Desmoid (Fibroid) Tumor of 
the Abdominal Walls, 
BY / 
EDWARD J. ILL, M.D., 
NEWARK, N. J. 
REPRINT FROM TRANSACTIONS, 
YOL. I, 1888. DESMOID (FIBROID) TUMOR 
OF THE 
ABDOMINAL WALLS. 
BY / 
EDWARD J. ILL, M.D., 
NEWARK, N. J. 
REPRINTED FROM TRANSACTIONS OF 
AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, 
SEPTEMBER, 1888. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1889. DESMOID (FIBROID) TUMOR OF THE ABDOMINAL 
WALLS. 
By EDWARD J. ILL, M.D., 
NEWARK, N. J. 
The conclusion of the medical man naturally follows his 
experience. Let me, therefore, relate two cases of desmoid 
tumors which have occurred in my practice within the past 
year, and then I will ask your indulgence as to what my 
experience and reading have taught me. 
Case I.—Mrs. L. T., American, aged twenty-three, married four and a 
half years, mother of two children, last child three weeks ago, was brought 
to my notice on February 12, 1887, through the kindness of Dr. Brumley, of 
Newark, N. J. The history, as was kindly given by the doctor, was this : 
For some time during the earlier part of the patient’s pregnancy, she noticed 
a swelling situated in the upper portion of the left lumbar and umbilical 
regions. No special notice was taken of it, however, although there was a 
pricking pain occasionally experienced. The doctor discovered it during 
the confinement of the patient. While the child was still in utero it was 
taken for a uterine myoma. When the child was expelled, however, it was 
noticed that the tumor still remained in its former position. 
The patient was a woman of small stature, pale, nervous, and slender 
build. On uncovering the patient’s abdomen a hard, very smooth, laterally 
and, within a certain limit, freely movable tumor was noticed about ten 
centimetres in length by seven centimetres in width, reaching from the 
lower border of the ribs in the left liypochondrium downward into the left 
lumbar and umbilical region, remaining about two centimetres from the 
median line. It was prominent above the surface of the abdominal walls 
surrounding the tumor, and seemed to dip into the abdominal cavity about 
as far as it was above the abdominal walls. It was moderately tender to the 
touch, there was dulness all over it, and tympanitic resonance around its 
border. The spleen was made out easily by percussion, in its proper place, 
as was also the liver, both being separated readily from the tumor by an 
intestinal resonance. There was no difference in the percussion sounds over 
the region of the kidneys, from which it was inferred that those organs were 
in their proper place. The spleen and liver dulness were normal. During 2 
ILL, 
deep inspiration and expiration it remained stationary, or, rather, there was 
a forward and backward movement. 
The fundus uteri, which was felt just above the pubes, had no connection 
with the tumor, nor was there any evidence of the tumor having any connec- 
tion with the pelvic organs generally. 
After finding this condition of things, I felt very certain that I had to 
deal with a desmoid (possibly sarcoma) of the abdominal walls, and recom- 
mended its removal. At this time the patient objected to any interference, 
and pressure was not brought to bear upon her, since a prolonged observa- 
tion was deemed advisable to satisfy any doubt as to the diagnosis. On 
October 12, 1887, was the next date when the patient was seen by me. This 
was eight months after I had first seen her. Her general health seemed as 
good, if not better, than it was on February 12th, though the woman nursed 
her baby during this time. The tumor had grown almost double in size, 
and was situated in the same position. It had grown more laterally than 
downward, so that it reached the median line, and extended to near the 
quadratus lumborum; below, it was near the crest of the ilium, gave the 
patient great uneasiness, simply from its pressure, and some dull, aching 
pain. She was now willing to have it removed, but wanted to have it seen 
by some prominent surgeon for his unbiassed opinion. Her doctor selected 
a most distinguished and prominent gynecologist in New York to see her, 
and it was in his office where I saw her for the second time on the date above 
stated. 
The doctor rather nonplussed us (Dr. Brumley and myself) by calling it 
an enlarged spleen, and, when that was shown to be an impossibility, a dis- 
placed and enlarged kidney. This diagnosis was also objected to, and an 
exploratory abdominal section was advised as the only means for getting at 
a correct view of the case. The doctor did not commit himself to any posi- 
tive diagnosis, saying that desmoids of the abdominal walls were too rare to 
make a positive diagnosis. As will be seen further on, this doubt of so 
prominent and so highly esteemed a surgeon rather changed my plan of 
operation, and possibly made it more complicated. 
The patient was admitted into my service of the Woman’s Hospital of 
this city on November 1st, for operation. 
The usual treatment as to diet, bowels, and baths, such as we are accus- 
tomed to use in this institution in all cases where the peritoneal cavity is 
opened, was given. The plan of the operation was clearly laid out and 
followed in all its details, as the gentlemen present at the operation can 
testify. 
In the main, I followed the method of Dr. M. Sanger, of Leipzig, to whose 
excellent article in the Archiv fur Gynakologie, Band 24, Erstes Heft, I am 
highly indebted, and will frequently make reference to in the detailed history 
of my case and resume. 
Operation November 5, 1887. The patient was anesthetized. I was ably 
assisted by Dr. Balleray, Dr. Bennett, and the house staff; Dr. Brumley and 
many of the gentlemen of the staff of St. Michael’s Hospital being present. 
After proper antiseptic preparation of the abdomen, dry carbolized towels f. Tumor. 
g. Median line. 
h. Anterior sheath of the rectus. 
d. Fascia tranversalis. 
x. Subperitoneal cellular tissue. 
e. Peritoneum. 
r L A T E I. 
a. Skin. 
b. Superficial fascia. 
c. Abdominal muscles. DESMOID TUMOR OF THE ABDOMINAL WALLS. 
3 
were laid all over the patient except the field of operation. Since such a 
strong doubt as to the diagnosis was expressed by our New York consultant, 
I first made an exploratory incision to the right of the tumor in the median 
line, about five centimetres in length. When the incision had been carried 
into the peritoneal cavity there was no longer room for a doubt in the diag- 
nosis. The tumor could be taken between the fingers in the peritoneal 
cavity and the hand outside, and the posterior surface of the tumor was 
seen to be covered with peritoneum. It now also appeared that the tumor 
dipped into the abdominal cavity as deep as it arose above the abdominal 
walls. A transverse section of the tumor and relative position of its cover- 
ing and surroundings would appear as shown in Plate I. (which I would 
say is a modified drawing from Sanger’s article). (I should say that the 
subperitoneal cellular tissue should have been drawn much thinner.) 
A transverse section of the skin was now made, reaching from the middle 
of the exploratory incision to nearly the outer edge of the tumor in the 
lumbar region. The upper portion of the flap was now dissected backward 
far enough to allow the finger and the needle carrying the suture to enter 
between the costal cartilages and the tumor. Two ligatures were thus 
carried, one near the tumor and the other near the costal cartilage, and the 
tissue intervening cut. It now became impossible to continue the ligatures 
on account of the proximity of the tumor to the cartilages. 
The lower portion of the tumor was now attacked, and double ligatures 
were carried, one near the tumor, the other about two centimetres from the 
first, and the tissue between was cut. The ligatures were carried about two 
centimetres apart, with a strong needle fastened to a handle similar to a 
perineum needle, except that its edges were dull. The succeeding ligature 
always caught up some tissue of the foregoing, so that there was complete 
prevention of hemorrhage. As soon as the opening was large enough to 
admit the introduction of a flat sponge, this was done, and all fluid, blood, 
etc., kept from entering the cavity of the abdomen. 
While separating the skin and superficial fascia from the tumor there was 
a great loss of blood from the tumor side, and nothing but a sponge or the 
fingers pressed firmly on the tumor prevented bleeding. The openings made 
by a needle, to stop the flow by ligature, even proved a source of annoyance 
and worry. Thus it occurred that the skin was dissected off by successive 
steps only so far as was necessary to get at the edge of the tumor. Fifty-six 
ligatures were thus inserted, twenty-eight on the tumor side and a like 
number on the distal side. The portions ligatured near the crest of the 
ilium and the costal cartilages proved to be the most troublesome, and in 
the latter place it occurred that a ligature slipped and hemorrhage took 
place from a very large artery, which I took to be the internal mammary or 
one of its branches. All these ligatures were made of strong silk. The 
visceral organs which appeared in the wound were the left portion of the 
greater curvature of the stomach, a portion of the left lobe of the liver, the 
transverse and beginning of the descending colon, omentum, and small in- 
testine. We now had a large opening in the abdominal wall about twelve 
by fourteen centimetres in size, and nothing to cover it except skin and 4 
ILL, 
superficial fascia. There was no chance of bringing the peritoneum together, 
since the opening extended from the border of the ribs to the crest of the 
ileum and from the linea alba to near the quadratus lumborum. The intes- 
tines were now cleared from all coagula, the omentum carefully spread over 
the whole surface exposed to the superficial fascia. The skin was now raised 
in a fold and five silver wire button-sutures were placed at the base of this 
mass. Above this, eight deep silver wire sutures and a like number of super- 
ficial silk sutures were inserted. Then the wound in the median line was 
closed by five deep silver wire sutures, taking in the peritoneum from the 
healthy side; absorbent cotton, iodoform, and a tight bandage finished the 
dressing. No drainage tubes were used, and the patient was put to bed. 
The operation lasted three hours. Plate II., Fig. 1, will explain the 
arrangement of the sutures, and Plate II., Fig. 2, the appearance of this 
fold of the skin. Plate III. is a photographic view of the abdomen just 
before removal of the stitches. 
The tumor measured twelve centimetres in width by fifteen in length, and 
twelve in diameter, and weighed 750 grammes, was perfectly solid, and cut 
like a very hard myoma of the uterus, only it appeared much more dense 
and no bloodvessels were seen on its cut surface. The anterior sheath of 
the rectus was inseparably connected with the tumor tissue. 
Dr. T. M. Prudden, who kindly examined the tumor for me, sent the 
following report: 
The tumor is a fibroma, one of those fibromas which look translucent to 
the eye en masse because of the large amount of interfibrillar fluid. The 
outer layers of the tumor, on the side covered with peritoneum, were toler- 
ably firmly attached to the latter, but structurally there was a distinct line 
of demarcation between them. 
Nov. 5, 3 P. H. An hour after the operation the patient’s pulse was 130; 
resp. 24; temp. 101°. Complained of some pain during respiration. Later 
in the day the temp, rose to 102°. 
6th, 7 A. M. Temp. 101°; pulse 120; resp. 16. Still some pain in the 
wound, for w’hich five drops of solution of Magendi are given hypodermati- 
cally. There is no tympanites and she perspires freely. Vomited at noon 
of this day. At 6 p. M. temp, was 102°; resp. 19; pulse 124. During the 
night she passed flatus for the first time. 
7th, 7 A. M. Temp. 101§°; pulse 124; resp. 18. .At 8 p. m. pulse 116; 
resp. 18; temp. 100^°. 
3th, 7 A. m. Pulse 112; resp. 18; temp. 100|°. 6 P. M. Pulse 108; resp. 
18; temp. 100°. 
9th, 7 A. m. Pulse 108; resp. 18; temp. 100°. 6 p. M. pulse 108; resp. 18; 
temp. 100|°. 
10th, 7 A. M. Pulse 100; resp. 18; temp. 99°; after which there was no 
longer any rise of temperature. 
13th. Bowels were moved by an enema, and then removed all except the 
button sutures, wrhich were removed three days later. 
There was union by first intention of the whole large surface of the wound, 
and the patient left the hospital, with a well-fitting truss, on the 29th of I’ L ATE f I. 
Fig. 1. 
Fig. 2. DESMOID TUMOR OF THE ABDOMINAL WALLS. 
November. Six months later an abscess formed at the lower margin of the 
rectus muscle, from which the tumor was removed, and a ligature removed 
by incision. 
Up to the present time there has been no difficulty experienced by the 
patient from the want of so large a piece of the abdominal muscles. Her 
breathing is perfectly regular, and only on forced coughing is there be a 
slight protrusion at the site of the tumor. 
Case II.—Mrs. R. H., married, aged twenty-eight, of good family history, 
three children, last child fifteen months ago, presented herself on May 28, 
1888. She has been ailing more or less for five or six years with pain across 
the abdomen, dragging-down pain, backache, and some premenstrual pain, 
otherwise was healthy. Two weeks ago she noticed a pain just above the 
pubes when leaning against some hard object or when lifting a heavy 
weight. 
Physical examination revealed a deeply lacerated cervix; uterus movable, 
anteflexed; to right of uterus, not connected with it, was a hard, broad, later- 
ally slightly movable tumor reaching eleven centimetres above the upper 
edge of the middle of the pubes, and eight centimetres in width. The ova- 
ries could not be made out, and the patient was directed to present herself 
again for the purpose of anesthesia. She again presented herself on June 
30th for the above purpose. The physical examination then showed the 
following: A tumor, beginning exactly in the median line about two and a 
half centimetres above the middle of upper portion of the pubes and extend- 
ing eight centimetres further up, and also five centimetres to the right, is 
found to be smooth, laterally quite freely movable and with but little motion 
in an up-and-down direction. The tumor can be grasped by the hand and 
slightly raised. Respiration does not affect it. Uterus is freely movable 
and has no connection with the tumor. Right ovary is lodged in Douglas’s 
cul-de-sac and enlarged. Left ovary is normal and in normal position. A 
very tense and short cord (tendon of the rectus) runs from the tumor to the 
crest of the right pubic bone. A sound in the bladder indicates that the 
tumor is outside of that organ. The tumor has no connection with the 
pelvic organs. The diagnosis is a desmoid tumor (sarcoma) in the right 
rectus muscle, probably originating in its posterior sheath. The operation 
for its removal was undertaken on July 18th, no particular increase in its 
size having been noticed at that time. An incision about five centimetres 
in length was made about two and a half centimetres to the right of the 
median line and directly over the site of the tumor. After opening the 
external sheath of the rectus and separating its fibre, the tumor was struck 
and showed itself of a grayish color, covered on all sides by muscular fibres. 
The tumor was separated on both sides from the muscular fibres, the tendon 
cut across and the tumor raised by a vulsellum, and now it became evident 
that its origin was the internal sheath of the rectus. Knowing that the 
peritoneum was very loosely attached to the deep fascia, I hoped to separate 
it without much trouble; but the tumor was so closely adherent to the peri- 
toneum that an opening two by four centimetres broke into the peritoneum 
at that place where the diameter of the tumor was largest. The enucleation 6 
ILL, 
was carried on, however, until the upper portion was reached. The rectus 
muscle was here transfixed, doubly ligated, and the tumor removed. In 
separating the outer portion of the tumor the deep epigastric was cut and 
retracted, so that it became quite difficult to secure and ligate it. Hemor- 
rhage at times was very free, and several ligatures were used in different 
portions of the wound. The torn portion of the peritoneum was closed by 
continuous catgut suture. The rectus retracted very much, leaving a large 
opening in its sheath, into which a drainage tube Avas inserted. The wound 
was closed by deep silver wire sutures, which carried with them the lateral 
portion of the cut rectus muscle, the fascia and the skin, and by superficial 
sutures. I hardly need say that the operation was carried on under the 
most careful antiseptic precautions. The operation lasted one hour and 
a quarter. The drainage tube and superficial stitches were removed on 
the fourth day, no notable rise of temperature having taken place. The 
patient made a speedy recovery. Plate IV. explains the relative position 
of the tumor, with its surroundings. 
The microscopic examination revealed the tumor to be a true desmoid. 
In comparing the experience of these two cases I should say 
that Case II. was the most difficult to diagnosticate, both on 
account of the stoutness of the patient as 'well as its proximity 
to the pelvic organs, and, unless ether had been administered, 
would not have been satisfactory. 
Concerning the method of operation, there was so much 
difficulty experienced in separating the tumor from the peri- 
toneum that I would henceforth much rather extirpate por- 
tions of the peritoneum as I had done in the first case. The 
removal will be more complete and there will be less liability 
to recurrence. 
In my studies on desmoids I have remarked the following: 
With rare exceptions the tumor originates from the posterior 
sheath of the rectus abdominis muscle. Continuing to grow, 
it separates and absorbs the muscular tissue. They therefore 
naturally produce an elevation in the abdominal walls; but 
on account of the large deposit of fat on the abdomen, rarely 
affect the skin. As a rule, however, they also grow toward 
the abdominal cavity. Thus they may be*found to have gone 
as far as the loose subperitoneal cellular tissue, or they may be- 
come closely and inseparably adherent to the peritoneum, and 
even may break into and through that membrane (Volkmann). 
The latter ones are, however, most apt to be sarcomatous. 
Laterally they may grow to take in the muscles of the loin PLATE III. DESMOID TUMOR OF THE ABDOMINAL WALLS. 
7 
and above or below become adherent to the bone of the pelvis 
or the cartilage of the ribs. The form of the tumor is usually 
round or oval; at times that portion of the tumor which is 
connected with the fascia transversalis becomes contracted, 
and then the form of a shirt-stud results. 
The size of the tumor, of course, varies. Commonly a patient 
will not seek the advice of a physician until the tumor has 
reached a considerable size, or because of the pain it produces. 
The smallest in my record of cases was reported by Dr. Heitz- 
mann, of the size of a walnut; the largest by Dr. Weir, of 
New York, reaching the enormous weight of eleven pounds. 
They are fed by the deep epigastric, which enters rectus 
at about eight centimetres above the ossa pubes; also the 
superior epigastric, internal mammary, and lumbales. 
Anatomy.—The tumor itself, as a rule, is quite dry and not 
very bloody. In my first case, however, the quantity of blood 
which came from the outer portion of the tumor through the 
torn veins was amazing, and the blood lost in my second case 
was large, though it came from outside the tumor. 
The tumors have invariably been found to originate in the 
fibrous sheaths of the muscles, and never lie loose between 
them. Structurally, they are composed of dense fibrous tissue. 
The growth of the tumor takes place by the production of in- 
tercellular fibrous substance. In this way it appears that the 
cellular tissue is in some portions of the tumor larger than in 
others, and therefore it will often be difficult to tell whether 
one portion of the tumor is sarcomatous or still purely fibroid. 
At times the fibrous tissue will accept (by metamorphosis) a 
colloid or mucoid appearance. Never, however, has a cal- 
careous or fatty degeneration been observed. A sphacelated, 
ulcerated, and gangrenous condition, however, is not infre- 
quent (see Parks’ case), and hemorrhage of deadly character 
has occurred. Very frequently the growth begins during a 
pregnancy and continues with more or less slowness. Suadi- 
cani1 (Esmarch) has observed a cessation of the growth after 
confinement in two cases. The female seems to be more prone 
to suffer from this form of tumor. In my own collection of 
cases eighty-two per cent, were women. 
1 Inaugural Dissert., Kiel, 1875. 8 
ILL, 
In males they are most apt to be recurrent; thus in four 
cases in men reported by Volkmann, only one case remained 
without recurrence. In these cases the recurrent tumors were 
of a soft sarcomatous character. 
Metastases are not mentioned, nor do any speak of glandular 
infiltrations. 
Concerning the etiology very little is known. Graetz (Cohn- 
heim)1 considers that its foundation is laid in the embryo. It 
seems doubtful, however, whether the origin of these homolo- 
gous tumors can be explained by his theory. Nor does it seem 
likely that an injury to the muscles, to which Herzog2 attributes 
his case, can be charged with this form of tumor; since no one 
else ever heard of this form of tumor being the result of injury. 
Symptomatology.—As a rule, patients will not present them- 
selves to the doctor until the tumor has reached a large size, or 
unless it is in such portion of the body where pressure is ex- 
erted upon it. We can, therefore, consider that they produce 
but little trouble in the early stages. When they become large 
they become troublesome by compression of the abdominal 
organs, by the disfigurement of the patient, or by the incon- 
venience produced by the pressure of the clothing, as in my 
own cases. When they become still larger, gangrene of the 
skin over the most elevated portion of the tumor, and thus 
septic infection or deadly hemorrhage may take place. It has 
been observed that these tumors are more sensitive during 
menstruation than at any other time. Under ordinary circum- 
stances they are but slightly sensitive to touch. The tumor in 
my Case I. could be moved about freely without producing 
any real pain. In Case II. it was more painful on pressure. 
Diagnosis.—The fact that between eighty and ninety per 
cent, of all cases will be women must be taken into considera- 
tion when a diagnosis is made; also that the tumor rapidly in- 
creases during a pregnancy, though it may have been present 
before and of very slow growth. From the cases I have col- 
lected you will see that the tumor grows two or three times its 
size in about a year. 
By inspection the tumor will appear above the surface of the 
1 Colmheim, Allg. Pathologie, p. 634. 
2 Ueber Fibroma der Bauchdecken, Munchen, 1883. Ir. Left rectus muscle. 
ml. Median line. 
t. Tumor. 
d. Superficial fascia. 
e. Skin. 
rr. Right rectus muscle. 
I’ L ATE I V. 
a. Peritoneum. 
b. Subperitoneal cellular tissue. 
c. External and internal layer of deep abdominal fascia. DESMOID TUMOR OF THE ABDOMINAL WALLS. 
9 
abdominal walls, if it has reached any large size and the pa- 
tient is not over-fat. The skin, possibly, is covered by large 
veins. This will be more so the larger the tumor appears. 
During respiration the tumor will be lifted forward and back- 
ward only, the patient being on her back. When the tumor 
is of excessive size, forced respiration might cause an upward or 
downward movement of the growth. There will be no lifting 
up of the abdominal walls from the tumor on deep inspiration, 
as is so often seen in intra-abdominal growths. 
By palpation the tumor will be found to be very circum- 
scribed, at times perfectly smooth (uni-lobular), at others un- 
even and nodular (multi-lobular), and generally of solid, board- 
like feel. Occasionally fluctuations will be noticed, as was 
observed in Dr. Weir’s1 case, and probably accounted for the 
mistaken diagnosis. If not too large, and occurring in a 
multipara, the fingers of both hands can almost pass around 
the tumor and the posterior smooth or nodular surface dis- 
tinguished. This, however, will not be the case when the 
patient is directed to contract the abdominal muscle, when 
the tumor will appear immovable. This must be an im- 
portant point in the differential diagnosis between a tumor 
situated within or outside of muscles and fascia. For when 
the tumor is situated in the subcutaneous cellular tissue it will 
be movable no matter what condition the muscles are in. If 
the tumor is intra-peritoneal, any contraction of the muscle 
will not send the tumor back to its place, as would be the case 
with a tumor situated in the muscular or fibrous layers of the 
abdominal walls. If the tumor were in the deep layer of the 
abdominal muscles, any contraction would tend to throw the 
tumor into the abdominal cavity; if in the outer layer, the ten- 
dency would be to raise the tumor above the level of the ab- 
dominal walls. The tumor will not often be sensitive to 
pressure. 
The percussion note, of course, will be dull all over the 
region of the tumor. Percussion will often help us out in 
differentiating between tumors of the abdominal walls and an 
enlarged spleen, especially when the growth is situated in the 
1 Medical Record, Dec. 3, 1887. 10 
ILL, 
left hypochondriac region. Thus there was a distinct tym- 
panitic resonance between the tumor and the location of the 
normal spleen-dulness in my Case I. 
Thus it was, also, that the tympanites between the left lobe 
of the liver and the tumor could be noticed only when the 
patient made a deep expiratory effort. While the dulness 
over the liver rose and sank by inspiration and expiration, the 
dulness over the tumor remained stationary. Whether there 
would be resonance between the kidney and the tumor, if the 
tumor Avere situated in the flank, would depend upon the size 
which the tumor had reached and how far it was pushing itself 
into the abdominal cavity. In my Case I. there was a distinct 
and unmistakable resonance between the tumor and the dul- 
ness of the region of the kidney. In case of a tumor of the 
kidney the percussion over the lumbar region of the affected 
side would be dull, while if it were a desmoid the percussion 
sound would be normal. The dulness between the tumor and 
a full bladder could only be mistaken if the bladder was not 
carefully emptied of its contents. The same might be remarked 
about a large amount of feces in the colon. 
If the tumor were in the lower part of the abdominal wall, 
possibly closely connected with the ilium and very large, the 
diagnosis becomes more difficult, and the examination under 
an anesthetic would probably give the required result. This 
had to he done with my Case II. before any decision could be 
obtained. When the tumor is in this region and becomes 
very large, its differentiation from uterine fibroids, solid tumors 
of the ovary or round ligament might become impossible, and 
exploratory incision becomes the proper procedure. A case of 
localized peritonitis, which originated during pregnancy in the 
left hypochondrium and simulated a desmoid in many respects, 
was only understood after aspiration and careful thermometric 
observation. It seems to me hardly possible that there could 
he any difficulty in differentiating between malignant tumors 
of the intestine or omentum and a desmoid. 
An adherent displaced kidney might be taken for a tumor 
in the abdominal walls. But the form of the kidney and reso- 
nance over that portion of the lumbar region where the 
kidney was missing, and the muscular symptoms of which I DESMOID TUMOR OF THE ABDOMINAL WALLS. 
11 
have just spoken, would probably give the necessary infor- 
mation. 
The sense of touch given by adipose tissue, whether as a 
lipoma of the omentum or sub-peritoneal or subcutaneous fatty 
tissue, is so much different from that of a desmoid that they 
could hardly be confounded with each other. Thus, also, an 
umbilical hernia containing a lipoma of the omentum would 
present a soft, lobulated condition, which is never the case in 
the desmoids. 
A ventral or umbilical hernia could, if strangled, produce a 
tumor which is very hard, but the symptoms of strangulation 
and the outer appearance of the tumor, and other points in 
the history of the case, would leave no doubt as to its nature. 
Cysts of the urachus cannot possibly be confounded with 
desmoids; since these cysts commonly empty themselves by 
the navel or bladder, thus producing a disappearance of the 
cyst temporarily. 
Desmoids of the abdominal walls are rare, since only one case, 
by Nelaton, has been described, and very possibh7 it came from 
an ovary, as did the myoma of Dr. Marcy’s case come from the 
uterus. 
The treatment is extirpation, and the sooner this is done the 
better for the patient. 
While the tumors are still small and in a location where the 
peritoneum is not closely adherent to the deep fascia, extirpa- 
tion without opening the peritoneum may be resorted to, and 
must be our aim, but it will rarely succeed. As a rule, how- 
ever, extirpation with resection1 of the peritoneum will be, 
under careful antiseptic precautions, the safest by guarding 
against recurrence, should the tumor prove to be sarcomatous. 
The prognosis of the true desmoid after removal is good 
so far as its benign character is concerned. The prognosis 
without extirpation must be almost fatal unless we consider 
such fortunate cases as those reported by Suadicani. Thus, 
also, will partial removal result disastrously, as Esmarch’s 
second case would prove. 
1 Sanger, Archiv fur Gynakologie, Band 24, p. 20. 12 
ill, 
No. 
Reporter. 
Age 
Family 
history 
as to 
tumors 
gener- 
ally. 
Sex 
Length 
of time 
the 
tumor 
was 
known 
to exist. 
Loca- 
tion. 
Size 
when 
first 
noticed. 
,Size 
when 
last 
seen 
by the 
operator 
Length 
of time 
inter- 
vening. 
Report- 
er’s 
opinion 
of the 
origin 
of 
tumor. 
Prob- 
able or 
possible 
cause. 
Treat- 
ment. 
Result. 
Ana- 
tomical 
charac- 
ter of 
tumor. 
Remarks. 
1 
T. G. Richardson, 
New Orleans. 
30 
F. 
Right 
iliac. 
Goose 
egg- 
Ex- 
cision. 
Cured. 
Strictly 
fibrous. 
“ The peritoneum was closely at- 
tached to the posterior surface, 
covering about a square inch. 
In endeavoring to dissect off the 
serous membrane the peritoneal 
cavity was opened, but as no 
blood entered irrigation was not 
practised. Drainage tube used, 
but not entering the peritoneal 
cavity.” 
2 
C. Heitzmann, 
New York. 
45 
M. 
Left 
lower 
iliac 
region. 
Hazel- 
nut 
Ex- 
cision. 
Cured. 
• 
Dense, 
fibrous 
connec- 
tive- 
tissue 
bundles 
freely 
inter- 
lacing. 
3 
D. W. Cheever, 
Boston, Mass. 
25 
F. 
Betw’en 
umbili- 
cus and 
pubes. 
Size of 
ostrich 
egg. 
Re- 
moval. 
Cured. 
Solid. 
No recurrence. Involved peri- 
toneum on under surface by 
contiguity. Peritoneum was 
opened at time of removal. 
4 
R. F. Weir, 
New York. 
41 
F. 
4 years. 
Both 
iliacs 
and um- 
bilical 
region. 
11 lbs. 
Trans- 
versalis 
fascia. 
Extirpa- 
tion. 
Cured. 
Purely 
fibrous 
tissue. 
Reported in the Medical Record, 
Dec. 3, 1887. Peritoneum as 
large as two hands was removed 
with the tumor, and peritoneum 
brought together by nature. 
5 
C. K. Briddon, 
New York, 
27 
None. 
F. 
9 mos. 
Right 
inguinal 
Fascia 
trans • 
versalis. 
Extirpa- 
tion. 
Cured. 
Peritoneum was not opened. Re- 
port in Medical Record, Decem- 
ber 3, 1887. 
6 
J. A. McGraw, 
Detroit, Mich. 
23 
None. 
F. 
Not re- 
corded. 
Right 
iliac 
fossa. 
Double 
fist. 
Several 
years. 
None. 
Extirpa 
tion. 
Cured. 
Fibro- 
ma. 
Peritoneum not opened. 
6 
30 
None. 
F. 
Not re- 
corded. 
Right 
iliac 
fossa. 
Double 
fist. 
Several 
years. 
None. 
Extirpa- 
tion. 
Cured. 
Fibro- 
ma. 
Peritoneum not opened. 
Desmoid (Fibroid) Tumors of the Abdominal Walls. DESMOID TUMOR OF THE ABDOMINAL WALLS. 
13 
7 
Chris. Fenger, 
20 
None. 
F. 
6 mos. 
Lower 
Walnut 
334X2^ 
6 mos. 
Tendon 
None. 
Extirpa- 
Cured. 
“Firm 
Peritoneum was not opened since 
Chicago, 111. 
part of 
inches. 
of the 
tion on 
fibroma 
“the fascia transversalis could 
left 
internal 
Jan. 31, 
micro- 
be peeled off the abdominal sur- 
hypo- 
oblique 
1880, in 
scopical 
face of the tumor.” 
gastric 
abdo- 
Cook Co. 
appear- 
region. 
minal 
Hospital 
ance of 
muscle. 
a ute- 
rine 
Beeves Jackson, 
8 
8 
None. 
M. 
Not 
Umbili- 
Prob- 
Not 
Enucle- 
Cured. 
“Macro- 
Enucleation and very slight loss 
Chicago, 111. 
known. 
cal, 
ably 
given. 
ation. 
scopical 
of blood; peritoneum not open- 
right 
3X5 
charac- 
ed. Recovery prompt. 
hypo- 
inches. 
ter of a 
chon- 
uterine 
driac, 
fibroid 
lumbar, 
perhaps 
and 
less 
D. Prince, 
Jacksonville, 111. 
None. 
hypo- 
gastric 
regions. 
dense.” 
9 
? 
F. 
4 inches 
in diam- 
Extirpa- 
tion. 
Cured. 
Macro- 
scopic 
Peritoneal cavity was not opened. 
ter. 
appear- 
ance 
R S. Sutton, 
None. 
of a 
fibroid. 
10 
23 
F. 
2 years, 
Right 
Small. 
Size of 
2 years. 
Fibres 
Extirpa- 
Cured. 
Macro- 
The tumor never returned; peri- 
Pittsburg, Pa. 
inguinal 
orange. 
of inter- 
tion. 
scopic 
toneum not opened ; the wound 
and uni- 
nal ob- 
appear- 
healed by first intention.1 
bilical 
lique. 
ance 
region. 
that of a 
fibro- 
11 
Edward J. Ill, 
28 
None. 
F. 
10 mos. 
Above 
7-10 
16X20 
9 mos. 
Fascia 
Extirpa- 
Cured. 
Purely 
Case I. of my paper. Peritoneal 
Newark, N. J. 
the left 
centi- 
centi- 
trans- 
tion. 
fibrous 
cavity was opened, and about 
lumbar 
metres. 
metres. 
versalis, 
tissue. 
100 square centimetres of peri- 
and um- 
i,e.9 pos- 
toneum removed. 
bilical 
terior 
region. 
sheath 
of rec- 
tus ab 
dominis 
12 
30 
None. 
F. 
6 w’ks 
Right 
5-8 
No ap- 
G mos. 
Poste- 
Extirpa- 
Cured. 
Purely 
Case II. of my paper. Peritoneal 
iliac 
centi- 
preci- 
rior 
tion. 
fibrous 
cavity was opened. 
in rectus 
metres. 
able dif- 
sheath 
tissue. 
abdo- 
ference. 
right 
minis. 
rectus 
abdo- 
minis. 
1 Very probably this was a true fibroma and is reported under this heading for that reason, no microscopical examination having been made. 14 
ILL, 
No. 
Reporter. 
Age 
Family 
history 
as to 
tumors 
gener- 
ally. 
Sex 
Length 
of time 
the 
tumor 
was 
known 
to exist. 
Loca- 
tion. 
Size 
when 
first 
noticed. 
Size 
when 
last seen 
by the 
reporter 
Length 
of time 
inter- 
vening. 
Report- 
er’s 
opinion 
as to the 
origin 
of the 
tumor. 
Prob- 
able or 
possible Treat - 
cause. ment. 
Result. 
Ana- 
tomical 
charac- 
ter of 
tumor. 
Remarks. 
1 
J. W. Gouley, 
New York. 
30 
M. 
Left 
flank 
and 
lumbar 
region. 
Remov’l 
of tumor 
and its 
recur- 
rence 
at five 
different 
times. 
Recur- 
rence a 
few 
months 
after 
last ope- 
ration, 
and 
death. 
Spindle- 
celled 
sarcoma 
2 
R. Park, 
Buffalo, N. Y 
36 
None. 
F. 
Difficult 
to say as 
there 
was a 
hernia 
of con- 
genital 
origin. 
Umbili- 
cal 
region. 
258 lbs 
Tumor 
arose 
from 
the sac 
wall. 
Com- 
plete ex- 
cision of 
tumor 
and her- 
nial sac 
in July 
1885. 
Cure. 
Fibro- 
sarcoma 
llad given particular trouble since 
two years. No return after ope- 
ration. Sac and all was so largo 
that when she sat down the tu- 
mor touched the chair before the 
buttocks did. 
3 
H. T. T. llanke, 
New York. 
27 
None. 
F. 
C mos. 
Right 
inguinal 
1 inch 
in diam- 
eter. 
2X3 
inches. 
6 mos. 
? 
Extirpa- 
tion. 
Cure(?) 
Recur- 
rent 
fibroid. 
A year after the first operation the 
reporter removed a second one 
on the opposide side, and after 
two years more two further tu- 
mors appeared in other parts of 
the walls of the abdomen. 
(Partly reported in the Ameri- 
can Journal of Obstetrics, 1884, 
partly by personal correspon- 
dence.”) 
Other Forms of Tumors of the Abdominal Walls. DESMOID TUMOR OF THE ABDOMINAL WALLS. 
15 
4 
II. 0. Marcy, 
Boston, Mass. 
Not 
given. 
F. 
Uterine. 
Extirpa- 
tion 
Cure. 
Calcar- 
eous 
myoma. 
The tumor was removed by the 
late Dr. H. A. Martin, of Rox- 
bury, Mass., and is said to have 
been in the abdominal wall. 
Whether it formed part of the 
abdominal muscles is not spoken 
of. The tumor was removed 
without opening the abdominal 
cavity. Dr. Marcy thinks it a- 
uterine myoma that became 
detached from the uterus. 
5 
It. S. Sutton, 
Pittsburg, I’a. 
70 None. 
M. 
Some 
weeks. 
Below 
navel 
to right 
side. 
Walnut. 
Walnut. 
A few 
weeks. 
Oblique 
fibres of 
the ab- 
dominal 
muscles. 
Extirpa- 
tion. 
Recov- 
ery. 
Not 
known. 
Patient died, seven or eight years 
later, of sarcoma in the corre- 
sponding groin. 
6 
40 None. 
F. 
1 year. 
Right 
groin. 
Small. 
Goose 
egg. 
1 year. 
Deep 
cellular 
tissue of 
the ab- 
dominal 
walls. 
None. 
Death. 
Sarcoma 
Growth of tho tumor very rapid. 
7 
' (C (< 
22 None. 
F. 
More 
than a 
year. 
Above 
Pou- 
part’s 
lig’ment 
on left 
side. 
Small. 
Goose 
egg. 
1 year. 
Fibres 
of the 
obliquus 
exter- 
nus. 
Blow. 
None. 
Death. 
Sarcoma 
Patient declined extirpation. 16 
DESMOID TUMOR OF THE ABDOMINAL WALLS. 
I have for my instruction collected as many cases of desmoids 
and other tumors of the abdominal walls (see Tables), as I was 
able to reach by correspondence with American surgeons and 
reference to American medical literature. I wish to draw 
your attention to a few of the following points: 
Among the desmoids all but two were females. Among 
these the ages ranged between twenty-three and forty-one 
years. The ages of the males w*ere eight and forty-five years. 
The longest time any of the tumors was known to exist was 
four years. (Dr. Weir.) 
In five cases the origin of the tumor was given as the fascia 
transversalis; in one, the fibres of the internal oblique 
muscle. The knife was the treatment in every case. In six 
cases the tumor was so closely adherent to the peritoneum that 
this cavity was opened by rupture of that membrane, and in 
two of these by excision of large portions. And, lastly, that 
they all have recovered. From personal correspondence I 
know that Dr. Thomas has removed four such tumors, and 
that he will publish the results himself. 
Of the other forms of tumors, five were females and two 
males. Five cases were denominated sarcoma, one each a re- 
current fibroid, and one calcareous myoma. 
Five of the tumors were removed by operation. They all 
recovered, but recurrences are noticed in three of these. 
Bibliography. 
S. Graetzer. Inaugural Dissertation. Breslau, 1879. 
E Suadicani. Inaugural Dissertation. Kiel, 1875. 
W. Billroth. Die Allg. Chirurg. Path, und Therapie. v. Pitha und Billroth. 
Handbuch der Allg. und Spec. Chirurgie, iii. 2. 
Cohenheim. Allgemaine Pathologie. 
Gross. Surgery. 
It. F. Wier. A Huge Fibroma, etc., Medical Record, December 3, 1887, p. 703. 
M. Sanger. Ueber Desmoid der Baucbdecken, etc., Arcbiv fiir Gynak., Band 24, 
Erstes Heft. 
C. Rokitansky. Path. Anatomie, 1856. 
Rindfleisch. Lehrbucb der Path. Gewelslehre, 1875. 
Wagner. Handbuch der Pathologie, 1872. 
Forster. Path. Anat., 1865. 
Gouley. Diseases of Man, etc., 1888. 
Herzog. Ueber Fibroma der Bauchdecken. Miinchen, 1883.