BENIGNANT TUMORS OF THE ILEUM. 
BY 
Christian Fenger, M. D.. 
Opening Address of the Session of 1894-5 ;it "Northwestern University 
Medical School, Sept. 25, 1894. 
THE CHICAGO CLINICAL REVIEW. 
Reprinted from 
December, 1894. BENIGNANT TUMORS OF THE ILEUM.* 
By Christian Fenger, M, D., Chicago. 
Benignant tumors of the intestinal tract are not uncom- 
mon, but they rarely develop; to such a size or in such a loca- 
tion as to cause danger to life. While both benignant and 
malignant tumors are relatively common in certain portions 
of the intestinal tract, the small intestine is usually exempt, 
with the exception of the portion where the bile and pancre- 
atic ducts enter the duodenum, in which localities carcino- 
mas are quite common. 
From the connective tissue and muscularis, tumors of 
the connective tissue type develop ;the sarcomas of the small 
intestine have been recently described by M, Baltzer1, who 
could find only fourteen cases in the literature. 
Benignant tumors—myomas, fibromas, lipomas, angio- 
myomas—are more common, but have attracted less attention, 
as they only exceptionally give rise to obstruction as such, 
more often to invagination. They consequently play only a 
secondary part in the causation of the grave symptoms 
attendant upon invagination. 
Leichtenstern1 distinguishes between—l. Fibromas, 
which originate in the submucosa and protrude in the lumen 
of the bowel as fibroid polypi, and which may cause obstruc 
tion or invagination. 
2. Myomas, originating in the muscularis mucosa, or intes- 
address of the session of 1894-5 at Northwestern University Medical 
School, September 25,1894. penger; benignant tumors of the ileum 
testinal muscularis, in some cases rich in vessels, (angio- 
myomas) in other cases more fibrous; these latter protrude 
into the intestines as polypi, and give rise to the same dis- 
turbances as the first variety. 
3. Submucous lipomas, which protrude as peduncu- 
lated polypi, often multiple, but which seldom attain such a 
size as to cause obstruction. 
4, Mucous polypi, papillomatous or with a smooth sur- 
face. 
As to the frequency of polypi of all the different varie- 
ties in the entire intestinal tract, Leichtenstern gives the 
following table; 
Rectum (estimate too low) 75 
Colon 10 
Csecum, 4 
Ileo-cmcal valve 2 
Lower portion of the ileum (usually found by causing 
invagination) 30 
Jejunum 5 
Duodenum 2 
He states that they often give only indistinct symptoms, 
until in some cases, obstruction is caused either by conges- 
tive swelling and rapid growth, or more commonly, when 
situated in the lower ileum, by invagination. As the tumors 
are never large enough to be discovered by palpation, they 
are not diagnosed, with the exception of the polypi of the 
rectum, which are found on rectal examination. 
Rokitansky10 in speaking about connective tissue tumors 
of the intestine, states that such tumors may develop from 
the subperitoneal tissue or the muscularis, may become pen- 
dulous toward the peritoneal cavity and, by traction on the 
intestinal wall, form a pocket communicating with the lumen 
of the intestine. They may also in rare instances, extend 
into the lumen of the intestine, and cause disturbance by 
reason of their size. Thus they may cause obstruction or 
intussusception, or if they press upon the bile duct or pan 
creatic duct may cause retention of the respective secre 
tions. 
Forster 4 states that fibroid tumors in the intestinal 
tract are commonly myomas which develop in the submu- 
cous tissue and protrude into the lumen of the intestine. 
Such a tumor, in the case of a man of seventy, developed FENGER: BENIGNANT TUMORS OF THE ILEUM. 
from the muscular coat of the intestine, he has described as 
follows: The tumor was round, six to seven lines in diameter, 
originated from the muscularis of the ileum, the muscular 
fibres extending continuously into the tumor. The tumor 
protruded toward the peritoneal surface with its whole mass 
so that the lumen of the intestine was not narrowed. Micro- 
scopical examination showed the tumor to consist of organic 
muscle fibres interwoven with a sparse stroma of connective 
tissue, and a normal development of blood-vessels. The 
muscle-cells in the tumor were two or three times as large 
as those in the wall of the intestine, and the nuclei were cor- 
respondingly larger than those in normal muscle fibre. 
He remarks that such tumors might be of practical 
importance if they should develop to more considerable size 
or protrude into the lumen o£ the bowel, but neither in the 
literature nor in his experience had he found a single in- 
stance of this kind. 
Virchow11 states that myomas are rare, and, if we 
exclude uncertain observations, develop only into small 
tumors. He has found these tumors only in the small intes- 
tine. He describes a specimen from the Berlin Museum, of 
a tumor in the transverse portion of the duodenum, the size 
of a cherry stone, clad with mucous membrane, which pro- 
truded into the lumen of the intestine, and which had under- 
gone calcareous degeneration. Microscopical examination 
showed that the tumor was composed of connective tissue 
and muscle-fibres, and that it was connected with the mus- 
cularis of the intestine. 
He also states that sub-mucous lipomas are found in the 
stomach, jejunum and colon. They may become peduncu- 
lated, and the large polypi of the jejunum are usually pedun- 
culated lipomas which push the mucosa before them, and 
which often extend for an inch into the intestine. Innocent 
in themselves, they may give rise to intussusception, but 
Virchow does not state that they have ever caused occlusion 
by their size alone. 
Huss5 reports a case of lipomas in the mucous mem- 
brane of the small intestine. The patient, a man forty-four 
years of age, had a dysentery a year before, followed by 
chronic diarrhoea, cachexia and death, but had no symptoms PENGER: BENIGNANT TUMORS OF THE ILEUM. 
of ileus. In the small intestine twelve polypi the size of 
a hazel-nut,were found protruding into the gut; chronic dys- 
enteric ulcers were also found in the rectum and large intes- 
tine. The lipomas were not caused by the dysentery, nor 
did they cause any symptoms. 
Klebs6 considers intestinal myomas rare, and states that 
their muscle fibres are much larger than normal. 
Bottcher3 has described a myomatous polypus of the 
ileum from the Dorpat Pathological Museum. The specimen 
consisted of a piece of intestine which showed an angular 
flexure with stenosis. In the angle was a tumor 5i cm. long 
and B cm. in diameter, which protruded into and almost 
filled the lumen of the dilated intestine. The polypus was 
covered with normal mucous membrane. On transverse sec- 
tion, three layers of the tumor could be distinguished; first, 
a whitish layer \ cm. thick, consisting of thickened mucous 
membrane and containing dilated vessels in firm fibrous tis- 
sue. Next to this was seen a wavy band 1 to 1\ mm. in 
diameter, extending into the muscular coat and representing 
a thickened layer of intestinal muscularis. The main mass 
of the tumor consisted also of muscular fibre with a sparse 
amount of connective tissue, but a large number of vessels. 
B ttcher believes that this myoma had grown into the 
lumen of the intestine in the following manner: By reason 
of its weight it pulled the peritoneal surface of the intestine 
inward, causing a funnel-shaped depression on the outside, 
and consequent agglutination of the peritoneal surfaces thus 
brought in contact with each other. 
Wesener13 thinks it likely that the myoma, as such, may 
be developed toward the mucous side of the intestine. 
Peris9 states that leiomyomas are not very rare in the 
intestinal tract, but that they usually remain small, from the 
size of a cherry to that of a plum. Larger myomas are 
found only in the fundus of the stomach. 
Birch-Hirschfeld3 states that submucous pedunculated 
lipomas have been known to reach the size of an apple. If 
developed to this extent, they might cause stenosis directly 
or might be caught by the peristaltic movements of the 
intestine and cause invagination. Mucous polypi originate 
by chronic catarrhal inflammation, are often multiple and fenger: benignant tumors of the ileum. 
5 
may attain a large size. They are most commonly found in 
the lower part of of the ileum, colon and rectum. 
Wesener,12 to whom we are indebted for a careful and 
exhaustive review ol the literature of the subject, found in 
the Pathological Museum of Giessen, a round tumor of the 
duodenum, the size of an apple. It was located in the poster 
ior wall of the duodenum, s'cm. above the entrance of the 
bile duct; but the large mass of the tumor extended into the 
peritoneal cavity and protruded only slightly into the lumen 
of the intestine. Behind the tumor were the pancreatic 
and bile ducts which, however, were not compressed. On 
microscopical examination this tumor was found to be a 
myoma. 
Wesener also found a myoma of the duodenum in the 
following case; A man fifty-five years of age had suffered 
from gonorrhoeal cystitis and chronic polyarthritis, and 
toward the end of his life presented indistinct symptoms of 
intestinal disturbance, constipation alternating with diar- 
rhoea, and occasional attacks of copious vomiting which per- 
sisted for two or three days and then disappeared, to recur 
after a short time. The increasing emaciation for the last 
few months before the patient died caused the diagnosis of 
carcinoma of the stomach to be made, though neither tumor 
nor coffee-ground vomiting was observed. The autopsy 
showed a dilated stomach, together with dilatation of the 
pylorus and the upper portion of the duodenum, but no car- 
cinoma, Fifteen centimeters below the pylorus, a nodular 
tumor the size of a plum protruded into the intestine. On 
its apex was a depression with loss of substance, where the 
mucous membrane was wanting. The tumor in the duode- 
num was part of a larger tumor, the size of a fist, situated 
outside of the intestine between the duodenum and the trans- 
verse colon, lying on the atrophied pancreas, to the head of 
which it was adherent. Microscopical examination showed 
the tumor to be a myoma which had originated in the circu- 
lar fibres of the muscularis of the intestine-without causing 
absolute obstruction, The tumor had evidently caused a 
certain degree of stenosis, as was shown by the dilatation of 
the duodenum and stomach above. 
Pellizari8 reports the case of a young girl in whom a FENGER; BENIGNANT TUMORS OF THE ILEUM. 
large round tumor presented in the ileo-cascal region. This 
tumor was supposed to be ovarian. It caused no symptoms 
at first, but later on pain, vomiting, constipation, and finally 
symptoms of ileus occurred. Sixteen days later a myoma, 
one pound in weight, was passed by the rectum, and the 
symptoms disappeared. 
I am not aware that any benignant tumors of the small 
intestine have been operated upon, with the exception of 
polypi in cases of invagination, where they play only a sec- 
ondary part in the obstruction. 
I desire to report the following case as an instance in 
which the myoma itself caused obstruction, and in which 
the tumor was successfully removed by operation;— 
Case. Synopsis. Chronic intestinal obstruction, with inter- 
mittent attacks of fecal vomiting, accompanied by paroxysmal 
pain and visible peristaltic contraction of isolated coils of intestine. 
No tumor felt. Exploratory abdominal incision in the interval 
between attacks. Sessile tumor of ileum. Longitudinal incision 
of intestine. Excision of tumor. Suture of intestinal wound. 
Recovery. 
R. M., male, seventy-five years of age, consulted me 
May 16, 1898. Family history negative. General health 
always good until a year before, when he had occasional 
attacks of constipation unattended with vomiting. During 
the last five or six weeks bowels have moved but slightly 
and the stomach has refused food, or after eating he 
would feel a sensation of heaviness and become 
nauseated; in an hour or two after eating there 
was occasional vomiting of fecal matter. During the last 
two weeks he has vomited almost every day, first the stom- 
ach contents, then the contents of the bowels. Paroxysmal 
pain in the abdomen, the paroxysms becoming more fre- 
quent. No pus or blood in the feces. 
Examination. Patient in bed, old, .pale, decrepit, emaci- 
ated . Abdomen not tympanitic, but when a paroxysm of 
pain occurred, I found that it was accompanied by peristal- 
tic contraction of coils of intestine, which was plainly visi- 
ble through the thin abdominal wall. The paroxysm lasted 
a few minutes. No tumor could be felt anywhere on the 
abdomen; no hernia existed. Rectal examination negative. pengner; benigant tumors of the ileum. 
7 
Diagnosis. Chronic Intestinal obstruction from carci- 
noma probably in large intestine, high up in the sigmoid 
flexure, or in the left or right flexure of the colon. 
The patient was advised to go to the hospital for oper- 
ation. I proposed to make an exploratory median laparot- 
omy. If an inoperable carcinoma of the colon was found, to 
make the Maydl colotomy in two stages; if operable, to per- 
form the radical operation. 
Operation. On May 19, at the Emergency Hospital, in 
the presence of doctors from the Polyclinic, and assisted by 
Drs. Waters, Bernauer and Livingston, I operated in the 
following manner: 
During the two days preceding operation the patient had 
not vomited. On palpation in narcosis no tumor was felt. 
During the preparation of the field of operation, a copious 
evacuation of the bowels occurred, due probably to the 
relaxation of the intestine in narcosis. 
An incision three inches in length was made in the me- 
dian line below the umbilicus, and the peritoneum sutured 
to the skin. The loops of small intestine which came into 
view were neither injected nor dilated. Examination with 
the hand in the abdominal cavity revealed nothing abnormal 
in the rectum or colon. This made me think that perhaps a 
false diagnosis had been made and that the patient’s condi- 
tion was merely due to chronic senile constipation. 
Upon examination of the small intestine, I now discov- 
ered a small round tumor, which felt like an intus- 
susception, and pulled the loop in which it was con- 
tained out of the abdominal wound. The tumor was the 
size of a walnut; the intestinal wall over it was somewhat 
thickened and movable, but the tumor could not be dis- 
lodged. Attempts at dislodgement caused traction upon the 
base of the tumor, which was seen to be 
lA- cm. in diameter, covered with serosa, not the 
smooth muscularis, but a slightly depressed, slightly lobu- 
lated surface. It was situated on the side of the loop, mid- 
way between the convex border and the mesenteric attach- 
ment; half an inch from the latter (Figure 1.). 
The loop was now emptied to a distance of five inches 
on each side of the tumor, and a strip of iodoform gauze FENGER: BENIGNANT TUMORS OP THE ILEUM. 
pushed through the mesentery and tied, to prevent feces 
from getting into the loop. 
A longitudinal incision an inch and a half long was now 
made over the tumor, in the middle line of the convex bor- 
der of the loop, whereupon the tumor came out. (Figure 2) 
Figure 2—Tumor. 
Cylindrical tumor 45 mm. long; 28 mm. in diameter, clad with mucosa. 1. Base, 
proximal end, of tumor in wall of ileum as seen in Figure 1. 2. Border of mucous 
membrane covering tumor. 3. Distal end of tumor, dark, discolored, mucosa yel- 
low from imbibition of bile coloring matter from feces, signifying necrosis of 
mucosa. 4. Mucosa: Light red, ecchymosis at‘-5.” 
It was smooth, cylindrical, rounded, 45 mm. long and 28 mm. 
in diameter, clad with mucosa, dark at the rounded end, and 
yellowish from imbibition of bile coloring matter from feces. 
As the base or pedicle of the tumor, which was li cm. in 
diameter, extended beyond the line of incision, the latter 
was prolonged to the base which was excised leaving a 
transverse incision one inch in diameter. 
The T-shaped intestinal wound was now united by step 
sutures, first a continuous silk suture from the distal end of 
the longitudinal to the transverse wound, and the transverse 
wonnd united by interrupted sutures passed through the 
mucosa only. Interrupted Lembert sutures were then intro- 
duced through the serosa and muscularis to bury the 
mucosa sutures, especial care being taken at the angles of 
the wound. 
Examination of the intestine as to its permeability for 
feces and gases now revealed an indentation on the side of PENGER: BENIGNANT TUMORS OP THE ILEUM. 
the intestine opposite to the base of the incision, indicating 
that one of the mucosa sutures had caught the mucosa on 
the opposite side of the intestine. The sutures of the trans- 
verse wound were therefore loosened and the opposite wall 
of the intestine freed by division of the offending suture. 
The transverse wound was then reunited by mucosa and 
sero-muscular sutures as before, and the loop flushed with 
sterilized water. 
The iodoform gauze strips which compressed the loop 
above and below were removed, and the permeability of the 
intestine as to feces and gases again tested. It was 
found that the intestine was entirely permeable at the place 
of operation and that at the line of sutures the intestine was 
air tight. The intestine was now flushed again with steril- 
ized water. 
An omental flap was then made by pulling down the 
omentum, which was followed by the transverse colon. The 
omentum was not quite long enough to go around the loop 
without some compression, but it was brought around and 
sutured to both sides of the mesentery. 
The loop in the field of operation and the omental flap 
were now anchored by sutures to the parietal peritoneum at 
the lower border of the wound and an iodoform gauze drain 
laid down to the base of the loop. The remainder of the 
abdominal wound was then united in the usual manner. 
The operation occupied about an hour and a half. At 
its close the patient was in good condition; pulse 110, and 
strong. He made a good and uneventful recovery and is at 
this time, sixteen months later, well. 
The tumor is 45 mm. long, 28 mm. broad, cylindrical, 
smooth. At its distal end it is dark brown with spots; of 
yellow from imbibition of bile coloring matter from the feces. 
The surface here is clad with mucosa necrosed as in typhoid 
ulcers, with red stripes from injection and ecchymosis. 
Over the remainder of the tumor the mucosa is normal. The 
base of the tumor, which is li centimeters in diameter, is 
situated in the muscularis from which it probably originated- 
MACROSCOPICAL EXAMINATION OF THE TUMOR. 
The cut surface of the tumor (Figure 3) is smooth gray, 
tough, moist, a fibro-myoma. At the apex which correjs- FENGER: BENIGNANT TUMORS OF THE ILEUM. 
ponds to the necrotic mucosa, it is dark red brown from im 
bibition with blood or hsematin. 
Figure 3—Tustob Laid Open. 
1. Distal end. 2. Normal mucosa on surface of tumor. 3. Divided mucosa 
and muscularis at base of tumor. 4. Tumor tissue at base covered with perito- 
neum. 5. Out surface of tumor, smooth, homogeneous, grayish-white, perfectly 
uniform, tough. 6. Divided mucosa, immovable on tumor (no submucosa). 7. Out 
surface of distal end of tumor, dark brown from imbibition of blood (haamatin.) 
Sections from the base at the place of the divided 
mucous membrane show:— 
MICROSCOPICAL EXAMINATION OP THE TUMOR. 
1. The mucous membrane is of normal thickness and 
structure, with perfect tubular glands and a normal layer of 
lymphoid cells between them. 
2. The muscularis mucosa also extends over the whole 
surface of the tumor and forms a layer of bundles of organic 
muscular fibres half as thick as the mucosa proper, conse- 
quently considerably hypertrophied; there is a sharp line of 
definition between this muscularis and the tumor tissue 
and the elements of the one are not interwoven with those 
of the other. 
8. The deep or circular layer of muscular fibres pre- 
sents at the base of the tumor the following conditions: At 
the free end of the base (Fig, 3) it is of normal thickness 
and cdvered with a normal layer of the longitudinal 
muscularis. But at the corner where the tumor com- 
mences, the fibres spread out in bundles separated by fibrous 
tissue, the tissue of the tumor. These bundles of the mus- 
cularis can be followed as long radiating tracts deep into 
the tumor; they spread out like a fan and their branches be- 
come gradually more slender until bundles of 4 to 10 mus- cular fibres form bands that finally are lost in the tissue of 
the tumor. 
PENGRE: BENIGNANT TUMORS OP THE ILEUM. 
4. The longitudinal or outer layer of muscular fibres 
is present i.i normal condition as a continuous covering 
outside of the circular layers, and is covered with a normal 
layer of peritoneum. 
The tissue of the tumor 'proper is a dense connective 
tissue with small connective tissue cells, and has many ves • 
sels; the latter are empty and not dilated, almost all small 
subcapillaries; neither larger veins nor arteries are seen. In 
many places, as well between the bundles of the circular 
muscle fibres above mentioned, as in the tumor inside of them, 
are tracts of myxoma tissue with branched cells and fine 
fibrillated—rarely homogeneous inter-cellular substance. 
The anatomical character of the tumor would thus be 
designated as a mixed form of the connective tissue type— 
a myo-myxo-fibroma. 
The tissue from which the tumor originated is the 
muscular coat of the intestine, not the external layer of 
longitudinal muscle fibres, but the inner layer of circular 
muscle fibres exclusively. 
269 La Salle Avenue. 
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1. Baltzer, M. Archiv filr klinische Ghirurgie. Band xliv, 
heft 4, page 717. 
2. Birch-Hirschfeld, P. V. Lehrbuch der pathologischen 
Anatomie. Band ii, 2nd half, page 585. 
3. Bottcher. Archiv der Heilkunde. Band xi, page 125. 
4; Forster. Virchow’s Archiv. Band xiii, 1858, page 270. 
5. Huss. Schmidt’s Jahrbticher. Band li, page 171. 
6. Klebs. Handbuch der pathologischen Anatomie. Band 
i, Abtheilung 1, page 266. 
7. Leichtenstern. v. Ziemssen’s Handbuch der Speciellen 
Pathologic und Therapie. Lieferung 19, page 542. 
8. Pellizari. Centralblatt filr Ghirurgie. No. 14, 1875, page 
222. % 
9. Peris. Lehrbuch der pathologischen Anatomie und 
Pathogenese. 1877, Theil i, page 425. 
10. jßokitansky. Lehrbuch der pathologischen Anatomie 
Band hi, page 231. 
11. Virchow, R. Die Krankhaften Geschwtilste. Band i, 
page 382. 
12, Wesener. Virchow’s Archiv. Band xciii, page 377.