBLIOGRAPHY. Alsberg— Deutsch Med. Wochenschr, 1887, p. 904. Belkowaky— Rev. Med. de la Suisse Romande, 1803, p. 431, (abstract in Joseph- son and Vestberg. Buckner-Am. J. of Med. Sc, XXIV., 1852, p. 358. « , Broca— Bull. See. d'anat, 1850, p. 137. Bruntzel— Berlin. Klin. Wochenschr. Dec. 4, 1892, p. 40. Cauvy— Montpellier MMical, XXXII., 1874, p. 07 (abstract in Terrillon). Cooper Foster— Path. Trans., XIX., 1868, p. 246. Dreschfeld-Path. Trans., XXXI., 1880, p. 287. Homans— Lancet, 1883, 1., p. 440. Josephson and Vestberg— Hygiea (Stockholm), LVII., 1895, p. 396. Kiimmel— Deutsch. Med. Wochenschr, 1886, p. 903. Lauwers— Bull, de I'acad de Med. Beige., 1891, p. 311 (abstr. in Josephson and Vestberg). Lundin and Hedbom— Upsala lakiire forenlngs for hiindl., XXX., 1895 ; No. 2 abstr. in Universal Med. Jl., Phila., June, 1895. Madelung— Berlin Klin. Wochenschr, 1881, pp. 75 and 03. Monod. Rev. de Chirurg. XII., 1892, p. 1047. Morgagni— De sedibus et causis morborum. Epist. 39, 5 (note in Madelung, transl. in J. and V.) Moynier— Ctes. rend. d. 1. Soc. de Biol., scr. I., tome II., p. 139. P^an— Diagnostic et traitement des tumeurs de I'abdomen, Paris, 1881, pp. 1120 and 1131 ; Bull, de Therap,, Nov. 15, 1885, p, 420 ; and Gaz. des Hdpit. No. 38, 1886. Pernice-D. Med, Wochenschr, 1884, p. 850. Pick-Path. Trans., XX, 1800, p. 337. Pollock— Half-yearly abstract of Med. Sciences, XVI., 1852, p. 357. Roux (Lausanne)— Semaine Med., 1893, p. 150. Salzer -Wiener Klin. Wochenschr, 1888, pp. 199, 221 and 238. 13 Schiller v. Josephaon and Vestberg, p. 470. Spencer Wells-Path. Trans. XIX., 1868, p. 243. Terrier and GulUemain— Rev. de Chlrurg., 1892, p. 747. Terrlllon-Arch. G6n6r. de Medecine, 1886, p. 257. Thiriar (Brussels) Congr^s Franc. deChirurg., quoted by Baubj and Daunic, Le MldlM^d. II., 1893, p. 542. Tlllman-Hygiea, 1891, 1., s. 277 (abstr. in .J. and V.) Waldeyer and Freund Virch. Arch., XXXII, 1865, p. 543. Wigglesworth— Lancet, 1883, 1., p. 1121. , 'M TABIiB I.— RETROPRRITONEAIi lilPOM ATA.— OASES Authority. 1. MURHAUNI. nm. 2. MOYNIBK. 1850. 3. Spenceh Wells, 1868. 4. Bruntzei 1882. 6. WiGGLESWORTH., 1883. 6. KUMMKLL 1886. 7. Salzer (1) 1888. Kundrat's case. 8. Salzer (2) Kolisko's case. 9. Salzer (.S) Billroth's case. 10. Thiriar ,1889. 11. Tillman 1891. 12. MoNOO 1892. 18. Author Dr. Hanna'8 case. 14. Author Army Museum case. Age AND Sex. F. 60 F. 47 F. 43 F. S'i F. 43 M. 38 M. Mid. Age. F. 53 M. 40 Several months. Not known. Several years. 5 or 8 years. 2 years. 3 years. F. 63 F. 28 M. - M. 4.5 M. (JO Duration OF Growth. Very slowly growing, Not stated 2 years. Not given. Suffered from cancer of uterus ending in peri- tonitis. Confined to room for last year. Good health for several years ; progressive enia ciation ; latterly pains down left lower limn. Emaciation ; dyspnoea. Rapid growth during last few months ; no symp toms mentioned. Not given. 1 year. Not stated 13 months. 2 years. General Symptoms. Not given. Growth progressive, pain less ; good appetite ; regu lar motions ; no vomitmg or icterus ; great emacia- tion ; oedema of lower limbs for last year. Growth more rapid during later months, with dys- Not stated. (Jrowth progressive and painless ; appetite good no digestive troiioles suppuration of part of growth ; towards end slight (itdenia of legs. Steady painless growth ; uo nt. erent to pendix and icum. umandasc. Ion over mour. s in meno- lon of siK- jid. Termination. Laparotomy ; re covery . Laparotomy ; died 10th day, diarrhwa. Laparotomy; died 4th day, exhauotinn . Laparotomy ; re covery. Laparatomy ; re covery . Laparotomy ; re' covery. Laparotomy ; re covery. Laparotomv; par alysis of Dowel, collapse 3rdday Rblationhhii* to KiDNRY. Portion of tumour in neighbourhood of the kidney left behind . Nature of Tumour. Apparently a norolipoma. Lipoma. Fibro-lipoma with osteoid and calcareouH areas. Lipoma . Lipoma, in part.s niyxo ■ lipoma, in parts calci- fied. Lipoma. Lipoma. Fibro-myxo I oateo-Hpoma. Weioht Not given 12 kilo. i»kilo. 25 kilo. 34 lbs. (German ) Not given ekllo. Remarks. Stated to be in mesentery be- tween lamina' of peritoneum. Stated to be behind mesentery. Stated to be behind mesentery. Diagnosed solid mesenteric tu- mour ; fllirous pedicle to pre- vertebral periosteum: enceinte •') months at operation, child l)orn at term . Tumour grew between the two kidneys, pushing transv. colon down. Resected 18 ctm. of tr. colon , Situated in region of sigmoid ; lipoma of meso-colon. Resected four feet of small intes- tine ; stated to be mesenteric . Stated to have grown in mesen- tery of sigmoid flexure. llilAC FOS8^ OR FROM BROAD LIGAMENT. Apna>a. Laparotomy ; re covery . Laparotomy; died 8th day, intestinal occlu- sion. Laparotomy ; re covery. Lipoma with for mer fibrolipo- matous nodule. Simple fatty tu- mour. Pure lipoma. Pure lipoma. Pure lipoma. t Lipoma. Lipomata with nbromatti. About ISDied soon after admission to kilo. j hospital before particulars j could be obtained. lEvidently small, found at au- I topsy in tissues of b'd|ligament. .55 lbs. .Stated to have originated in I right iliac region. 15 kilo. Diagnosi-s ; ovarian cyst (?) from I broad ligament ; 6 intra-liga- I mentous cysts were removed I at same time. I 7.850 kilo. (Tapped without result ; diagnos- is, retroperitoneal lipoma, ad- herent at side to fossa iliaca ; right ovary also adherent ; tumour occupied -^ abdomen. Stated to be growing in right iliac fossa, in association with a fibroma. One growth in right iliac fossa (flbromatous); another in meso- colon of sigmoid flexure and extending up along left ureter (lipomatous). >