Chapter Xxxviii, Is, Nevertheless, Practically a Cyst of Congenital

origin involving the spinal meninges. One form of spina bifida is constituted by cystic dilatation of the central canal of the spinal cord, and produces syringomyelocele. These conditions will be treated more fully in their appropriate places.

Sutton has rendered a great service by showing that the brain and spinal cord are evolved from a segment of the primary intestines, and that the intestinal canal and the neural canal communicate in fetal life at their lower terminations; while it has been shown by several that in the earlier forms of mammalian life they were also connected by their anterior terminations. It is in this way that certain complex tumors of the sacral and coccygeal region are to be explained. So also is the collection of lymphoid tissue in the vault of the pharynx, known as Luschka’s tonsil, and in the coccygeal region, known as Luschka’s gland, it being a curious and instructive fact that lymphoid tissue of this character is always met with in the neighborhood of obsolete canals.

=Hydatid Cysts.=--These cysts are the indirect product of the eggs of the Tænia echinococcus, a form of tape-worm which infests the alimentary canal of dogs. The eggs reach in some direct or indirect way the food or water taken into the human stomach and are there hatched; the young animals migrate through vessel walls and are deposited in some tissue or organ where the cyst later develops. These cysts have a thick, elastic wall, with a lining containing cells, involuntary muscle fibers, and a water-vascular system. After such a cyst has attained the size of an inch or more, small vesicles, or “brood capsules,” begin to develop, which present at one point a retractable head, with scolices so arranged in crown form as to produce sucking disks. According to the date at which the cyst is opened appearances will differ. Sometimes a large cavity will be filled with multiple “daughter cysts,” and sometimes these will have disappeared, so that the cyst fluid contains nothing distinctive. After having ceased to develop, hydatids frequently undergo atrophy and even become calcified; the characteristic hooklets are the last of the distinctive features to disappear.

These growths may be rapid, even to the point of producing necrosis and rupture, or may be very slow and persist almost unchanged for years. The disease is uncommon among the native-born population of the United States, and most of its examples are seen in emigrants. It is exceedingly prevalent in Iceland and in New Zealand. It occurs most often in the liver, but is frequently met with in these countries in the lungs, the brain and spinal canal, and the bones, but may be encountered in any part of the body. When located near the intestinal tract or the air tract the cysts are more liable to penetration by ordinary germs of sepsis, and then may suppurate. It is not infrequent to have conversion of an hydatid cyst into an abscess. Before or after such change it may undergo rupture, spontaneous or traumatic, and this, according to the nature and amount of its contents, and the location of the opening, will promptly produce more or less grave symptoms. While spontaneous recovery has, in rare instances, followed rupture, it has perhaps more often led to fatal result. At all events, it will produce serious and perhaps distressing symptoms.

The only radical treatment for hydatid cysts is extirpation. When this is not possible the cyst may be opened and the margins of the opening attached to those of the skin wound. After being evacuated it should be packed and drained, and then may be expected to slowly contract, perhaps even to the point of obliteration. The contents of such a cyst should not be allowed to escape into any of the body cavities, since their sterility can not be always relied upon.

=Cystic Degeneration.=--Hematocele is an expression meaning a tumor composed originally of effused blood which has undergone chemical and other changes, which consist of lamination and thickening of its exterior portion and fluidification of the interior, until in course of time such an internal blood clot may be converted into a distinct and plainly walled cyst. This condition may be seen in two locations--namely, in the pelvis and between the cranium and the brain, or in the brain. The hemoglobin gradually disappears, and the contents of these cysts are translucent or even watery in appearance. Hematoceles may form where there has been internal hemorrhage in certain locations which has failed to absorb, and where no pyogenic infection has occurred.

Pseudocystic changes occur in other tumors and in other parts of the body as the result of mucoid and colloid liquefactions. In the midst even of apparently dense and entirely defined tumor masses changes of this kind occur, and lead to formation of cavities containing fluid of variable consistence, causing the tumor when divided to present the appearance of the geodes or quartz rocks, containing cavities lined with quartz crystals. The occurrence of such cystic changes is indicated, in naming such a tumor, by prefixing the term cysto-, as cystosarcoma, cystofibroma, etc.

2. =Dermoids.=

Dermoids are cysts or tumors containing tissues and appendages which are developed from the epiblast, and which occur when skin and mucous membrane are not normally found. The simplest form of dermoid is a cyst whose interior is lined with modified skin, containing sebaceous glands and hair follicles, from which often numerous long hairs are produced. Even sweat glands may be present. Its cavity is occupied by mixed material, pultaceous in character, made up of sebum, cholesterine, and growing hairs which are often rolled into balls. The sebum is the product of the glands contained in the cyst wall.

A complex form of so-called dermoid cyst is met with in which there are unstriped muscle fiber, teeth, mammary glands, etc. These belong rather to the class of teratomas, as they contain more or less tissue not of epiblastic origin.

A dermoid tumor is one lacking cystic characteristics, made up of tissue largely developed from the epiblast, with more or less tissue of mesoblastic origin. Such a tumor may contain much connective tissue, fat, fetal hyaline cartilage, and nerve tissue, while from its exterior long hair may grow, and teeth project from its surface or be embedded within its substance. Such tumors are generally found in the pharynx and about the rectum.

The explanation of dermoids and teratomas may be gleaned from embryology, and rests upon the arrangement of the different blastodermic layers of the developing ovum, and upon the facts already alluded to in explaining Cohnheim’s hypothesis of the origin of tumors. Strictly speaking, a dermoid should contain only that which may be developed from the epiblastic layer. It is well known that teeth and hair, as well as sebaceous material, are epiblastic products. Consequently such material may be found within a dermoid and needs no further explanation than an epiblastic inclusion, according to Cohnheim’s views. But so soon as such a tumor contains bone, muscle, etc. (i. e., tissues of mesoblastic origin), we should drop the term dermoid and consider it a teratoma. Such is the distinction between these two terms. According to Wilm’s researches, any tumor of this sort which contains epithelial products as teeth or hair is sure to contain also mesoblastic elements, and thus to belong to the latter. The term epidermoids has been applied to the former.

The most prominent characteristics of dermoid cysts are: (1) Skin, which may be thick or thin, lined with papillæ, containing more or less pigment, its deeper layers possessing a quantity of fat. (2) Hair, which next to skin is the most constant structure found in dermoids; this may be present in trifling amount or in long coils or balls. It is of interest that in dermoids found in animals covered with wool we find the same character of hairy structure, while in birds dermoids contain feathers rather than hairs. (3) Sebaceous glands and their peculiar secretion are invariably found. These may be of large size, and sebaceous retention cysts may be seen in the walls of dermoids. Sometimes horny matter or tissue is found in these, indicating the same relation between horn and sebaceous structures, as we see upon the external skin in other instances. So, too, material resembling the texture of finger-nails is occasionally found projecting into the cavity.

The fluid or semifluid contents of these cysts consist usually of sebaceous material, cholesterin, epithelial debris, etc. Sometimes it is thick, sometimes thin--and occasionally consists almost entirely of mucus.

It is not uncommon to find structures in ovarian dermoids closely analogous to, or actually resembling, mammary glands. These may be mere nipple-like processes of skin, or completely developed mammæ, well formed, but without ducts or gland tissue, may occupy such a cyst. These really are pseudomammæ, because they have no ducts. Nevertheless, glandular tissue is not always absent. This resemblance proceeds even farther, in that in some of these ovarian mammæ changes occur analogous to those which take place in normal breasts.

The epiblast seems to have the power of developing mammary glands or supernumerary mammæ in many locations--in fact, upon any part of the body surface. About the thorax they are common; upon the abdomen they are rarely observed; and they have been found even upon the labia.

Sweat glands are infrequent in dermoids. Teeth are quite common. These may vary in number from two or three up to several hundred--may be embedded in definite sockets or simply sprout from the cyst wall. Occasionally bone material, lodging such teeth and crudely resembling a jaw, will be found.

Dermoids containing mucous membrane are found, especially in connection with the ovary and with the postanal gut (i. e., the original communication between the spinal and alimentary canals).

It is curious that under these circumstances mucous membrane is sometimes furnished with hair, as it normally is in the stomach or other cavities of some of the lower animals. Mucous glands and retention cysts of these glands are also found in ovarian dermoids. This will be more readily understood if the mutability of skin and mucous membrane be not forgotten. The transition from one to the other is not difficult, and we find all intermediate stages between the two extremes--if not in man, at least in animals. This will account for the fact that skin-covered dermoid tumors are found in certain parts of the alimentary canal, and particularly in the pharynx. These tumors grow also from the mucous membrane of the bowel, of the rectum, or even of the small intestine.

Sutton has made a division of dermoids into three classes:

1. Sequestration;

2. Tubulodermoids;

3. Ovarian.

1. =Sequestration Dermoids.=--Sequestration dermoids occur chiefly in situations where during embryonic life coalescence takes place between two surfaces possessing an epiblastic covering, although sometimes this coalescence practically occurs late in life and by implantation.

Dermoids of the trunk occur particularly where opposite halves of the body wall coalesce--that is, in the midline of the trunk and head. Dermoid cysts are rarely found in connection with spina bifida, and certain tumors spoken of as spina bifida undoubtedly are dermoids. Anteriorly dermoids occur frequently in the scrotum, and occasionally in the testicle. At the umbilicus they are rarely found--usually as pedunculated tumors projecting externally. In the midline of the thorax and neck they are most common opposite the manubrium, dropping down behind it to invade the anterior mediastinum. Near the hyoid bone they occur relatively frequently; about the head they are met with most commonly at the angles of the orbits--more so at the outer than at the inner angle. Dermoid cysts are known to oculists as growing upon the iris or springing from the conjunctiva. About the ear they are not infrequent; in the roof of the mouth, especially if this be incomplete, we frequently find cysts of epiblastic origin.

Sequestration dermoid cysts are also undoubtedly found in connection with the dura mater, in the scalp, most commonly at the anterior fontanelle, at the root of the nose, and at the external occipital protuberance, where they may be confounded with sebaceous cysts or with meningoceles. In order that a dermoid of the dura may communicate with the skin there must of course be osseous defect.

Sequestration dermoids upon the limbs have been mostly reported as sebaceous cysts. They are rare, and usually associated with antecedent injury, by which epiblastic structures are driven in and implanted in such a way that as they develop they give rise to these peculiar tumors. These are what Sutton calls implantation dermoids. They are found upon the fingers and elsewhere.

2. =Tubulodermoids.=--These are largely connected with obsolete canals and ducts. It is a great service which Sutton has rendered in proving, apparently beyond the possibility of doubt, that the central canal of the nervous system is really of intestinal origin, and may be regarded as a disused segment of the primary alimentary canal. He has also shown how it behaves occasionally as do other functionless ducts, and that cysts and dermoids in connection with it are to be thus explained. He and others have also shown the anterior as well as the posterior communication of these canals, and the pituitary body are to be regarded in this light as the same formation of lymphoid tissue around an obsolete canal which we see in Luschka’s tonsil close by, and in Luschka’s gland at the other extreme of the canal.

Solid dermoid escaping from pelvis. (Original.)]

Congenital dermoid cyst of pelvis. (Ahlfeld.)]

The primary alimentary canal was a continuous tube lined with a continuous layer of columnar epithelium. That portion connected with the yolk sac develops into the intestine, the balance into the central nervous canal. Portions of this canal are in postnatal life absolutely obsolete; others persist in a rudimentary condition. Dermoid cysts and dermoid tumors develop in connection with each of these. In some there is a large central cavity; others are almost absolutely solid. Thus we find dermoids in the coccygeal region, which have been variously regarded as sarcomas, adenomas, etc., which are really of origin as stated above and should be considered simply as dermoid tumors. Most of these project outwardly; some of them arise and develop within the pelvis. Dermoid cysts and tumors are also met with in connection with the rectum--sometimes between the rectum and the bladder, and between the rectum and the spine. Dermoid tumors are also found in connection with the pituitary body. These sometimes develop within the cranium, or, again, protrude perhaps into the orbit, perhaps into the pharynx.

Thyroid dermoids are tumors of great interest. They develop sometimes about the craniopharyngeal canal, which may be detected as a small canal in the macerated sphenoid bone of a fetus, and which before birth is filled with fibrous tissue. It connects with a recess in the middle line and at the base of the skull, presenting in the pharynx, which is often referred to as the bursa pharyngea. It is around this recess that the lymphoid tissue known as the “pharyngeal tonsil” develops. It may be thus expected that the roof of the pharynx should be the occasional site of dermoids. It is from the pharynx or the floor of the mouth that in vertebrates the thyroid body arises. In higher forms it becomes dissociated from the pharynx and shifts its position. The thyroid body is developed around the thyroid duct, which first appears as the thyrohyoid duct, which later becomes divided, that portion in relation with the tongue becoming the thyrolingual duct, the remaining portion persisting as the thyroid duct. These are present about once in every ten subjects, according to Sutton, the canal when persistent being lined with epithelium. When the extremities of these ducts become occluded retention cysts may form. In the same way dermoids of the tongue are formed, similar to those occurring on the scalp. These are frequently mistaken for sebaceous cysts. They may be unilateral, central, or even bilateral. The lingual duct is also of interest, because it would appear that certain cases of epithelioma of the tongue arise along this duct, and perforating malignant ulcer of the tongue is thus produced. Dermoid tumors of the lingual or thyroid ducts resemble in structure the thyroid body. The thyroid duct may also be detected in many adults running from the isthmus of the thyroid body to the posterior aspect of the hyoid bone, and surrounded by muscle tissue. Sometimes the space usually occupied by this duct is represented by a series of detached bodies known as accessory thyroids. These are not infrequently the seat of cysts, sometimes of considerable size. (The accessory thyroids often enlarge when the main thyroid has been extirpated for disease.) Thus cysts in close relation to the hyoid bone are common. Some of them grow slowly, while others grow rapidly and contain much fluid. Many of them are unilateral, and are often mistaken for enlargements of one lobe of the thyroid. Cysts growing from accessory thyroids are often filled with papillomatous masses, and are occasionally the seat of malignant degeneration.

In the omphalomesenteric duct or its remains, especially in relation with the umbilicus, we often meet with small cysts or tumors in infants and young children. When the duct is persistent it presents normal intestinal structure, and, like the appendix, possesses much adenoid or lymphoid tissue.

Another and very important form of tubulodermoids develops in connection with the branchial clefts of the neck. Congenital fistulas of the neck have been long known, but only comparatively recently understood. Of the branchial clefts it is well known that the first alone should persist, as the Eustachian tube. Occasionally, however, they fail to become obliterated, and then we have congenital tumors or cysts, which may, perhaps, not develop to appreciable size until somewhat late in life; or there may be fistulous passages opening either into the pharynx or externally, forming canals varying in length from half an inch to two inches, secreting a little fluid because lined with epithelium. When these become inflamed an abscess results. When they open externally the opening is often marked by a little tag of skin containing a fragment of yellow cartilage. These are often referred to as cervical auricles. They open along the line of the sternomastoid muscle. The internal openings of these fistulas frequently form diverticula from the pharynx or esophagus. Thus it will be seen that dermoid cysts about the neck are principally relics of openings or ducts, which are normal in embryonic life, but which should have been obliterated at or long before birth. Congenital fistulas, however, may be met with in the middle line of the neck, which are not to be confounded with branchial fistulas, but rather with the ducts previously described.

3. =Ovarian Dermoids and Teratomas.=--These may be unilocular or multilocular cysts, usually the latter. They are lined with epithelium, and contain mostly mucoid fluid, the inner coat being practically identical with mucous membrane. Occasionally, however, the skin is furnished with hair, sebaceous glands, teeth, and even nipples. The multilocular cysts are practically an aggregation of those just described. They are surrounded by dense capsules, often attain great dimensions, and are made up of primary cysts resembling large cavities in a honeycomb-like mass, which itself is occupied by secondary cysts, and belong rather to the class of mucous retention cysts, these being occupied by still smaller ones, which are histologically indistinguishable from distended ovarian follicles. In these large tumors we find in some cases hair, in others teeth, and in others sebaceous glands, etc., the dermoid constituents being scattered throughout. As Wilms has shown, in almost every tumor of this character a projection may be found whose summit is covered with epiblastic elements, which when cut in serial transverse sections will show in its deeper portion other epithelial collections representing a feeble attempt to develop a nervous system, or lung tissue, while mesoblastic elements, like connective tissue, cartilage, and bone, appear scattered throughout, as though a very crude effort had been made to reproduce an atypical embryo.

3. =Teratomas.=

So far the endeavor has been to limit the term dermoid to tumors which are essentially of epiblastic formation, their location being explained on the inclusion theory of Cohnheim. There is also a still more complicated type of tumor, composed of tissues of both epiblastic and mesoblastic origin, perhaps even hypoblastic. Their consideration belongs to that department of pathology known as teratology, which is supposed to deal especially with monsters. Strictly speaking a teratoma refers to an irregular tumor or mass containing tissues and fragments of viscera of a suppressed fetus which is attached to an otherwise normal individual. Nevertheless the term is often applied to growths which are the result of luxuriant mesoblastic development in which neither form nor member of a suppressed fetus is present.

The presence of supernumerary members is largely connected with what is called dichotomy, alluding thereby to cleavage either at the anterior or posterior end of the developing embryo. When the whole embryonic axis divides twins may be produced, but should cleavage be partial we may have a monster with two heads if it be anterior, or one with three or more limbs if it be posterior. Children born with these deformities are usually called monsters, and the study of such cases belongs entirely to teratology. But in certain tumors small portions of a suppressed fetus may develop, as, for instance, from the posterior portion of the sacrum, or within the abdomen or thorax, or upon the neck or face, which on dissection may contain a few vertebrae or processes resembling fingers associated perhaps with a structure resembling intestine or liver. This should be called a teratoma. Such tumors possess for the pathologist the greatest value. In surgery, however, they are rare, and there are scarcely two cases alike. The question of operation will often arise, as it does with supernumerary limbs, and each case should be studied upon its own merits. Sometimes they are amenable to extirpation.

=Embryonal Adenosarcoma.=--Embryonal adenosarcoma is a term given to certain teratomatous tumors peculiar to renal and adrenal structure, which present peculiar characteristics in the mixture of elements which enter into their composition. At various times these tumors have been called adenoma, sarcoma, rhabdomyoma, congenital cystic kidney, etc. They have been also likened to the thyroid. They comprise a group of neoplasms, always congenital in origin, which usually appear early in life, but occasionally occur in advanced adult life. One of the most marked specimens of this kind the writer removed from a man over fifty years of age. Most of the specimens, however, described in literature pertain to the young. On minute examination they often present a strange, mixed picture of voluntary muscle elements intermingled with epithelium arranged to imitate acinous glands, with cystic dilatations of the true kidney tissue. They often attain enormous size, and undergo such proliferation of mesoblastic elements as to resemble sarcoma. Their occurrence is to be explained only on the principles of Cohnheim’s hypothesis. When the original Wolffian body is being differentiated from the elements about it a confusion of the same with the excretory tubular beginnings, which are to empty into the Wolffian duct, occurs. Thus we have the commencement of a mixed mass which presents itself as a more or less rapidly growing tumor, in which even cartilage or other mesoblastic structures may be met with. It is scarcely possible that any two specimens should yield exactly the same microscopic picture, much depending on whether one element or the other prevail. In a few of them there may occur also a mixture of adrenal elements. Sometimes the renal structure itself is more or less distinct, and rides, as it were, upon the surface of the tumor; at other times it is entirely mixed up with it. While the condition is usually limited to one side it may be a double affection, so that the second kidney becomes useless and the patient succumbs. The only treatment is extirpation.

Teratomatous tumors are sometimes found hanging in the pharynx, attached by a small pedicle, where they may be confounded with dermoids unless carefully examined after removal. Many instances of this type of tumor are found in animals. Here no false sentiment will prevent complete examination and preservation of the specimen. They are also encountered in the sacral and coccygeal regions.

4. =Tumors of Connective-tissue Type.=

=Lipoma.=--Lipomas, or tumors composed of fat, are the most common of the neoplasms. Their normal type is the ordinary adipose tissue of the body, and may be divided into the encapsulated and the diffuse, the former of which are surrounded by fibrous tissue. The diffuse lipomas are those which have no capsule, and where the pathological collection of fat merges into that normally present--in other words, they are not circumscribed.

=Subcutaneous Lipomas.=--Subcutaneous lipomas are perhaps the most common of all, and are usually irregularly lobulated and encapsulated, adherent rather to the skin than to the deeper tissues. Usually but one is found in an individual, though instances of multiple lipomas are not rare. They develop sometimes to enormous size, cases being on record where the tumor has even weighed one hundred pounds. They may be met with at any point on the surface of the body. The lobules often burrow between the muscles, and those found in the palm of the hand penetrate even beneath the palmar fasciæ. They are sometimes markedly pedunculated, and often hang by a small stem. The diffuse subcutaneous lipoma is most common about the neck, in the groin, and in the axilla.

=Subserous Lipomas.=--Subserous lipomas are mostly retroperitoneal, and large tumors of this character, mistaken for ovarian, have been successfully removed by operation. They also occur in the hernial canals and spaces. They develop beneath the peritoneum covering the intestines, and in this location give rise occasionally to intussusception. Here in their pathological development they have the general form and significance of appendices epiploicæ.

=Subsynovial Lipomas.=--Subsynovial lipomas occur about various joints and tendon sheaths; within the knee they assume a distinctive type which has been called lipoma arborescens, where they take on a dendritic appearance and arrangement. Submucous lipomas are rare. Intermuscular fatty tumors are occasionally met with, an interesting variety being that which develops between the masseter and buccinator muscles. Intramuscular forms rarely occur, as well as a variety known as parosteal, which arises in connection with the periosteum. Fatty tumors also occur within the spinal dura, as well as outside of it within the spinal canal, and more or less lipomatous alterations are common in connection with spina bifida.

Lipomas are ordinarily easy of recognition, save when deeply located. The subcutaneous forms are intimately related with the overlying skin, and have a dough-like consistence which is usually pathognomonic. Tumors, suspected to be fatty, in the middle line of the back or cranium are always to be viewed with suspicion, as they are often connected with congenital meningeal protrusions.

An encapsulated lipoma when thoroughly removed will not return.

Mixed forms of fibrous and fatty neoplasm are occasionally seen, and are referred to as lipoma fibromatosum or fibroma lipomatosum, according as one or the other tissue predominates. These growths are innocent in their character, but call for thorough extirpation. They frequently give rise to considerable discomfort or pain, and are called lipoma dolorosa.

=Fibroma.=--Fibromas are tumors composed of fibrous tissue, which, when of pure type, are found to be not so common as was formerly supposed, the majority of tumors hitherto roughly grouped as fibromas containing either muscle tissue or sarcomatous elements, which takes them out of the category of pure fibroma. A typical fibroma is ordinarily dense, and is composed of wavy bundles of fibrous tissue whose cells are long and slender and closely packed together, the mass being permeated by distinct bloodvessels.

Fibroma occurs most commonly in the ovary, the uterus, the intestine, the gum (epulis), in nerve sheaths, and in the skin in the form of so-called painful subcutaneous tubercles and molluscum fibrosum. There is also a fibrous tumor of the skin, known as keloid, sustaining to fibroma the same relation that exists between exostosis and osteoma.

Painful subcutaneous tubercle is a sample of pure fibroma in the shape of a small, flattened, pea-like tumor which never attains great size. It is situated loosely in the subcutaneous structure and may form a visible prominence. Insignificant as it would thus appear, it becomes the seat of exasperating pain, particularly when touched or handled, which may radiate to considerable distances. The etiology of these growths is unknown.

In the ovary, the uterus, the intestine, and the larynx true fibrous tumors are pathological curiosities rather than common lesions.

Keloid of external ear: a, dense tissue of skin; b, fibrous connective tissue; c, epidermis. (Klebs.)]

=Epulis.=--Epulis means any tumor growing upon the gum. The term was formerly applied in an indistinct and too comprehensive way, although it is still retained in literature. But pure fibromas do spring from the fibroösseous structure of the gum and alveolar process. They are covered with the gingival mucous membrane and seem to spring from the periodontal membrane. They seldom attain large size, and then only by neglect. By the pressure of such tumors teeth may be separated and distortion of the mouth produced. They should be promptly extirpated.

=Keloid.=--Keloid is a fibrous neoplasm arising mainly in cicatricial tissue, which is essentially fibroid in structure. It is a neoplasm which often follows the general outline of the scar in which it grows, consists in elevation of the surface, ordinarily quite smooth, sometimes of a delicate pink from the dilated vessels which it contains. Keloid is the bête noir of surgeons, as it frequently complicates and disfigures scars which have at first been satisfactory, and since it indicates a condition which it is discouraging to deal with, because when it is removed there is usually recurrence of growth within a few months after cicatrization. It often occurs in stitch-hole scars and upon the site of extensive burns, and may be observed after puncture of the ears for ear-rings, and has also been observed in scars left by smallpox, acne, etc. It is more prevalent in the colored race than in the white. In negroes multiple keloid tumors are often seen, occasionally in large numbers. Their explanation is unknown, and it may be that some trifling injury has preceded each individual tumor (Fig. 74).

The treatment of keloid will be considered in the chapter on the Surgical Diseases of the Skin.

=Desmoids.=--This term has been applied to tumors of a certain clinical type which arise from the fibrous structures, usually of the abdominal wall, and produce neoplasms like the fibromas of other parts of the body. The use of the term should be restricted to those tumors which proceed primarily only from muscles, tendons, and aponeuroses, or perhaps from ligamentous and periosteal tissues. These tumors are usually single, attain sometimes considerable size, grow slowly, rarely involve other structures, and not infrequently develop to such an extent as to encroach upon either pelvis or the abdomen, or both. They have been known to attain to the weight even of ten pounds or more. They are usually more or less encapsulated, and are firm and dense in structure. Under the microscope they have the general appearance of cellular fibroma. Sarcomatous elements may be met, while they occasionally undergo cystic degeneration. Their occurrence may be explained, at least in some instances, on the embryological theory of Cohnheim.

Multiple enchondromas.]

The treatment of desmoids consists in their complete extirpation. They should not be allowed to attain large size because their removal may entail a serious weakening of the abdominal wall. There should be such plastic rearrangement of abdominal protecting membranes as to reduce the resulting weakening to a minimum.

=Psammoma.=--Psammoma is a term applied to a form of hard fibroma met with in the dura mater, in which there has occurred a petrefaction of some of the cells--i. e., a deposition of calcareous salts, which gives it a gritty or sandy appearance.

=Chondroma.=--The true chondroma is a tumor composed of hyaline cartilage. It occurs in the long bones, usually in relation with epiphyseal cartilages, and is often noted during the earlier years of life. While it is usually a solitary tumor, multiple chondromas are often seen, especially upon the hands. These tumors are often encapsulated and form deep hollows, in which they rest. Unless pressing upon nerve trunks they are painless and slow of growth. They are exceedingly dense and hard, and ordinarily immovable. Mucoid softening (i. e., cystic degeneration) is common, and the softened areas may give rise to fluctuation. There may be coincident calcification or ossification in any of these growths. It is noted as a curious circumstance by Sutton that their tissue resembles histologically the bluish, translucent, epiphyseal cartilage seen in progressive rickets.

To the small local hypertrophies of cartilage which are seen especially about joints, about the laryngeal cartilages, and the triangular cartilage of the nose, are given the term ecchondroses. They are most common in the knee in connection with rheumatoid arthritis, and occur as prominences along the margins of the joint cartilage. They may project to such an extent as to be detached by accident, after which they become movable and floating bodies in the joints. Many of the floating cartilages or bodies found in joints are detached ecchondroses, which may be smoothed off by attrition, and may be found singly or multiple, even several hundred existing in one joint.

Chondromatous changes as occurring in sarcomatous tumors have been alluded to. It seems to be easy for connective tissue to form hyaline cartilage, and mixed tumors may thus be seen in connection either with sarcoma, fibroma, or other forms.

=Treatment.=--The treatment of chondroma is solely operative. Unless the integrity of a member or a limb be compromised, such a tumor can usually be shelled out from its location, but requires that the matrix be completely extirpated; all of which may call for the use of powerful bone instruments. At other times amputation is the only measure which may relieve from deformity, pain, and disability. The ecchondroses occurring within joints necessitate incision and evacuation, with the most rigid aseptic precautions, with or without drainage. When practised according to modern technique this is almost invariably successful. In former times many lives were lost because of septic infection.

=Osteoma.=--Under the head of nomenclature I have already endeavored to distinguish as between exostosis, or irregular bone outgrowth, and osteoma, as a distinct tumor which is composed of bone tissue, with the subvariety odontoma, or tumors of dental origin and structure. Osteoma is regarded by some as ossifying chondroma, for it is nearly always found near epiphyseal lines, and is always covered by hyaline cartilage when thus found. Nevertheless it is not invariably such. We speak of compact or ivory osteoma and of a cancellous form. The former is identical with the compact tissue of the shafts of long bones, and may occur anywhere, but is most common about the cranium, at the frontal sinus, the external meatus, and the mastoid process. Osteomas growing into the frontal sinus of oxen form large, lobulated, bony masses, sometimes weighing several pounds, and as dense as ivory. Some of these tumors growing into the cranial cavity have been regarded as ossified brains. Osteomas in connection with the external auditory meatus may partially obscure this channel and cause deafness. They constitute ivory-like growths, which sometimes defy the finest steel instruments with which the surgeon can supply himself.

Double osteoma of the skull. (Musée Dupuytren.)]

Cancellous osteomas grow in the cranium as well as in the long bones, and, like the compact forms, only occasion pain by pressure upon nerve trunks.

=Exostoses.=--Exostoses are classed by Sutton as--

1. Those formed by ossification of tendons and their attachments. There should be excluded from this group such natural or evolutionary processes as the supracondyloid process, the third trochanter of the femur, etc. Over or around such exostoses bursæ will form to mitigate as much as possible the effect of friction. Such an outgrowth is known as an exostosis bursa; it is most frequently seen on the inside of the femur immediately above the knee.

2. Subungual exostoses, occurring usually beneath the nail of the big toe.

3. Exostoses due to calcification of inflammatory exudations, including the rare condition known as myositis ossificans.

FIG. 1

Round-cell Sarcoma. (Low power.)

FIG. 2

Spindle-cell Sarcoma. (Low power.)]

When a true osteoma is once thoroughly removed there is no tendency to recurrence. Thorough removal, however, calls sometimes for serious and often mutilating operations, which may become dangerous when the growth involves the curve of a rib or a large portion of the skull. At other times amputation is rendered necessary. Special forms require special treatment.

=Sarcoma.=--Formerly this name implied a fleshy tumor, and was made to cover many different conditions. Now sarcoma means a tumor composed of immature mesoblastic or embryonic tissue in which cells predominate over intercellular material. Sarcomas are sometimes encapsulated; they merge into and infiltrate the surrounding tissue and disseminate widely, and have usually these propensities and characteristics to such a degree as to constitute malignancy. For the laity sarcomas and carcinomas are together included in the comprehensive term of cancer; for the surgeon they constitute but one form of cancer. Sarcomas are classified, according to the shape of their cells and their disposition, into--

A. Round-cell;

B. Spindle-cell;

C. Myeloid.

To these are added other varieties mentioned below.

Osteoma of frontal sinus. (Neisser.)]

Recurring sarcoma of parotid. (Original.)]

A. =Round-cell Sarcoma.=--This is simple in construction, and consists of round cells containing very little intercellular substance. The nuclei of the tumor cells stain easily, the cells themselves varying in size in different cases. Bloodvessels lead up to the tumor, but in the interior appear rather as channels. These tumors have no lymphatics: they grow rapidly, infiltrate easily, recur quickly, and give rise to numerous metastatic or secondary deposits. They may affect any part of the human body. The size of the cells is supposed to be in some measure an index of their malignancy--the smaller the cell the more malignant the tumor. They appear at all periods of life. They are perhaps the most commonly seen of malignant tumors in animals. (See Plate XVII.)

=Lymphosarcoma.=--This tumor is composed of cells similar to the previous form, but enclosed in a delicate meshwork resembling that of lymph nodes, hence the term lymphosarcoma. Lymphosarcomas are not to be confounded with enlargements nor with the specific granulomas involving these lymphatic structures.

B. =Spindle-cell Sarcoma.=--In this form the cells have a spindle shape and run in all directions, so that sections will show them in various shapes and sizes. In some cases the cells are small and slender, in others large. The size of the cell is a measure of the malignancy of the tumor. (See Plate XVII.)

The largest of these spindle cells are frequently striated transversely like voluntary muscle fiber, and tumors composed of this form have been considered as tumors of striped muscle tissue, and are generally called rhabdomyoma. There is no tumor of striped muscle fiber, and the rhabdomyomas of writers generally should be considered as spindle-cell sarcoma, or may be dignified by the name myosarcoma. (See Rhabdomyoma, under Myoma.)

=Alveolar Sarcoma.=--This is a rare form, in which the cells, contrary to the general rule of sarcomas, assume an alveolar arrangement strongly imitating that of epithelial cells in carcinoma. Almost invariably, however, on close examination it will be possible to distinguish a delicate reticulum between individual cells, which is never met with in cancer.

C. =Myeloid, or Giant-cell Sarcoma.=--In this form the tissue resembles histologically the red marrow of young and growing bone, containing large numbers of multinuclear cells embedded in a matrix of spindle or round cells. These tumors usually occur in the long bones, and when freshly cut look like a piece of liver. They constitute most of the epulides or cases of epulis--i. e., spongy tumors springing from the gums. (See Plate XVIII., Fig. 2.)

Sarcoma of femur following fracture--i. e., developing in callus. (Original.)]

Giant or multinuclear cells should be present in considerable numbers to entitle a tumor to classification in this group. When round cells, spindle cells, or giant cells mingle in nearly equal proportion the tumor should be called a mixed-cell sarcoma.

D. =Osteosarcoma.=--Osteosarcoma is something more than sarcoma of bone, which latter may spring from the fibrous or medullary elements. It is sarcoma of the specific bone-forming connective tissue, including the osteoblasts and osteoclasts; in other words, of the stroma of the bone. Under these circumstances real bone develops throughout the tumor, and it is essentially a bony neoplasm. In like manner there may be true osteofibroma. These tumors are to be distinguished, even clinically, from the medullary sarcomas, which develop within the bone and expand it, even to enormous proportions, the bony covering then being a mere shell.

E. =Chondrosarcoma.=--Chondrosarcoma resembles osteosarcoma in that it is sarcoma of the stroma of cartilage, or of the specific tissue which produces cartilage. In it true cartilage (white fibrous) also is found throughout the tumor. Chondrofibroma is also possible. (See Plate XIX.)

F. =Endothelioma.=--Endothelioma has been called various names, and its true character has been only lately determined. It is composed particularly of the endothelial cells which line the lymph spaces, and which have no peculiar secretion. It is met with most often in the skin (especially of the face), in the parotid region, in the genital glands, the bones, the lymph nodes, and dura.

FIG. 1

Angiosarcoma. (Low power.)

FIG. 2

Giant-cell Sarcoma. (High power.)]

FIG. 1

Chondrosarcoma. (Low power.)

FIG. 2

Osteosarcoma. (Low power.)]

Melanosarcoma of Skin. (Dry high power.)]

The microscopic picture of these tumors varies greatly, the endothelial cells often shaping and grouping themselves so as to imitate epithelioma. In doubtful cases the primary location or origin of the growth should be ascertained.

Endotheliomas are mainly of rapid growth, and often show a high degree of malignancy. If thoroughly extirpated before metastasis has occurred, prognosis is fair; but metastases happen early because of the direct connection of the tumor with the lymph current.

Endothelioma of the soft palate: a, dilated lymph space; b, endothelial cells with beginning cystic formation; c, completely formed cyst. (Volkmann.)]

G. =Angiosarcoma.=--Angiosarcoma is a sarcoma arising from the adventitia of the bloodvessels. It is characterized by its extraordinary vascularity, the ease with which hemorrhages into the structure of the tumor take place, and the frequency of pigmentation. Peritheliomas constitute a subvariety, met with especially in the kidneys, the bones, and the skin, and originate in the perithelial cells between the capillaries and the perivascular lymph spaces. They are more vascular than the angiosarcomas. The latter are common in the liver. In many cases the cells of these tumors simulate the columnar epithelium of adenocarcinoma. (See Plate XVIII, Fig. 1.)

H. =Cylindroma.=--This is a term applied to tumors of the angiosarcomatous type in which hyaline changes have occurred, so that along the vessels appear cylindrical masses of altered cells. Similar appearances are noted in certain endotheliomas and are due to the same hyaline degeneration.

I. =Melanosarcoma= (better known as Melanoma).--This refers to the deposition of pigment, rather than to type or shape of cell, the distinguishing feature of these growths being the presence both in the cells and in the intercellular substance of a variable quantity of blackish pigment. Of all the forms the melanotic growths are considered the most malignant. They invariably recur after removal, lead to secondary deposits at long distances, and present the most intractable and incurable forms of cancer. Deposition of pigment in carcinomas is most rare, if ever met with, and the growths of melanotic type should be relegated entirely to the class under consideration. The tumors most often develop from pigmented nevi of the skin, though primary melanoma of the deeper parts of the body is known. These will be treated more fully in the chapter on the Skin. (See Plate XX.)

This name has been variously applied by different writers to different growths. In order to avoid confusion it would be well, in using it, to be definite.

=General Characteristics of Sarcomas and Endotheliomas.=--The vascular supply of sarcomas varies within wide limits. In nearly all instances it is of capillary character, the blood circulating rather through vessels without well-marked walls. While large vessels may be found about and in the periphery of these tumors, distinct vascular structure is usually absent from the more internal portions, which will explain the frequency of hemorrhage, its persistency after operation, and the ease with which large extravasations occur. True hematocele may thus take place within sarcomatous tumors, with the usual later cystic alterations, and thus in one way we have the condition known as cystosarcoma.

In attacking these growths the vascular and bloody area may be met just about their margins, the bloodvessels expanding as they arrive at the tumor, and sometimes bleeding extensively. Under most circumstances, however, this hemorrhage can be controlled by packing or by operating at a greater distance from the circumference of the growth.

Metastasis in sarcoma is common, dissemination occurring mainly along the veins, as these growths connect with the venous channels and permit of easy detachment of fragments, which are then carried along as emboli. These emboli pass naturally to the right side of the heart, and thence to the lungs, where it is most common to find secondary growths, except in areas emptying into the portal veins, in which case the liver will be the most common site. Sarcomas are destitute of lymphatics, and dissemination does not occur through these channels.

Infiltration is also a common phenomenon with these growths. This is generally seen in muscular tissue, particularly with growths proceeding from the periosteum and projecting into it.

Sarcomas, like other tumors, tend to grow along the lines of least resistance. Hence processes of these tumors will insinuate themselves into fissures and interspaces, and penetrate perhaps even into the cavities, from which it is hazardous or impossible to remove them. Thus, sarcomas springing from the head of a rib have been known to extend through an intervertebral foramen and give rise to an intraspinal tumor, causing fatal pressure.

Secondary changes are usually seen in sarcomas, the most frequent being hemorrhage. Myxomatous degeneration is also frequent, and gives rise to cystic conditions. Calcification is common, particularly in the slowly growing tumors which arise from bone. Upon the other hand, necrosis (i. e., ulceration) is common in growths which project upon the surface or into any of the open cavities of the body. Ulceration here is growth at a rate faster than nutrition will justify, and gangrene is to be regarded as a failure to supply sufficient blood. It may also mean infection, of which it is a usual expression.

Tumors of this character, which luxuriate upon reaching the surface, and bleed easily upon the slightest touch, were formerly known as fungus hematodes. The name may be preserved for the sake of convenience, but should be held to mean, in almost every instance, a rapidly growing round-cell sarcoma.

Sarcoma is common in the lower animals, particularly so in horses--most common in those of gray color. It is met with also in cows and various other domestic and undomesticated animals.

=Myxoma.=--The myxomas are composed of mucous tissue, whose best-known normal representative is the Whartonian jelly of the umbilical cord. True myxoma should be distinguished from myxomatous degeneration, which occurs frequently in cartilage, fibrous tissue, and sarcoma, and which brings about a similar condition of affairs, though of essentially different origin. Myxomas appear under the following forms:

1. =Polypi.=--These include many of those which grow in the nose. The pure form of nasal myoma proceeds from the mucous membrane of the nasal passages or sometimes from the accessory sinuses. But most of the so-called nasal polypi are due to edematous hypertrophies of the submucosa. The polypi usually hang as gelatinous tumors of grayish-yellow tint, being present sometimes singly, sometimes in clusters or in large numbers. Their principal effect is to produce nasal obstruction, with, perhaps, subsequent serious disorder, due to decomposition or to extension into the pharynx or other cavities. Similar growths also occur from the mucous membrane of the tympanum, and constitute the common variety of aural polypi.

2. =Cutaneous Myxoma.=--Cutaneous myoma is not common. It presents usually as a sessile tumor, although about the perineum and labia the tumors may become pedunculated. It is often difficult to distinguish between a myoma of the skin and a sarcoma of the same which has undergone myxomatous degeneration, and which then should be called sarcoma myxomatodes. The latter tend to recur after removal; hence the importance of exact diagnosis.

3. =Neuromyxoma.= Neuromyxoma is a similar condition involving the nerve trunks, and is dealt with under Neuroma.

Myxomas require complete removal, and, in the nose especially, cauterization or destruction of the surface from which they spring. When this is thoroughly done they do not recur; otherwise, they are likely to require subsequent operation.

=Myoma.=--The true myoma is a tumor composed of unstriped or involuntary muscle fiber. Until recently it has been customary to divide the myomas into the leiomyomas in contradistinction to the rhabdomyomas, the latter being supposed to be tumors of voluntary muscle fiber. Myomas are met with only where involuntary muscle fiber is found--namely, in the uterus and adnexa, the vagina, the esophagus, alimentary canal, the prostate, the bladder, and the skin. They form encapsulated tumors composed of fusiform muscle cells with a rod-like nucleus, the size of the cells varying greatly in different specimens. The bundles of muscle fibers are much contorted, and it is often difficult in a single section to decide to just what class of cells they belong.

These tumors are most common in and about the uterus, and are referred to as intramural when developing in the true uterine tissue, and submucous and subserous when situated just beneath one or the other of the adjoining membranes. They differ in their rate of growth, are firm in composition, and are moderately vascular, sometimes containing areas of softening and becoming even cystic. In rare instances they become enormously vascular, and are then known as cavernous myomas. Aside from mucoid or colloid changes they occasionally undergo fatty metamorphosis or calcareous infiltration. The latter is possible to such an extent as to lead to a condition of uterine calculi.

Uterine myoma is liable to septic infection, which frequently follows exploration of the uterus or the changes incident to pregnancy or parturition. It then becomes a case for immediate operation. Uterine myomas do not occur before puberty, rarely before the age of thirty-five, and are most common between the thirty-fifth and forty-fifth years of life. They produce disaster not alone by their size, but by hemorrhage, by pressure on adjoining viscera (rectum, kidneys, etc.), and occasionally by torsion of a long pedicle.

Myomas are found in the esophagus, in the walls of the stomach, where they are frequently confounded with malignant tumors, in the prostate and wall of the bladder, and in connection with the skin. As soon as they give rise to inconvenience or to dangerous symptoms they are to be dealt with surgically, as no other treatment has proved of lasting benefit.

The rhabdomyomas deserve but brief description. The striated muscle fibers of which these tumors are composed have been often confused with spindle-shaped sarcoma cells. They are met with almost exclusively in the mixed tumors of the kidney under Teratomas.

Myoma or myofibroma is exceedingly likely to undergo sudden conversion into a form of growth entitling it to be called malignant myoma.

=Angioma.=--Angiomas are tumors composed of bloodvessels, and group themselves under three headings, in accordance with the structure of the vascular system:

1. =Capillary Angioma, or Nevus.=--Capillary angioma, or nevus, is the most common form of all, and is frequently seen in the skin and subcutaneous tissue. When the condition is spread over a relatively large area it gives rise to a discoloration known as port-wine mark, and called telangiectasis by the pathologists. The condition is often congenital or begins soon after birth. The color of the affected area determines whether the vessels belong to the venous or to the arterial system. These tumors may be found in all parts of the body, on the surface, on the submucous surfaces of the tongue, the inside of the mouth, the conjunctiva, and the vulva. The tendency is toward gradual increase in size; rarely, spontaneous contraction and obliteration occur.

2. =Cavernous Tumors.=--These are similar in structure to the corpus cavernosum, and are called erectile tumors. They are common in connection with the skin, and are exaggerated forms of the variety first described, the vessels becoming not merely dilated but cavernous in arrangement. They occur occasionally in the tongue, in the voluntary muscles, and in the liver, and are noted very rarely in the mammæ, in the larynx, and subperitoneally.

A similar condition is met with in the so-called cavernous tumors which involve various organs, especially the thyroid and the liver. In these instances a part or the whole of the organ may be involved, and presents great increase in size and evidences of vascularity.

In cavernous growths of the thyroid are vessels, veins especially, the size of the thumb, while with the ear not touching the body of the patient a distinct venous murmur may be heard.

3. =Arterial or Plexiform Angiomas.=--Arterial or plexiform angiomas, when of any particular size, are called cirsoid aneurysm or aneurysm by anastomosis. This form consists of arteries abnormal both in number, length, and diameter, tortuous in arrangement, occurring often in the scalp, but rarely in the perineum or genitalia, and seldom in other parts of the body. (See Aneurysm, Chapter XXIX.) These tumors are liable to rupture from external injury, and necessitate ligation of the main arterial trunks, with perhaps extirpation of the tumor mass.

Recognition of angiomas is not difficult unless they are deeply concealed. The effect of intermitting pressure, the emptying and refilling, and the distinction between arterial and venous growths by the result of alternating pressure and relaxation, either above or below the growth, with discoloration of the skin, and, in the larger growths, audible murmur, leave little doubt of the character of the growth.

When such growths are small they may be dealt with by electrolysis, the needles from both poles being introduced, or that from the negative, the positive being applied upon some neighboring portion of the body. The effect of the electric current is to determine coagulation of the blood in the tissues acted upon, and this is followed by organization of thrombus, conversion of vascular into cicatricial tissue, shrinkage, and possible eventual disappearance of the mass. Radical excision under an anesthetic should be made, dissecting out the mass, securing bleeding vessels, and reuniting the parts by sutures, with the expectation of securing primary union. This is the quickest and in many cases the least disfiguring method. Old methods of ligation of surrounding vessels or the subcutaneous ligature are now practically discarded. The injection methods as formerly practised, especially the use of iron salts in solution, are severely condemned, as death is liable to occur. With electrolysis and excision the surgeon has nearly all the measures which he will need to practise for the medical treatment of angiomas.

Lymphangioma of lip; macrocheilia. (Neisser.)]

=Lymphangioma.=--Lymphangiomas are tumors composed of lymph vessels and bear resemblance to the tumors above considered. They may be divided into three varieties:

1. =The Lymphatic Nevus.=--The lymphatic nevus is composed mostly of lymphatics nearly normal in size, and occasionally colored red by the presence of bloodvessels. When pricked, pure lymph or blood-stained lymph, will flow. They are usually small, and are noticed during childhood. They may occur anywhere upon the surface of the body or in the mouth, generally in connection with the tongue, where they may appear as large papillæ involving a portion or all of the dorsum. When the lymphatic structures of the tongue are thus enlarged and involved the condition is known as macroglossia, and consists of enlargement of the organ, sometimes to a degree not permitting its retention in the mouth, but leading to its constant protrusion (Fig. 81).

2. =Cavernous Lymphangioma.=--Cavernous lymphangioma corresponds to cavernous angioma, and is a condition in which the lymph vessels become positively cavernous and sacculated.

3. =Lymph Cysts.=--Lymph cysts are the still more aggravated form which lymphatic dilatation may attain, and are usually encapsulated, complicated with more or less tense tissue, and produce a condition of the parts, especially about the scrotum and labia, to which the term elephantiasis is often applied (Fig. 83).

The question of congenital occlusion or dilatation of lymph channels is one which has been made the subject of large separate monographs (especially by Busey). Numerous tumors, essentially of lymph-vascular origin, are found upon the lips, in the neck, and elsewhere, which grow slowly, are more or less elastic and spongy upon pressure, are frequently covered with skin, from which hair grows most luxuriantly, and in which pigment or papillomatous structures are dispersed. These tumors are called cavernous tumors, are of slow growth, and undergo spontaneous involution, but usually require surgical relief. They are often confounded with branchiogenic and other congenital cysts of the neck.

=Treatment.=--The treatment for the smaller lymphatic tumors is simple, but here electricity is less to be relied upon and excision is more urgently demanded. Electrolysis will cause coagulation of blood, but not of lymph--at least not to nearly the same extent; consequently its usefulness is restricted to blood-vascular tumors. Excision, then, is the best remedy. When this is impracticable much can be done by galvanopuncture or ignipuncture, the cicatricial contraction following multiple punctures leading to reduction in size of the affected part. The enlargement of the tongue spoken of above as macroglossia may be treated by ignipuncture or by electrolysis, if necessary under an anesthetic, the effect of the electric current here being not to produce coagulation, but apparently absorption of fibrous tissue and changes which come slowly rather than by obliterative processes.

Congenital lymphangioma. (Original.)]

Lymphangioma of lower extremity. (Original.)]

5. =Tumors of Nerve Elements.=

=Glioma.=--Glioma is a malignant tumor developing directly from actual nerve structure or that of the original nerve elements, and is clinically allied to the sarcomas. It arises from the neuroglia, and hence is confined to the central and peripheral nervous system, mainly the former. It is most common in the brain, the cord, and in connection with the optic nerve and fundus of the eye. It is often extremely vascular, the vessels being sacculated, and is usually met with in solitary form. When near the surface of the cortex such a tumor may appear like a great convolution (Virchow). In the basal portions of the brain it may attain considerable size. In the cord it is rare, usually limited to the cervical region. In the orbit and eye it may produce marked exophthalmos. It is more frequent in the young than in the aged.

Glioma is an exceedingly malignant form of tumor, and operation is rarely performed sufficiently early to more than prolong life. Dissemination by continuity is the rule rather than metastasis. It kills usually by its pressure effect on the nerve centres.

=Neuroma.=--True neuromas spring from the structures of nerve trunks, which trunks may also be the site of other tumors, mainly fibromas and sarcomas, with which neuromas may be easily confounded. The most common nerve tumor is the neurofibroma, which grows from the structure of a nerve sheath, its long axis usually coinciding with that of the nerve trunk. Tumors of this class vary greatly in size, are often multiple, and in other instances affect nearly all the nerves in the body. They are extremely liable to myxomatous degeneration, which will account for many of the instances reported as myxoneuroma, etc. They attack cranial and spinal nerves alike, and no nerve or nerve root in the body is exempt. The sensory nerves appear more liable to attack than the motor. The nerve least often attacked is the optic. They are not rare upon the roots of the spinal nerves, in which location they may attain to such size as to press upon the cord and induce paraplegia. Multiple neuromas are often associated with molluscum fibrosum (q. v.). There is an instance on record in which 1600 of these tumors were found after careful dissection of the neuroskeleton, and another in which at least 2000 were found, 60 of them involving the pneumogastric trunks and their branches.

Plexiform neuroma, dissected free from all adherent tissues. (Lexer.)]

Plexiform neuroma of chest wall in a young child. Illustrating its gross external resemblance to lymphangioma. (Lexer.)]

=Plexiform Neuroma.=--Plexiform neuroma is relatively rare. This is a type of nerve tumor in which all the branches of a given nerve which are distributed to a particular area become enlarged and elongated, the overlying skin being stretched and thin. Such a tumor seems like a loose bag containing a number of vermiform bodies, resembling the sensation given when palpating a varicocele. On section each of the affected nerves reveals a quantity of myxomatous tissue replacing the nerve sheath. They are in large measure congenital. The skin overlying a plexiform neuroma will frequently be found to be pigmented, variously altered in thickness, and covered with fine hair. These growths have been frequently mistaken for lymphangioma (Figs. 84 and 85).

=Malignant Neuroma.=--Malignant neuroma (so called) will generally be found to be a true sarcoma of nerve structures, usually of the spindle-cell variety. Traumatic neuroma is often seen in amputation stumps, where the terminations of the divided nerves become bulbous, attaining the size of cherry stones, the tumors being composed of a mixture of connective tissues and nerve fiber, from which in time the true nerve structure usually recedes or vanishes. They form when suppuration has been profuse or healing long delayed, and when sufficient care has not been exercised to prevent entangling of the nerve ends in the scar of the wound. They give rise to much pain, and often necessitate re-amputation. The bulbous enlargement is the result of prolonged irritation in a nerve, and has been noted around various foreign bodies.

True neuroma is innocent in tendency, though often painful. It is the sarcoma of nerve tissue which produces signs of malignancy. A true neuroma which causes unendurable pain should, when accessible, be removed. It is sometimes possible to separate the tumor mass from the balance of the nerve trunk, and thus to remove it without excision of the nerve. At other times it is impossible to avoid division and ensuing paralysis. Divided nerve ends should be brought together by catgut suture, by which means it may be possible to avoid permanent loss of function. Nerve grafting is also resorted to for repairing such defects. Removal of painful neuromas due to injuries to the head has more than once been the means of curing traumatic epilepsy.

6. =Tumors Derived from Epithelium.=

These tumors consist of specific epithelial elements supported and more or less bound together by a vascular connective-tissue stroma. The only apparent exception to this statement is tumor of dental tissue. The teeth are positively modified and petrified or calcified epithelial products.

=Odontoma.=--The odontomas are tumors composed of one or more of the dental tissues, arising either from tooth changes or teeth in process of development. They may be divided, according to Sutton, as follows:

1. =Epithelial Odontomas.=--These are provided with a capsule, and present usually as a series of cysts separated by thin septa, containing mucoid fluid, while the growing portions have a reddish tint not unlike sarcoma. They are most frequent about the twentieth year of life, but may occur at any age. They probably arise from persistent remains of the epithelium of the original enamel organs.

2. =Follicular Odontomas.=--These are often called “dentigerous cysts.” They arise in connection with permanent teeth, and especially with the molars, sometimes attaining great size and producing conspicuous deformity. The tumor consists of a wall representing the expanded tooth follicle, and a cavity containing viscid fluid, with some part of an imperfectly developed tooth, occasionally loose and more or less displaced in location. The cyst wall always contains calcareous material. These tumors rarely suppurate. They occur also in animals.

3. =Fibrous Odontomas.=--These consist of condensed connective tissue in a developing tooth, presenting as a tumor with a firm outer wall and a loose inner texture, blending at the root of the tooth with the dental papilla and indistinguishable from it. The developing tooth thus becomes enclosed within the capsule before it protrudes from the gum. These tumors are most common in ruminants, being often multiple.

4. =Cementoma.=--A tumor of fibrous character whose capsule has ossified or calcified, the developing tooth thus becoming embedded in a mass of dental cementum. These tumors occur most frequently in horses.

5. =Compound Follicular Odontomas.=--These are tumors containing a number of masses of cementum resembling small teeth, or even amounting to well-formed but ill-shaped teeth composed of all three dental elements. In such a tumor teeth may be found in great numbers. They occur in the human subject as well as in animals.

6. =Radicular Odontomas.=--These are tumors which arise after the crown of the tooth has been completed and while its roots are yet in process of formation. The crown, being unalterable enamel, does not enter into the composition of these growths, which then consists of dentine and cementum in varying proportions. They are rare in man, but frequent in other animals, and often multiple.

7. =Composite Odontomas.=--These are hard tumors, bearing little or no resemblance in shape to normal teeth, occurring in the jaws, consisting of a conglomeration of enamel, dentine, and cementum, presenting abnormal growth of all the elements of the tooth germ. So far this tumor has only been found in man.

Little is said about the odontomas in general surgical literature. These tumors, as they grow, are often regarded as due to necrosed bone or to unerupted teeth, while fibrous odontomas have been often regarded as myeloid sarcomas. No tumor of the jaw, especially in young people, should lead to excision of the jaw until it has been demonstrated that the tumor is not one of the above forms. When diagnosticated as true odontoma its complete removal is all that is necessary.

=Papilloma, or Fibro-epithelioma.=--The type of papilloma is this common wart, consisting of a central stem of fibrous tissue and bloodvessels covered by epithelial projections and proliferations. Papillomas are usually sessile and villous.

1. =Warts.=--These are sessile papillomas, most common on the skin, often seen on mucous surfaces, and occurring sometimes singly, often in crops. They are exceedingly common about the perineum, where skin and mucous membrane meet, and are regarded as due to the irritation of specific discharges. The papillomas occurring about the genitalia are known as condylomas. The growths in these instances are frequently so luxuriant and proliferative that they assume fungoid shape, and are called mulberry growths. Warts grow slowly or rapidly according to circumstances. Warty growths may attain enormous size and become vascular. Late in life they are frequently the starting points of epithelial ingrowths, and then become true epitheliomas--i. e., cancer. Warty growths sometimes line the buccal cavity and complicate cases of macroglossa. They occur also in the larynx, and when situated near the glottis may cause dyspnea and fatal obstruction to respiration. It is claimed by some that cutaneous warts will disappear with continued small internal dosage of Fowler’s solution. (See Plate XXI.)

Warts are by many pathologists considered as mere evidences of hypertrophy from persistent irritation. They are here retained among the tumors lest too much violence be done to formerly received notions.

Papilloma of the bladder.]

2. =Villous Papillomas.=--These are met with most commonly in the bladder, occasionally in the pelvis of the kidney. They are identical with chorionic villi, and occur most often singly. It frequently happens that long, fine tufts are detached and carried away with the escaping urine. Another form of villous growth arises from the choroid plexuses of the lateral ventricles in the brain. These may grow and attain a size sufficient to produce disturbance (Fig. 86).

3. =Intracystic Villous Growths.=--These are seen, for example, in mammary cysts. These, of course, are lined with epithelium, which acts here as it does in other localities, and proliferates more or less rapidly under unknown circumstances. In dealing with paroöphoritic cysts the presence of these growths has also been alluded to.

4. =Ovarian Papilloma.=--There is a form of ovarian papilloma which partakes of the nature of a malignant tumor, in that separated particles seem to attach themselves to peritoneal surfaces, where they grow luxuriantly. Either this is an expression of parasitism or infectivity, or else of the implantation of tumors, which, to the writer’s mind, constitutes a strong argument for the parasitism of cancer. After abdominal section, with removal of the original focus, these growths often disappear. This affords a parallel to the instances of cure of tuberculous peritonitis after the same procedure.

Photographic Reproduction of Papilloma. Low power. (Gaylord.)]

5. =Cutaneous Horns.=--These are also epithelial outgrowths, and are met with in four varieties (Sutton):

(a) Sebaceous horns, quite common, arising by protrusion of contents of a sebaceous cyst through a rupture in its wall or through its duct, with consequent desiccation by exposure to the air, while fresh material is consequently added at the basis so long as sebaceous secretion continues. These growths soften when soaked in weak liquor potassæ.

(b) Warty horns, structurally identical with the above, but growing from warts instead of from sebaceous cysts. Both these forms are often found about the head. Cutaneous horns are also met with in ovarian dermoids. They are common in the lower animals and may attain large size.

(c) Horns growing from cicatrices, especially of bones, are rare, but a cornified condition of the cicatrix itself, with formation of scales resembling those from horns, is not uncommon.

(d) Nail horns are simply overgrown nails, occurring on the digits and toes of bedridden patients who never walk (Fig. 87).

Nail horns. (Original.)]

=Treatment.=--All these forms of epithelial outgrowth call for radical removal, which implies complete extirpation of the membrane or tissue from which the growth occurs, after which, if effected, there is no recurrence. If some be left there is tendency to recedive.

=Mucous Polyp.=--Similar papillary and often pedunculated epithelial tumors frequently hang or project from the mucous membrane--e. g., the rectum. The pedicle really projects from the submucosa. Between the layers of the overgrown mucosa are found altered glands. So long as the growth of these polyps is toward the exposed surface they are innocent and wellnigh harmless, unless they attain fair size; but so soon as they grow inward and the boundary of the submucosa is transgressed they assume malignant aspects at once. Such transformation is by no means rare, and constitutes a strong argument for their prompt removal.

=Goitre; Struma.=--Pathologically the various enlargements of the thyroid known as goitre or struma constitute essential neoplasms. (See chapter on Regional Surgery of the Neck.) In this condition either the epithelial or the connective tissue may be primarily at fault.

1. =Struma Parenchymatosa Nodosa.=--This includes also the colloid and the cystic varieties, and refers to an enormous overproduction of the epithelial elements (parenchyma) in distended alveoli, where they often undergo colloid softening. So marked are these changes in numerous instances that multiple cysts (minute or large) result. The collective volume of such altered tissue may be very large.

2. =Struma Fibrosa.=--This presents itself in the way of dense enlargement of the thyroid, the stroma being the tissue now involved, even to the extent of causing much of the alveolar structure to disappear or become obliterated. In this condition calcification is common, and calcareous concretions or patches are often found.

Even benign tumors of the thyroid show occasionally a tendency to metastases. Cases are on record of benign goitre causing general metastases, and even of metastasis without noticeable thyroid enlargement. These occur most often in the bones, less frequently in the lungs and other organs. They are more common when the goitre has undergone colloid changes. The reasons for these changes are unknown.

In either form hemorrhages are common, with their resulting blood cysts or their solid residue, in which case pigment is usually found. Both forms are often accompanied by enlargement of the vessels, and sometimes these become enormously dilated and constitute an almost insuperable obstacle to successful removal. (See Thyroidectomy.)

=Ovarian Cystoma.=--The cystomas of the ovarian region assume two types: (1) Glandular cystoma, and (2) papillary cystoma.

1. =Glandular Cystoma.=--The glandular type produces the multilocular forms, with numerous small and large cavities, filled with fluid which varies in color and appearance within wide limits, having usually the consistency of mucus or thin pus, and containing a small number of cylindrical epithelial cells. The cyst wall may contain tubular glandlike structures reaching into the surrounding connective tissue.

2. =Papillary Cystoma.=--The papillary type presents projections into cavities of papillomatous outgrowths from their walls, which are covered by cylindrical epithelium, which latter also lines the cavities. It is most common in the parovarium.

It is rare to find a pure type of either variety; both forms are usually blended. Malignant transformation, of the latter type especially, occurs easily and insidiously, and explains many disappointments in result.

=Adenoma and Fibro-adenoma.=--Adenoma is a tumor whose type is the normal secreting gland, from which it differs in being an abnormal outgrowth or product, but particularly in that it has no power of producing the secretion peculiar to the gland tissue or type from which it grows. The adenomas occur for the most part as circumscribed tumors in the mammæ, parotid, thyroid, liver, and in the mucous membranes of the bowels and the uterus. They may be single or multiple; in the intestine they are usually multiple. In certain locations (e. g., the mammæ) they attain enormous dimensions, and in the ovary tumors of this character may be met with weighing forty or fifty pounds. The true adenoma shows no tendency to infection of neighboring lymphatics, and gives rise to no secondary deposit, and when it causes death it is usually because of size or pressure upon important organs. It displays a marked tendency to cystic alteration, while the relative proportion of epithelium and connective tissue or stroma varies within wide limits. In some cases, in which the former is small in amount, the preponderance of the latter has caused the use of the term adenosarcoma, which is really a misleading name.

The distinction between adenoma and true carcinoma is in some respects but slight, and this fact will account for the conversion which many innocent gland tumors seem to undergo from one into the other. As soon as the epithelial cells lose their regularity of disposition and collect in groups, or make their way outside of the acini into the tissues, then the change from the benign to the malignant tumor has begun, and the entire clinical aspect of the case has altered. This change may be the result of external irritation, of such tissue changes as pregnancy and lactation, or of the undefined changes which advancing years seem to produce. (See Plate XXII, Fig. 2.)

Adenoma occurs in the breast as cystic adenoma or fibro-adenoma. The former often attains large size, is encapsulated, the acini are much dilated, while from the walls of the epithelium-lined cavities frequently project papillomatous processes, forming what are called intracystic growths. Cystic adenomas grow slowly, produce atrophy of mammary tissue by pressure, occur after puberty until the menopause, and rarely give rise to pain until they become large. As they grow they distort the breast until it may become pendulous. When the growth of connective tissue, peculiar to the tumor in that it is rich in nuclei, forms well-marked partitions between alveoli, the growth is called pericanalicular adenofibroma, which may assume a tubular or an acinose type. When the alveoli and ducts are themselves invaded by ingrowth of this tissue, then we have the intracanalicular adenofibroma, which constitutes a growth sometimes bordering on the malignant. When the arrangement of epithelial cells in the acini and ducts becomes irregular and atypical, then malignant transformation has begun.

FIG. 1

Fibromyoma of Uterus. (Low power.)

FIG. 2

Fibro-adenoma of Breast. (Low power.)]

FIG. 1

Epithelial Pearl Formation in Squamous Epithelioma. (Middle power.)

FIG. 2

Malignant Adenoma of Rectum. (Middle power.)]

Fibro-adenoma occurs also in the breast as a small tumor, encapsulated, usually superficially placed, movable in its site, often multiple; most common between the twentieth and thirtieth years of life; often painful, especially during menstruation; tender upon pressure. Both forms may occur in young men. A form of fibro-adenoma in which fibrous tissue is greatly in excess, which never attains great size, is common in the breasts of unmarried women. It gives rise to much pain and distress, but is clinically not malignant. (See Plate XXII, Fig. 2.)

Adenoma occurs frequently in sebaceous glands as:

1. =Sebaceous Cysts.=--Sebaceous cysts are generally known as wens. These tumors commonly begin as retention cysts, the ducts of the sebaceous glands becoming occluded. But in many cases there is no occlusion of the ducts, and their secretion may be easily expressed. They occur wherever sebaceous glands abound, but especially upon the scalp. They are usually multiple, vary greatly in size, are easily movable over the bone, and are intimately related to the skin, while the duct orifice is frequently recognized by a black spot, after removing which sebum can be expressed. These cyst-adenomas are encapsulated, and can be easily shelled out of their matrices, save when inflamed, in which case they are often astonishingly adherent. Their contents consist of pultaceous debris resembling old epithelial scales, fat, cholesterin, etc. The contents of these cysts are very prone to decompose, and they become as offensive as anything with which the surgeon has to deal. Putrefaction may be independent of inflammation or coincident with it. When irritated these gland cysts become inflamed and may suppurate, suppuration being tantamount to cure by spontaneous processes. They may also ulcerate, without suppurating, and form foul-smelling ulcers, or give rise to cutaneous horns.

Multiple atheromatous cysts (wens). (Lexer.)]

2. =Sebaceous Adenomas.=--These arise from the sebaceous glands, which are lobulated, like those about the nose and ear. Adenomas from this source are extremely liable to ulceration, may undergo calcification, and are often mistaken for epithelioma because of the fungous ulcerations to which they give rise.

3. =Adenocarcinoma.=--Sutton has also described an adenocarcinoma of the peculiar sebaceous glands named after Tyson. These are found particularly at the base of the prepuce, this form of tumor being rare. Adenomas arising from the mucous glands, which are usually transformed into cysts, are also known, as well as other gland tumors springing from the glands of Bartholin, Cowper, etc. (See Plate XXIII, Fig. 2, and Plate XXIV.)

Pituitary adenomas are either analogous to struma or belong to the mixed tumors of dermoid or teratomatous type.

Prostatic adenoma is in large degree fibromyoma of that body, with more or less hypertrophy of its glandular structures. Minute cystic alterations may occur also, as well as growth resembling intracanalicular fibro-adenoma.

Adenoma is occasionally observed in the salivary glands, where it is usually encapsulated, and may undergo cystic changes. It has been observed in the liver and pancreas. In the former its pseudo-ducts often contain inspissated material of bile-green tint.

The lesions of the kidney referred to as cystadenoma are now grouped among the teratomas, and are described under that heading. They present interesting examples of mixed tumors.

In the testis, as in the ovary, epithelial tumors frequently present themselves, but they partake less often of the type of pure adenoma, and incline rather to that already described under Ovarian Cystoma. Even in the paradidymis tumors of this same character are found, with cystic or even papillary alterations.

In the mucous membrane of the stomach and bowels adenoma usually presents as an ovoid tumor, attaining such size as to give rise to mechanical obstruction either by pressure or by traction. Adenoma of the pyloric region is a repetition in structure of the pyloric glands. In the rectum it presents usually as a polypoid outgrowth, often seen in young children. Such tumors are generally small, and when solitary they often hang by a distinct stalk.

Similar polypoid tumors present in the cervical canal of the uterus, where are also found sessile and racemose tumors, all of which are structural repetitions of the glands met with in the cervix uteri. Adenoma of the uterine cavity is seldom seen; it is also rare in the Fallopian tube, but occasionally presents as a dendritic outgrowth from the mucous membrane distending the tube.

=Epithelioma.=--Epithelioma is common, especially where there is transition from one kind of epithelium to another, and, of all other localities, particularly where skin and mucous membrane meet--e. g., the lips, the vulva, and the anus. Epithelioma differs from papilloma in that the former is no longer limited by basement membrane, but passes beyond it into the underlying connective tissue and presents down--rather than up--growth. Characteristic of epithelioma are the so-called cell nests or pearly bodies, where there seems to be a tendency to globular arrangement of cells with such condensation or alteration that they lose their ability to take stains, and appear as a more or less lustrous mass, showing off by contrast among the standard surrounding tissue. On this account they are often called pearly bodies. Recognition of these is tantamount to diagnosis of epithelium. (See Plate XXIII.)

This form of neoplasm is essentially the same, no matter what its clinical varieties. These comprise a wart-like growth or nodule, which quickly becomes an ulcer with elevated edges, ulceration being due to necrosis of cells farthest from the periphery; or, again, the disease may start as an ulcerated fissure, ulceration and infiltration keeping pace, in which case there is a sharply defined ulcer with undermined edges. A third variety, often seen upon the lips, comprises a projecting mass, with more or less horny surface. In nearly all of these, however, the characteristic cell nests with their onion-like arrangements of cells will be found.

Epithelioma, especially when exposed to the air or to surface irritation, quickly ulcerates and tends to involve all the surrounding tissues, while occasionally the distinctive cells proliferate so rapidly as to give the ulcer more or less of a bursal or a cauliflower-like arrangement. From such a surface there is a constant discharge of foul-smelling detritus or of sloughs. Even bone cannot resist its progressive invasion and slowly disintegrates before the advancing mass. Cartilage is resistant, and usually preserves its integrity. In other words, the tendency of epithelioma is toward constant encroachment and infiltration, and toward a fatal termination from hemorrhage by ulceration, from septic infection, exhaustion, or other accidents. The wart-like forms run the slowest course of all, but even here the malignant tendency is most evident.

=Lymph-node Infection.=--A striking characteristic of epitheliomas is the invasion of the adjoining lymph nodes, which attain a size disproportionate and bearing no necessary relation to that of the primary growth. This constitutes one of the most serious complications of the condition. This lymphatic invasion partakes of the malignant character of the disease, and from every focus of this character infiltration and destruction proceed. Infected nodes also show an early tendency to central degeneration and to spurious cyst formation. When the overlying skin becomes involved we have extensive sloughing and the conversion into large malignant ulcers. Dissemination to a distance (i. e., metastasis) is rare in epithelioma--much more so than in carcinoma. (See Plate XXV, Fig. 2.)

About the mouth epithelioma is not common before the thirty-fifth year, though I have seen it on the lip of a twenty-year-old woman. It is vastly more common in men than in women, and more frequent on the lower than the upper lip. In the tongue it seldom occurs before the fortieth year. It seems to be more common both on the lip and tongue in men with bad teeth and in confirmed smokers, thus giving rise to the view often held that it is purely a matter of irritation. It may, however, be due to contact infection should it be regarded as of parasitic origin. In one-fifth of the cases of epithelioma of the tongue there are preceding lesions, usually described as leukoplakia or ichthyosis of the tongue--conditions characterized by epithelial reduplication and the formation of dense plaques or scales. These lesions are usually regarded as precancerous conditions. (See Plate XXVI.)

FIG. 1

Primary Papillary Adenocarcinoma of the Kidney. (One-half original size.) (Gaylord.)

FIG. 2

Papillary growth into tubule

Section of the Primary Growth. (Gaylord.)]

FIG. 1

Carcinoma developing in a Thrombus in the Portal Vein. (Middle power.) (Gaylord.)

FIG. 2

Metastasis of Squamous Epithelioma in a Lymph Node. Pearl Formation. (Middle Power.)]

FIG. 1

Epithelioma of Tongue. Enlarged three diameters.

FIG. 2

Paget’s Disease of the Nipple. Enlarged two diameters.

Photographs from hardened unstained specimens.]

The disease often starts near the stump of a carious tooth, in which case infiltration and erosion begin promptly and progress rapidly. Epithelioma of the tongue has been known to follow along the obliterated track of the thyrolingual duct, and in this way to bring about a perforating ulcer.

Epithelioma of the esophagus is a common cause of stricture of this passage-way. It leads to ulceration, and usually to perforation into the trachea or some other cavity or passage (i. e., a bloodvessel). In the larynx the disease is well known, and gives rise to intense and finally fatal symptoms, but has been dealt with successfully by radical operations for extirpation of the entire organ. (See Chapter XLI.)

Epithelioma of forehead and eyelid. (Neisser.)]

Epithelioma of lip. (Neisser.)]

Occurring upon the scrotum, epithelioma has been called chimney-sweeper’s cancer, or soot-warts, and has been ascribed to the irritation of foreign material. Ulceration and infection of the inguinal nodes usually proceed rapidly and disastrously. It is believed also that tar and paraffin may produce similar irritation, and paraffin cancer has been described by various writers. It usually occurs upon the scrotum.

The skin lesions which precede the formation of paraffin cancer resemble those seen in chimney-sweeper’s cancer. The skin becomes dry, thickened, parchment-like, while the openings of the sebaceous glands become obstructed by the tar or other material, producing acne-like lesions. Warty outgrowths then occur, and these become the seat of malignant ulceration. In chimney-sweeper’s cancer the scrotum is usually first affected in a chronic dermatitis, to which warty outgrowths succeed, these enlarging and growing downward as ulceration takes place.

About the external genitalia epithelioma is not uncommon, particularly in and about the prepuce. Such a degree of phimosis as leads to retention of smegma is certainly a predisposing cause, not only in man but in the lower animals. Epithelioma of the vulva has been described under the name esthiomène, and requires to be recognized and dealt with promptly if the surgeon should attempt a radical cure. In the vagina and about the cervix uteri it is common, a large proportion of cases of cancer of the uterus being essentially epitheliomas of the cervix.

In and about scars and upon granulating ulcers epithelioma is quite common. One danger to which a chronic ulcer is always exposed is that of epitheliomatous transformation. These growths also attack lupus scars, or even any tissues actively involved in the lupoid process. This is particularly true between the fortieth and sixtieth years of life.

Among the viscera the gall-bladder is probably more often involved in distinct epitheliomatous changes than any other. It presents as a uniform thickening, and causes augmentation in size, so that a distinct tumor projects from beneath the liver. In this location dessemination is rare.

Epithelioma is to be regarded as having an essential malignant tendency. Its treatment demands early removal of diseased parts and complete extirpation of involved lymph nodes. It is only the small and incipient growths which should be attacked by such destructive agencies as cancer pastes or the electrolytic current.

=Rodent Ulcers.=--Under the name of rodent ulcers, lupus exedens, noli-me-tangere, etc., writers, mostly English, have described a variety of epithelioma, met especially upon the face, to which a separate classification has usually been assigned. Until recently it has been generally regarded as a local ulceration, distinct from cancer. In some text-books it is described as lupus exedens. It is preceded usually by a nodular condition of the skin, vascular, breaking down into a regular ulceration, but little elevated, the base of the ulcer deeply excavated, with a striking disproportion between ulceration and new-growth. In this particular variety infiltration seems to be continuously in advance of the rodent process, the former being excessive, the latter but slight. This variety of epithelioma rarely produces lymphatic involvement; the discharge is slight, the pain complained of inconsiderable. Occasionally it entirely alters its aspect, and may present features of the conventional epitheliomatous type.

FIG. 92

Rodent ulcer. (Original.)]

The development of cancer in lupus areas is now of sufficiently frequent occurrence to demand attention. Whether the epithelium which gives rise to it is to be accounted for by Cohnheim’s hypothesis, as having been cut off in the course of healing and become a cell rest to subsequently undergo malignant degeneration, is not yet settled. It has been suggested that curettage might cause fragments of epidermis to be loosened and then entangled in the cicatrix, and thus be responsible for subsequent malignant changes. When lupus thus degenerates it assumes usually the papillomatous form, which rarely involves lymph nodes, while the change which follows x-ray treatment often succeeds a hyperkeratosis and rapidly involves gland structure.

Rodent ulcer allies itself with the type of tubular epithelioma springing from the outer sheath of the hair follicle, sending out cylindrical processes which freely blend with one another. It is to be regarded as an equally malignant type of ulceration with other cancerous ulcers, and demands the same thorough and radical measures for its relief as do other forms of epithelioma. It is perhaps the most favorable one with which to deal, because of the usual freedom from involvement of deep lymphatics. No distinctive measures are necessary for its relief--only those which are thorough.

=Carcinoma.=--Carcinoma is a tumor springing from preëxisting gland tissue, which it more or less closely resembles in type, save that the structural similarity is incomplete, the epithelial cells now collecting in irregular clusters, or filling the acini and obstructing the ducts, or bursting beyond the basement membrane and invading the surrounding tissues. They frequently so fill the ducts as to appear in columnar arrangement when seen under the microscope, and this has given rise to the use of a term so vague as to have no place in pathology--i. e., cylindroma. Carcinomas may arise from any of the secreting glands, but more commonly from some than from others. They have no capsules. They infiltrate the surrounding tissues, usually involve the lymphatics early, are liable to spread to the superficial tissues and to ulcerate, and to undergo various degenerative changes. Nearly all cancerous tumors abound in lymphatics, which will explain the rapidity with which the lymph nodes become infected, as well as the tendency to dissemination, which is characteristic of these growths. Dissemination leads to so-called secondary or metastatic growths, which may make their appearance in any organ or tissue, even in the bones, where they give rise to changes of texture that make spontaneous fracture easy. It is characteristic of carcinoma that the metastatic tumors which it may produce will reproduce almost perfectly the type of the primary tumor whence the embolic fragments which have produced them spring. The amount of dissemination varies exceedingly: it may even become so marked and widespread as to produce a condition analogous to that met with in miliary tuberculosis--miliary carcinosis. A similar condition, much more rare, is seen in dissemination of sarcoma, and is known as miliary sarcomatosis. A constantly spreading cancerous infiltration of the superficial tissues, which is noted most often after mammary cancer, is described under the form of cancer en cuirasse, or jacket or corset cancer. Instances will be seen in which this infiltration of the surrounding structures has extended nearly or even completely around the thorax. It gives rise to a brawny induration which is unyielding, and is studded here and there by nodules that tend to ulcerate, to fungate, and to bleed easily. It is perhaps the most hopeless form of cancerous disease.

The older writers have constituted two or three clinically distinct forms of carcinoma, based mainly upon the relative hardness or softness of the tumor and the invaded tissues. The term scirrhus is thus applied to a tumor in which connective tissue preponderates and epithelial cells are relatively deficient. On the other hand, the term encephaloid has been applied to a tumor in which the connective tissue seems barely sufficient to hold the mass together, while the epithelial cells are in vast preponderance. These are all tumors of the round epithelial-cell type, and these distinctions are of clinical interest, yet have no great pathological import, save that in a general way the greater the proportion of epithelial elements the sooner will life be terminated by destructive processes. In other words, the more the tumor may partake of the encephaloid type the worse the prognosis or the shorter the probable duration of life. Again, these tumors pursue a varying clinical course. In those tumors, particularly of the scirrhus type, where the connective tissue largely preponderates, there is often an eventual reduction in the size of the part involved, and such reduction of vascularity and of nutritive activity that the rate of growth is thereby perceptibly checked. The so-called atrophying cancers of the breast are the best examples of this type of cancerous disease. Here the volume of the gland is diminished rather than augmented, and the disease may last for a number of years. It is questionable whether it is well to operate.

The so-called colloid forms of cancer are simply the expression of pathological changes occurring in growths of more distinct type. Thus colloid softening may occur in any tumor in which cancer cells predominate, and the so-called colloid cancers of the peritoneum, the ovary, etc., are either examples of such alterations or are possibly endotheliomas arising in these locations. The term villous cancer, with other terms like it, should be expunged from all scientific literature, unless these terms are used in purely adjective and clinical sense, for they imply nothing accurate as to histological structure, and are often misleading and inaccurate.

Carcinoma is most common in the following regions:

In the breast it appears particularly in two forms:

1. Acinous Cancer; and

2. Duct Cancer.

1. =Acinous Carcinoma.=--Acinous carcinoma is usually of the scirrhus type. It may arise at any portion of the breast, and if anywhere near the nipple it will cause retraction of that prominence, which is always pathognomonic; elsewhere it leads to puckering and adhesion of the overlying skin. These tumors infiltrate widely, especially along the connective-tissue stroma and the fibrous tissue which intersperses the fat of the breast. They are usually firm and sometimes exceedingly dense. A form of scirrhus known as atrophying scirrhus consists largely of strands of fibrous tissue, injected here and there with epithelial cells. It is the slowest in growing of all the forms of cancer, and by its contraction tends to reduce rather than augment the size of the mamma.

Acinous cancer is rare before the age of thirty, most common between forty and fifty. It occurs in women in all conditions of life, married and single, but is rarely noted in the male breast. The most dangerous form is that which appears during lactation. Ordinarily its progress is slow. As it augments in volume it infiltrates the surrounding tissues, becomes adherent to the pectoral fascia, infiltrates the muscle fibers, and finally attaches itself to the periosteum of the ribs. The infiltrated tissues tend to shrink rather than to increase in volume. Lymphatic injection occurs early in this form, and is a pathognomonic sign. It occurs mostly in the axillary lymphatic nodes, but may often be detected in the neck above the clavicle. When the skin is involved there is a tendency toward ulceration and fungoid condition. This is preceded by the purplish appearance of the tense skin. (See Plate XXVII.)

“Pig-skin” appearance of cancerous breast.]

Pain is an uncertain and variable feature. It is important to emphasize this fact, as many of these conditions have been lightly regarded because of freedom from pain. Pain is not a constant phenomenon in cancer. On the other hand, it is sometimes intense, either localized or radiating and referred to distant points. Pain is particularly noticed in cases which assume the form of cancer en cuirasse. Secondary deposits in viscera frequently occur, particularly in the abdominal organs and the lungs; but any organ may be the seat of secondary infection, and this is found occasionally in the bone-marrow, not alone of the sternum or ribs, but of distant bones, and is called marrow injection. As the result of cancerous affection of serous membranes effusions of fluid frequently take place, as in the pleura, peritoneum, and pericardium, and this fluid is often blood-stained.

In consequence of pressure upon the venous trunks in the axilla there is often a swelling of the arm upon the affected side, dropsical in character, known as lymphatic edema. The arm grows heavy, the patient loses control of it, and the skin may become so distended by effusion as to cause the limb to resemble a cast. This is due not alone to pressure upon the veins but to involvement of the lymphatics, and upon careful examination positive dilatation of the lymphatic vessels may be noted. Pain is a usual accompaniment of this form of edema.

2. =Duct Carcinoma.=--This appears especially about the time of the menopause, when glandular structure has disappeared and only ducts remain. It is common, without reference to cancer in these instances, to find cystic dilatation of numerous ducts, which vary in size from a mustard seed to that of a cherry. These are referred to by Sutton and others as involution cysts. They are filled with mucoid material and have a bluish tint. They occur usually upon the under surface of the gland. Such cystic breasts are common, and when appearing in diffused form may be easily mistaken for cancer. Pain is not frequent. This condition is certainly a precancerous stage, since the dilated ducts are often the starting points of cancer, and occasionally of papillomatous or villous outgrowths from their walls.

Duct cancer implies the form which arises in these dilated ducts, most commonly in the terminal branches, appearing ordinarily as a single tumor, but sometimes as a mass of separate nodules. Intracystic and intracanalicular growths of this character are often found. When assuming the truly cancerous phases they may be spoken of as duct cancers, otherwise as duct papillomas. They have generally been referred to as intracanalicular fibromas. Duct cancers are less tense than the preceding variety, and when situated near the surface often discolor the skin. It is from these cases that there is seen a more or less abundant discharge of fluid resembling bloody milk. These tumors grow slowly, lymphatic involvement is late, and in general they present the least malignant forms of breast cancer.

FIG. 1

Scirrhus Carcinoma of Breast. (Middle power.)

FIG. 2

Soft Infiltration Carcinoma of Breast, showing Stroma. (Mallory’s connective-tissue stain.)]

Carcinoma of sebaceous glands is by all means most common in those specialized glands named after Tyson, occurring about the prepuce. They give rise to the usual forms of cancer in this locality.

Carcinoma in the prostate is not common, and is usually confined to old men. Infiltration proceeds around the base of the bladder at the same time and binds the pelvic viscera together. The pelvic lymphatics become early infected and dissemination is frequent. (See Prostatic Hypertrophy.)

Recurring carcinoma of male breast. (Original.)]

Carcinoma in the salivary glands is not common; it is more frequent in the parotid region, occurring at middle life, growing rapidly, infiltrating surrounding parts, and tending to ulceration.

Carcinoma of the liver varies in its arrangement and appearance. Sometimes it appears in the form of nodules; at other times, as a more diffuse malignant infiltration by cells relatively abundant in number, so that the clinical aspects of the case conform rather to the encephaloid or medullary type.

Carcinoma of the kidney was formerly described as encephaloid, meaning thereby simply a malignant tumor of soft structure. It is probable that a large proportion of these tumors were sarcomas. Nevertheless, true carcinoma of the kidney is possible.

Carcinoma of the ovary may originate as such, or be the result of a transformation from an ovarian cystoma (see above). No better illustration can be offered of the infectivity of cancer cells (be the secret of this infectivity what it may) than the rapid dissemination of cancer throughout the peritoneal cavity, which sometimes follows the removal of an apparently non-malignant tumor which is undergoing this change.

On the other hand, in the testicle such tumors are common--more so than sarcomas. It is likely that many of them arise from the paradidymis.

Carcinoma of the stomach is a frequent disease. It involves the tubular glands, especially in the pyloric region, and conforms to them in type. After involving the mucosa it spreads to the entire coats of the stomach and infiltrates adjacent structures, while the mesenteric lymphatics are usually early and notably involved. Were it possible to recognize this involvement early in the course of the disease diagnosis of pyloric cancer and operative interference would be much more common and hopeful. Secondary involvement is generally in the adjoining viscera, but may be seen at a distance. Miliary carcinosis has been noted after pyloric cancer. This form usually occurs between the fortieth and sixtieth years of life, the duration of the disease not being long.

In the intestine, and particularly in the rectum, carcinoma proceeds also from the mucous glands, and tends constantly to extend at its periphery and involve the entire lumen of the bowel. It seems to be inseparable from a tendency to contraction of the gut and consequent annular stricture. Ulceration, favored by surface irritation and infection, occurs almost always early. Above the rectum it usually occurs in the neighborhood of the sigmoid flexure. Cripps has observed that when cancer of the rectum spreads downward and involves the anus, it loses its typical glandular character and assumes the type of epithelioma, or squamous-cell cancer. In these cases the pelvic and mesenteric lymphatics are infiltrated and metastatic affections are common.

Carcinoma may appear in any portion of the uterus, but is more common in the lower than in the upper half. It assumes the type of the cervical glands, spreads rapidly, infiltrates widely, ulcerates early, and disseminates frequently. By extension of ulceration the formation of urinary and of fecal fistulæ is common. Pyosalpinx and hydrosalpinx are also favored, while the spread of the disease is, in fact, more common when it involves the cervix than when it involves the uterine fundus.

=Malignant Chorion Epithelioma.=--This has also been called deciduoma malignum, a malignant growth of chorionic epithelium. Inasmuch as this tumor also includes a syncytial layer it has been known as syncytioma. Such tumors usually contain elements derived from both layers of the chorion. They follow pregnancy, generally within a few months, and are often preceded or accompanied by a hydatidiform mole. This growth constitutes a malignant neoplasm. It pertains to ulcerating uterine growths characterized by early extensive metastasis, which prove fatal. It has been shown that similar growths occur not only in the uterus but also in the testicle, and thus the scope of the term has been much enlarged. In its biology it resembles the sarcoma; in its histology, the carcinoma. It is more malignant than any other known growth. (See Plate XXVIII.)

Occurring within the uterus its most important clinical feature is a tendency to frequent and alarming hemorrhage. When occurring about the testicle this trouble rapidly becomes fungoid, bleeding easily and excessively, the lungs being among the first organs to show metastasis, which takes place through the blood as well as the lymphatic vessels, for the cells of these growths seem to penetrate the capillaries. By the time a diagnosis is made a case is likely to be too far advanced to admit of radical treatment. If scrapings could be examined early, shreds of syncytioma would be found, and it might be possible that a complete hysterectomy would be of use.

Metastatic nodules consist mostly of round, dark masses presenting a more or less pronounced fibrous structure. These are generally found in the lungs and cerebrum, where the vessels are large and the tissues soft. There is usually a sharp contrast between such a tumor and the surrounding tissues. The time which elapses between delivery and the appearance of the growth is from three to ten weeks. The tumor rapidly spreads to the upper portion of the vagina. The trouble probably begins some time before delivery.

The latest tendency among pathologists is to refer a growth of this kind to the teratomas. In women this tumor is particularly a teratoid growth, some cells of the fecundated ovum giving rise to neoplasms, while the ovum itself thus derived may misdevelop into a hydatidiform mole. The tumor may be properly regarded as consisting in effect of fetal cells; it is built up of these cells, without bloodvessels and connective tissue, and so belongs to a class by itself. Occurring in women it is almost always a consequence of pregnancy; occurring in the testicle or in the ovary it should be regarded as proceeding from ectodermal cells. For their treatment the earliest and most radical measures only will suffice.

=Suprarenal Epithelioma; Hypernephroma.=--Grawitz has distinctly established the right of these tumors to separate consideration, for he first determined their origin and identity. Hypernephroma is a tumor, found mainly in the kidney, composed of adrenal rests, or bits of accessory suprarenal tissue imprisoned within the renal capsule. Their minute structure is often that of the adrenals, with a tendency toward the type of perithelioma. They have hitherto been considered examples of sarcoma of the kidney, but are to be abruptly distinguished from it in most instances. Tumors of this character have also been found within the capsule of the liver and along the spermatic artery. In the kidney the tumor portion is usually distinct from the renal tissue; it is often enclosed within a sort of capsule, and rarely connects with the pelvis. Hence, though exceedingly liable to hemorrhages, blood rarely escapes by the ureter. Hypernephroma is delicate in structure, and its vessels give way readily. After this has happened a true hematoma may result. (See Plate XXVIII.)

Similar neoplasms form in the adrenals themselves. These tumors vary in degree of malignancy, some of them scarcely deserving the designation malignant. They may be met at any age, but are more common in adult life. Before removal they are not to be differentiated from other tumors of the kidney. Their cells manifest this peculiarity in that they contain a notable percentage of glycogen. It should also be added that even in true sarcoma of the kidney proliferating adrenal elements may be found.

FIG. 1

Hypernephroma Renalis. (Medium magnification.)

FIG. 2

Chorion Epithelioma.]

GENERAL DIAGNOSTIC FEATURES OF MALIGNANT GROWTHS.

The following tables are here inserted, trusting that they may aid the young practitioner in distinguishing in a general way between benign and malignant tumors, and even in making a diagnosis between sarcoma and carcinoma. I have also inserted a table differentiating the clinical appearances of epithelioma and of lupus. In these tables comprehensiveness has not been aimed at, rather simplicity, while it is not denied that cases are met with in which diagnosis may be exceedingly difficult, and in which the common signs herein mentioned may be found either absent or misleading:

TABLE I.--DIFFERENTIATION BETWEEN BENIGN AND MALIGNANT GROWTHS.

Benign Growths. Malignant Growths.

Common at all ages. Rare in early life. Usually slow in growth. Usually rapid in growth. No evidences of infiltration or Infiltration in all cases, dissemination. dissemination in many. Are often encapsulated, nearly Never encapsulated, seldom always circumscribed. circumscribed. Rarely adherent unless inflamed. Always adherent. Rarely ulcerate. Often ulcerate--nearly always when surface is involved. Overlying tissue not retracted. Overlying tissue nearly always retracted. No lymphatic involvement when not Lymphatic involvement an almost inflamed. constant feature. No leukocytosis. Leukocytosis often marked. Elimination of urea unaffected. Deficient elimination of urea (?).

TABLE II.--DIAGNOSIS BETWEEN SARCOMA AND CARCINOMA.

Sarcoma. Carcinoma.

Occurs at any age. Rare before thirtieth year of life. Disseminates by the bloodvessels Disseminations by the lymphatics. (veins). Arises from mesoblastic Arises from glandular (epithelial) structures. tissues. Distant metastases are more Less so. common. Contains blood channels rather Contains vessels of normal type. than complete bloodvessels. Less prone to ulceration. More so. Involvement of adjacent Almost invariably adjacent lymphatics not common. lymphatics are involved. Secondary changes and Degenerations not common; other degenerations are more common. secondary changes rare. (Sugar present in the blood?) (Peptone present in the blood?)

Differential diagnosis between epithelioma and ulcerating gumma will be found in Chapter X.

TABLE III.--DIAGNOSIS BETWEEN EPITHELIOMA AND TUBERCULOSIS (LUPUS).

Epithelioma. Tuberculosis (Lupus).

Preceded usually by continued Irritation plays no figure. Preceded irritation or warty growths. usually by nodules. Diathesis plays no known part. Diathesis evident. Coincident evidences of tuberculous disease elsewhere. Rarely multiple. Often multiple. Area of thickening ahead of Extension of ulceration not preceded ulceration. by thickening. Ulceration advancing from a Various foci, which may coalesce. central focus. Border usually raised and Border abrupt, eaten, irregular, everted, regular in outline. thickened, firm, often inverted, irregular in outline. Often assumes fungoid type. Never fungoid. Base may be deeply excavated. Base nearly level with surface. Usually painful. Seldom painful. Bleeds easily. Seldom bleeds. Never tends to cicatrize. As marginal ulceration proceeds there is often cicatrization at centre. Most rare in the young. Common in the young. Discharge is very offensive. Discharge rarely offensive. Lymphatic involvement nearly Rarely. always.

GENERAL CONSIDERATIONS CONCERNING CANCER.

Cancer is one of the most fatal of diseases, yet has no symptomatology of its own. It produces no symptoms which may not be produced by other affections, and this lack of pathognomonic features constitutes one of the great difficulties in diagnosis. It may disturb every function of the part involved. Experimenters have sought in vain for a distinctive feature by which the disease can be recognized; neither in the blood nor in the various organic tissues have such changes been found that can be explained only on the hypothesis of cancer. The pain which it is supposed to cause is often lacking, and is extremely variable and uncertain. The cachexia of its terminal stages is not characteristic, no matter how pronounced, and may be explained by a variety of conditions, all of which may accompany the disease. The search for the suspected parasites cannot be made with such certainty as to lead to any definite conclusions. It is known by a complex of clinical conditions or by microscopic sections of tissues already removed.

When the disease is superficial it is easily recognized, but when deep-seated, recognition comes later.

Since the discovery of Spirochæta pallida in syphilis, Mulzer and Loewenthal have found spiral organisms on the surface of ulcerating tumors. Borrel also found spirochætæ in conjunction with helminthia in two enclosed mouse tumors, and also in a large tumor sent from Ehrlich’s laboratory. None of these authors attributed any significance to the presence of these organisms, but recently, through the publication of Gaylord, in the Journal of Infectious Diseases, who has found a characteristic small spiral organism in nine out of ten primary mouse tumors, and in all of the transplanted mouse tumors of three distinct strains in the New York State Cancer Laboratory, the subject has attracted new interest.

Rat with primary cystosarcoma of thyroid; cage infection in previously healthy animal kept in cage formerly occupied by rat with same condition. (Gaylord and Clowes, Jour. Amer. Med. Assoc., January 5, 1907.)]

Rat with tumor produced by transplantation from that represented in Fig. 95. (Gaylord and Clowes, loc. cit.)]

Gaylord’s organism is best demonstrated by the Levaditi silver method, but can be seen by experienced observers in the living fresh state. It measures from 2.5 to 7.8 microns in length, and the individuals have from four to thirteen closely packed abrupt turns. The organism measures 0.6 micron in diameter. Thus far it has been impossible to stain it with any of the aniline stains, which characteristic appears to distinguish it from the organism described by Borrel and Loewenthal. Calkins has also found this organism in a spontaneous mouse tumor in New York. The distribution of the organism in the growing periphery of the tumors, when considered in the light of Fischer’s work with Scarlet-R, would make it appear not impossible that the organism bears an etiological relation to the tumors in which it occurs.

In the light of the well-authenticated cases of cage infection and the evidence of immunity now definitely determined, the way should be prepared for the discovery of the organism or organisms of cancer. At present this organism would appear strongly in evidence as its cause.

The microscopic picture may explain considerable in regard to the future as well as the past. For instance, in a case of sarcoma the presence of small, round cells, and especially of pigment, bespeaks a degree of malignancy which probably nothing yet known can baffle. A chemical examination of the tumor after removal may make the surgeon alert regarding the future of the case, according to the amount of glycogen contained within the mass, since the glycogen content is in direct proportion to its malignancy. For a while some reliance was placed upon the percentage of urea elimination, but this is influenced by so many factors as to have proved unreliable.

The relations which cancer bears to other diseases are of considerable interest. Those between cancer and trauma have been discussed; tuberculosis perhaps is the condition which, next to pure local irritation, predisposes to cancerous invasion. The transformation of tuberculous into cancerous lesions can be best appreciated where it can be most readily inspected, i. e., on the skin, and it is well known that lupus lesions frequently undergo this change. This is also true of large ulcers, which may undergo a direct transformation into epithelioma, or pass through the intermediate stage of tuberculous infection. Cancer in tuberculous lymph nodes is also a matter of interest. Again, cancers and tuberculous lesions may exist side by side in the same organ, as in the lung or the brain. Distinct sarcomatous nodules have been found in infiltrated lungs and alongside of tuberculous cavities, while cancer of the face will not infrequently be found associated with tuberculosis of the cervical lymphatics. Lubarsch has claimed that 4 to 5 per cent. of tuberculous patients suffer also from cancer, and that about 20 per cent. of cancer patients suffer from tuberculosis.

The method of death in cancerous patients is as free from distinctive characteristics as the course of the disease. It is usually associated with two prominent features, malnutrition and some terminal infection. At the last there is usually some toxemia, which renders the closing hours free from actual pain, while if the toxemia be profound patients may linger unconscious for several days.

GENERAL REMARKS ON THE TREATMENT OF CANCER.

Accepting the views expressed when discussing the nature of the cancerous process, the following may be assumed to be true: Cancer begins as a local disease. There is therefore a period in its history when if it be recognized in time, if it be or can be made accessible, and if it be thoroughly removed, it can be frequently cured. The “ifs” in the foregoing statement afford such insuperable obstacles in so many cases that the difficulties in the way of treatment are very great. It has been said that, “The resources of surgery are rarely successful when practised upon the dying.” It happens too often that these cases are not submitted to the surgeon until long after the favorable period above indicated is past. This is explained by the difficulties of diagnosis, by the inaccessibility of many primary cancers, and by the unwillingness of patients to submit to the knife. Nevertheless the best time to treat a cancer is when its existence is first suspected, and the best way is the most radical, i. e., by thorough extirpation.

While such extirpation should include a wide area of apparently healthy tissue and of the entire organ which seems to be involved, for instance, in the case of the liver, this last may be impossible; and yet by removal of a considerable area of healthy liver around a cancerous gall-bladder the writer has seen complete and apparent final recovery follow. The principal direction is to be thorough.

That cancer so often returns after operative attack is largely due to the fact that the general practitioner, under whose observation most of these cases first come, is slow to recognize the malady, and timid to advise radical methods.

It has been recognized that in cancer the internal administration of arsenic has been beneficial. In order to obtain the best results from its use, it must be pushed to the physiological limit and in preparations of the most active and reliable kind.

The preparations of arsenic which have proved most satisfactory are the imported cacodylate of sodium, which comes in capsules ready sterilized for use, and the following solution, which is original and needs to be made up in accordance with the formula herewith furnished:

(1) Dissolve 7 grains mercuric biniodide with 10 grains potassium iodide in a little water. (2) Dissolve 48 grains arsenic bromide in a little water with the aid of gentle heat. (3) Dissolve 24 grains gold chloride in a small amount of water. (4) Mix the mercuric and the arsenic solutions and then add the gold solution, which will cause a whitish precipitate, becoming brownish in color. (5) Heat this mixture and decant the clear portions, setting it aside. (6) Add 2 drachms nitromuriatic acid to the above precipitate and heat gently until a clear red solution results. (7) Add to this the decanted portion of 5, which will cause a reddish precipitate. Heat the whole mixture up to the boiling point and until all residue is dissolved. (8) Add sufficient distilled water to make 15 fluidounces. The product should be bright, clear, and wine colored.

Of this solution 10 drops are supposed to represent ¹⁄₁₀₀ grain mercuric chloride, ¹⁄₃₀ grain gold chloride, ¹⁄₁₅ grain arsenic bromide. The commencing dose is 10 minims, which may be increased to 25 or more, taken in abundance of water.

=Treatment by Toxins of Erysipelas.=--A number of years ago Fehleisen, calling attention to the fact that cancers had seemed to improve or possibly even disappear after an attack of erysipelas, suggested deliberate infection of the surface of such a growth from a case of erysipelas. In this procedure he met with some success, but there were numerous objections to it, one being the impossibility of controlling the spread of the infection thus produced. Coley, of New York, then undertook a much more systematic study of the relation between the two diseases, and devised a method of injecting the toxins produced by the streptococci of erysipelas and of reinforcing them, if necessary, by those of the bacillus prodigiosus. The intent of this treatment is to produce reasonable reaction in the hope of mitigating the rapidity of the growth, checking its progress, or even causing its disappearance. It has been on trial now for several years, and while in a few cases of sarcoma, especially in the hands of its originator, the treatment has apparently been of service, it has proved disappointing in the majority of instances.

=Liquid Air.=--The application of liquid air to superficial malignant growths has proved successful in a number of instances, but inasmuch as this is practicable in only one or two of the largest cities of the country, it is not a measure which need be discussed here at length. The liquid seems to act as an almost painless escharotic, and its use produces sloughing, or a drying up under a scab, which after a day or two will loosen and be easily detached.

=Radium.=--This remarkable element has aroused within the past few years an amount of scientific interest and experimentation with which there is little else to compare. The enormous expense of a preparation of any great activity, and the rather bewildering contradictory statements which have been made by those who use the weaker preparations, have caused it to occupy a doubtful position in any list of reliable therapeutic agencies. It is undeniable that certain rodent ulcers, tuberculous lesions of the skin, and a few carcinomatous lesions have been much improved or apparently cured by its use. It is ordinarily used in glass or aluminum tubes or capsules, which are applied upon the surface of the growth to be treated. It has also been used sprinkled upon a plaster whose surface has been prepared with Canada balsam, and thus directly applied. Again, it has been enclosed in a capsule to which a strong silk thread has been fastened so that the former may be swallowed, retained in the stomach for a few hours, and then withdrawn. These last means of using it are of questionable value. Of still less value are the suggestions to dissolve it in water or to administer water in which a receptacle containing radium has been allowed to stand. There is much of interest and perhaps something of value in radiotherapy, but nothing as yet of positive value in the hands of the profession generally.

=Ultraviolet Light=, or, as it is often named after its promoter, Finsen light, has proved of value in many cases of lupus, and in some cases of superficial epithelioma. Its effects, however, can scarcely be made to penetrate into the deeper tissues, and in its use it is even necessary to make pressure upon the part treated with quartz compressors, because ordinary glass shuts out a great proportion of these rays from whatever source may produce them, and because it is necessary to create a temporary anemia of the lesions, as the fluids of the body have the same effect as does glass. For these reasons the method, which is of but limited value, can be made serviceable in but a small proportion of cases.

=X-ray Therapy.=--The Röntgen or cathode rays have played a large part during the last few years in the therapy of cancer. Such varying statements have been made concerning their value as to keep them still on trial and nothing very positive can be said regarding their efficacy. It may be said, however, that the nearer the malignant growth is to the surface of the body the more promptly can their effects be produced. The superficial growths, especially of the epitheliomatous variety, often yield readily to their use; the deeper the lesion the more vague the effect, both in character and permanence. It has been the writer’s experience that they furnish the best method of relieving pain, in a large number of these growths, short of the anodyne effects produced by powerful drugs, which are in every other respect undesirable. He holds that no one can predicate with certainty what may be their effect in any given instance, but that they are worthy a trial in every inoperable, painful, or otherwise hopeless case. Occasionally improvement follows their use, while in the next, apparently a similar case, one may be doomed to great disappointment. There are as yet no indications by which the cases which are most amenable can be easily recognized. Even in cases of extensive and disseminated abdominal cancer marvellous improvement may follow, but never a cure. It is indeed questionable whether deep cancer can ever be really cured by these means. As against their undoubted and unchallenged value in some instances, certain disadvantages are met in the difficulty of selecting a proper vacuum tube, the frequency and duration of exposure, the distance, etc. Dermatitis, sometimes mild, sometimes severe, has too often followed the injudicious use especially of a “high” tube, and more painful, irritable, or intractable ulcers are seldom seen than some following so-called “x-ray burns” of the skin. Moreover this is not the worst of these cases, for efforts intended for the best have been in repeated instances turned into a travesty by the development on surfaces thus burned of epithelioma, necessitating later mutilating operation. A well-known American surgeon suffered amputation of one hand and nearly all of the other as a penalty for inattention to the destructive effects of too prolonged exposure of his hands. It has, therefore, impressed itself upon the writer that the x-rays should not be indiscriminately employed. Nevertheless in skilled hands and used with great discretion they can be made a powerful instrument for good in many cases, especially for the relief of pain. They should never be regarded as a substitute for operation if operation be feasible, but they may often be employed to advantage after operating, in serious cases, where there is reason to fear recurrence.

The efficiency of the x-rays is apparently enhanced by the simultaneous administration of thyroid extract; although the explanation for this improvement is not known, it is, however, of enough importance to be borne in mind. The extract should be given in 5-grain doses three or four times a day. All the remarks above made may pertain as well to the employment of cathode rays in non-malignant affections, i. e., tuberculous lesions, neuralgia, etc.

=Miscellaneous Measures.=--A large number of suggestions concerning the treatment of cancer have emanated from various sources and from men of widely different views. Beaston, of Glasgow, being impressed by the physiological relationships and sympathies between the ovaries and the mammary glands, has suggested the benefit of the removal of the ovaries in hopeless cases of mammary cancer, holding that the nutrition of the mamma being thus influenced there would be more or less subsidence of pathological activity. He has reported instances in which, apparently, this measure had the desired effect; nevertheless it has not found general favor.

Based upon views concerning the hyperacidity of the blood and tissues in the cancerous condition, it is believed that there is a pronounced indication for the internal use of alkalies; and the hypodermic injection of 5 minims of a 1 per cent. solution of a chemically pure soap has been recommended by Webb, on the theory that it promotes the separation of cholesterin from the living cell. He would increase the dose until 60 minims are given at one time, every other day. A 20 per cent. solution of Chian turpentine, dissolved in sterile oil, has also been recommended to be used in the same way. These are recent suggestions of unknown value.

In the general management of cancer patients, two things should be kept in mind: (1) That they are entitled to relief from suffering in the least harmful way in which it may be offered, and (2) there comes a time in the history of many of these cases when all other considerations may be set aside in favor of comfort and tranquillity. Opium and other “drugs that enslave” have their disadvantages, but these cannot outweigh the benefit which they may confer in the last stages of cancer. The terminal pains of malignant disease should he assuaged at any necessary cost of other considerations.

But while all this is going on elimination must not be neglected. Opiates are peculiarly liable to diminish secretions and peristaltic activity. The skin, the kidneys, and the bowels should be kept active by measures which serve this purpose, and if it be desirable to prolong life, nutrition should be regulated and frequently administered, but it is absolutely necessary to maintain elimination.

The latest suggestion, viz., to treat cancer by injections of pancreatic ferments (trypsin and amylopsin), seems to the writer to be based upon erroneous notions concerning the nature and causation of the disease, and to hold out only specious hope of self-justification.