Class __BIL£lS \ 
 
 Book_ , S4-"1 2. 
 
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 COPSRIGHT DfcPOSir. 
 
THE 
 
 PATHOLOGY 
 
 AND 
 
 SURGICAL TREATMENT 
 
 TUMORS 
 
 BY 
 
 N. SENN, M.D., Ph.D., LL.D. 
 
 PROFESSOR OF SURGERY, RUSH MEDICAL COLLEGE, IN AFFILIATION WITH THE UNIVERSITY OF 
 CHICAGO J PROFESSOR OF SURGERY, CHICAGO POLYCLINIC ; ATTENDING SURGEON TO PRES- 
 BYTERIAN HOSPITAL ; SURGEON-IN-CHIEF, ST. JOSEPH'S HOSPITAL, CHICAGO. 
 
 SECOND EDITION, REVISED 
 
 ILLUSTRATED BY 478 ENGRAVINGS, AND 12 FULL-PAGE 
 PLATES IN COLORS 
 
 PHILADELPHIA 
 
 W. B. SAUNDERS 
 
 925 WALNUT STREET 
 1900 
 
TWO cop.po 
 
 Ubrary of Ce BfPet fc 
 
 APR 2 01900 
 
 HegJsttr of Copyrlgj,^ 
 
 Copyright, 1900 
 By W. B. SAUNDERS 
 
 SECOND COPY, 
 
 ELECTROTYPED BY PRESS OF 
 
 WESTCOTT & THOMSON, PH1LADA, W. B. SAUNDERS, PHILADA. 
 
 . /?) if 0-0 
 
TO THE MEMORY 
 
 SAMUEL DAVID GROSS 
 
 A MASTER IN SURGERY ; A PIONEER IN PATHOLOGICAL ANATOMY ; A SURGEON 
 
 HONORED AND REVERED WHEREVER HIPPOCRATIC MEDICINE IS TAUGHT 
 
 OR PRACTISED; A MAN WHOSE EMINENT PROFESSIONAL 
 
 REPUTATION WAS CROWNED BY THE PURITY 
 
 OF HIS PRIVATE CHARACTER, 
 
 THIS WORK IS 
 
 REVERENTLY AND AFFECTIONATELY INSCRIBED BY HIS FRIEND 
 
 THE AUTHOR. 
 
PREFACE TO THE SECOND EDITION. 
 
 During the time that has elapsed since the appearance of the first 
 edition of this work, no great discoveries or advancements have been 
 made concerning the nature and treatment of tumors. The parasitic 
 origin of malignant tumors continues to attract the attention of patholo- 
 gists and surgeons, but we have made very little progress in establishing 
 this theory by actual facts. In the proper place will be found an 
 account of recent work done in this direction, notably by Roncali, of 
 Rome. The text has been carefully revised and many additions have 
 been made. A new section has been added on Sarcoma of the 
 Decidua. Many of the old illustrations have been eliminated, and are 
 replaced by others intended to explain more satisfactorily the subjects 
 they represent. Most of the new illustrations are original. The pub- 
 lisher has again placed the author under many obligations for his 
 liberality in inserting so many new illustrations. 
 
 N. SENN. 
 
PREFACE. 
 
 The appearance of a treatise on " The Pathology and Surgical 
 Treatment of Tumors " at this time needs no apology. Books 
 specially devoted to this subject are few, and in our text-books and 
 systems of surgery this part of surgical pathology is usually condensed 
 to a degree incompatible with its scientific and clinical importance. 
 Again, the attention and energies of pathologists and surgeons during 
 the last quarter of a century have been directed more toward the 
 foundation and development of the new science of bacteriology and 
 the advancement and improvement of operative technique than to a 
 more thorough investigation of the equally important though less 
 inviting subject relating to the origin, nature, structure, clinical aspects, 
 and treatment of tumors. 
 
 Every teacher of pathology and surgery knows how difficult it is 
 to impart to the student a knowledge of the structure and clinical 
 tendencies of the different kinds of tumors sufficiently accurate to 
 enable him to make a reliable diagnosis at the bedside. The gen- 
 eral practitioner often remains painfully conscious of this defect in 
 his early training, and the surgeon is frequently in doubt when to 
 apply his art or when to pursue a conservative or palliative course 
 w T hen applied to for treatment by patients suffering from obscure 
 tumors or tumors presenting one or more of the numerous compli- 
 cations to which they are subject. 
 
 The author has spent many years in collecting the material for this 
 
 work, and has taken great pains to present it in a manner that should 
 
 prove useful as a text-book for the student, a work of reference for the 
 
 busy practitioner, and a reliable, safe guide for the surgeon. For 
 
 the purpose of simplifying diagnosis a special effort has been made 
 
 to trace every tumor to its proper anatomical starting-point and histo- 
 6 
 
PREFACE. 7 
 
 genetic source, and to make a sharp histological and clinical distinction 
 between true tumors, inflammatory swellings, and retention-cysts. 
 
 The increase in volume caused by a tumor is due entirely to erratic 
 cell-growth from a matrix of embryonal cells of congenital or post- 
 natal origin ; the enlargement of a part or an organ caused by chronic 
 inflammation which so often simulates a tumor is due to proliferation 
 of pre-existing mature cells acted upon by pathogenic micro-organisms 
 or their toxines, and to the vascular changes and cell-migration charac- 
 teristic of inflammation ; while a retention-cyst essentially consists of 
 an accumulation of a physiological secretion in a pre-formed glandular 
 space, the result of a mechanical obstruction. 
 
 The classification of tumors in this work is in accord with this 
 theory of the origin of tumors. The microbic origin of tumors is 
 briefly disposed of, as it has not been established by any convincing 
 experimental investigations or clinical observations. Should future 
 research demonstrate a direct causative relationship between certain 
 as yet unknown bacteria and the growth of some of the tumors, such 
 tumors would have to be eliminated from this group of pathological 
 products and be classified with the granulomata. 
 
 The first part of this treatise is devoted to a general consideration 
 of tumors, and it is this part which is intended more especially for the 
 use of students. Following the section on Classification, each class 
 of tumors is considered separately, beginning with benign epithelial 
 tumors and terminating with sarcoma, to which is appended a section 
 on Retention-cysts. It will be observed that by following this course 
 each tumor is brought to the notice of the reader three different times. 
 Repetitions like these cannot fail in permanently impressing the sub- 
 ject upon the memory of the reader. It has been deemed advisable 
 to discuss benign tumors first, as they do not deviate so far from the 
 normal type of tissue-growth as do malignant tumors of the same 
 germinal layer. 
 
 Retention-cysts are not true tumors, but they are discussed in the 
 last section of the volume, as their differentiation from tumors is often 
 exceedingly difficult, and in their structure and clinical course they 
 resemble more closely tumor-formation than the products of inflam- 
 mation. A description of each class of tumors is followed by a con- 
 
8 PREFACE. 
 
 sideration of the topographical distribution of that particular kind of 
 tumor in the different regions and organs of the body, with a 
 description of the different operative procedures for their removal. 
 
 The intention of the author in illustrating the text so profusely 
 was to keep constantly before the reader's eye the microscopical pic- 
 ture of the tumor, which in many places is contrasted with the normal 
 structure of the tissues corresponding with the anatomical location 
 of the tumor. The more difficult operations are fully described and 
 illustrated. More than one hundred of the illustrations are original, 
 while the remainder were selected from books and medical journals 
 not readily accessible to the student and the general practitioner. 
 
 The author desires to acknowledge his indebtedness to Mr. W. B. 
 Saunders, who has spared no expense in presenting this book to the 
 profession, and to Mr. John Vansant and Mr. Thomas Dagney of his 
 publication rooms, for valuable assistance in supervising the details 
 of the preparation of the work ; also to Drs. Lecount and Mellish 
 for a number of well-executed original drawings. 
 
 N. Senn. 
 
CONTENTS. 
 
 PAGE 
 
 I. Origin and Nature of Tumors 17 
 
 Definition, 19. Histological and Clinical Differences between a 
 Tumor and an Inflammatory Swelling, 20. Histogenesis, 23. 
 
 II. Morphology and Multiplication of Tumor-cells 28 
 
 Morphology, 28. Karyokinesis, 30. 
 
 III. Anatomy and Biology of Tumors 34 
 
 Blood-vessels, 35. Lymphatic Vessels, 35. Nerves, 36. Biology, 37. 
 Relation of Tumors to Adjacent Tissues, 40. 
 
 IV. Pathology of Tumors 42 
 
 Fatty Degeneration, 43. Mucoid Degeneration, 44. Colloid Degen- 
 eration, 44. Amyloid Degeneration, 45. Hyaline Degeneration, 45. 
 Caseation, 46. Calcification or Cretefaction, 47. Ossification, 47. 
 Interstitial Hemorrhage and Thrombosis, 47. Capsule of Tumor, 
 51. Lymphatic Glands, 51. Inflammation, 51. Ulceration, 52. 
 Grafting of a Malignant upon a Benign Tumor, 53. 
 
 V. Tumors in Plants and Animals 55 
 
 Tumors in Plants, 55. Tumors in Animals, 57. 
 
 VI. Etiology of Tumors 60 
 
 Congenital Tumors, 60. Heredity, 61. Race, 64. Climate, 65. Age, 
 65. Sex, 67. Traumatism, 68. Irritation, 69. Inflammation, 69. 
 Contagion, 70. 
 
 VII. Clinical Aspects of Benign and Malignant Tumors 71 
 
 Relative Frequency with which Different Organs are Affected by 
 Tumors, 71. Benign Tumors, 72. Malignant Tumors, 74. Local 
 Infection, 75. Regional Infection, 75. General Infection, 76. Fre- 
 quency of Recurrence after Extirpation, yS. Intrinsic Tendency 
 of the Tumor to Destroy Life, 79. 
 
 9 
 
io CONTENTS. 
 
 PAGE 
 
 VIII. Transformation of Benign Tumors and Post-natal Embryonic 
 
 Tissue into Malignant Tumors 80 
 
 Transformation of Benign into Malignant Tumors, 80. Transforma- 
 tion of Embryonic Tissue of Post-natal Origin into Malignant 
 Tumors, 84. 
 
 IX. Diagnosis of Tumors 88 
 
 Clinical History, 88. Length of Time Tumor has Existed, 89. Loca- 
 tion of Tumor, 89. Rapidity of Growth of Tumor, 89. Pain, 90. 
 Tenderness, 90. Examination of the Patient, 91. Examination of 
 the Tumor, 94. Tactile Examination, 96. Connection of Tumor 
 with the Mother-soil, 97. Resistance and Consistence, 98. Pulsa- 
 tion, 101. Tenderness, 101. Crepitation, 102. Auscultation and 
 Percussion, 102. Rontgen Ray, 102. The Value of the Micro- 
 scope as an Aid in the Diagnosis of Tumors, 103. 
 
 X. Prognosis of Tumors 108 
 
 XI. Treatment of Tumors 113 
 
 Medical Treatment, 113. Radical Operation, 115; Ligation of the 
 Principal Blood-vessels Nourishing the Tumor, 116; Galvano- 
 puncture, 116; Parenchymatous Injections, 117 ; Injection of Ery- 
 sipelas Toxines, 118; Cauterization, 119; Ligature, 123; Galvano- 
 caustic Wire, 124; Ecrasement Lineaire, 125; Avulsion, 126; 
 Extirpation, 126. Palliative Treatment, 129. 
 
 XII. Classification of Tumors 131 
 
 Virchow's Classification, 131. Cohnheim's Classification, 132. Wil- 
 liams's Classification, 133. Senn's Classification, 136. 
 
 XIII. Papilloma and Onychoma 137 
 
 Papilloma, 137. Histology and Pathology, 137. Transformation 
 into Malignant Tumors, 140. Topography, 141 : Skin, 141 ; Cornu 
 Cutaneum, 142; Respiratory Organs, 144; Digestive Tract, 144; 
 Urinary Organs, 145 ; Female Organs of Generation, 146 ; Brain, 
 149. Diagnosis, 149. Prognosis, 149. Treatment, 150. Ony- 
 choma, 150. 
 
 XIV. Adenoma 152 
 
 Histology and Pathology, 153. Etiology, 155. Topography, 156: 
 Skin, 157 ; Adenoma Sebaceum, 157 ; Adenoma Sudoriparum, 157 ; 
 Digestive Tract, 1 57 ; Nasal Cavities, 1 59 ; Uterus and its Append- 
 ages, 159; Thyroid Gland, 162; Mammary Gland, 167; Prostate 
 Gland, 171 ; Lachrymal Gland, 172 ; Parotid Gland, 172 ; Testicle, 
 172; Liver, 173; Kidney, 175. Diagnosis, 175. Prognosis, 176. 
 Treatment, 176. 
 
CONTENTS. II 
 
 PAGE 
 
 XV. Cystoma 178 
 
 Etiology, 180. Diagnosis, 180. Prognosis, 181. Topography, 181 
 Traumatic Epithelial Cyst, 181 ; Deep-seated Atheroma, 183 
 Mucous Cysts, 185 ; Mesoblastic Cysts, 186 ; Thyroid Gland, 187 
 Mammary Gland, 188; Ovary, 189; Vagina, 198; Testicle, 198 
 Eye, 199; Cysts of the Vitello-intestinal Duct, 199; Allantoic 
 (Urachus) Cysts, 200; Bone, 200. 
 
 XVI. Carcinoma 203 
 
 Definition, 203. Views Past and Present regarding the Origin and 
 Nature of Carcinoma, 204: Histogenesis, 208. Histology, 212: 
 Squamous-celled Carcinoma, 213; Cylindrical-celled Carcinoma, 
 214; Glandular Carcinoma, 215. Malignancy, 215 : Local Infec- 
 tion, 216; Regional Infection, 220; General Infection, 225. Eti- 
 ology, 231 : Heredity, 232 ; Traumatism, 233; Age, 234; Diet, 
 235 ; Climate, 236 ; Mental Depression, 236 ; Tuberculosis, 236 ; 
 Prolonged Irritation and Inflammation, 236 ; Microbes, 239. 
 Pathology, 242. Histological Varieties of Carcinoma, 250: 
 Squamous-celled Carcinoma, 250; Cylindrical-celled Carcinoma, 
 252 ; Glandular Carcinoma, 253. Diagnosis, 256. Prognosis, 
 264. Treatment, 266 : Palliative Operations, 269 ; Radical Oper- 
 ations, 271. Topography, 273: Skin, 275 ; Lip, 280; Face, 282; 
 Mouth, 289; Tonsil, 291; Tongue, 292; Parotid, 298; Thyroid, 
 300 ; Mammary Gland, 303 ; CEsophagus, 323 ; Stomach, 326 ; 
 Intestines, 335 ; Rectum, 339 ; Testicle, 346 ; Penis, 347 ; Ovary, 
 350 ; Uterus, 353 ; External Female Generative Organs, 370 ; Eye, 
 372 ; Bladder, 372 ; Kidney, 374. 
 
 XVII. Fibroma . 378 
 
 Definition, 379. Histogenesis and Histology, 379. Retrograde Meta- 
 morphoses, 382. Etiology, 383. Symptoms and Diagnosis, 383. 
 Prognosis, 384. Treatment, 385. Topography, 385 : Skin, 385 ; 
 Mucous Surfaces, 389 ; Subcutaneous Connective Tissue, 390 ; 
 Abdominal Wall, 391; Nose, 391; Mammary Gland, 396; 
 Uterus, 397 ; Ovary, 397 ; Vulva, 398 ; Gums, 399 ; Periosteum 
 and Bone, 400, Serous Surfaces, 401. Cholesteatoma, 401. 
 
 XVIII. Lipoma 404 
 
 Definition, 404. Histology, 404. Regressive Metamorphoses, 405. 
 Anatomical Varieties, 405. Symptoms and Diagnosis, 406. Prog- 
 nosis, 407. Treatment, 408. Topography, 408 : Subcutaneous 
 Adipose Tissue, 408; Eyelids, 411; Subserous Lipoma, 411; 
 Submucous Lipoma, 412 ; Meninges of the Brain and Spinal Cord, 
 413; Intermuscular Lipoma, 413; Periosteum, 413 ; Joints, 413; 
 Tendon-sheaths, 414; Eye, 414; Broad Ligament, 414; Vulva, 
 414; Scrotum, 414. 
 
12 CONTENTS. 
 
 PAGE 
 
 XIX. Myxoma 415 
 
 Definition, 415. Histology, 416. Etiology, 417. Symptoms and 
 Diagnosis, 417. Prognosis, 417. Treatment, 418. Topography, 
 418: Skin, 418; Intermuscular Spaces, 418 ; Nose, 419; Middle 
 Ear, 420 ; Nerve-sheaths, 420 ; Glands, 421. 
 
 XX. Chondroma 422 
 
 Definition, 422. Origin, 422. Histology, 424. Retrogressive Meta- 
 morphoses, 425. Etiology, 426. Symptoms and Diagnosis, 427. 
 Prognosis, 427. Treatment, 428. Topography, 428 : Cartilage, 
 428 ; Bone and Periosteum, 429 ; Joints, 430 ; Salivary Glands, 
 431; Testicle, 432 ; Ovary, 432 ; Connective Tissue, 432. Chon- 
 droma Branchiogenes, 432. 
 
 XXI. Osteoma 434 
 
 Definition, 434. Histogenesis, 435. Histology, 435. Anatomical 
 Varieties, 437. Symptoms and Diagnosis, 437. Prognosis, 437. 
 Treatment, 437. Topography, 438 : Cranial Bones, 438 ; Frontal 
 Sinus, 440 ; External Meatus, 441 ; Jaws, 441 ; Brain, 441 ; Epiph- 
 yses of the Long Bones, 442 ; Muscles and Tendons, 442 ; Seat 
 of Fracture, 443 ; Orbit, 443 ; Eye, 444 ; Subungual Osteoma, 444. 
 
 XXII. Odontoma 445 
 
 Definition, 445. Classification, 445. Epithelial Odontomes, 445. 
 Follicular Odontomes, 445. Fibrous Odontomes, 446. Cemen- 
 tomes, 446. Compound Follicular Odontomes, 446. Radicular 
 Odontomes, 446. Composite Odontomes, 447. 
 
 XXIII. Angioma 447 
 
 Definition, 447. Histogenesis, 449. Histology, 449. Complica- 
 tions, 451. Anatomical Varieties, 452. Symptoms and Diag- 
 nosis, 456. Prognosis, 456. Treatment, 456. Topography, 458 : 
 Skin and Mucous Membranes, 458 ; Deep Connective Tissue, 
 459 ; Bones, 461 ; Intracranial Angiomata, 462 ; Liver, 462 ; 
 Mammary Gland, 463 ; Tongue, 463 ; Muscles, 463 ; Larynx, 464. 
 
 XXIV. Lymphangioma 465 
 
 Definition, 465. Anatomical Varieties, 465. Histology and Histo- 
 genesis, 465. Regressive Metamorphoses, 471. Symptoms and 
 Diagnosis, 472. Prognosis, 473. Treatment, 474. Topography, 
 474: Tongue, 474; Lips/474; Neck, 475; Subcutaneous and 
 Submucous Connective Tissue, 477 ; Uterus, 477. 
 
 XXV. Lymphoma 478 
 
 Definition, 478. Histology and Histogenesis, 480. Retrograde 
 Metamorphoses, 480. Symptoms and Diagnosis, 481. Treat- 
 ment, 484. 
 
CONTENTS. 13 
 
 PAGE 
 
 XXVI. Myoma 485 
 
 Definition, 485. Embryology, 485. Rhabdomyoma, 486. Leio- 
 myoma, 487. Histology and Histogenesis, 487. Regressive 
 Metamorphoses, 491. Symptoms and Diagnosis, 491. Prog- 
 nosis, 492. Treatment, 492. Topography, 493 : Uterus, 493 ; 
 Broad Ligament, 519 ; Fallopian Tube, 520 ; Round Ligament, 
 521 ; Alimentary Canal, 521 ; Pharynx, 521 ; (Esophagus, 
 521; Stomach, 521; Small Intestines, 521; Rectum, 522; 
 Bladder, 522. 
 
 XXVII. Neuroma 524 
 
 Definition, 524. Embryology, 524. Histology and Histogenesis, 
 524. Regressive Metamorphoses, 530. Etiology, 530. Symp- 
 toms and Diagnosis, 530. Prognosis, 531. Treatment, 531. 
 Topography, 532 : Multiple Neurofibromata, 532 ; Cranial 
 Nerves, 533 ; Spinal Nerves, 533 ; Upper Extremity, 533 ; 
 Lower Extremity, 533 ; Plexiform Neuroma, 534 ; Vulva, 535 ; 
 Prepuce, 535. 
 
 XXVIII. Sarcoma - . . 536 
 
 Definition, 536. Histology and Histogenesis, 537. Morphology 
 of Sarcoma-cells, 541. Histological Varieties, 542. Regressive 
 Metamorphoses, 558. Local and General Infection, 561. Meta- 
 stasis, 564. Etiology, 566. Symptoms and Diagnosis, 568. 
 Prognosis, 571. Treatment, 571. Topography, 574: Skin, 
 574 ; Submucous Connective Tissue, 576 ; Fascial Sarcoma, 
 578; Lymphatic Glands, 580; Bones, 582; Histological Varie- 
 ties, 583; Mammary Gland, 601 ; Thymus Gland, 604; Sali- 
 vary Glands, 604 ; Tongue, 606 ; Tonsil, 606 ; Intestinal Canal, 
 606; Omentum, 607 ; Kidney, 607 ; Uterus, 610; Deciduoma 
 Malignum, 612 ; Ovary, 613; Vagina, 614; Vulva, 615; Tes- 
 ticle, 615 ; Brain and its Envelopes, 616; Eye, 616 ; Bladder, 
 616 ; Prostate, 617. 
 
 XXIX. Teratoma 618 
 
 Definition, 618. Origin, 618. Endogenous Teratomata, 620. Ec- 
 togenous Teratomata, 620. Branchial Cysts, 623. Embry- 
 ology and Anatomy, 624. History, 625. Classification, 626. 
 Mucous Branchial Cysts, 628. Atheromatous Branchial Cysts, 
 628. Serous Branchial Cysts, 629. Hemato-cysts of Branchial 
 Clefts, 629. Etiology, 630. Diagnosis, 631. Prognosis, 631. 
 Treatment, 632. Dermoid Cysts, 635. Definition, 636. His- 
 tology, 637. Regressive Metamorphoses, 639. Diagnosis, 640. 
 
'14 CONTENTS. 
 
 PAGE 
 
 Prognosis, 641. Treatment, 641. Topography, 641 : Trunk, 
 641 ; Thorax, 642 ; Face, 644 ; Palate and Pharynx, 645 ; 
 Scalp and Dura Mater, 646 ; Eye, 647 ; Tongue, 647 ; Rec- 
 tum, 649; Auricle, 650; Ovary, 651; Scrotum, 655. 
 
 XXX. Retention-cysts 657 
 
 Definition, 657. Histology, 658. Etiology, 660. Symptoms and 
 Diagnosis, 661. Prognosis, 664. Treatment, 664. Topogra- 
 phy, 665 : Thyroid Gland, 665 ; Ovary, 665 ; Skin, 666; Mu- 
 cous Membrane, 668; Hydrokolpos, 671; Hydrometra, 671 ; 
 Hydrosalpinx, 672; Trachea and Bronchial Tubes, 674; 
 Appendix Vermiformis, 674 ; Bile-ducts, 675; Pancreas, 678 ; 
 Kidney, 699 ; Testicle, 704 ; Mammary Gland, 706 ; Salivary 
 Glands, 707. 
 
 INDEX 711 
 
PATHOLOGY 
 
 SURGICAL TREATMENT 
 
 OF 
 
 TUMORS. 
 
THE 
 
 PATHOLOGY AND SURGICAL TREATMENT 
 
 OF 
 
 TUMORS. 
 
 I. ORIGIN AND NATURE OF TUMORS. 
 
 The subject of tumors is one of the much-neglected departments 
 of surgical pathology. Laboratory investigation, experimental research, 
 and clinical observations have revolutionized the etiology and pathology 
 of inflammatory diseases during the last decade. During that time the 
 attention of pathologists has been occupied largely in the etiological 
 and pathological elucidation of infective diseases, while surgeons have 
 expended their energies in enlarging the scope of operative surgery 
 by an increased knowledge thus gained, and by the diminution of the 
 immediate and remote risks to life of operative procedures attending 
 the general adoption of antiseptic and aseptic precautions. The benefit 
 to humanity in the saving of life and the lessening of suffering derived 
 from these investigations and from improved practice is incalculable. 
 The great work initiated by Pasteur, Lister, and Koch has inaugurated 
 a new era in the study and treatment of disease, and must serve as 
 a permanent foundation for all future investigations. When we realize 
 the amount of suffering and the number of deaths resulting from tumors, 
 it appears somewhat strange that this vast department of pathology 
 has received so little attention on the part of modern investigators. 
 It is true that recently a great deal of work has been done to establish 
 the microbic origin of malignant tumors, but no positive results have 
 been obtained so far, and we must confess that but little additional 
 light has been shed on the etiology and pathology of tumors since 
 the epoch-making labors of Virchow and Cohnheim. 
 
 History. — The old authors regarded tumors as something entirely 
 foreign grafted upon the organism. John Hunter taught that a drop 
 of blood, being accidentally extravasated, became organized and as- 
 sumed a growth independent of the adjacent tissues, and continued to 
 grow till it was limited by some obstacle opposed to it. Effusion of 
 2 17 
 
18 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 lymph has been considered as a possible cause. It was suggested that 
 in the development of the tumors the lymph played the same role 
 claimed by Hunter for the extra- vascular blood. Chronic inflammation 
 was regarded for a long time as the essential etiological factor. These 
 and many other vague theories advanced in regard to the origin and 
 nature of tumors prior to the time they were recognized as a part of 
 the body they inhabited, the result of proliferation of pre-existing cells, 
 do not merit an extended discussion in a modern text-book. Schleiden 
 established the cell theory which inaugurated the science of biology ; 
 Schwann showed from a cellular basis the analogy of the structure of 
 plants and of animals. 
 
 The study of tumors in plants and in the lower animals has done 
 much in adding to our knowledge of the etiology and pathology of 
 tumors. Pathological processes in plants are much simpler than in 
 animals, owing to the absence in the former of many complicating fac- 
 tors, such as nerves and blood-vessels ; at the same time, the plants are 
 constructed upon a much simpler embryological plan. Both animal 
 and vegetable cells have in common the nitrogenous carbon compound 
 called " protoplasm." Johannes Muller applied the cell theory to the 
 study of tumors. Virchow elaborated this doctrine in establishing by 
 his immortal researches the motto of his great work on cellular path- 
 ology, Omnis cellida e cellula. Cohnheim imparted a new stimulus to 
 the study of tumors by advancing a novel theory in reference to 
 their origin. It appears recently that Durante of Rome was the 
 real originator of the theory of the embryonic origin of tumors, as 
 his publication on this subject antedates that of Cohnheim by one 
 year. Virchow taught that an epithelial tumor could develop from 
 connective tissue. Cohnheim referred every tumor to its proper embry- 
 onic layer, and claimed that a tumor never had its origin from mature 
 tissue, but always developed from a matrix of embryonic tissue. This 
 essential tumor-matrix he traced back to its embryological source. He 
 believed that during the process of cell-differentiation in the embryo 
 groups of cells not utilized in the growth of the embryo, or displaced, 
 were arrested in their further development, and remained in a latent 
 condition until their activity was awakened later, when the product of 
 their proliferation resulted in the formation of a tumor. This theory 
 found many supporters, but at the present time only a few authors 
 uphold it in its entirety. As we shall see further on, it has much to 
 recommend it, but it does not satisfactorily explain the origin of all 
 tumors. In the absence of better proof of the origin of tumors, the 
 writer will adhere to the doctrine advanced by Cohnheim, and in addi- 
 tion to it will claim that the essential tumor-matrix may be composed 
 
ORIGIN AND NATURE OF TUMORS. 19 
 
 of embryonic cells, the offspring of mature cells which for some reason 
 have failed to undergo transformation into tissue of a higher type, and 
 wliicJi may remain in a latent, immature state for an indefinite period 
 of time, to become, under the influence of either hereditary or acquired 
 exciting causes, the essential starting-point of a tumor. 
 
 It has been the good fortune of Roux to discover isolated colonies 
 of cells in the middle, more rarely in the inner embryonal layer of 
 frog embryos, sometimes in large numbers — once as many as thirteen — 
 scattered among the other cells. Barfurth, in his experiments in the 
 regeneration of the embryonal layers, observed that by puncturing and 
 turning inward the ectoderm of the gastrulse that a growth of cells 
 very like a dermoid took place. Grawitz traced some of the tumors 
 of the kidney. to islets of separated and displaced suprarenal tissue. 
 These experiments and observations have a very important bearing 
 upon the development of tumors from displaced embryonal cells. 
 
 Definition. — So long as our ideas in reference to the origin and 
 nature of tumors rest exclusively on a theoretical basis, it is evident 
 that no satisfactory definition can be given. The definition of each 
 author must necessarily vary according to his views on the subject. 
 A few definitions will be given to corroborate the correctness of this 
 statement. John Hunter thus defines a tumor : "A tumor is a circum- 
 scribed substance produced by disease, and different in its nature and 
 consistence from the surrounding parts." " Neoplasm is a new growth 
 characterized by histological diversity from the matrix in which it 
 grows," is the description of a tumor given by J. Bland Sutton. Bar 
 regards the characteristic feature of a tumor as an " active multiplica- 
 tion of cells which takes place independently of inflammatory pro- 
 cesses." The process which leads to the formation of tumors he calls 
 " a monstrosity in the development of cells." Liicke wrote on the 
 subject of tumors from the standpoint that a tumor is " an increase of 
 volume by the production of new tissue without a corresponding physi- 
 ological function." Cohnheim, in consonance with his definite ideas 
 concerning the origin of tumors from embryonic tissue, and the difference 
 between the character of the tissues of which they are composed and 
 the structure of the tissues in their immediate vicinity, describes a tumor 
 as " a circumscribed, atypical production of tissue from a matrix of 
 superabundant or erratic deposit of embryonic elements." From these 
 definitions it becomes apparent how difficult it is to give even an 
 approximately correct definition of a tumor. " Many pathologists have 
 regarded tumors as a localized form of hypertrophy, but upon making 
 a closer comparison we find that, to whatever extent the adapted hyper- 
 trophy may develop, the overgrown part maintains itself in the normal 
 
20 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 type of shape and structure, while a tumor is essentially a deviation 
 from the normal type of the body in which it grows, and, as a rule, the 
 longer it exists the more marked becomes the deviation " (Williams). 
 One of the greatest difficulties in the way of a proper appreciation of 
 what is meant by a tumor is a failure on the part of authors and teach- 
 ers to draw a dividing-line between tumors and inflammatory swellings. 
 That tumors should have been confounded with inflammatory swellings 
 before the essential causes of the latter were discovered and understood 
 is not strange, but that these entirely different pathological processes 
 should not be separated sharply at the present time is inexcusable. 
 
 It has been the writer's custom for ten years, in his lectures, didactic 
 and clinical, to make a sharp distinction between a tumor, an inflam- 
 matory swelling, and retention-cysts. In writing this book this dis- 
 tinction will be maintained by eliminating from discussion all affections 
 of which the microbic origin has been established, as well as swellings 
 caused by retention of a physiological secretion, the latter of which 
 will be discussed in a separate part of the book, and the definition of 
 a tumor will therefore be framed upon a more limited basis. The 
 definition of a tumor should explain its origin, its histological character- 
 istics, and its behavior toward its immediate environment. A tumor is 
 a localized increase of tissue, the product of tissue-proliferation of embry- 
 onic cells of congenital or post-natal origin, produced independently of mi- 
 crobic causes. This definition refers all tumors histogenetically to embry- 
 onic cells, which, according to Cohnheim, may be of congenital origin, 
 or which, according to the writer's views, may also be of post-natal 
 origin, being derived from pre-existing mature tissue in consequence 
 of injury or disease, and, failing to undergo the normal transformation, 
 may give rise to tumor-formation in the same manner as embryonic 
 cells of fetal origin. This definition also excludes mature tissue and 
 pathogenic microbes as etiological factors in the production of tumors, 
 thus establishing a well-defined line between a true tumor and an 
 inflammatory swelling. It is not necessary to include absence of func- 
 tion in the definition, as this applies equally, if not more forcibly, to 
 swellings of an inflammatory origin. The writer does not claim that 
 this definition is above criticism, but it will convey to the student what 
 is so essential in teaching — a correct idea concerning the histogenesis 
 and the essential pathological features of tumors, which knowledge will 
 enable him, later, at the bedside to make a correct differential diagnosis 
 between a true tumor and an infective swelling. 
 
 Histological and Clinical Differences between a Tumor and an 
 Inflammatory Swelling-. — According to our definition, the most im- 
 portant histological difference between a tumor and a swelling caused 
 
ORIGIN AND NATURE OF TUMORS. 21 
 
 by infection consists in the fact that in the former the localized increase 
 of tissue is the result of proliferation of embryonic cells (of pre- or post- 
 natal origin) which are not utilized in the growth and development 
 of the body or in the repair of injured or diseased parts, constituting 
 thus a process entirely distinct and independejit of the tissues i?i its 
 immediate vicinity ; while an inflammatory swelling results from tissue- 
 proliferation provoked by the action of pathogenic microbes or their 
 toxines upon pre-existing mature tissue-cells. The incipient pathological 
 product is therefore always more localized and better defined in tumor- 
 formation than in inflammatory affections. A benign tumor always 
 remains local, tissue-growth being limited to the fixed primary matrix. 
 A malignant tumor has a similar local origin, but it gives rise to dissem- 
 ination by migratio7i of cells into the adjacent tissues or by their trans- 
 portation to distant parts through the lymphatic or general circulation. 
 In the production of an inflammatory swelling the fixed tissue-cells 
 which have been exposed to pathogenic microbes or to their toxines 
 participate ; the new cells produced mingle with the corpuscular ele- 
 ments of the blood, reaching the inflamed area through damaged cap- 
 illary walls caused by the same agents, and constituting with the trans- 
 udation the inflammatory product. Inflammatory affections lack from 
 the very beginning the localized character of a true tumor. Progressive 
 and often very speedy extension by continuity and contiguity of struct- 
 ure is one of the most conspicuous clinical features of inflammatory dis- 
 eases as compared with tumor-formation, and the existence or absence 
 of such manifestations is often of great importance to the surgeon in 
 making a correct differential diagnosis between a tumor and an inflam- 
 matory swelling. Another important point in the early differentiation 
 between a tumor and a swelling of infective origin is the durability of 
 the new tissue-product. The tissue of which a tumor is composed is 
 permanent. While in cases of progressive marasmus the subcutaneous 
 fat disappears ultimately almost completely, a fatty tumor in such an 
 individual remains unaffected, showing its independence from the gen- 
 eral laws of nutrition and waste that govern the body. A tumor never 
 disappears except by removal or destruction. There is no authenticated 
 record of spontaneous disappearance of a tumor or of disappearance 
 of a tumor under any kind of internal medication. In all cases in 
 which such a termination is said to have taken place we have instances 
 in which an infective swelling was mistaken for a tumor. The growth 
 of a tumor is usually progressive. Some of the benign tumors, such 
 as neuroma and osteoma, reach a certain size, when further growth is 
 spontaneously arrested. The nearer the tumor-elements resemble nor- 
 mal tissue, the greater the probability of spontaneous cessation of 
 
 x 
 
22 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 growth. The inflammatory product, whether the result of an acute 
 or of a chronic process, is composed of tissue which is destined to suc- 
 cumb sooner or later to the microbic influences which produced the 
 inflammation. The blood-corpuscles and the embryonic cells, the prod- 
 uct of the fixed tissue-cells, are destroyed by the primary cause of the 
 inflammation, either quickly or slowly according to the type and intensity 
 of the inflammatory process. One kind of swelling which has been, 
 and still is, erroneously designated as a tumor is the struma miasmatica. 
 According to our views, a struma due to miasmatic causes is not a 
 tumor, because the early use of proper therapeutic agents, such as the 
 internal and external use of iodine, by removing or rendering harmless 
 the primary, as yet unknown microbic cause, succeeds in effecting a 
 cure. Under the influence of iodine fatty degeneration, disintegration, 
 and absorption of the cells of a parenchymatous struma are effected 
 and a restitution ad integrum takes place. The swelling or pseudo- 
 tumor disappears because the remedy administered has succeeded in 
 removing or in neutralizing the primary cause. A hyperplasia of tissue 
 due to an infective cause is amenable to absorption or removal on 
 removal of the primary cause, but no such termination can be expected 
 in the case of a tumor, whatever its structure and character may be. 
 We must therefore regard permanency of the new tissue as one of the 
 evidences in favor of a doubtful enlargement being a true tumor ; while 
 early, and especially acute, degenerative changes would indicate an inflam- 
 matory origin. The general symptoms are also to be taken into con- 
 sideration in the differential diagnosis between a tumor and an inflam- 
 matory swelling. Acute suppurative inflammation is attended by such 
 violent local and general symptoms that it is seldom mistaken for 
 malignant disease. Chronic inflammatory affections, such as tubercu- 
 losis, gumma, and actinomycosis, are often mistaken for tumor, and 
 vice versa. Local and general increase of temperature is usually absent 
 in all benign tumors, and is either absent or only slightly increased in 
 malignant tumors. In chronic inflammatory affections a slight rise in the 
 local and general temperature is often observed. The use of the clinical 
 thermometer is therefore indicated in obscure cases in making a differ- 
 ential diagnosis between a tumor and an inflammatory affection. The 
 exclusion of the granulomata (granulation-swellings) produced by the 
 bacillus of tuberculosis, the actinomyces, the unknown microbe of 
 syphilis, and the bacillus of glanders from the list of tumors has greatly 
 narrowed the field of this part of pathology, and it is possible that 
 further restriction will take place when convincing proof can be fur- 
 nished of the microbic origin of one or of both varieties of malignant 
 tumors. As soon as it can satisfactorily be shown that carcinoma and 
 
ORIGIN AND NATURE OF TUMORS. 23 
 
 sarcoma are caused by microbes, they must be classified with infective 
 swellings, and not with tumors. From the present standpoint of patho- 
 logical and bacteriological investigations we are forced to include these 
 affections among the non-infective neoplasms. Enlargement of the 
 superficial veins and oedema, such common symptoms of inflammatory 
 lesions, are occasionally present in rapidly-growing malignant tumors ; 
 in fact, it may be stated that the nearer a malignant tumor resembles 
 inflammatio7i, the greater is its malignancy. 
 
 Histogenesis. — A tumor never originates de novo, but is always an 
 integral part of the organism, the product of tissue-proliferation from 
 a matrix of embryonic cells. Tumor-formation consists in the growth 
 and development of pre-existing immature tissue-elements. The struct- 
 ure and character of a tumor depend upon the stage of the arrested cell- 
 growth and the embryonic layer from which the matrix is derived. For 
 instance, a matrix of epithelial cells from the epiblast in which cell- 
 growth was arrested near the completion of the process of differen- 
 tiation will in all probability become the starting-point of a benign 
 epithelial tumor ; on the other hand, if the development of the same 
 cells was arrested at an earlier stage, the proliferation will result in 
 tissue of a lower type, and the resulting tumor will be a carcinoma. 
 The same holds true of mesoblastic tumors : the more imperfect the 
 differentiation, the greater the tendency to the production of a sarcoma 
 than to that of a fibroma. The tumor-cells always correspond in type 
 to the embryonic cells from which they are derived. In cases of dermoid 
 cysts in man we never find heterologous structures ; we always look 
 for the products of tissue-proliferation representing the normal tissues 
 from the epiblast. While we expect to find in such instances in the 
 interior of the tumor hair or other products of epithelial proliferation 
 and degeneration, we never find feathers nor any other heterologous 
 tissues ; while in birds, when dermoid cysts occur, we find no hair, but 
 invariably feathers. So the products of a displaced epiblastic matrix 
 always represent normal tissue-elements in an abnormal place. Tumors 
 of the connective-tissue type are invariably derived from a matrix of 
 mesoblastic tissue, and all epithelial tumors are connected with the 
 epiblast or hypoblast or spring from a displaced matrix from either 
 of these embryonic layers. As Jn the majority of cases the tumor- 
 matrix is composed of immature cells of fetal origin, it will be necessary 
 to discuss in detail the 
 
 Differentiation of Tissue in the Embryo and the Origin and 
 Disposition of the Germinal Layers. — During the earliest stages of 
 developmentthe embryo is composed of a mass of indifferent cells. At this 
 time it would be impossible to make a distinction under the microscope. 
 
24 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Segmentation of the eggs of the frog was first described in 1836 
 by Prevost and Dumas. Pander in 1847 distinguished in the embryo 
 of the chick three layers : the external, the serosa ; the internal, the 
 mucosa ; and the middle, the muscular layer. This classification of 
 the germinal layers corresponds to the more modern into epiblast, 
 hypoblast, and mesoblast. Bar, the pupil of Pander, called the ger- 
 minal layer stratum proligerum, and divided the embryonic tissue into 
 two principal layers, (1) animal and (2) vegetative. Each of these 
 layers he subdivided into two layers, the first (1) skin and (2) muscles, 
 the second (1) vascular and (2) mucous. More recently His divides the 
 unspecialized tissue of the embryo into two layers, (1) archiblast and 
 (2) parablast. The archiblast includes all the tissues which are later 
 
 .ung 
 
 ch uw ao sp dd df 
 
 Fig. i. — Transverse section through embryo of chick two days old; X 100 (after KSlliker) : dd, hypo- 
 blast; ch, cord; uw, primitive vertebra; u n h, primitive vertebral canal; a o, primitive aorta; ung, 
 primitive urinary channel; sp, cleft in lateral plates (first indication of pleuro-peritoneal cavity), which 
 through the same is lost in the hpl and intestinal connective-tissue plates df, which are connected through 
 the mesoblast mp ; mr, medullary tube; h, epiblast thickened at some points. The embryo at this time is 
 composed of two epithelial layers, the outer the epiblast, the inner the hypoblast, connected by the middle, 
 the mesoblast. 
 
 transformed into epithelial cells, and it is equivalent to the epiblast 
 and the hypoblast. The most active tissue-changes occur during early 
 embryonic life. It is during this time that specialization of the indiffer- 
 ent cells takes place, upon which specialization depends the formation 
 of different tissues and organs according to the demands of the indi- 
 vidual or the adaptation of cells to their immediate environments. The 
 division of embryonic tissue into epiblast, hypoblast, and mesoblast 
 will be retained in this book, in preference to including the epiblast 
 and hypoblast under the one term " archiblast," since in the discussion 
 of epithelial tumors the student will more readily comprehend the loca- 
 tion of the tumor, as well as the structure of the epithelial cells, by 
 separating the epidermal (epiblastic) from the mucous (hypoblastic). 
 Based upon the researches of Remak, Reichert, and Kolliker, embry- 
 ologists trace all the tissues and organs of vertebrate animals, includ- 
 ing man, to these three germinal layers which are found in embryos 
 a few days old. In the embryo of the chick two days old (Fig. 1) 
 these germinal layers can plainly be distinguished, and the complicated 
 arrangement between the outer and inner layers and the mesoblast can 
 be traced distinctly. 
 
ORIGIN AND NATURE OF TUMORS. 25 
 
 A few words concerning the disposition of these germinal layers 
 during the differentiation of their cells. From the epiblast are devel- 
 oped all the tissues and organs composed of epidermis, the skin, the 
 hair, the nails, all cutaneous glands, including those terminating in 
 the mouth, also the lens of the eye and the epithelial lining of the 
 cavity of the mouth, the nasal passages, and the labyrinth of the ear. 
 Reichert was the first to prove that the medullary plate, the primitive 
 central nervous system, is formed by the epiblast, and consequently 
 that the brain and the spinal cord are epiblastic structures — a discovery 
 which was later corroborated by the investigations of Remak and 
 K611iker. 
 
 The epiblast at the stage of development we are now considering 
 is arranged in the shape of a double tube — namely, first the covering 
 of the whole body (epidermis), and secondly, its central part, the med- 
 ullary tube — while the hypoblast constitutes a single tube, the gastro- 
 intestinal canal with its glandular appendages. The hypoblast fur- 
 nishes the whole epithelial lining of the digestive tract and the urinary 
 organs, and from it are also developed the glands of the mucous lining 
 and the glandular elements of the pancreas, the liver, the lungs, the 
 thyroid, and the kidneys. The middle germinal layer, the mesoblast, 
 forms the framework of the body, the bones, the connective tissue, 
 the nerves, the muscles, the serous membranes, the vascular organs, 
 including the lymphatics and the ductless glands, the thymus, and the 
 spleen. The differentiation of the cells that takes place in the embryo 
 limits their function to the part or organ to which they belong. No 
 transition from one type to another takes place. The law of the specific 
 genetic nature of the tissues as now generally recognized is observed in 
 the embryo everywhere, and it remains in force during the entire life of 
 the individual. In the growth of tumors the same law applies. One 
 of the most convincing proofs that the specific nature of imperfectly 
 differentiated cells is permanently retained is the familiar clinical fact 
 that a displaced matrix of embryonic epithelial cells, isolated from the 
 epiblast or hypoblast and buried in the mesoblast, when it becomes the 
 starting-point of a tumor invariably results in the formation of an 
 epithelial growth. Such an embryological enkatarrhophy is most prone 
 to take place where the most complicated tissue-changes occur in the 
 embryo, as about the orbit, the genital organs, and the muco-cutaneous 
 junctions. Some of the cells remain in a state of incomplete differen- 
 tiation for a long time even in man, as shown by the development of 
 the teeth, the thymus, the mammary gland, the organs of generation, 
 the bones, etc. These and many other facts prove the possibility of 
 tissues remaining in a dormant condition for variable periods, and then 
 
26 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 assuming, under the influence of an increased physiological or patho- 
 logical stimulus, renewed activity, growth, and development. During 
 a certain time of the life of the individual, or in consequence of acquired 
 pathological conditions, cells may arise where they have no legitimate 
 existence, or at a time when they ought not to be produced, or to an 
 extent beyond the physiological limits. In this manner monstrosities 
 and malformations are produced in the embryo, and later tumors are 
 formed from such latent imperfectly specialized tissue under the same 
 conditions. We know that certain organs up to the time of puberty 
 remain to a certain extent in a dormant condition, not keeping pace 
 with the general growth of the body ; but when the period of puberty 
 arrives, the genital organs, the mammary gland in the female, the skin 
 and its appendages, are suddenly stimulated by a physiological impetus 
 which results in increased tissue-growth. In pathology the proof of 
 the correctness of this assertion is based on the fact that during this 
 period are prone to appear certain epithelial tumors which are seldom 
 met with before the age of puberty or late in life. There is no fact 
 better establislicd in pathology than that during this time of life, charac- 
 terised by the highest degree of post-natal tissue-activity, the intrinsic 
 capacity of cell-production in an cpiblastic matrix of cells is suddenly 
 aroused, and the new tissue thus produced results in the formation of an 
 epithelial tumor. It is during this time of life that we most frequently 
 meet with dermoid cysts in their favorite localities, branchial cysts, and 
 adenoma of the breast. We have reason to believe that many persons 
 the possessors of the essential tumor-matrix of congenital or post-natal 
 origin fail to become the subjects of a tumor either from an insufficient 
 intrinsic capacity of cell-growth and reproduction on the part of the 
 latent cells composing the matrix, or owing to an inadequate degree of 
 local or general stimulation. Under such circumstances the cells of the 
 matrix remain permanently in a latent condition. 
 
 A general excess of embryonic tissue under favorable post-natal 
 conditions gives rise to general giant growth. Localized excess repre- 
 senting the different tissues of a part or an organ results in local giant 
 growth. Friedberg observed a case where, in a female child at the 
 time of birth, the right leg was considerably larger than the left ; after 
 birth symmetrical development failed to take place, and the larger limb 
 assumed giant growth, which fact induced Friedberg to assert that giant 
 growth is not only congenital, but progressive. If an excessive amount 
 of embryonic tissue is present at the time of birth, giant growth may 
 take place at any subsequent period during life, awaiting a favorable 
 opportunity until an increased afflux cf blood to the part results in 
 increased tissue-proliferation, the asymmetrical growth being due essen- 
 
ORIGIN AND NATURE OF TUMORS. 27 
 
 tially to the amount of embiyonic tissue originally stored up in the 
 part. 
 
 Abnormal additional centres of embryonic tissue in the embryo 
 result in all kinds of monstrosities, parasitic fetuses, supernumerary 
 fingers and toes, accessory glands, etc. A defective amount of build- 
 ing material in the embryo is responsible for many of the fetal defects, 
 such as hare-lip, cleft palate, absence of or defective limbs, etc. 
 Another familiar instance substantiating the correctness of the theory 
 of the origin of tumors from a matrix of embryonic cells is furnished 
 by the pregnant uterus. As a rule, hypertrophy of tissue is attended 
 and produced by increased physiological function. In the gravid uterus 
 there is an increase of muscular tissue attending simply an increased 
 physiological growth of an organ, unattended by a corresponding 
 increase of function, but preparatory to a sudden emergency requiring 
 great functional activity. During pregnancy the muscular fibres re- 
 main in a condition of rest during the intervals between slight mus- 
 cular contractions first observed and described by Braxton Hicks. 
 The uterus receives an unusual blood-supply. We can explain the 
 attending muscular hyperplasia only by assuming the presence of a 
 superabundant deposit of embryonic cells awaiting a favorable oppor- 
 tunity to develop into mature, functionally-active muscular tissue. 
 
 The origin of a tumor from post-natal embryonic tissue is suscep- 
 tible of a satisfactory explanation. Every surgeon can recall instances 
 of the development of tumors from inflammatory products — scar-tissue 
 and immature callus. We must take it for granted that in such tissue 
 cells or groups of cells have failed to undergo transformation into 
 mature tissue, and that they perform in the production of tumors the 
 same role as the congenital matrix of embryonic cells of Cohnheim. 
 In the absence of a more plausible theory, the writer is forced to 
 conclude that every tumor is the product of tissue-proliferation of a con- 
 genital or post-natal matrix of embryonic cells, aroused into activity by 
 a general or local physiological stimulation or by congenital or acquired 
 abnormal conditions in its immediate environment. 
 
II. MORPHOLOGY AND MULTIPLICATION 
 OF TUMOR-CELLS. 
 
 Morphology. — The shape of a tumor-cell corresponds very closely 
 to that of the cells of the organ or part in which the tumor originated. 
 In the growth of a tumor the cells retain their original type. The 
 development of the cells of benign tumors ultimately reaches the 
 highest degree of perfection, so that under the microscope it is difficult 
 if not impossible to distinguish between tumor-tissue and the tissue 
 to which it belongs or which it represents. The macroscopical and 
 microscopical resemblance between a lipoma and normal fatty tissue and 
 
 an adenoma and normal glandular tissue 
 is often almost perfect. The cells of 
 which malignant tumors are composed 
 do not attain maturity; consequently they 
 resemble more closely the fixed tissue- 
 cells in their juvenile state. From the 
 illustration showing the shape of young 
 connective-tissue cells (Fig. 2) and sar- 
 coma-cells, it will be seen that their 
 morphology is more nearly identical than 
 would be expected from the difference in 
 their source and the accomplishment of the ultimate object of their 
 existence. The most striking difference between a sarcoma-cell and an 
 immature connective-tissue cell under the microscope is the size and 
 number of the nuclei. The nucleus of the sarcoma-cell is large and 
 often multiple, showing greater vegetative activity as compared with the 
 mononucleated connective-tissue cell. Absence of uniformity of size 
 in the sarcoma-cells is another distinguishing criterion. 
 
 Most of the older text-books on pathology contain elaborate 
 descriptions of a morphologically specific cancer-cell. The application 
 of this teaching in practice resulted in many mistakes in diagnosis by 
 placing too much reliance upon the morphological appearances of cells 
 under the microscope. It is stated above that the structure of the cells 
 of benign tumors is so closely akin to that of the normal cells of the 
 part which the tumor represents that the microscope alone cannot be 
 relied upon in distinguishing between the pathological product and the 
 
 28 
 
 Fig. 2. — Embryonal connective tissue: 
 the intercellular substance is only slightly 
 differentiated (after Piersol). 
 
MORPHOLOGY OF TUMOR-CELLS. 
 
 29 
 
 normal tissue. This assertion will be strengthened by illustrations rep- 
 resenting a non-malignant epiblastic tumor and the middle strata of the 
 epidermis. 
 
 Fig. 3. — Cells from a spindle-celled sarcoma treated fresh in a solution of sodic chloride ; X 250 (after Perls). 
 
 In carcinoma, the malignant tumor of the epiblast and hypoblast, 
 the cells again bear a great resemblance to the cells which compose 
 the respective germinal layers. Like sarcoma-cells, they do not attain 
 maturity ; consequently they present in their structure more the type 
 
 Fig. 4.— Prickle-cells from papilloma of ski 
 X 250 (after Ziesing). 
 
 Fig. 5. — Prickle-cells from middle strata 
 of the epidermis (after Piersol). 
 
 of embryonic than mature epithelial cells. In contradistinction to the 
 normal epithelial cells, we find that many of the carcinoma-cells arc 
 polynucleated. The caudate prolongation of many of the cells is not 
 a characteristic feature of a malignant epithelial cell, as was formerly 
 supposed, but is one of the results of rapid cell-growth and pressure 
 
30 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 from without. The polymorphism of the cells of malignant tumors is 
 largely due to the combined effect of these two factors in modifying 
 cell-form. The student should remember also that the contour of a 
 cell under the microscope will depend greatly on the direction of the 
 cutting in making the sections. Thus if, in case of a spindle-celled 
 
 Fig. 6. — Cells from an epithelial carcinoma of the bladder; X 250 (after Perls). 
 
 sarcoma, the section is made in the direction of the long axis of the 
 cell, the cell will present a spindle-shaped appearance ; on the other 
 hand, if the cell is cut transversely, it will present an oval outline or 
 will appear round, as in cases of round-celled sarcoma. In conclusion, 
 it must be said that while polymorphism and multiple large nuclei 
 strongly point toward the malignant character of cells, these conditions 
 cannot be relied upon in making a positive distinction between normal 
 and benign and malignant tumor-cells. 
 
 Karyokinesis. — It is now generally conceded that every patholog- 
 ical process has its physiological prototype. Cell-multiplication in 
 disease may arise at a place where it is not needed, or at the wrong 
 time, or to an extent beyond the limits of local normal requirement. 
 Tumor-cells multiply, like most of the normal tissue-cells, by indirect 
 
MORPHOLOGY OF TUMOR-CELLS. 31 
 
 division, a process called karyokinesis. This is the method of repro- 
 duction of nearly all the fixed tissue-cells of a higher type in the 
 body. This method of cell-segmentation was first described and care- 
 fully studied by Flemming, who termed the process karyomitosis. The 
 essential constituents of a cell are the protoplasm and the nucleus. 
 There is a strong tendency at the present time to refer all kinetic 
 changes in the cell-contents to the agency of the nucleus, and to ascribe 
 to the protoplasm the passive role of a nutritive substance. In the 
 impregnated ovum influences of nuclear changes have been described, 
 but at the same time it was shown that the protoplasm is capable of 
 automatic as well as responsive action. Pfluger thought that gravita- 
 tion is the sole guiding factor in segmentation. According to Born, 
 Hertwig, Weismann, and Kolliker, the protoplasm alone is isotropic, 
 but Whitman thinks that this is far from the truth. Others, like Pfluger, 
 believe that the protoplasm contains physiological molecules from which 
 organs are developed. Polarity of the protoplasm and the nucleus 
 exists independently, and is not reciprocal. Contractions in the unfer- 
 tilized eggs have been observed. The protoplasm is an active rather 
 than a passive structure. M. Nussbaum was the first to establish the 
 important fact that enucleate pieces of an infusorium are incapable of 
 regenerating lost parts, while nucleate fragments soon regain the specific 
 form. From this observation it will be seen that the nucleus is indis- 
 pensable to the preservation of the formative energy of the cell, while 
 the protoplasm performs an important but less essential role in the 
 reproduction of cells. Nussbaum very correctly asserts that both the 
 protoplasm and the nucleus are necessary in a cell to enable it to per- 
 form its specific function and to reproduce its own kind. The nucleus 
 does not change its form except when it is the seat of active kinetic 
 changes, while the form of the cell is changeable and is greatly influ- 
 enced by its environments. 
 
 The researches of Flemming, Strassburger, Butschli, and others have 
 demonstrated the great importance of the nucleus in the reproduction 
 of cells. The protoplasm under the highest powers of the microscope 
 is seen to consist of a fine reticulum of protoplasmic strings, the meshes 
 of which contain a homogeneous fluid. The mature cell is enveloped 
 by a separate cell-wall. The meshes of a similar network in the nucleus 
 are filled with a granular fluid. According to Carnoy and Mayzel, the 
 nucleus contains, besides, a distinctive substance called " nuclein," or, 
 from its intrinsic capacity to receive and to hold coloring material, 
 " chromatin." The nucleoli in mature cells are globular masses of 
 chromatin, one or several in number. It is the chromatin which, when 
 properly stained, outlines the figures observed during the different 
 
32 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 stages of the kinetic process. The kinetic process is divided into stages 
 differently. Thus, Klebs makes four, while Strassburger describes the 
 process as consisting of three stages: (i) Prophase; (2) metaphase; 
 and (3) anaphase. During the first stage the nuclear chromatin arranges 
 itself in the form of an oval mass. The metaphase is the stage of the 
 equatorial crown when the nuclear spindle has an equatorial accumula- 
 tion of chromatin fragments. During the last stage the nucleus and 
 the protoplasm of the cell are divided into two symmetrical halves and 
 complete the segmentation. Karyokinesis of the nucleus without 
 division of the protoplasm of the cell results in multinucleated and 
 
 A B 
 
 Fig. 7. — Cells from the epidermis of very young larva of newt (after Piersol) : A, resting nucleus ; B, close 
 skein; C, loose skein ; D and E, mother-stars, seen from the polar field and appearing as the wreath stage; 
 F, mother-star from the side; G, migration of segments; H, daughter-stars; /and J, segments grouped 
 about new polar fields (in J this protoplasm exhibits constriction) ; K s daughter-skeins (division of nucleus 
 complete, with slight constriction of cell-body) ; L, completed division of nucleus and protoplasm. 
 
 giant cells. This incomplete karyokinesis frequently occurs in the 
 cells of malignant tumors. The different karyokinetic figures are well 
 shown in Figure 7. Cell-division by karyokinesis is called by Williams 
 agamoge?iesis, in contradistinction to sexual reproduction, which he 
 terms gamogcnesis. In slowly-growing benign tumors new cells are 
 added to the growth by karyokinesis ; in stationary tumors the cells 
 lost by degeneration are replaced by the same process ; while in malig- 
 nant tumors the karyokinetic process assumes great activity, resulting 
 
MORPHOLOGY OF TUMOR-CELLS. 33 
 
 in rapid growth and imperfect development of the cells. Karyokinesis 
 in malignant tumors has received the careful attention of pathologists, 
 and passes through the same phases as in the reproduction of normal 
 tissue. In the centre of Figure 8 is seen a nucleus in which segmen- 
 tation is nearly completed, while other nuclei represent incipient kinetic 
 
 Fig. 8. — Nuclear division in the epithelial cells of the skin in Paget's disease of the nipple ; X 800 (after 
 Karg and Schmorl). The deepest section of the picture represents, in the form of a small segment, the cutis 
 infiltrated with leucocytes. After this follows the epidermis with its hasal layer of cylindrical cells. The 
 epithelial cells show different stages of nuclear division. Large nuclei are seen in the incipient stage of seg- 
 mentation, surrounded by a light zone. In the centre of the field is a mass of chromatin threads in the stage 
 of star-formation. Several chromatin loops have been separated from the dividing nuclear mass. The neigh- 
 boring cells have been pushed sidewise. To the left and above, daughter-star with beginning constriction of 
 the nuclear body. The threads of the achromatic figure are indicated. (Fixation and hardening in sublimate 
 and alcohol ; haematoxylin staining.) 
 
 changes. It is natural to suppose that such speedy and frequently 
 imperfect karyokinesis would give rise to rapidly-growing, planless 
 growths characterized by their early invasion of adjacent tissue, gen- 
 eral dissemination, and an intrinsic tendency to destroy the life of the 
 patient. 
 
III. ANATOMY AND BIOLOGY OF TUMORS. 
 
 The life-history of tumors is of great interest to the pathologist and 
 of the utmost practical importance to the surgeon. The student must 
 become familiar with the influences which favor and retard tumor- 
 growth before he can formulate a correct clinical distinction between 
 the different varieties and outline a rational course of treatment. In 
 the preceding sections we have studied the origin and growth of the 
 parenchyma of tumors. We traced the tumor-cells to their original 
 
 Fig. 9. — Channel polypus of cervix uteri; X 50 (after D. J. Hamilton): a, fibro-cellular stroma of tumor; 
 b, a. gland of uterine mucous membrane; c, a channel; d, lining of columnar epithelium. 
 
 source and showed their manner of reproduction in the body. Before 
 considering the biology of tumors it will be necessary to discuss a few 
 of the more important points in their anatomy. The essential part of 
 a tumor is its parenchyma ; it is this which imparts to a tumor its ana- 
 tomical characteristic and its clinical significance. The cells of a tumor 
 are always limited by or imbedded in a stroma of connective tissue. 
 34 
 
ANATOMY AND BIOLOGY OF TUMORS. 
 
 35 
 
 Fig. 10. — Fibro-chondroma from capsule of knee ; 
 X 400 (after D. J. Hamilton): a, cartilage-cells; 
 b. the matrix. 
 
 In Figure 9 is shown an adenoma of the cervical canal of the 
 uterus in which the essential tumor-elements, columnar epithelial cells, 
 are attached to and limited by a powerful stroma of connective tis- 
 sue. This picture affords a good 
 illustration of the relation of the 
 tumor-cells to the stroma in benign 
 tumors of the epiblast and hypo- 
 blast. In malignant and mesoblastic 
 tumors the parenchyma appears as 
 an interstitial product, the cells being 
 enclosed on all sides by the stroma. 
 The stroma or reticulum of a tumor 
 is always derived from the meso- 
 blast, and consists of some form 
 of connective tissue in greater or 
 lesser abundance (Fig. 10). In epiblastic and hypoblastic tumors the 
 tissue reaches the tumor from the base ; in mesoblastic tumors it fur- 
 nishes a framework for the tumor on all sides. 
 
 Blood-vessels. — A tumor is nourished by the blood-vessels which 
 supply the part or organ in which the tumor is located (Fig. 1 1). The 
 blood-vessels constitute an important part in the structure, character, 
 and life-history of a tumor. The vascularization of a tumor usually takes 
 place by the formation of new blood-vessels from pre-existing vessels 
 in its immediate vicinity by a process of budding. A more atypical 
 blood-supply is sometimes procured by canalization of cells and the 
 entrance of blood into pre-existing hollow spaces or into connective- 
 tissue channels entering into communication with neighboring blood- 
 vessels. Most of the tumors contain a complete vascular system ; that 
 is, one or a number of arteries enter it from the periphery and divide 
 into smaller branches, which terminate in a network of capillaries from 
 which the blood is returned to the general circulation through veins. 
 The blood-vessels follow the connective tissue of the stroma, and in 
 very soft and cellular tumors they often come in direct contact with 
 its parenchyma (sarcoma). The structure of the walls of blood-vessels 
 is often very defective, especially in soft and rapidly-growing sarcoma. 
 Great vascularity of a tumor usually indicates rapid growth and imper- 
 fect development of the parenchyma-cells of the tumor. Perforation 
 of the walls of the blood-vessels by the tumor-tissue, especially the 
 veins, is often observed in malignant tumors, and leads to thrombosis 
 or embolism, or both of these complications may occur in rapid suc- 
 cession. 
 
 Lymphatic Vessels. — The existence of lymphatic vessels in tumors 
 
& 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 was first discovered by Van der Kolk, who, as well as Krause, found 
 them in carcinoma (Fig. 12). Lucke and Klebs attempted to inject the 
 lymphatics of carcinoma of the lip before the extirpation of the tumor, 
 but did not succeed in accomplishing the desired object. The benign 
 growths are scantily, if at all, supplied with lymphatics. In carcinoma 
 they are undoubtedly always present — a fact which explains on an 
 
 Fig. 11. — Blood-vessels of tumors (after Lucke) : a, vascular injection in an osteoid chondroma; b, 
 reticulum of veins from a sarcoma of the parotid ; c, capillary network from a fibroma of the abdominal 
 wall ; d, same from a very vascular myeloid sarcoma of the lower jaw ; e, vascular network from a carcinoma 
 of the tonsil; J", alveolar vascular network from a carcinoma of the breast; g, injected preparation from a 
 carcinoma of the lip. 
 
 anatomical basis the manner of regional dissemination which is so con- 
 stantly observed during the clinical course of this tumor, irrespective 
 of its anatomical location. 
 
 Nerves. — But little is known concerning the innervation of tumors. 
 In the myelinic variety of neuroma the production of new nerve-fibres 
 has been demonstrated. The tenderness and the spontaneous pain 
 
ANATOMY AND BIOLOGY OF TUMORS. 
 
 37 
 
 which belong to certain varieties of other tumors would suggest the 
 presence of new nerve-fibres, and should induce pathologists to make 
 additional researches relative to the nerve-supply of tumors. The want 
 of proper innervation undoubtedly determines largely the planless 
 growth of tumors. 
 
 Biology. — The life-history of a tumor is greatly influenced by the 
 inherent formative capacity of its cells as well as by the. general condition 
 of the patient. Cells endowed with maximum reproductive power are 
 always found in rapidly -growing malignant tumors, and the same type 
 of tumor grows with variable speed and attains unequal size in differ- 
 ent individuals during the same length of time. In certain individuals of 
 
 c 
 
 Fig. 12. — Lymphatic vessels from a fungous carcinoma of the region of the hip-joint of a young man 
 (after W. Krause) : a, lymphatic vessels of subcutaneous tissue which was attached to the stroma of the car- 
 cinoma; b-d, lymphatic vessels from the stroma of the carcinoma itself, which communicated with the 
 vessels of the subcutaneous tissue ; at b a lymphatic vessel projects beyond the level of the section. 
 
 the same age, living under apparently similar conditions, a fatty tumor 
 may not exceed the size of a walnut after a lapse of twenty years, while 
 in another person it may reach colossal dimensions in a much shorter 
 time. This difference in the rapidity of growth of benign tumors can- 
 not be explained upon any known physiological or pathological laws. 
 Some of the benign tumors grow to a certain size, and then remain 
 stationary permanently or for an indefinite period of time, when, under 
 certain local or general acquired causes, there again takes place active 
 tissue-proliferation, which often assumes a much more active phase 
 than during the first stage of tumor-growth. It has been observed by 
 Lucke and others that pregnancy plays an important role in the etiology 
 and growth of tumors. This influence is particularly well marked in 
 
38 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumors of the uterus and its appendages and in tumors of the breast — 
 that is to say, tumors in organs the seat of prolonged and irregular con- 
 gestions during pregnancy and lactation. Age influences the type and 
 location of tumors. Benign tumors occur most frequently in young 
 persons, while carcinoma attacks in preference persons past middle age. 
 Sarcoma manifests no such predilection for senile tissue. Benign tumors 
 grow more rapidly in the young than in the aged, and malignant tumors 
 manifest a greater degree of malignancy in children and young adults 
 than in persons advanced in years. Clinical experience has shown that 
 acute infective diseases exert a retarding influence upon the growth of 
 tumors. A tumor composed almost exclusively of parenchyma-cells 
 is more prone to undergo early degenerative changes than is a tumor 
 in which the stroma predominates. The growth of all tumors requires 
 an adequate quantitative and qualitative blood-supply. The importance 
 of this requirement in furthering the growth of a tumor is well shown 
 by the tumors so frequently met with during the age of puberty — 
 dermoid cysts. The growth of these cysts is determined by an 
 increased physiological activity of the entire organism — and more par- 
 ticularly of the skin, its appendages, and the organs of generation — 
 which is initiated at that time. The increased physiological blood- 
 supply to special organs during this time of life explains the frequency 
 with which we meet with dermoid cysts of the ovary, the face, the 
 base of the tongue, and the neck in young adults. To determine the 
 growth of a tumor it is not only necessary to have an adequate blood- 
 supply, but the blood itself must contain the nutritive and chemical 
 ingredients necessary for the formation of the different kinds of tumor- 
 tissue. In the development of an osteoma it is not only necessary to 
 have present an embryonal matrix of indifferent bone-cells, but the 
 blood must also bring to the part during the growth of the tumor the 
 proper constituent elements (the earthy salts) which enter into the 
 formation of bone. So, likewise, in a case of lipoma it is not only 
 essential to have present an adequate quantitative blood-supply, but the 
 quality of the blood brought to the tumor must be such as to produce 
 fat instead of connective tissue or bone. 
 
 An increase of blood-supply favors tissue-growth, and we can trace 
 this increased vascularization in connection with tumor-growth either 
 to a physiological increase or as one of the consequences of antecedent 
 pathological conditions. The increased physiological blood-supply is 
 either general or local. The general increase gives rise to giant growth, 
 which consists in hyper-production of normal histological elements 
 throughout the entire body ; local increase of physiological blood- 
 supply leads to local hyperplasia, localized giant growth, which may 
 
ANATOMY AND BIOLOGY OF TUMORS. 39 
 
 implicate an entire organ or limb. Anything which in the organism 
 will determine an increased physiological blood-supply to a pre-existing 
 tumor-matrix favors tumor-growth — an assumption well established in 
 cases of tumors of the breast commencing during pregnancy or lactation, 
 at a time when the organ receives a largely increased supply of blood, 
 which increase cannot fail in exerting a potent influence in stimulating 
 cell-proliferation from a latent matrix. So, in cases of uterine tumors, 
 the periodical recurrences of congestion in the affected parts during 
 menstruation create a condition which accelerates tissue-growth. Con- 
 sequently, myofibroma of the uterus almost without exception makes 
 its appearance during the childbearing period of life, and its further 
 growth is usually arrested with the cessation of menstruation. Sur- 
 geons have utilized this clinical fact, and have adopted a therapeutic 
 resource which aims at diminishing the increased physiologial blood- 
 supply to this organ by suspending artificially this periodical function 
 by the removal of the ovaries and the Fallopian tubes in the treatment 
 of some forms of myofibroma of the uterus. 
 
 A tumor frequently presents to the naked eye an appearance of 
 abnormal vascularization characterized by an increased circulation, 
 either arterial, venous, or capillary, as the case may be, according to 
 its anatomical location or the peculiarity of the structure of the new 
 blood-vessels in the tumor-matrix or its immediate vicinity. The most 
 striking example of atypical vascularization is furnished by tumors 
 which present pulsation as one of their most conspicuous clinical 
 features. By a pulsating tumor we understand, clinically, a tumor in 
 which to the usual evidences of tumor-formation are added the pathog- 
 nomonic symptoms of aneurysm. In such instances many of the larger 
 new blood-vessels are either entirely devoid of a proper vessel-wall, or, 
 when this is present, it is defective, forming irregular cavities or spaces 
 into which the blood enters from some adjoining vessel, returning either 
 in the same direction or emptying into another channel. This peculiar 
 structure and arrangement of vessels in many sarcomatous tumors 
 would explain the frequency with which pulsation can be felt in ex- 
 amining them, more especially if they have their starting-point in the 
 interior of a bone. Such tumors are noted for their rapid growth, and 
 have repeatedly been mistaken for aneurysms. 
 
 Local irritation increases tumor-growtk. Tumors located upon the 
 surface of the body or in other parts exposed to irritating influences 
 grow, as a rule, more rapidly than tumors occupying more protected 
 localities. The application of irritants, such as iodine, blisters, and 
 stimulating ointments, liniments, and plasters, produces the same effect. 
 The same can be said of exploratory punctures and parenchymatous 
 
40 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 injections. The incomplete destruction of a malignant tumor by 
 caustics is invariably followed by more rapid growth of the tumor- 
 remnants, extensive regional infection, and early general dissemination. 
 
 Relation of Tumors to Adjacent Tissues. — The tumor-tissue is 
 produced exclusively from the matrix of embryonic cells from which it 
 started ; the adjacent tissues take no active part in the growth of tumors. 
 The adjacent tissues are acted upon by the tumor, but take no part in 
 its development. The benign tumors push the tissues aside or apart to 
 make room for themselves ; the malignant tumors, particularly carci- 
 noma, infiltrate the surrounding connective tissue and include it as a 
 temporary passive constituent of the tumor-mass. The pre-existing con- 
 nective tissue under such circumstances is subsequently destroyed and 
 removed by the tumor-tissue. Sarcoma follows connective tissue, nerve- 
 sheaths, and blood-vessels ; carcinoma invades the lymphatics, and it is 
 through them that regional dissemination takes place. A tumor always 
 enlarges in the direction offering the least resistance. One of the con- 
 stant effects of tumor-pressure is atrophy of the tissues exposed to 
 pressure. Pressure-atrophy of the adjacent tissues is most certain to 
 occur, and is most marked if the tumor is anatomically so located that 
 its increasing size meets with great resistance. An ordinary sebaceous 
 cyst of the scalp or a dermoid cyst above the orbit, although of slow 
 growth, often produces by atrophy a cup-shaped depression in the 
 underlying bone. A lipoma of great size occupying the panniculus 
 adiposus produces little if any pressure-atrophy, because the tumor 
 meets with little or no resistance to its outward growth. The pressure 
 of a tumor upon a nerve often causes intense pain, and may eventually 
 destroy its function. Prolonged compression of a large artery may 
 result in the formation of a thrombus and the complete obliteration of 
 a vessel. A carcinoma or a sarcoma may destroy the wall of a large 
 artery, such an occurrence becoming often the immediate cause of 
 death from hemorrhage. At other times a false aneurysm is estab- 
 lished in the same manner. 
 
 Perforation of a vein by malignant tumors, preceded or followed by 
 thrombosis, will be alluded to farther on as one of the many compli- 
 cations of carcinoma and sarcoma. Serious and often fatal complica- 
 tions may arise from the compression of an important internal organ 
 by a tumor. Thoracic and mediastinal tumors frequently destroy life 
 by causing compression of the heart, the lungs, or the large blood- 
 vessels. Abdominal tumors of large size often result in death from 
 marasmus by interfering with digestion. Tumors impacted in the pelvis 
 may cause retention of urine, compression of the ureters, and intestinal 
 obstruction. 
 
ANATOMY AND BIOLOGY OF TUMORS. 41 
 
 Benign tumors frequently appear multiple primarily or in slow suc- 
 cession ; malignant tumors, while primarily multiple only in exceptional 
 cases, give rise to secondary tumors in the same region or in distant 
 parts. It can therefore be asserted, as a rule, that primary multiplicity 
 would indicate a benign character of the tumors, while secondary 
 multiplicity is almost an infallible evidence of the malignant nature of 
 the primary tumor. 
 
IV. PATHOLOGY OF TUMORS. 
 
 The form of a tumor depends largely upon its location and on 
 the structure of the tissues in its immediate neighborhood. A tumor 
 developing from a surface and projecting beyond it, with a wide 
 base, is said to be " sessile." If the tumor becomes more prominent 
 and the base narrows, a pedicle forms, when it is called a "pedun- 
 culated " tumor. Such tumors attached to a mucous membrane are 
 usually described under the term " polypus." If a tumor originates 
 from a part surrounded by tissues offering the same degree of resist- 
 ance, it usually assumes a globular or an oval shape. If it occupies 
 a locality covered in by a broad resisting structure, it becomes flattened 
 out, as is the case with intra-articular lipoma, called lipoma arborescens. 
 Unequal resistance over the surface of the tumor moulds it in all 
 imaginable shapes. The surface of the tumor may be smooth, lobu- 
 lated, or nodular. Benign tumors are usually smooth ; lipoma is often 
 lobulated ; sarcoma is either smooth or lobulated ; carcinoma is nodular. 
 The density of a tumor depends on its structure, the character of the 
 tissues in its immediate vicinity, and the degenerative changes that have 
 taken place. A tumor composed largely of parenchyma-cells is usually 
 soft ; tumors supplied with a well-developed stroma are hard ; a tumor 
 composed almost exclusively of blood-vessels (angioma) is greatly 
 reduced in size under pressure ; a tumor with liquid contents (cyst) 
 ordinarily presents fluctuation ; a solid but soft tumor (lipoma and sar- 
 coma) is often mistaken for a cyst or an abscess, because on palpation 
 a sense of fluctuation can be felt (pseudo-fluctuation). The color of 
 tumor-tissue is greatly influenced by its vascularity, the character of 
 the cells of which it is composed, and the extent and nature of the 
 degenerative changes which have taken place. Most of the benign 
 mesoblastic tumors present a whitish appearance. Sarcoma, as its name 
 indicates, resembles on section flesh. The cut surface of a firm carci- 
 noma is very similar in appearance and density to a raw turnip. Fatty 
 degeneration of the contents of the alveoli imparts to the cut surface 
 of the tumor a yellowish tinge. Hemorrhage into the substance of a 
 tumor produces pigmentation of various degrees, from almost black to 
 a yellow tinge. The black color of melano-sarcoma and melano-car- 
 cinoma is a distinguishing feature of these forms of malignant tumors. 
 
 42 
 
PATHOLOGY OF TUMORS. 
 
 43 
 
 Tumor-tissue, stroma and cells, is subject to the same pathological changes 
 as the normal tissues of the body. Among the more important of 
 these changes are the regressive metamorphoses of the cellular elements. 
 Fatty Degeneration. — Fatty degeneration of the parenchyma-cells 
 of a tumor is one of the most frequent secondary pathological changes 
 observed in tumors. The immediate cause of this form of degeneration 
 is a defective blood-supply ; hence it occurs most frequently in old 
 benign tumors and in malignant tumors in which vascularization does 
 not keep pace with the increase of tissue. It is a constant occurrence in 
 slowly-growing carcinoma of the lip and the breast. In ulcerating sur- 
 face epithelioma the fatty material can be squeezed out from the alveoli 
 in yellowish-white masses resembling the contents of a small retention- 
 cyst of the sebaceous glands. In glandular carcinoma the alveoli which 
 have undergone this change present themselves on the cut surface as 
 yellow areas of variable size, from which the same kind of material 
 escapes under pressure. If this material is examined under the micro- 
 
 . O 
 
 Fig. 13.— Fat-crystals ; X 250 (after Perls). 
 
 scope, nothing but a granular detritus can be seen, with here and there a 
 fat-crystal (Fig. 13) or a cholesterin-plate (Fig. 14). The fatty change 
 commences as an infiltration of the cells, this infiltration finally resulting 
 in the breaking up of the cells into granular matter. The distinction of 
 cells by this or by any other form of regressive metamorphosis retards 
 tumor-growth ; but while the growth has become stationary at one place 
 it continues in other places, so that a tumor is seldom entirely removed 
 by degenerative changes. Degeneration commences either in the oldest 
 part of the tumor or in parts of it which by accident have been deprived 
 suddenly or gradually of an adequate blood-supply. It is upon this 
 well-known and thoroughly established pathological fact that surgeons 
 
44 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 have made an attempt to imitate and anticipate the natural forces 
 which tend to limit or to arrest tumor-growth by cutting off the blood- 
 supply from the part, as suggested by Wolfler in the treatment of 
 
 Fig. 14. — Cholesterin-plates ; X 250 (after Perls). 
 
 tumors of the thyroid gland, and by gynecologists in ligation of the 
 uterine arteries in the treatment of non-malignant tumors of the uterus. 
 Mucoid Degeneration. — The transformation of active tumor-cells 
 into a harmless, innocent mucoid substance has been observed in tumors 
 belonging to the connective-tissue type, fibroma and 
 chondroma, and also occasionally in adenoma. The 
 part of a tumor which undergoes this form of degen- 
 eration becomes cystic. 
 
 Colloid Degeneration. — The exact chemical com- 
 position of colloid material has not been determined. 
 Scherer regards it as an albuminous substance in 
 combination with a carbohydrate analogous to mucin 
 and metalbumin. Colloid material is a jelly-like, 
 structureless substance derived by a degenerative 
 process from the parenchyma-cells or the stroma of a tumor. This 
 form of degeneration takes place in both benign and malignant tumors, 
 but is observed most frequently in tumors of the thyroid gland, of the 
 ovary, and of the gastro-intestinal canal. If the parenchyma-cells 
 undergo this change, the colloid material appears in the protoplasm 
 of the cell at one or different points, and the process continues until 
 the cell-walls give way, when the colloid material is liberated (Fig. 15). 
 
 Fig. 15.— Colloid de- 
 generation of the epithe- 
 lial cells of a cancerous 
 tumor of the mamma ; 
 X 400 (after D.J. Ham- 
 ilton). 
 
PATHOLOGY OF TUMORS. 
 
 Plate 
 
 
 X 
 
 \ 
 
 ' \ 
 
 \ 
 
 '■ 
 
 $ 
 
 
 " • 
 
PATHOLOGY OF TUMORS. 45 
 
 Colloid cysts of the ovary often attain a colossal size, and abdominal 
 surgeons are well aware of the fact that such cysts are prone to 
 return even after what seemed a thorough removal of the tumor. 
 
 Amyloid Degeneration. — The transformation of tumor-cells into 
 a starchy substance takes place most frequently in the cells of malig- 
 nant epiblastic tumors, also in secondary carcinoma of the lymphatic 
 glands. We have no positive knowledge concerning the true nature 
 of the corpora amylacea found in certain tumors as one of the many 
 degenerative changes, and in other pathological products. It is un- 
 doubtedly an albuminate, as its micro-chemical actions correspond with 
 those given by other albuminates. This substance has never been 
 detected in the blood ; it is therefore reasonable to suppose that it is 
 formed in the places in which it has been found. In a specimen of cyst 
 of the choroid plexus in the museum of Rush Medical College numer- 
 ous corpora amylacea were found in close proximity to a large blood- 
 vessel (PL i, Fig. i). The degeneration of an adenoma into a colloid 
 substance imparts to the tumor an entirely new aspect, transforming it 
 from a solid into a cystic tumor. 
 
 Hyaline Degeneration. — The product of hyaline degeneration dif- 
 fers from the amyloid substance in that it does not give the reactions 
 to iodine. The hyaline substance in tumors appears either alone, when 
 the entire tumor has undergone degeneration, or in circumscribed places 
 surrounded by the cells or stroma of the tumor. It is found in benign 
 and malignant tumors of all germinal layers. Tumors in which this 
 change was marked have been called by different names — tumeurs 
 heteradeniques (Robin) ; Schlauchknorpel-geschwulst (V. Meckel) ; 
 cylindroma (Billroth) ; Schleim-cancroid (Forster) ; Schlauch-sarcom 
 (Friedreich) ; siphonoma (Henle). Thiersch insisted that such tumors 
 do not represent a special clinical or anatomical variety, but are tumors 
 in which parts have undergone regressive metamorphosis. Hyaline 
 degeneration in other pathological products attacks in preference the 
 small blood-vessels, and it is more than probable that when it occurs 
 in tumors it begins in the same place and extends from the blood- 
 vessels to the stroma or the parenchyma-cells. Hyaline degeneration 
 most frequently attacks endothelial structures, but it extends into the 
 connective-tissue spaces where the hyaline substance is deposited, as is 
 shown on Plate 2, (Fig. i). A very interesting tumor of the orbit, 
 which tumor in all probability started from the internal angle of the 
 eye, examined in the laboratory of Rush Medical College, showed very 
 extensive hyaline degeneration (PI. I, Fig. 2). If hyaline degeneration 
 commences at the same time in several parts of the tumor, by coales- 
 cence large spaces are formed in which no tumor-elements can be found.. 
 
4 6 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Caseation. — Local anemia is a recognized cause of caseation, but it 
 remains an open question whether this form of degeneration can occur 
 independently of the bacillus of tuberculosis, so that when this kind of 
 metamorphosis is found in a tumor it is well to inquire into the pres- 
 
 Fig. 16. — Petrifaction of a glioma (psammoma) of the brain; X 250 (after Perls) : A, large laminated 
 concrements; B, calcification of capillaries; deposition of the lime-salts in the form of homogeneous 
 masses. 
 
 ence of the specific influence which is known to produce tyrosis. A 
 tumor may become the seat of infection with the bacillus of tuberculo- 
 sis, and the presence of this specific cause will determine the character 
 of the regressive metamorphosis. It is only reasonable to assume that 
 the atypical vascularization of tumors furnishes a condition favorable 
 
PATHOLOGY OF TUMORS. 47 
 
 to localization of floating germs, and consequently constitutes one of 
 the causes of auto-infection. 
 
 Calcification or Cretefaction. — This degenerative process has been 
 seen in all kinds of tumors and in all the cellular elements, paren- 
 chyma-cells and stroma. By this process a chalky substance is sub- 
 stituted for the tumor-tissue. It is usually preceded by fatty degener- 
 ation ; at other times it prepares the way for ossification of the tumor. 
 It occurs frequently as a marantic change in the arteries and cartilage 
 of the aged. The chalky material is deposited in the form of small 
 granules in the tissues, taking the place of pre-existing degenerated 
 cells. In a normal condition the lime-salts are kept in solution in the 
 tissues by organic acids and by free carbonic acid. Deposition under 
 abnormal conditions is caused by diminution in the quantity of organic 
 acids and free carbonic acid, by the existence of insoluble in place of 
 soluble lime-salts, or by an abnormal increase of lime-salts reaching 
 the affected part, resulting in direct infiltration of the tissues. In some 
 instances the entire tumor eventually is petrified, the inorganic substi- 
 tute retaining the shape of the original tumor. 
 
 The so-called lime-metastasis described by Virchow has been ob- 
 served in cases of extensive disease of the bones, and is caused by the 
 return into the circulation of the liberated lime-salts, which become 
 deposited in distant organs, notably the kidneys and lungs. Petrifac- 
 tion was noted in a sarcoma of the soft tissues of the arm by Liicke. 
 Maceration of this part of the specimen in an acid, examined under 
 the microscope, revealed spindle-shaped cells. Calcification frequently 
 occurs in benign epiblastic tumors and in adenomatous tumors, particu- 
 larly of the thyroid gland and ovary. 
 
 Ossification. — Calcification in a tumor has frequently been mis- 
 taken for ossification. We can speak of ossification only if, after the 
 removal of the tumor, the specimen decalcifies and the remaining part 
 exhibits under the microscope the structure of bone. Ossification of 
 the tumor-cells always takes place in osteoma. It occurs also in chon- 
 droma and in dermoid cysts. Periosteal sarcoma is noted for its bone- 
 producing capacity. In periosteal sarcoma of the cranial, pelvic, and 
 long bones we find an irregular framework of long, delicate spicules 
 of bone, the spaces filled in with sarcomatous tissue. In some carti- 
 laginous and sarcomatous tumors immature bone (osteoid tissue) is 
 formed in place of true bone. 
 
 Interstitial Hemorrhage and Thrombosis. — The great vascularity 
 of some tumors and the imperfect structure of the walls of blood-vessels 
 frequently result in spontaneous hemorrhage, or hemorrhage under 
 such circumstances is produced by a slight trauma, such as a contu- 
 
48 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 sion, a palpation of the tumor, or an exploratory puncture. The blood 
 escapes into pre-existing spaces (cysts) or is diffused through the 
 stroma of the tumor or between the cells. If the hemorrhage is con- 
 siderable, the tumor increases suddenly in size and becomes more tense. 
 The tension thus produced is also the cause of a sudden appearance 
 or increase of pain. The extravasation, if limited in quantity, is usually 
 removed by absorption ; if this does not occur, it either leads to the 
 formation of a cyst or determines infection of the tumor by pathogenic 
 microbes. Hemorrhage always causes a change in the appearance of 
 the tumor-tissue from the presence of the coloring material of the 
 extravasated blood which is imbibed by the tissues. 
 
 If the hemorrhage is profuse, the presence of extravasated blood 
 in the tumor is often indicated on the surface, a few days after the 
 accident, by the appearance of ecchymosis. The atypical vasculariza- 
 tion of a tumor renders the blood-vessels peculiarly amenable to im- 
 plication during the degenerative changes of the tumor-tissue. For 
 instance, if, according to the views taught by Rokitansky, new blood- 
 corpuscles form from the endothelial lining of a new closed blood-space 
 by gradual growth and dilatation, this space is brought in contact with 
 a vein-wall within or outside the tumor, and by a process of pressure- 
 atrophy a communication is established between the pre-existing vein 
 and a new blood-channel. Such an occurrence determines atypical 
 vascularization of a high degree and imparts to the tumor important 
 clinical and pathological features. The blood entering such spaces 
 from adjacent vessels, and not meeting with normal resistance on 
 account of a defective vascular wall, produces pulsation, and in many 
 instances, if such abnormal vascularization exists on a large scale, there 
 can be heard on auscultation a marked bruit caused by irregular dis- 
 tribution of the blood in the atypical vessels. These are the cases 
 described by the older surgeons and pathologists as " bone-aneurysm," 
 when the disease affects the bone. A simple hemorrhagic cyst re- 
 sembles one of these new blood-spaces, with or without a communi- 
 cation with adjacent vessels. The new vessels in a tumor, when 
 imperfect in structure and largely dilated, often become the seat of 
 mural thrombosis, the irregular surface of the defective intima pre- 
 senting projecting points upon which, by conglutination, the third 
 corpuscles of the blood become arrested and implanted, constituting 
 in the course of time a white thrombus, which, when it encroaches 
 upon the lumen of the vessel or blocks it completely, gives rise to 
 coagulation-necrosis in the impeded blood-current on the distal side 
 or upon the surface of the white thrombus, furnishing the necessary 
 conditions for the formation of a red thrombus, which then completely 
 
PATHOLOGY OF TUMORS. 
 
 49 
 
 obstructs the circulation in the corresponding part of the vessel. 
 Another form of thrombosis and obliteration of a vessel is met with as 
 the result of perforation of the vessel-wall by a tumor, usually of a ma- 
 
 'urc. Trachcie. 
 
 Fig. 17. — Thrombosing carcinoma-proliferation in the left jugular vein in carcinoma at the base of the 
 brain (after Ziesing) : ;;z, hyo-thyroid muscle ; g, proximal termination of inferior thyroid vein, with pro- 
 jecting plug of tumor-tissue ; e and b, internal jugular vein ; e, cut open, showing intravascular part of 
 tumor, f: b, part of vein not laid open, and terminal part of facial vein; a, probe in jugular foramen ; rfj 
 carcinomatous infiltration of cervical glands. 
 
 lignant type. This accident is one of the most interesting- conditions 
 in the pathology and clinical history of a malignant tumor. If, for 
 instance, a carcinoma attacks a vein-wall, destroying pre-existing struo 
 4 
 
50 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tures by infiltration, retrograde metamorphosis, and pressure-atrophy, 
 until by perforation the tumor projects into the vein, forming a neo- 
 plastic thrombus composed of tumor-tissue, when the axial blood- 
 current comes in contact with abnormal tissue, that tissue being devoid 
 of the physiological properties required for a normal circulation, the 
 thrombus increases in size by conglutination of the third corpuscle upon 
 the most prominent part of the projecting tumor-mass, the neoplastic 
 thrombus serving as a foreign body in the vessel ; mural stasis of the 
 white corpuscles also takes place, the conglutinated and aggregated 
 corpuscular elements of the blood furnishing a most favorable soil for 
 further cell-proliferation from the intravascular part of the tumor, which 
 necessarily soon terminates in complete obstruction of the affected ves- 
 sel. The writer has seen the internal jugular vein obstructed in its entire 
 length in cases of secondary glandular carcinoma of the neck (Fig. 17). 
 The neoplastic thrombus always manifests a tendency to increase in 
 size by infiltration of the temporary obstructing thrombus, the blood- 
 coagulum with tumor-cells, and when loose fragments become detached 
 they are carried along with the blood-current, and, arriving at a point 
 where the vessel is too narrow for their passage, become arrested and 
 give rise to embolic metastasis. In some cases embolism takes place by 
 the projection of the proximal end of the thrombus into the lumen of a 
 larger vein ; isolated cells and small fragments, becoming detached, are 
 washed away by the blood-current : embolism in such cases establishes 
 independent centres of tumor-growth wherever such tumor-infarcts 
 occur, the products of tissue-proliferation at the distant points corre- 
 sponding in every respect with that of the primary matrix. As in 
 cases of septicemia and pyemia the emboli produce at distant points 
 the same characteristic tissue-changes that are typical of the primary 
 thrombus, so in cases of thrombosis and embolism in malignant growths 
 the distant secondary tumor produced by an embolus from a neoplastic 
 thrombus corresponds in structure and type with the primary tumor. 
 Thrombosis and embolism in such instances effect a transplantation, 
 as it were, of a part of the primary tumor to some distant part, the 
 secondary tumors of embolic origin being the direct offsprings from 
 the maternal or primary tumor. Dissemination of benign tumors by 
 thrombosis and embolism is unknown. 
 
 The existence of thrombosis of many veins or of a large vein within, or 
 in the immediate vicinity of, a malignant growth should be suspected by 
 the presence of oedema and enlargement of the subcutaneous veins in the 
 region from which the blood is returned through the obstructed veins. In 
 one case of complete obstruction of the entire lumen of the internal 
 jugular vein which occurred as a complication of carcinoma of the 
 
PATHOLOGY OF TUMORS. 51 
 
 lower jaw with extensive glandular infection, the oedema extended to 
 the face on the same side and to the temporal region, and all the 
 superficial veins were greatly distended. 
 
 Capsule of Tumor. — All benign tumors are encapsulated ; that is, 
 a well-defined connective-tissue partition is interposed between the 
 tumor and the adjacent tissue, beyond which partition the tumor 
 never extends. Malignant tumors are devoid of such a limiting 
 boundary-line between tumor and surrounding tissues. In sarcoma 
 a capsule is often found, but pathologically it is absent, because it is 
 infiltrated with tumor-cells and the cells permeate it and infect the 
 adjacent tissues. In carcinoma there is never even an attempt at the 
 formation of a capsule. 
 
 Lymphatic Glands. — Enlargement of the lymphatic glands in the 
 region occupied by the tumor indicates one of two things : 1 . The 
 introduction into the lymphatic channels of pathogenic microbes 
 through an ulcerating inflamed benign tumor; 2. The transportation 
 from a primary malignant tumor of tumor-cells through the lymphatic 
 channels into the lymphatic glands. Enlargement of lymphatic glands 
 in connection with benign tumors never occurs unless the tumor by a 
 loss of continuity on the surface furnishes an infection-atrium for the 
 entrance of pathogenic microbes from without. The termination of 
 the complicating lymphadenitis under these circumstances will depend 
 upon the number and kind of microbes that have reached the lym- 
 phatic glands. Sarcoma seldom gives rise to glandular infection. Car- 
 cinoma, superficial and deep, almost invariably is complicated sooner bv 
 later by regional infection through the lymphatic vessels and glands. 
 This subject will be discussed more exhaustively in the sections on 
 malignant tumors. 
 
 Inflammation. — If inflammation occurs in a tumor, it is an unmis- 
 takable proof that the tumor-tissue has become infected with patho- 
 genic microbes. Infection may occur with and without a tangible 
 infection-atrium. In the former case the tumor-tissue is exposed 
 directly to infection by an abrasion, a cut, a puncture, or an ulcer, 
 and through such defects pyogenic and other pathogenic microbes 
 reach the tumor-tissue, and produce there, as elsewhere, their specific 
 pathogenic effect. In the absence of such a direct port of entrance 
 we must explain the occurrence of inflammation by floating microbes 
 which reach the tumor with the circulating blood, and after localization 
 has taken place incite inflammation in the same manner and to the 
 same extent as when infection takes place through a more direct route. 
 Tumor-tissue possesses a lower resisting power to inflammation than docs 
 normal tissue ; hence inflammation often results in extensive suppuration 
 
52 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 a?id gangrene, which in the case of benign tumors- may result in a spon- 
 taneous and permanent cure. Malignant tumors are often the seat of 
 infection and inflammation, but there is not a single authenticated case on 
 record in which a spontaneous and permanent cure was effected in this 
 manner. Inflammation, as a rule, increases the malignancy of malig- 
 nant tumors, and the effects produced by it increase the suffering and 
 hasten death. Inflammation in a tumor is often unintentionally pro- 
 duced by making an exploratory puncture without the necessary 
 aseptic precautions and by making subcutaneous or parenchymatous 
 injections. 
 
 Ulceration. — Ulceration of a tumor is either the result of accident 
 or it follows causes inherent in the tumor itself. In the great majority 
 of cases ulceration takes place when the tumor implicates the over- 
 lying skin or mucous membrane — when, either in consequence of 
 pressure-atrophy or of the destruction of the skin by the tumor, a 
 surface defect is produced and the tumor-tissue is exposed to direct 
 infection. Sometimes, when the skin has become greatly attenuated 
 by pressure from beneath, a small abrasion serves as a point of 
 entrance, and the destruction of skin is hastened by an infective 
 inflammation. The superficial ulcer in such cases is often the fore- 
 runner of a deep phlegmonous inflammation of the tumor, followed 
 by more or less extensive sloughing. Suppurative inflammation and 
 abscess-formation not infrequently are the direct causes of the super- 
 ficial ulceration. 
 
 Accidental ulceration is often produced by friction on the part of 
 the clothing, by contusions and wounds, by the application of irritating 
 substances, and also by incomplete operations. The clinical behavior 
 of an accidental ulcer varies according to its size and the character of 
 the tumor. An ulcerated surface communicating with a suppurating 
 cyst by a fistulous tract will not heal until the epithelial structures 
 lining the cyst-wall are destroyed by the suppurative inflammation or 
 are removed with the knife or destroyed by caustics. Defects of 
 benign grov/ths caused by inflammation, by caustics, or by incomplete 
 operations heal, as a rule, in the same manner as do wounds of normal 
 soft parts — by granulation, cicatrization, and epidermization. 
 
 Spontaneous ulcers — that is, ulcers caused by conditions inherent 
 in the tumor — are constantly seen on the surface of carcinoma of 
 the skin. The initial defect always occurs about the centre of the 
 growth, covered by a crust which, when removed, leaves a raw 
 and often bleeding surface. A spontaneous ulcer, as a rule, never 
 heals : its tendency is to enlarge. The margins and the base pre- 
 sent the firm induration so characteristic of this form of carcinoma. 
 
PATHOLOGY OF TUMORS. 
 
 53 
 
 Ulceration of glandular carcinoma is frequently followed by slough- 
 ing, suppuration, and putrefaction from the action of putrefactive bacilli 
 upon dead tissue. The sloughing and suppuration of such a carcinoma 
 usually give rise to a deep excavation in the centre of the tumor, in 
 which excavation the secretions stagnate and putrefy, becoming the 
 source of a sickening odor. In ulcerating sarcoma the tumor-tissue 
 often projects far beyond the surface of the ulcer in the form of a 
 fungous mass, the fungus hcematodes of the old authors. 
 
 Grafting- of a Malignant upon a Benign Tumor. — By the grafting 
 of a malignant upon a benign tumor is meant, not the transformation 
 
 Fig. 18. — Lipoma with a sarcoma grafted upon it (Liicke) : a, fatty tissue; b, connective tissue; c, sarcoma. 
 
 of a benign into a malignant tumor, but the appearance of a malig- 
 nant tumor in the immediate vicinity of a benign tumor. Such an 
 intimate connection between a malignant and a benign tumor is shown 
 in Figure 18. The occurrence of the malignant tumor in such cases 
 appears purely accidental, and yet from an embryologieal standpoint 
 a more intimate relationship in the etiology of the two entirely differ- 
 ent tumors can be shown. For instance, in the specimen shown in 
 
54 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Figure 18 it is evident that the lipoma sprang from a matrix of embry- 
 onic cells in the panniculus adiposus, while the sarcoma had its origin 
 from a similar matrix in the connective tissue of the skin. It is more than 
 probable that the embryonic cells composing the sarcoma-matrix were 
 arrested in their development at an earlier stage than were the embryonic 
 cells in the adjoining fatty tissue ; consequently, the matrix in the skin 
 gave rise to tumor-tissue of an embryonic type, while the matrix in the 
 fatty tissues produced tumor-cells which possessed the intrinsic prop- 
 erty to develop into mature tissue. From the illustration it can readily 
 be seen that the sarcoma would eventually invade the lipoma, the tissue 
 of which would yield to it in the same manner as would normal adipose 
 tissue. 
 
 In concluding this section it is proper to recapitulate that tumor- 
 tissue is subject to the same degenerative changes as normal tissue altered 
 by accident or by disease, and that it constitutes a locus minoris resist- 
 entiae in the event of direct or indirect infection with pathogenic microbes. 
 
V. TUMORS IN PLANTS AND ANIMALS. 
 
 Before considering the etiological factors concerned in provoking 
 tumor-growth it will be of interest to learn something of tumors in the 
 lower animals and plants, for the purpose of showing that tumors occur 
 in frequency in proportion to the complexity of the organism they 
 inhabit ; that is to say, they are least frequent in plants and animals 
 of a low degree of development, and most frequent in man. 
 
 Tumors in Plants. — For the remarks on this subject the writer is 
 largely indebted to the work of Mr. Williams on Ca?icer- and Tumor- 
 formation. The resemblance of tumors of the higher animal organisms 
 and those of plants was pointed out by Virchow years ago. In tumor- 
 formation we find kindred processes throughout the organic world. 
 Each cell leads to a certain extent a parasitic existence. If it were not 
 for the restraining and modifying influence exerted by the whole 
 organism, each cell might develop into the form of the parental organ- 
 ism. In proportion as the cells are highly specialized their primitive 
 reproductive function is either greatly diminished or altogether lost. 
 In the higher organism certain cells remain unspecialized. Under 
 favorable conditions certain unspecialized or indifferent cells may grow 
 and develop without regard to the requirements of the adjoining tissues 
 and of the organism as a whole. Tumors can be studied to better 
 advantage in plants than in animals. Buds may remain in a latent 
 condition for years, and yet under favorable conditions their activity 
 may revive. Buds may arise on any part of the plant ; in fact, wherever 
 there is an excess of nutritive materials capable of being utilized for 
 growth by the cells of the part, there buds arise. Under such circum- 
 stances buds may be formed wherever undifferentiated cells are present. 
 Vegetable tumors are produced by abnormal bud-evolution. Mr. 
 Williams classifies plant-tumors into three main groups. The first group 
 is represented by the discontinuous or circumscribed growths (Fig. 19), 
 to which the vaguely-used term of knaurs should be restricted, and 
 includes all those nodules so often met with in the bark of the beech, 
 elm, oak, birch, holly, cedar, and other trees. These tumors corre- 
 spond with the benign cpiblastic tumors in man. The older nodules 
 are generally found lying completely isolated in the bark, enclosed in 
 
 55 
 
56 
 
 PATHOLOGY AND TREATMENT OF TUMORS, 
 
 a distinct capsule. A narrow fibre-vascular pedicle may sometimes 
 be seen connecting the younger nodules with the woody tissues of the 
 trunk or stem. These tumors have been traced to abnormal growths 
 of adventitious or latent buds. The writer examined the branch of a 
 cedar tree which had evidently been injured, and found a tumor which 
 apparently belonged to the second 
 group. From the tumor sprang a 
 tuft of flowering branchlets entirely 
 different from the remaining branches. 
 It is apparent that in this instance the 
 injury excited tissue - proliferation 
 from two distinct matrices, one re- 
 sulting in the formation of the tumor, 
 the other resulting in the production 
 
 M 
 
 of branchlets bearing the generative 
 
 a% 
 
 The second group, comprising the 
 
 continuous tumors — to which the 
 term exostosis should be restricted — 
 
 Fig. 19. — Five circumscribed tumors in the bark 
 of a holly tree; natural size (after Williams). 
 
 Fig. 20. — A continuous tumor (exostosis) from an 
 elm tree, in longitudinal section (after Williams). 
 
 present themselves as nodose outgrowths of the trunk or branches 
 (Fig. 20). The stem and branches of a tree bear a great resemblance 
 in structure to the long bones. The centre or medulla corresponds to 
 the medullar}- canal, the Avood to the bone-tissue, and the cambium 
 to the periosteum. 
 
 Tumors belonging to this group often attain great size. Dutrochet 
 attributes these growths to an excessive local cell-proliferation of the 
 cambium layer, but their connection with the woody tissue of the stem 
 exists from the beginning and is never lost. Mr. Williams regards them 
 as abnormally-developed branches. 
 
 The third group is represented by growths which present a surface 
 thickly studded with shoots and stunted branches, constituting a com- 
 bination of exostosis with diffuse bud-formations. The tumor of the 
 cedar branch alluded to represented both the second and third groups 
 of plant tumors. The production by these groAvths of large quantities 
 of proliferating, loAAdy-organized cellular tissue Avhich subsequently 
 
TUMORS IN PLANTS AND ANIMALS. S7 
 
 undergoes imperfect evolution constitutes the nearest approach in 
 vegetable pathology to the malignant tumors of animals. Every gar- 
 dener knows that injury to plants is one of the most common ways by 
 which latent buds in plants can be made to develop, and he makes use 
 of this knowledge in the propagation of some of the plants in which 
 latent buds are most constantly found. 
 
 Tumors in Animals. — J. Bland Sutton has done more than any 
 other living author in adding to our knowledge concerning tumors in 
 animals, and the writer can do no better than to quote freely from the 
 chapter on this subject in his excellent book, Tumors, Innocent and 
 Malignant, recently issued from the press. 
 
 Lipomata. — Fatty tumors are rare in animals. They are found most 
 frequently in the subserous adipose tissue in horses, oxen, and sheep. 
 In stall-fed oxen excessive accumulation of fat is common in the sub- 
 peritoneal tissue, especially in the omentum ; but such formations 
 accompany general obesity, and do not come into the category of 
 tumors. 
 
 Osteomata. — These are very generalized tumors ; they have been 
 met with in several species of fish. The bony outgrowths to which 
 the term "exostosis " is applicable are of fairly common occurrence in 
 mammals, and their frequency on the bones of horses can be appre- 
 ciated only after a visit to a veterinary museum. 
 
 Odontomcs are more frequent in animals than in man. The animals 
 in which they are found most frequently are the marmot, agouti, por- 
 cupine, goat, sheep, bear, kangaroo, horse, and elephant. 
 
 Myomata. — Uterine myomata are almost unknown in mammals. 
 The only specimen which came under the observation of Mr. Sutton 
 occurred in a female baboon, and was rather a general enlargement of 
 the uterus than an actual tumor. 
 
 Sarcomata have the widest zoological distribution. They occur 
 with very great frequency, especially the round-celled and spindle- 
 celled species ; they are met with in fish, birds, rats, mice, horses, 
 sheep, dogs, cats, goats, oxen, monkeys, bears, marsupials — indeed, in 
 all the orders of mammals and in snakes. 
 
 Epithelial tumors in animals, wild or domesticated, form a subject 
 of great interest in its bearings on cancer and its allies. Unfortunately, 
 few reliable observations pertaining to this subject are available. For 
 instance, a cursory review of veterinary periodical literature would 
 indicate that epithelioma of the penis is a common disease in bulls 
 and horses, but a critical examination of the cases reported shows 
 clearly enough that many supposed examples of epithelioma are, as a 
 matter of fact, instances of penile warts, and all competent histologists 
 
58 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 who have investigated this subject are unanimous in asserting that epi- 
 thelioma of the penis in horses and bulls is exceedingly rare. A 
 specimen of secondary glandular carcinoma of the neck in a chicken 
 has recently come into the writer's possession. The histological 
 
 Fig. 21. — Secondary glandular carcinoma of the neck of a chicken, X200 : a, epithelial nests ; b, vessels. 
 
 structure of the tumor, as shown in Fig. 21, is very similar as in 
 the same organ in man. Wild animals in a state of nature and those 
 living in confinement appear to be absolutely free from cancer. 
 
 Adenomata occur in domestic mammals. The bitch is especially 
 liable to tumors of the mammary gland that are analogous to the large 
 
 Fig. 22. — Carcinoma of the ovary of a chicken. 
 
 Fig. 23. — Frog with a supernumerary hind leg 
 (after Tuckerman). 
 
 cystic adenomata of women. These tumors often attain an enormous 
 size. Large cystic adenomata with intracystic processes are occasion- 
 ally seen in the udders of cows. The mammary glands of cats are 
 
TUMORS IN PLANTS AND ANIMALS. 59 
 
 liable to a disease histologically identical with mammary cancer in 
 women, but cancer such as attacks the human mamma is unknown 
 in cows, mares, ewes, goats, or bitches. Dogs are subject to ulcerating 
 sebaceous adenoma in the skin around the anus, the tumor being prone 
 to return after extirpation. 
 
 Teratomata are common enough among domestic animals, and 
 many examples have been described in fish, frogs and other batra- 
 chians, lizards, snakes, birds, rabbits, etc. 
 
 Cystic Tumors. — The frequency of these tumors in vertebrata gen- 
 erally forms a striking contrast to the infrequency of connective-tissue 
 and epithelial tumors. While true cystic tumors are rare, cystic tumors 
 resulting from retention of a physiological secretion are frequently met 
 with. Such conditions as hydronephrosis, congenital cystic kidney, and 
 dilatations of the vitello-intestinal duct have been observed. Hydrocele 
 of the tunica vaginalis is rare, because the funicular pouch in mammals 
 retains its connection with the general peritoneal cavity throughout 
 life. Cysts arising in connection with the central nervous system have 
 been observed in foals, pigs, and calves. Hydrocephalus is fairly 
 frequent, but spina bifida is rare. Oesophageal diverticulae are often 
 seen in horses, and the same animal is exceedingly liable to synovial 
 cysts and ganglia. 
 
VI. ETIOLOGY OF TUMORS. 
 
 In the first section the writer made an attempt to prove, so far as 
 present knowledge of this subject will permit, that all tumors, benign 
 and malignant, have their origin from a matrix of embryonic cells of 
 a congenital or post-natal origin. It remains to discuss here the influ- 
 ences which enable the latent cells to assume active tissue-proliferation, 
 upon which depends the production of tumor-tissue. We regard the 
 matrix of embryonic cells as the essential cause of tumorformatioji, without 
 which all intri?isic and external exciting causes are inadequate to produce 
 a true tumor. On the contrary, we must admit that such a matrix will 
 remain harmless in the absence of congenital or post-?tatal exciting causes. 
 Certain cells never become specialized to a high degree, and conse- 
 quently retain their original inherent power of proliferation. Before 
 discussing the influence of heredity and post-natal exciting causes ref- 
 erence will be made very briefly to congenital tumors. 
 
 Congenital Tumors. — In a certain sense the majority of tumors 
 are congenital in so far as the essential matrix of embryonic cells is 
 concerned. 7/ is only in cases in which a tumor develops from a matrix 
 of embryonic cells of post-natal origin that the essential tumor-matrix is 
 not congenital. When we speak of a congenital tumor, however, we 
 mean a tumor which is present at the time of birth. In such cases the 
 tumor-matrix is acted upon during intra-uterine life by influences which 
 determine tumor-formation, and the resulting product behaves clinically 
 after birth in the same manner as do tumors of post-natal origin. We 
 must therefore make a distinction between a true tumor and localized 
 hypertrophy or giant growth at the time of birth. There are in chil- 
 dren cases of " partial obesity" — cases in which the adipose tissue of a 
 certain region of the body is greatly in excess of the adipose tissue gen- 
 erally, and yet the characters of a tumor are wanting. Of such a nature 
 is the case related by Lebert, of a female aged nineteen, the left side 
 of whose abdomen Was the seat of an enormous increase of fat. This 
 growth began at the age of six months, and was thought to have 
 been congenital ; it grew in proportion to the rest of the body, and 
 ceased to grow when the girl attained puberty. Lebert calls this a 
 " lipoma diffusum." In giant growth the tissues are under the influence 
 of, and are controlled by, the same physiological laws which govern the 
 growth and development of the remaining tissues of the body, while a 
 congenital tumor recognizes and obeys no such governing influences. 
 Angiomata are nearly always congenital. The tumors, although pres- 
 
 60 
 
ETIOLOGY OF TUMORS. 61 
 
 ent at birth, are often overlooked, owing to their small size. Next in 
 frequency as congenital tumors are the lipomata and cysts. Nearly 
 all benign tumors may have a congenital origin. Only in very rare 
 instances have malignant tumors been found and recognized as such 
 at the time of birth. Cases of sarcoma in the cutis of the newly- 
 born have been reported by Jacobi, Karewski, Ramdohr, Mundil- 
 lon, L. W. Marshall, K. King, Senftleben Weinlechner, and several 
 others. Ramdohr has reported a case of congenital multiple angio- 
 sarcoma. The body of the child, which died shortly after birth, 
 showed a large angio-sarcoma in the region of the chin, and twenty-one 
 secondary superficial tumors ; also sixteen metastatic tumors of the vari- 
 ous internal organs. Ahlfeld reports a case of congenital fibro-sarcoma 
 of the genital organs in a child three and a half years of age, and a 
 case of congenital carcinoma in the distal end of an atresic rectum in 
 a new-born infant. It is a significant fact that many tumors arise from 
 rudimentary organs, vestiges (Sutton), or accessory organs — " rests " 
 (Sutton) which remain functionless in the body until the time of puberty, 
 when they become the starting-point of a tumor. Tumors from such 
 structures seldom form during intra-uterine life, but appear later. 
 Different forms of retention-cysts have been found in infants at the 
 time of birth. The mechanical obstruction causing the retention is 
 more often the result of a faulty development of the ducts of secreting 
 organs than of other intra-uterine pathological conditions. 
 
 Heredity. — Heredity in the etiology of tumors is a subject upon 
 which much has been said and written. We no longer speak of a 
 " tumor-dyscrasia," but we cannot ignore the influence of heredity in 
 the origin and growth of tumors. The laws of heredity depend upon 
 the persistence of impressions (unconscious memory) in protoplasm 
 (Williams) ; hence every living thing produces new ones, each after its 
 own kind. It is by virtue of this property that, in the words of Sir 
 James Paget, " a mark once made in a particle of blood or tissue is 
 not for years effaced from its successors." All are willing to admit 
 that there is a difference in the susceptibility to disease among different 
 individuals placed under the same conditions. Every military surgeon 
 knows that if a body of troops is quartered in a cold, damp garrison, 
 some will be attacked by catarrhal affections of different organs, others 
 will suffer from rheumatism, while' the greater number will retain their 
 health after having been exposed to the same morbid influences. We 
 must admit that a similar inherent susceptibility to tumor-formation 
 exists among different persons, and that such individual predisposition is 
 often the result of hereditary influences. Benign tumors are hereditary 
 in the same sense as monstrosities — per excessum. Supernumerary toes 
 
62 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and fingers have appeared through several generations in the same 
 family. The same can be said of most of the non-malignant tumors, 
 particularly angioma and lipoma. Very frequently such tumors were 
 not only hereditary, but also occupied the same localities. Paget found 
 carcinoma of the uterus in three generations — grandmother, mother, 
 and. daughter. The writer has repeatedly met with carcinoma of the 
 breast in two successive generations. Sibley relates an instance of 
 carcinoma of the uterus affecting a mother and her five daughters. 
 Warren observed a cancer of the lip in the father ; in one son and two 
 daughters cancer of the breast ; and in two grandchildren cancer of the 
 breast. The most interesting instance of hereditary predisposition to 
 carcinoma is reported by Broca: 
 
 First generation : Madame Z. died of cancer of the breast in 1788, aged 60. 
 Second generation : four married daughters : 
 
 A. Cancer of the liver, 62 years old, 1820. 
 
 B. Cancer of the liver, 43 " " 1805. 
 
 C. Cancer of the breast, 5 1 " " 1814. 
 
 D. Cancer of the breast, 54 " " 1827. 
 
 Third generation : Madame B., five daughters and two sons : 
 
 First son died during infancy. 
 
 Second son, cancer of the stomach, 64 years old. 
 
 First daughter, cancer of the breast, 35 " " 
 
 Second " " " " -x 
 
 Third " " " " 1 35-40 years old. 
 
 Fourth " " " liver, J 
 
 The fifth daughter escaped the disease. 
 Madame C. had five daughters and two sons : 
 
 The sons remained free from cancer. 
 
 The first daughter died of cancer of the breast in 1 837, 37 years old. 
 
 Of her five children, one daughter died in 1 854, of cancer of the breast, at the age 
 of 49. 
 
 The second daughter died in 1822, 40 years old, of cancer of the breast. 
 
 The third " " 1837, 47 " " " " uterus. 
 
 The fourth " « 1848, 55 " " " " breast. 
 
 The fifth " " 1856, 61 " " " " liver. 
 
 From these and other reliable observations it is evident that a predis- 
 position to cancer may be derived by inheritance. Paget collected the 
 histories of 322 cancerous patients with special reference to this point. 
 Of this number, there were seventy-eight, or nearly one-fourth, who 
 were aware of cancer in other members of their families. The proportion 
 is much larger than could be due to chance, and its import is corrob- 
 orated by the fact of many members of the same family being in some 
 instances affected. It is evident that where a tumor is inherited the two 
 essential causes are transmitted from parent to child : 1 . A matrix of 
 embryonic cells ; 2. A lack of resistance on the part of the whole 
 
ETIOLOGY OF TUMORS. 63 
 
 organism or of the tissues in the immediate vicinity of the matrix to 
 retard tumor-growth. For the growth of a tumor it is not only essen- 
 tial to have present the necessary matrix of embryonic cells, but it is 
 equally essential that the environment of the matrix should not exert 
 upon the cells an inhibitory influence which would interfere with their 
 assuming active tissue-proliferation. If the controlling or inhibitory 
 influence of the tissues in the vicinity of embryonic cells set apart in 
 the organism is diminished or completely abolished, such cells regain 
 their primitive reproductive activity and assume an individuality alone. 
 Under such circumstances there is established a new centre of tissue- 
 formation which has no laws to obey and no orders to observe. In 
 such a new centre of growth there is a departure from the definite order, 
 limitations, regular stages, and fixed periods of the normal growth. 
 Little is known in regard to the force which holds in check perma- 
 nently or for an indefinite period of time the tissue-proliferation from 
 such a matrix. For want of a better knowledge this force has been 
 called physiological resistance. Heredity implies, therefore, in connec- 
 tion with the subject now under consideration, two things : 1. A matrix 
 of embryonic cells ; 2. Suspended or diminished physiological resist- 
 ance in the tissues of the entire body or in the immediate vicinity of 
 the tumor-matrix. The existence of such a force has been demon- 
 strated by experiments. Cohnheim and Maas introduced into the jugu- 
 lar veins of animals small pieces of young periosteum, with the expec- 
 tation that they would become arrested in the smaller branches of the 
 pulmonary artery as emboli. The animals were killed in a few weeks 
 or months later, and the specimens examined to determine the extent 
 of tissue-growth from the periosteal grafts. The results were uniform. 
 The periosteum retained its bone-producing properties and produced 
 bone, but the new product was always limited in size to the lumen of 
 the vessel in which the periosteal embolus had become impacted. 
 When this size was reached further growth became arrested, and the 
 new bone in the course of time underwent complete removal by 
 absorption. It is apparent that the intrinsic force (physiological resist- 
 ance) in the adjacent tissues exerted a positive influence in limiting the 
 production of bone from the periosteal graft to the lumen of the vessel. 
 The same investigators have also shown that transplantation of grafts 
 of embryonal tissue is more successful than that of mature tissue. 
 Leopold, under the direction of Cohnheim, studied the fate of mature 
 tissue transplanted into the anterior chamber of the eye and the peri- 
 toneal cavity in rabbits. He found that all tissue that had reached 
 maturity was invariably removed by absorption in a short time, while 
 embryonic tissue taken from animals before they were born retained its 
 
64 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 vitality and continued to proliferate tissue to an astonishing extent. 
 Grafts of fetal cartilage increased to from two hundred to three hundred 
 times their original size, giving rise to a temporary chondroma of several 
 months' duration. Zahn repeated these experiments with the same 
 results. In the growth of an osteoma tissue-proliferation takes place 
 from a matrix of osteogenetic cells, and we must assume that in the 
 immediate vicinity of the matrix a diminution of the physiological 
 resistance of the tissues had taken place. In the transplantations of 
 malignant tissue, that have almost without exception been followed 
 by negative results, we can explain the failures only by taking it for 
 granted that the tissues in which the graft was imbedded presented an 
 adequate physiological resistance which prevented the growth and infil- 
 tration of the transplanted cells, and that the graft acted the part of an 
 absorbable foreign body, and was subsequently removed by the wall of 
 granulations thrown out by the injured tissues around the graft. The 
 physiological resistance in the adjacent tissues permits grafts from be- 
 nign tumors only to grow to a limited extent if at all, after which they 
 are removed like any other aseptic absorbable substance, while the same 
 resistance offers an effective barrier to infiltration by cells from grafts 
 taken from malignant tumors. From what has been said it follows 
 that there are two essential factors present wherever a tumor grows — ■ 
 namely : /. An embryonal matrix, or at least a matrix composed of embry- 
 onic cells ; 2. A suspension or diminution of the physiological resistance 
 in the tissues in the immediate vicinity of the matrix. The absence of the 
 former precludes entirely the possibility of the formation of a tumor, 
 and only the presence of the latter negative condition enables the matrix 
 to proliferate tumor-tissue. Future research must determine what con- 
 ditions produce diminution of physiological resistance. We have reason 
 to believe that this predisposition to tumor-formation is often hereditary, 
 and that it can be produced artificially by acquired pathological con- 
 ditions which weaken the tissues, such as irritation and inflammation. 
 That the chemico-vital changes which take place in inflamed tissue 
 diminish physiological resistance has been demonstrated unmistakably 
 by the experiments of Friedlander. It is therefore reasonable to sup- 
 pose that a person born with the essential tumor-germs is more likely 
 to become the subject of tumor-formation when the part in which they 
 are located becomes the seat of accidental pathological conditions which 
 result in diminution of the physiological resistance in the tissues sur- 
 rounding the matrix ; while persons born with a similar matrix not thus 
 affected may escape tumor-formation, the matrix-cells remaining in a 
 latent condition throughout life. 
 
 Race. — Race-influence plays an important part in the etiology of 
 
ETIOLOGY OF TUMORS. 65 
 
 tumors. Certain races are predisposed to special tumors. Negroes 
 suffer more frequently from the different forms of fibroma than does 
 any other race. Keloid, fibroma of the skin, and myofibroma of the 
 uterus in women are exceedingly common among the negroes in the 
 South. Lipoma is very prevalent among the Hottentots. The unciv- 
 ilized nations, in proportion to the population, furnish a smaller percentage 
 of malignant tumors than do the inhabitants of Europe and America. 
 
 Climate. — It is said that the inhabitants of southern countries are 
 more predisposed to tumor-formation than are the inhabitants of the 
 North; this applies particularly to carcinoma and sarcoma. Tumors 
 of the thyroid gland appear as endemic affections in certain parts of 
 Europe and in other countries. There is no doubt that malignant 
 tumors are unequally distributed over the world, being more prevalent 
 in some localities than in others. Heredity unquestionably plays an 
 important part in imparting to these tumors in some localities an en- 
 demic character. The accumulation of many generations in particular 
 localities would naturally increase the number of the victims. 
 
 Age. — Age has already been alluded to as an important determining 
 cause. It is a familiar clinical fact that certain benign tumors from 
 embryonic fetal remnants are likely to appear at the age of puberty, 
 at the time of post-natal life when the whole organism, and particularly 
 the organs of generation and the mammary gland in the female, are in 
 a state of the highest physiological activity. It is during this time of 
 life that we most frequently meet with branchial and dermoid cysts, cysts 
 of the ovary and parovarian cysts, and adenoma of the mammary gland. 
 In adult life fibroma, osteoma, chondroma, and other mesoblastic 
 tumors are more prevalent. Carcinoma manifests a predilection for 
 the conditions incident to senile marasmus, occurring most frequently 
 in persons between fifty and seventy years of age. It is in individuals 
 past middle life that we most frequently see transformation of benign 
 growths, such as moles, papilloma, and warts, into malignant tumors. 
 The conditions which determine such a change and which favor the 
 formation of carcinomatous tumors are not well understood. There is 
 anatomically such a thing as a non-malignant stage of cancer. In the 
 early stage of epithelioma we find simply a superficial increase in the 
 thickness of the epidermic layer — that is, the stage when carcinoma still 
 remains as a non-malignant growth ; but just as soon as the physio- 
 logical boundary-line between the epithelial layer and the subjacent 
 connective tissue is destroyed or is rendered permeable to migrating 
 cells — in other words, just as soon as epithelial elements are found in 
 places where they have no legitimate existence — we have to deal with 
 
 a carcinoma. 
 
 5 
 
66 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 A glance at Plate 2, Figures 2 and 3, and at Figures 24 and 25 
 will show the difference in the relation of epithelial cells in normal tis- 
 
 e " d 
 
 Fig. 24. — Epithelioma of skin (after Thiersch): 1-2, ulcerated surface; 2-3, adjacent skin; a, hair- 
 follicles with sebaceous glands made oblique by pressure from beneath ; b, sweat-glands ; c, epidermis, horny- 
 layer, which extends for some distance over ulcerated surface ; d, avascular cell-masses of an epithelial 
 nature, formed into irregular tubes by softening, only slightly attached to the stroma in which they are 
 lodged, or separated from the walls of the alveoli during the hardening process in alcohol; e, connective- 
 tissue stroma. 
 
 Fig. 25. 
 
 ■Columnar epithelioma of rectum (after Boyce) : a, an epithelial process from skin of anus ; 5, a 
 papillomatous gland-crypt. (Obj. £ without eye-piece; logwood staining.) 
 
 sue and in carcinoma. In the former instance the epithelial cells are in 
 an avascular district outside of the limiting membrane, membrana pro- 
 
ETIOLOGY OF TUMORS. 
 
 Plate 2. 
 
 
 /? 
 
 *** 
 
 .5 /> 
 
 ^) « 4* 
 
 1. Endothelioma hyalinum from capsule of submaxillary gland (after Klelis 1 ) : <?, stroma ; b, smaller part of 
 stroma; c, hyaline substance; d, cells. 2. Mucous membrane of large intestine of pig : \ $50 (after Klein). The 
 capillary blood-vessels cut in different directions surrounding the crypts are injected with carmine gelatin. ;. A 
 vertical section through the epithelium covering the skin -epidermis ; \ 350 (after Klein) : <;. rete Malpighii, or 
 rete mucosum ; b, granular layer (Langerhans) ; c, stratum lucidum (Schron) : d, Stratum corneum. 
 
ETIOLOGY OF TUMORS. 67 
 
 pria ; in the latter instance they have found their way through the limit- 
 ing membrane and have reached the underlying vascular mesoblastic 
 tissues, where they have no legitimate physiological existence, and where 
 they must be regarded pathologically as invaders. It appears that in 
 the subepithelial tissues a change takes place coincident with the senile 
 changes in the tissues of persons advanced in life. Thiersch advanced 
 the ingenious hypothesis that this change consists in a disturbance of 
 the normal relations between the skin and the underlying tissues, this 
 disturbance being caused by senile changes and resulting in a loss of 
 resistance to the proliferating epithelial cells. There can be no doubt 
 that in the aged some such alteration of tissue takes place, permitting 
 embryonic epithelial cells to part with their normal anchorage and to 
 find their way by migration into the subjacent altered tissue, where they 
 are no longer subject to the physiological laws which govern the repro- 
 duction and growth of normal epithelial cells, and where, in consequence 
 of such aberration and lawless conduct, they produce a planless, func- 
 tionless growth which invades all tissues, regardless of their anatomical 
 structure. 
 
 Sex. — Statistics show on the whole that the male sex is more 
 predisposed to tumor-formation than is the female. This difference 
 may be accounted for in part by the male sex leading a more active 
 life, and being subjected more to the exciting causes which later in life 
 become such a prominent feature in the etiology of tumors. Heredity 
 affects both sexes equally, and the difference in the frequency with 
 which tumors occur must therefore depend largely on occupation and 
 habits of life. Of 1145 cases of tumor treated at the clinic of Berne 
 during a period of twenty-five years, the males furnished 58.5 1 per cent, 
 and the females 41.49 per cent. C. O. Weber gives the proportion of 
 males to females as 64 : 36. The proportion varies with the different 
 forms of tumors. Carcinoma of the skin is much more frequent in the 
 male than in the female, while in glandular carcinoma the reverse is 
 the case. Moore in 1861 found in England one carcinoma patient 
 to every 5846 men, and one female patient to eveiy 2461 women. 
 In women tumors are more prone to occur during the childbearing 
 period of life than before and after. Carcinoma of the lip is common 
 in men, but extremely rare in women. Of 696 cases of carcinoma of 
 the lip collected by Lortet, 527 were men and 69 were women, the 
 proportion of men to women being 7.6: 1. According to the writer's 
 own observations, carcinoma of the stomach and the rectum is more 
 frequently met with in males than in females. In the female, carcinoma 
 of the breast and the uterus occurs probably more frequently than do 
 malignant tumors of all the remaining organs. 
 
68 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Social Status. — It has generally been claimed that the laboring 
 classes furnish the largest contingent to the whole number of patients 
 suffering- from carcinoma. The statistics from which this statement was 
 drawn were collected almost exclusively from the practice of hospital 
 physicians. A more careful inquiry into the actual facts shows that 
 the reverse comes nearer the truth. M. d'Epine found, in examining 
 the mortality statistics of malignant tumors of the city of Geneva, that 
 among the well-to-do classes came 106 deaths from this cause to every 
 thousand inhabitants, while- the poor furnished only 72 to every thou- 
 sand. Walshe found that \ of a million of people in London in ten 
 of the unhealthiest districts, 127 died of malignant tumors; in ten 
 healthier districts, 183 ; and in ten of the healthiest, 199. From similar 
 statistics gathered in England and Wales, Moore came to the conclu- 
 sion that cancer becomes more frequent with the increasing prosperity 
 of the people. In the United States carcinoma has been on a gradual 
 increase with the progress of civilization. The mortality from this 
 cause in 1850 was 9 for 100,000 inhabitants; in i860 it was 11.79; in 
 1870, 16; in 1880, 26; in 1890, 33.5. 
 
 Traumatism. — The influence of a trauma in exciting tumor-growth 
 can no longer be denied. The different forms of sarcoma frequently 
 follow an injury. Numerous cases are on record in which sarcoma 
 followed a fracture of the long bones. The statistics of Boll, collected 
 with a view to prove the traumatic origin of cancer, show that of a 
 large number of cases only about 12 or 14 per cent, were traceable to 
 traumatism. Ziegler studied the influence of trauma in the etiology 
 of malignant tumors in 282 cases, 180 men and 102 women. He came 
 to the conclusion that in 1 8 per cent, of the cases a single trauma was 
 the apparent cause of tumor-formation, while repeated injuries and 
 prolonged irritation were noted in 25 per cent. He regards trauma 
 and chronic irritations as potent factors in the causation of malig- 
 nant tumors. Traumatism alone can no more produce a tumor than 
 can inflammation occur without the presence of pathogenic microbes. 
 The trauma can act only as an exciting cause in stimulating a pre- 
 existing matrix of embryonic tissue into active tissue-proliferation, or in 
 furnishing by its remote effects on the tissue a post-natal matrix of 
 embryonic cells. In animals sarcomata are seen most frequently in parts 
 most exposed to injury — in fishes in the tail and fins, in frogs in the 
 limbs, and in birds in the neck and wings. The writer believes that in 
 a fracture of a bone which later becomes the seat of a sarcoma the 
 cells which are destined to furnish the bony callus fail to undergo the 
 typical transformation from embryonic into mature tissue in consequence 
 of some local or general cause, and that from these cells the sarcoma 
 
ETIOLOGY OF TUMORS. 69 
 
 takes its origin. Influenced by a preconceived idea, it is not difficult 
 to trace many of the local affections, including tumors, to a traumatic 
 origin. How long have we been in the habit of assigning to traumatism 
 the first position in the causation of suppurative inflammation? Recent 
 investigations have demonstrated that no amount of traumatism can 
 produce inflammation and suppuration unless the injured tissues become 
 infected with the essential cause of inflammation — pyogenic microbes. 
 Trauma in exceptional cases may and does act as an exciting cause 
 in the growth of a tumor, by diminishing the physiological resistance 
 of the injured tissues or by causing irritation or inflammation in the 
 immediate vicinity of a pre-existing tumor-matrix ; or in more excep- 
 tional cases it furnishes both essential conditions for tumor-growth — 
 a post-natal matrix of embryonic cells and a diminution of physiological 
 resistance in the immediate vicinity of the new matrix, 
 
 Irritation. — Prolonged irritation — microbic, mechanical, chemical, 
 and thermal — is a recognized exciting cause of tumor-growth. If we 
 examine the topography of carcinoma, we find that it attacks parts 
 and organs that are most frequently the seat of prolonged and repeated 
 irritation. The clay pipe in smokers, the coal-dust in chimney-sweeps, 
 foreign bodies in the tissues or in hollow organs, carious teeth, and 
 other local irritants have for a long time been regarded as important 
 causes in the production of tumors, more especially of carcinoma and 
 sarcoma. The influence of alcoholic drinks in the production of car- 
 cinoma of the oesophagus and stomach should be mentioned here. 
 A similar chronic local irritation is the chronic catarrh of the mucous 
 membrane of the nose which so often precedes the formation of 
 myxomatous tumors in this locality. Virchow very correctly mentions 
 the frequent occurrence of cancer of the testicle where the organ 
 remains in the inguinal canal and is subjected repeatedly to pressure 
 and traction. The ovary is equally liable to carcinoma if it constitutes 
 a part of the contents of a hernia. We shall assign to irritation and 
 inflammation an influence in the production of tumors similar to that 
 assigned to traumatism. 
 
 Inflammation. — Inflammation is never the sole cause of tumor- 
 formation. That it is an important factor in stimulating pre-existing 
 embryonic cells into a state of active tissue-proliferation few would 
 deny. Friedlander has shown that embryonic epithelial cells, by virtue 
 of their ameboid movement, can penetrate a subjacent inflamed sur- 
 face. It has been shown that cancer-cells possess the same ameboid 
 movement, which is a potent factor in the process of infiltration. 
 Inflammation always hastens tumor-growth : this statement applies 
 with particular force to malignant tumors. If a tumor-matrix is within 
 
yo PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the limits of an inflamed area, it receives suddenly an increased blood- 
 supply, which alone may be sufficient to arouse it from its dormant 
 condition into active tissue-proliferation ; at the same time the inflam- 
 mation will result in diminution of the physiological resistance of the 
 tissues around the matrix, thus still further favoring tumor-growth. 
 
 Contagion. — Under this heading of the etiology of tumors it is only 
 necessary to mention the malignant varieties, carcinoma and sarcoma. 
 The popular fear of the contagiousness of these growths lacks founda- 
 tion. There is not a single well-authenticated case on record in which 
 the disease was transmitted from man to man or from animal to animal 
 by contagion. The cases in which the disease was reproduced in the 
 same individual at a point opposite the primary tumor (by contact) or 
 by bringing an ulcerating carcinoma frequently in contact with a distant 
 part, as by rubbing (Kaufmann), are few, and the auto-inoculation was 
 undoubtedly preceded by pathological conditions which in themselves 
 might have furnished the essential conditions for tumor-growth, or 
 which, at any rate, created a favorable soil for the implantation of tumor- 
 cells. The negative results which have followed thousands of attempts 
 to reproduce carcinoma and sarcoma by implantation of fragments 
 of tumor-tissue in different animals furnish the most convincing proof 
 of the non-contagious and non-parasitic character of malignant tumors. 
 
VII. CLINICAL ASPECTS OF BENIGN AND 
 MALIGNANT TUMORS. 
 
 The clinical behavior of a tumor is determined by the nature of the 
 primitive matrix, the anatomical structure and physiological importance 
 of the part or organ affected, and the relations of the tumor to the adja- 
 cent tissues. A tumor-matrix composed of embryonic cells of the 
 lowest degree of development is more likely to result in the formation 
 of a malignant tumor than is a matrix representing embryonic cells 
 capable of development into tissue of the highest physiological type. 
 Again, the type of a tumor will depend upon the germinal layer from 
 which the matrix is derived. A matrix from the middle germinal layer 
 will produce a tumor of the connective-tissue type — either a benign meso- 
 b I as tic tumor or a sarcoma. A matrix of embryonic cells from the epiblast 
 or hypoblast will give rise to either a benign epitlielial tumor or a carci- 
 noma according to the intrinsic capacity of the cells to produce embryonic 
 or 7nature cells, and the resisting power of adjacent tissues. A tumor 
 of an important organ, such as the brain, heart, lungs, or digestive 
 tract, may destroy life by its presence producing mechanical conditions 
 incompatible with an essential function. Large tumors of less import- 
 ant organs may by compression of an important organ produce the 
 same result. Malignant tumors affecting important organs not only 
 give rise to functional disturbances by their mere presence, but they 
 also destroy the tissues of the part or organ affected, thus greatly 
 increasing the danger to life. A benign tiimor remains limited to the 
 part or organ primarily affected ; malignant tumors, on the contrary, 
 ignore all boundary -lines and affect adjacent tissues irrespective of their 
 anatomical structure. 
 
 Relative Frequency -with which Different Organs are Affected 
 by Tumors. — Every clinician knows that certain tumors show a predi- 
 lection for certain tissues and organs. Fatty tumors occur most fre- 
 quently in the panniculus adiposus, enchondroma in the long bones ; 
 sarcoma affects most frequently the connective tissue, the glands, and 
 the bones, while the muco-cutaneous orifices and the mammary gland 
 are the most frequent seat of carcinoma. C. O. Weber arranged the 
 following table of organs and parts to show their predilection for 
 tumor-formation : 
 
 Tl 
 
J 2 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 No. of Cases. 
 
 Organs of mouth, with maxillary bones > 217 
 
 Glands 174 
 
 Bones, excluding maxillary bones 161 
 
 Skin 93 
 
 Genital glands , 86 
 
 Lungs 64 
 
 Nose, pharynx, antrum of Highmore 56 
 
 Subcutaneous and intermuscular connective tissue, muscles, and nerves . . 51 
 
 Eyes and orbits 41 
 
 Genitals, including uterus 31 
 
 Intestines and anus 13 
 
 Urinary organs 13 
 
 Brain 13 
 
 That the relative frequency with which different tissues and organs 
 are affected is inaccurately represented by this table follows from the 
 fact that it undoubtedly includes many chronic infective swellings which 
 were formerly classified with tumors, and which even now are often 
 mistaken for tumors ; but the table is valuable in giving at least an 
 approximately correct idea of the topographical distribution of tumors. 
 Benign Tumors. — A benign tumor always grows slowly. Myofi- 
 broma of the uterus under favorable circumstances may attain great size 
 in the course of a few years (Fig. 26). Fibromata in other localities grow 
 
 less rapidly. Among the tumors of slow 
 growth, which, however, eventually often at- 
 tain great size, are the cystic adenomata and 
 chondromata. Slowness of growth must there- 
 fore be looked upon as an important clinical 
 feature of a benign tumor. Every benign 
 growth is surrounded by a limiting capside, 
 which separates it from the adjacent tissues, 
 and beyond which it never extends. This isola- 
 tion from the surrounding tissues is the most 
 fig. ^.-submucous pedunculated distinctive anatomical feature of benign as 
 myofibroma of the uterus (after compared with malignant tumors. The exist- 
 
 Paget) : a, capsule ; b, tumor. . . 
 
 ence of this connective-tissue capsule enables 
 the surgeon in the majority of cases to remove benign tumors by enu- 
 cleation. If the capsule of a benign tumor, owing to anatomical pecu- 
 liarities of the surroundings, sends prolongations into the adjacent 
 tissues, as is sometimes the case in lipoma and fibroma, parts of the 
 tumor may be overlooked by the surgeon, and from them takes place 
 a local recurrence later. We are therefore prepared to appreciate the 
 force of the statement that incomplete removal of a benign tumor is 
 
 always followed by recurrence unless the remaining part of the tumor 
 
BENIGN AND MALIGNANT TUMORS. 
 
 Plate 3. 
 
 
 . . 
 
 
 "*£ 
 
 Glandular carcinoma of the breast (after Klebs) : <i. epithelial layer of skin with long proliferating projec- 
 tions ; />, carcinoma-tissue of epithelial cells and connective tissue ■ c, the same with predominance of epithelial 
 cells ; d, milk-ducts. 
 
BENIGN AND MALIGNANT TUMORS. 73 
 
 is subsequently destroyed by suppurative inflammation or by degenerative 
 changes. 
 
 Encapsulation of a tumor imparts to it another clinical feature of 
 great importance — mobility. This mobility, however, may be diminished 
 or entirely prevented by the tumor being tied down by overlying firm 
 structures, such as fascia, skin, and muscles. If the tumor is attached 
 to the bone, as is the case in chondroma and osteoma, it is from the 
 beginning immovable, and so remains. The question of mobility of 
 a tumor is a valuable point in differential diagnosis, and is of special 
 importance in the case of tumors of the breast. An adenoma of the 
 mammary gland always remains movable, while in carcinoma of this 
 organ the tumor almost from the beginning is so intimately connected 
 with the surrounding tissues that the palpating finger receives an im- 
 pression as though the tumor were grasped and firmly held in place 
 by the surrounding tissues. Some of the benign tumors — myxoma, 
 chondroma, and some forms of fibroma— have received the reputation 
 of being semi-malignant on account of their occasional recurrence after 
 extirpation. A tumor is either benign or malignant : there is no connect- 
 ing-link between them. The recurrence of a tumor after extirpation may 
 be explained as follows: I. The tumor was incompletely removed; 
 
 2. The primary tumor removed was malignant from the beginning; 
 
 3. A new tumor may develop in the scar of the operation-wound or 
 in its immediate vicinity. Local recurrence after the removal of a 
 benign tumor has been observed most frequently in cases of chon- 
 droma, myxoma, and fibroma— tumors which, from their clinical 
 behavior as well as from the fact that their extirpation is sometimes 
 followed by recurrence, have been regarded by many surgeons as 
 suspicious or semi-malignant growths. We have reason to believe that 
 in most cases local recurrence was due to imperfect removal. These 
 tumors have a structure which renders their complete removal uncer- 
 tain. Fibroma, for instance, is often surrounded by minute nodules, not 
 large enough to be recognized by the naked eye,, which are in histo- 
 genetic connection with the main tumor, and which, if the main tumor 
 is removed by enucleation, remain in the tissues ; from these nodules 
 a recurrence takes place later. Such minute daughter-tumors arc no 
 evidence of the malignant nature of the primary tumor, as their histo- 
 genetic connection with the primary tumor can be demonstrated. The 
 jelly-like structure of a myxoma renders the outline of the tumor 
 irregular. Projections of the tumor between muscles and connective 
 tissue are often overlooked, .and if left in the bed of the tumor they 
 certainly would give rise to local recurrence. Virchow years ago 
 showed that chondroma originates not from the surface of a bone, but 
 
74 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 in its interior. Surgeons seldom extend the operation far enough to 
 include every vestige of the tumor, hence the frequency with which 
 an enchondroma returns. If a tumor is removed completely and local 
 recurrence takes place, it is more than probable that the primary tumor 
 was of a malignant character, and that the relapse is the result of tissue- 
 proliferation from malignant cells left in the tissues. The clinical course 
 of the tumor in such cases makes a more positive and reliable diagnosis 
 than the surgeon and pathologist. Finally, a new tumor may grow from 
 an additional congenital matrix of embryonic cells or from latent unutilized 
 embryonic cells in the scar or in its immediate vicinity. 
 
 Malignant Tumors. — To the surgeon the most important clinical 
 aspects of a malignant tumor are — I. Rapid growth; 2. Absence of 
 limitation of the growth ; 3. Local infection ; 4. Regional infection ; 
 5. General infection; 6. Frequency of recurrence after extirpation; 
 7. The intrinsic tendency of the tumor to destroy life. Rapidity of 
 growth, as compared with that of benign tumors, belongs to malignant 
 tumors as one of their salient clinical features. Some malignant tumors, 
 particularly epithelioma of the skin, may remain in a latent stage for 
 years before manifesting their true nature by rapid growth ; these are, 
 however, exceptional cases. 
 
 Absence of a limiting capsule is common to all malignant tumors. 
 In some forms of sarcoma, to the naked eye such a capsule exists, but 
 examination of the tissues adjacent to it under the microscope shows 
 that tumor-cells have passed through and beyond the capsule into the 
 connective tissue. The apparent capsule in such cases has been a 
 source of deception to the surgeon who enucleates such a tumor under 
 the belief that it is non-malignant. The absence of a proper limiting 
 capsule brings the tumor-tissue in direct contact with the surrounding 
 tissues, giving rise to local infection. The word " infection " as applied 
 to the process of dissemination of malignant tumors has a different 
 significance than when the same term is applied to the origin and 
 extension of acute and chronic infective diseases. In the latter case 
 infection signifies the presence in the tissues of pathogenic microbes 
 which exert their specific pathogenic effect upon pre-existing tissues. 
 The word infection used to indicate the local, regional, and general dis- 
 semination of malignant tumors means the separation from the primary 
 tumor of cells which migrate into the surrounding connective tissue, giving 
 rise to local infection, or which are transported through the lymphatics of 
 the region occupied by the tumor, causing regional infection ; or, lastly, 
 the malignant cells find their way directly or indirectly into the general 
 circulation and become arrested in some distant part or organ as tumor- 
 emboli, resulting in general infection or general dissemination. 
 
BENIGN AND MALIGNANT TUMORS. 75 
 
 Local Infection. — Local infection of a malignant tumor is caused 
 by the migration of tumor-cells from the place in which they were 
 produced — that is, from the primary tumor — into the connective-tissue 
 spaces in the immediate vicinity of the tumor. This migration of cells 
 in all directions around the tumor results in a zone of tissue-infiltration 
 by malignant cells, each cell establishing in its new location an inde- 
 pendent centre of tumor-growth. As soon as a malignant cell has left 
 its birthplace, it leads an independe?it existence and loses all histogenetic 
 connections with the mother-tumor. It is the establishment of innumerable 
 independent centres of tissue-proliferation in the zone of infiltration sur- 
 rounding a malignant tumor that determines its rapid growth. Infec- 
 tion from a malignant tumor implies, therefore, only the invasion of 
 adjacent or distant tissues by malignant cells ; it is an infection by cells 
 instead of by microbes, as is the case in the production of infective diseases. 
 Another great difference in the two kinds of infection is this : in infec- 
 tive diseases the microbes act upon and alter pre-existing tissue-cells, 
 while in tumor-growth the pre-existing tissue remains passive, the tis- 
 sues of the tumor being derived exclusively from the tumor-cells. 
 As a rule, local infection is much more pronounced and rapid in sar- 
 coma than in carcinoma, hence greater rapidity of growth and larger 
 size of the tumor. 
 
 Regional Infection. — Regional infection consists in the transporta- 
 tion of tumor-cells through the lymphatic channels some distance from 
 the tumor to the lymphatic glands in the region occupied by the tumor. 
 Familiar instances of regional infection are secondary carcinoma of the 
 submental, submaxillary, and cervical glands in advanced carcinoma of 
 the lip, and secondary carcinoma of the axillary glands in glandular 
 carcinoma of the mammary gland. The regional dissemination of car- 
 cinoma is accomplished almost exclusively through the medium of the 
 lymphatics. The carcinoma-cells, after finding their way into a lym- 
 phatic channel within or near the tumor, are transported by the lymph- 
 current, and are arrested usually in the first lymphatic gland, which 
 acts the part of a filter. The cell or cells establish here a new centre 
 of growth, from which the tissues of the ensuing secondary carcinoma 
 of the lymphatic gland are derived exclusively, the lymphoid cells 
 taking no active part in the production of the tumor. From a gland 
 thus infected tumor-cells again reach the lymphatic channel on the 
 opposite side of the gland, and are taken up by the lymph-current and 
 transported to the next lymphatic gland, where an additional centre oi~ 
 tumor-growth is established. By this progressive regional extension 
 of the tumor the whole chain of glands between the primary tumor 
 and the proximal termination of the lymphatic system becomes in- 
 
7 6 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 volved. The lymphatic glands serve as niters and contribute much 
 toward retarding general dissemination. General infection is likely to 
 occur at an early date if the lymphatic glands do not participate in the 
 regional extension of the tumor. The malignant cell after it has 
 become detached from the mother-tumor retains all the qualities in- 
 herited from it at birth, and consequently produces the same kind of 
 tissue, whether it remain in the vicinity of the tumor in the same region 
 or whether it is transported to the most distant organs. The secondary 
 tumors resemble the primary tumor histologically and clinically (Fig. 27). 
 Regional dissemination of a sarcoma takes place by a continuous 
 growth of the tumor, usually in the direction of fascia, blood-vessels, 
 or nerve-sheaths : it is a local infection on a large scale. Occasionally 
 
 a sarcoma gives rise to regional 
 infection in the same manner 
 and through the same channel 
 as carcinoma. 
 
 Another method of regional 
 infection takes place by the dif- 
 fusion of particles of tumor- 
 tissue or free tumor-cells over 
 serous surfaces — in the abdom- 
 inal cavity by the peristaltic 
 movements of the intestines and 
 the stomach, and in the pleural 
 cavity by the movements of the 
 lung during respiration. This 
 manner of regional infection is witnessed most frequently in sarcoma 
 of the peritoneum and the pleura, and in carcinoma of any of the 
 abdominal organs or of the lung after the tumor has reached the serous 
 cavity. 
 
 General Infection. — General infection during the growth of a malig- 
 nant tumor is called metastasis — that is, the reappearance of the same 
 disease in a distant organ. When this stage is initiated the tumor is no 
 longer local : the disease has become general. No modern pathologist 
 regards — as was formerly and quite recently done — a primary malig- 
 nant tumor as a local manifestation of a general disease or dyscrasia. 
 A careful study of the pathology and histology of malignant tumors, 
 as well as the results of accurate clinical observation, has demon- 
 strated that malignant tumors are primarily purely local affections, 
 amenable to successful surgical treatment, and that they become gen- 
 eral only by the dissemination of tumor-cells through the systemic 
 circulation. Metastasis may occur in one of three ways: 1. Tumor- 
 
 Fig. 27. — Secondary sarcoma of lymphatic vessels of omen- 
 tum in the course of a medullary sarcoma (after Liicke). 
 
BENIGN AND MALIGNANT TUMORS. 77 
 
 cells reach the venous circulation directly by their entrance from the 
 primary tumor or the regional glandular tumors into a vein ; 2. By 
 progressive extension of the disease through the lymphatic channels 
 until the last filter, the last lymphatic gland, is passed, when the 
 tumor-cells reach the general circulation ; 3. By the passage of tumor- 
 cells through the chain of lymphatic glands into the pulmonary or 
 systemic circulation without implicating the lymphatic glands. It is 
 strange that the tumor-emboli are not more constantly arrested in the 
 finer branches of the pulmonary artery. The result of post-mortem 
 examinations of persons who died of malignant tumors would tend to 
 show that such emboli readily pass the pulmonary filter, and may 
 become arrested in any of the more distant vascular organs. The 
 exemption of non-vascular tissues from metastatic carcinoma is one of the 
 many proofs that malignant tumors are generalized by cellular elements, 
 and not through the agency of a virus or of microbes. Metastasis always 
 takes place through the arteries. Usually the emboli are small (Fig. 28). 
 In some cases perhaps a single cell becomes implanted upon the wall 
 of an arteriole, and later a thrombus is formed by tissue-proliferation 
 from this cell. In other instances a vessel of considerable size is 
 obstructed by a malignant thrombus. Metastatic tumors frequently 
 
 Fig. 28. — Embolism of the right pulmonary artery from a pigmented sarcoma of the thigh (after Liicke). 
 
 extend in the direction of a blood-vessel of considerable size, the mul- 
 tiple tumors with the blood-vessels and its branches presenting the 
 appearance of a bunch of grapes (Fig. 29). 
 
78 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The number of emboli varies greatly, from a single metastatic tumor 
 to thousands of nodules. In some very malignant forms of carcinoma 
 and sarcoma the nodules are so numerous that the appearance of the 
 
 Fig. 29. — Medullary nodules in the course of an artery of the great omentum following a primary carcinoma 
 
 of the right tonsil (after Liicke). 
 
 internal organs resembles very closely that of miliary tuberculosis. 
 Metastasis occasionally takes place in the aged who have been the sub- 
 jects of latent carcinoma for years. In some instances the patients 
 were not aware of the existence of the primary tumor until the pres- 
 ence of a large and destructive metastatic tumor gave occasion to 
 consult a physician. Sarcoma gives rise to general infection more' 
 constantly and at an earlier date than does carcinoma. Small-celled 
 sarcoma is more frequently followed by early and diffuse general dis- 
 semination than are large-celled tumors. 
 
 Frequency of Recurrence after Extirpation.— It has been shown 
 that the recurrence of a benign tumor is always local, and is invariably 
 the result of incomplete removal of the tumor. The recurrence after 
 the removal of a malignant tumor is either local or metastatic — in the 
 former instance caused by incomplete removal of the primary tumor, 
 and in the latter instance a sad reminder that the operation was not 
 performed early enough to protect the patient against general infection, 
 
BENIGN AND MALIGNANT TUMORS. 79 
 
 The most competent surgeons are willing to admit that so far the best 
 results of operations for malignant disease have not yielded more than 
 about 15 to 25 per cent, of permanent recoveries. If we recollect how 
 a malignant tumor reaches out in all directions into tissue which to the 
 naked eye presents every indication of being normal, we can readily 
 understand why local relapse should follow so frequently even after 
 what seemed a thorough operation. Again, every surgeon has reason 
 to regret that in most cases he is called upon to operate for malignant 
 tumors after the disease has advanced beyond the limits of a successful 
 radical operation. In some instances no local recurrence takes place, 
 but the operation was performed too late, and the patient succumbs 
 sooner or later to metastatic carcinoma or sarcoma. In such cases 
 general infection had taken place when the operation was performed. 
 A local recurrence may take place from three to seven years after the 
 operation for carcinoma of the breast, as happened in a number of the 
 writer's cases, and it may be postponed, according to Billroth, twenty 
 years from the time of operation in cases of sarcoma. Sarcoma usually 
 returns in the scar; carcinoma, either in the scar or in the adjoining 
 lymphatic glands. 
 
 Intrinsic Tendency of the Tumor to Destroy Life. — If we reflect 
 upon the fact that with the best efforts of the surgeon only 15, and at 
 best only 25, per cent, of all persons suffering from malignant tumors 
 escape a painful and lingering death from their immediate and remote 
 effects, we must admit that the intrinsic tendency of a malignant tumor 
 is to destroy life. The average duration of life of all persons suffering 
 from malignant tumors of all kinds and of all parts and organs of the 
 body, without surgical intervention, is about three years. It is a source 
 of satisfaction to the surgeon to know that life is prolonged by radical 
 attempts to remove malignant tumors, and that in a fair proportion of 
 cases the disease never returns. Life is destroyed by regional or gen- 
 eral dissemination involving important organs, by the primary tumor 
 interfering with the function of an important organ, by hemorrhage, or, 
 lastly, by a progressive chronic sepsis or septico-pysemia caused by 
 an open ulcerating carcinoma or sarcoma. The so-called " cachexia " 
 which appears so constantly some time before the fatal termination 
 is the result of impaired nutrition and of the introduction into the cir- 
 culation from the tumor of toxic substances. 
 
VIII. TRANSFORMATION OF BENIGN TUMORS 
 AND POST-NATAL EMBRYONIC TISSUE INTO 
 MALIGNANT TUMORS. 
 
 The possibility of the transformation of a benign into a malignant 
 tumor has been asserted by a few and denied by most of the older 
 writers on surgical pathology. The subject is of great interest to the 
 pathologist, and of equal practical importance to the surgeon. Accum- 
 ulated clinical observations, since the diagnosis of tumors has been 
 made more accurate by increased knowledge of their pathology and by 
 a more frequent resort to the use of the microscope in the examination 
 of tissue removed for diagnostic purposes and of fresh specimens after 
 operation, have brought more convincing proof of the possibility of 
 such an occurrence. As the result of his own observations the writer 
 is convinced not only that such a transformation is possible, but also 
 that it takes place much more frequently than has heretofore been 
 supposed. The writer is equally certain that malignant tumors not 
 infrequently originate from embryonic tissue of post-natal origin. 
 
 Transformation of Benign into Malignant Tumors. — The trans- 
 formation of a benign into a malignant tumor implies a change in the 
 Jiistological structure of the cells of the benign tumor as zvcll as a change 
 in its environments. We have seen that the cells of which benign 
 tumors are composed resemble the normal cells of the part or organ 
 in which the tumor is located. In a myofibroma of the uterus the cells 
 resemble the connective tissue and the unstriped muscle-cells in the 
 uterine wall in which the tumor is located. The epithelial cells in an 
 adenoma of the breast cannot be distinguished from the epithelium of 
 the acini and tubules of the mammaiy gland. The transformation 
 depends, therefore, upon influences which accomplish such a change 
 from mature into embryonic cells. At the same time, and probably 
 from the same causes, the physiological resistance of the adjoining 
 tissues is diminished. 
 
 The liability of benign tumors to become malignant is of interest 
 not only as a subject of pathological study, but also in relation to an 
 opinion which is often made an argument for operations — namely, that 
 if a tumor of any kind is left to pursue its own course, it is not unlikely 
 to become malignant. This belief, which is entertained by the general 
 
 80 
 
TRANSFORMATION OF TUMORS. 8 1 
 
 mass of the people, is a strong inducement for patients suffering from 
 benign tumors to submit themselves to a timely operation. This pop- 
 ular belief should be strengthened, not undermined, by the medical 
 profession, as by doing so the patient's mind is relieved and all liability 
 to malignant disease from malignant tumors is removed, and this in- 
 formation and consolation should be imparted to the patient. Lebert 
 states that he has twice met with tumors which were first benign, but 
 afterward became cancerous. 
 
 Pirogoff relates three cases in which the removal of angioma was 
 followed by sarcoma at or near the seat of operation. 
 
 Benjamin Brodie relates a case in which he removed a tumor the 
 general mass of which appeared to be fatty substance somewhat more 
 condensed than usual, but " here and there was another kind of morbid 
 growth, apparently belonging to the class of medullary or fungoid 
 disease." 
 
 Lebert and Benjamin Brodie reported each a case of unquestionable 
 transformation of a benign into a malignant tumor. A few other 
 isolated cases are recorded, but such serious doubt was entertained 
 concerning this matter that at the time Sir James Paget published his 
 Lecttcres on Surgical Pathology (1870) he expressed himself in a very 
 guarded way on this subject : " It need not be denied that cancerous 
 growths may occur in tumors that were previously of an innocent kind, 
 but I feel quite sure that these may be regarded as events of the 
 greatest rarity." He believes that such transitional tumors were malig- 
 nant from the very beginning, and that the benignant stage simply 
 indicated latency of a carcinomatous growth. The occurrence of a 
 carcinoma in a scar following an operation for the removal of a benign 
 growth he attributes to the trauma acting on the tissues and furnishing 
 the necessary stimulus to the development of a carcinoma in persons 
 so predisposed by heredity. 
 
 Since Paget wrote on this subject numerous cases have been recorded 
 in which at the operation such mixed tumors were found, and in which 
 cases there could have been no doubt of the benign nature of the 
 primary tumor. An interesting case of this kind came under the 
 writer's observation. The patient was a married woman fifty-two years 
 of age, the mother of several children. For at least ten years she 
 suffered from a pelvic difficulty which six years ago was diagnosed as 
 myofibroma of the uterus. Since that time she has suffered from pro- 
 fuse menstruation. Examination disclosed a smooth tumor occupying 
 the middle of the lower part of the abdominal cavity and reaching as 
 far as the umbilicus. On vaginal examination the lower segment oi 
 the uterus was found high up and was affected by the movements o( 
 
82 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 f 
 
 
 ■■b-i 
 
 hit: - 
 
 ■HHIIffi '!■■■' 
 
 Fig. 30. — Myofibroma uteri ; X I 5o» 
 
 1 
 
 ■ * .... 
 
 
 • .4 -*«• 
 
 wmM 
 
 Fig. 31. — Sarcoma which started in a myofibroma uteri : transformation of a myofibroma into sarcoma ; X 485. 
 
TRANSFORMATION OF TUMORS. 83 
 
 the tumor. The absence of metrorrhagia and the clinical history spoke 
 in favor of the diagnosis previously made. On opening the abdomen 
 there was found what appeared to be a large myofibroma of the uterus 
 springing from the fundus between the cornua. The immobility of the 
 pelvic part of the tumor induced the writer to make a more thorough 
 examination, which revealed extension of the tumor-mass from the uterus 
 to the broad ligament on the right side. The operation proved to be a 
 very difficult one. The entire uterus, with the pelvic mass on the right 
 side, was removed. An examination of the specimen showed an intersti- 
 tial myofibroma, the lower segment soft and continuous with the extra- 
 uterine part of the tumor. Microscopic examination of the upper, dense 
 part of the tumor showed the characteristic structure of a myofibroma 
 (Fig. 30), while sections from the lower part of the tumor, the infil- 
 trated uterine wall, and the extra-uterine part of the tumor presented 
 the typical picture of round-celled and spindle-celled sarcoma (Fig. 31). 
 There could be no doubt in this case that the myofibroma had existed 
 for at least ten years, and, as the sarcoma constituted a part of the 
 tumor, it was evident that it occupied that part of the tumor which had 
 undergone transformation from a benign into a malignant tumor. The 
 sarcomatous degeneration did not remain limited to the tumor in which 
 it had its origin, but extended to the uterus, and from here to the tis- 
 sues outside of it, but in connection with it. The writer has seen in the 
 aged a number of instances in which papilloma assumed active growth 
 after having been in existence for twenty or more years, and manifest 
 clinical evidences of their transition from benign into malignant tumors ; 
 he has also witnessed the development of the most malignant form of 
 sarcoma in a small fibroma of the skin that had existed as a benign 
 tumor for years. The origin of sarcoma from pigmented moles is of 
 common occurrence and is generally recognized. In other cases the 
 naevus pigmentosus is transformed into carcinoma. If the mole under- 
 goes this transition, the principal seat of the carcinoma is in the super- 
 ficial layer of the cutis and the rete mucosum, the altered cell-prolifera- 
 tion being limited to the epiblastic structures of the mole. 
 
 The exciting causes in effecting a transition of a benign into a malig- 
 nant tumor are such local and general influences as transform mature 
 cells into embryonic cells, and which at the same time render the sur- 
 rounding tissues more passive to cell-infiltration. Among the local 
 causes may be enumerated injury, prolonged or repeated irritation, and 
 incomplete removal of the benign tumor by excision or by cauterization. 
 The writer regards the incomplete removal of a benign growth by the 
 application of caustics as one of the most fruitful sources in the trans- 
 formation of a benign into a malignant tumor. Papilloma and fibroma 
 
84 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 of the skin in localities exposed to friction by the clothing, the sus- 
 penders, etc. are liable to undergo such a transition. The incomplete 
 removal of a myxoma of the nasal cavities by ecraseur, forceps, or paren- 
 chymatous injections, if these procedures are frequently repeated, is very 
 liable to give rise to sarcomatous degeneration of the growth. The 
 senile state appears to exert a general influence which favors the change 
 of an innocent into a malignant tumor. Malignant tumors starting from 
 a benign tumor are met with most frequently in persons advanced in 
 years who were the subjects of benign tumors for from ten to thirty 
 years, and the clinical history usually points to agencies enumerated 
 above which have brought about this transition. 
 
 Transformation of Embryonic Tissue of Post-natal Origin into 
 Malignant Tumors. — Cohnheim's theory of the origin of tumors is 
 not applicable to tumors originating in the products of a chronic in- 
 flammation or in scar-tissue. The writer has for years maintained 
 that embryonic tissue of post-natal origin may in the production of 
 tumors serve the same purpose as Cohnheim's congenital matrix. 
 It is not difficult to understand that embryonic cells, during the pro- 
 cess of regeneration after inflammation or in the healing of a wound 
 or a fracture, may fail to undergo evolution into so complete a state 
 of perfection as the maternal cells which produced them, and that 
 such cells are set aside, and remain in the tissues in a latent condition 
 in a manner similar to that claimed by Cohnheim for his congenital 
 matrix of embryonic cells. The exciting causes which stimulate such 
 a matrix to tissue-proliferation are of the same nature as those de- 
 scribed in the section on the Etiology of Tumors. The kind of tumor 
 produced by such a matrix will correspond to the type of tissue from 
 which the matrix was derived. Epithelial cells buried in a scar will 
 produce an epithelioma. In the healing of a burn some of the new 
 epithelial cells which are derived from the epiblast and which are not 
 utilized in the process of epidermization become buried in the scar- 
 tissue, remain in an immature state, and not infrequently become later 
 the starting-point of an epithelioma. Every surgeon knows that car- 
 cinoma not infrequently develops in scar-tissue. Such an origin of 
 carcinoma is not limited to the surface of the body. Gynecologists 
 have claimed for many years that carcinoma of the cervix of the uterus 
 is very prone to develop in the scar-tissue produced by extensive 
 laceration of the cervix during labor. The embryonic cells upon which 
 depends callus-production, when for some reason, local or general, they 
 fail to develop into mature tissue, not infrequently constitute the matrix 
 of tumor-formation, and instead of a normal callus a sarcoma is pro- 
 duced. Not long ago the writer observed an interesting case of this 
 
TRANSFORMATION OF TUMORS. 85 
 
 kind : A man fifty years of age, apparently in perfect health, riding 
 on horseback through a woods, struck his right shoulder against a 
 tree. He was unable to use his arm after the injury. The physician 
 who examined the case pronounced the injury a fracture of the surgical 
 neck of the humerus. The fracture was treated in the customary man- 
 ner. Three months later, another physician gave it as his opinion that 
 the original injury consisted of a dislocation of the shoulder-joint for- 
 ward and fracture cf the upper part of the humerus. Six months 
 after the injury the patient entered St. Joseph's Hospital, Chicago. 
 The patient was unable to use the arm. The upper part of the 
 humerus was surrounded by a swelling which in the subcoracoid 
 region presented on palpation distinct fluctuation. About the centre 
 of the swelling an additional point of motion indicated that the fracture 
 had not united. Exploratory puncture of the tumor at a point corre- 
 sponding to the fluctuating area yielded blood and a few minute frag- 
 ments of tissue resembling in their naked-eye appearances granulation- 
 tissue. The patient complained of a great deal of pain in the tumor, 
 extending in the direction of the shaft of the humerus. As the pain 
 was greatly aggravated during the night, the patient was placed, on 
 gram doses of potassic iodide with mercurial inunctions over the 
 swelling. This treatment was continued for nearly two months with- 
 out making any impression on the subjective symptoms or on the size 
 of the tumor. Amputation through the shoulder-joint was made. The 
 upper five inches of the humerus was found almost completely de- 
 stroyed by a central myeloid sarcoma which had evidently started at 
 the seat of the fracture. The cartilage of the humerus was completely 
 detached by the tumor-mass, and the disease had reached the capsule 
 of the joint, which was carefully dissected away. The patient does not 
 recollect having suffered any pain or impairment of function of the arm 
 prior to the injury; hence it is safe to assume that the sarcoma devel- 
 oped, in consequence of the injury, from the embryonic tissue, which 
 was arrested in its development into mature tissue by unknown local 
 or general influences. 
 
 Maas illustrates the influence of traumatism in effecting transition 
 from a benign into a malignant tumor by reporting the case of a med- 
 ical student who had at the inner termination of the eyebrow an ordinary 
 small congenital angioma which was injured by a sabre-cut in a duel. 
 Within two years a racemose aneurysm developed in the scar. Maas 
 concludes that trauma can result in the formation of a tumor if the 
 essential embryonal matrix is present at the site of injury. We have 
 seen that a trauma acts as an exciting cause in provoking active tissue- 
 proliferation from a latent matrix of congenital embryonic cells, but 
 
86 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the case of Maas just quoted admits of another and more satisfactory- 
 explanation. In the repair of the vessel-wounds inflicted by the sabre- 
 cut the angioblasts must necessarily have taken an active part. In the 
 event of the new cells failing to undergo the necessary developmental 
 stages requisite in the ideal healing of an injured part, they would, 
 according to our position, become available as tumor-forming elements, 
 and their histogenetic origin would determine the production of a vas- 
 cular tumor of more active tendencies than the primary tumor. The 
 writer therefore believes that the trauma, instead of acting only as an 
 exciting cause, in this case furnished also the necessary tumor-matrix. 
 The relationship of irritation to tumor-formation has recently increased 
 in prominence. As is well known, the psoriasis lingualis, laryngis, na- 
 salis, and praeputialis, and the seborrhcea senilis of Richard Volkmann, 
 have engaged, and still engage, very considerable attention. Schuchardt 
 in 1885, Rudolph Volkmann in 1889, and others have brought together 
 a veiy considerable number of surface tumors which were preceded by 
 long-standing sources of irritation and inflammation, such as, for ex- 
 ample, those originating from soot-sifting, tar- and paraffin-working, 
 chronic sinuses, and lupoid and syphilitic ulceration. Cases in which 
 there existed a combination between syphilis and carcinoma have been 
 reported by Lang and Doutrelepont. In 1859, O. Weber showed the 
 etiological relations of lupus to carcinoma, and cases substantiating the 
 correctness of his observations were reported later by von Esmarch, 
 Hebra, Lang, and others. Neisser reminds us that " one ought not to 
 forget that complications of carcinoma and lupus occur, and in these 
 cases, owing to lack of resistance, in part, of the lupus tissue against the 
 encroaching cancer papillae, it is advisable to adopt early therapeutic 
 measures." Lesser commits himself on this subject as follows: "Occa- 
 sionally pathological changes in tissue are the seat of epithelial carcino- 
 mata which are in no way directly responsible for the origin of tumors, 
 such as ulcers of the leg, syphilitic ulcerations, lupus, etc." E. Friend 
 of Chicago, under the tutorship of Kaposi made a very careful study 
 of the microscopic picture of tissue representing a combination of lupus 
 and carcinoma. Friend saw three cases of lupus vulgaris of the face 
 complicated by carcinoma in Kaposi's clinic (Fig. 32). The probabilities 
 are that the atypical proliferation of the epithelial cells in the inflamed 
 tissues, and the diminished physiological resistance of the tissues in their 
 immediate vicinity, are the important factors in the production of carci- 
 noma in lupoid tissue as well as in other pathological conditions represent- 
 ing embryonic epithelial cells with a similar environment. The writer has 
 seen a number of instances in which a carcinoma developed on the sur- 
 face of a chronic ulcer of the leg. In such cases the islets of embryonic 
 
TRANSFORMATION OF TUMORS. 
 
 87 
 
 epithelial cells become the starting-point of a carcinoma when the causes 
 which maintain the ulceration have succeeded in diminishing the physio- 
 logical resistance of the tissues in their vicinity sufficiently to permit the 
 
 1 
 
 Fig 32 -Carcinoma in lupoid tissue (after Friend). Isolated tissue-masses, called by Leloir " lupoma, 
 l.'e irregularly and at different depths in the corium. Upper and papillary layer and rete Malpighi. appear 
 normal. Below and interspersed in these nodules are round and elliptical bodies with nests of epitheual cells. 
 Section from lupus vulgaris of face complicated by carcinoma. (Zeiss, A., ocular No. 3.) 
 
 embryonic epithelial cells to migrate into the surrounding tissues. We 
 must therefore' admit that the transformation of a benign growth and of 
 a matrix of embryonic cells of post-natal origin into a malignant tumor 
 is not only possible but probable when the embryonic cells, under the influ- 
 ences of local or general causes, assume active tissue-proliferation, and 
 their migration is permitted by a diminished physiological resistance on 
 the part of the adjacent tissues. 
 
IX. DIAGNOSIS OF TUMORS. 
 
 The diagnosis of tumors is a science and an art — a science, because 
 the accurate anatomical localization of a tumor and the correct appre- 
 ciation of its character and tendencies presuppose a thorough knowledge 
 of anatomy, physiology, and pathology ; an art, because the determina- 
 tion of the exact location and character of a tumor often requires deli- 
 cate manipulation and the most intelligent application of all known 
 diagnostic resources. The accurate eye and the trained sense of touch, 
 the tactus crudities, are always at hand, and, as a rule, can be more relied 
 upon than can the use of complicated instruments in ascertaining the 
 location, extent, and pathological characteristics of a tumor. Prac- 
 tical instruction at the bedside and examination of patients under super- 
 vision of the teacher will accomplish more in rendering the student 
 familiar with the means of diagnosis than will the most painstaking- 
 didactic teaching. An abundance of clinical material and thorough 
 and systematic examination by the students of the cases presented are 
 absolutely necessary in acquiring the necessary diagnostic skill. The 
 writer knows of no department of surgery more difficult to teach and 
 to comprehend. The interest of the student can be awakened and his 
 senses be trained properly only by bringing him in contact with patients 
 and by encouraging him in making thorough and systematic examina- 
 tions. Oncology is usually imperfectly taught in our medical colleges ; 
 this fact will go far in explaining the lack of interest of our students 
 in this, to them, perplexing subject. 
 
 Clinical History. — In each case of suspected tumor the clinical 
 history should be investigated carefully. A failure to carry out prop- 
 erly this, the initial, part of the diagnostic work has led many a distin- 
 guished surgeon astray in making a distinction between an inflamma- 
 tory swelling and a tumor. Every surgeon inquires almost instinctively 
 into heredity as a possible factor in the production of a tumor. It is 
 not only necessary to ascertain the existence of an hereditary influence 
 in the parents, but the investigation must be carried farther back, as we 
 have seen that this element may not assert itself in the offspring, but 
 may appear again in the second, third, or fourth generation. It is also 
 necessary to determine the existence of heredity in more distant mem- 
 bers of the family — uncles, aunts, cousins, and nephews — as heredity 
 
 88 
 
DIAGNOSIS OF TUMORS. 89 
 
 does not descend on all members of a family in the same degree, as is 
 shown by the statistics quoted on this subject. The existence of tumors 
 in different members of the family and in related families of two or more 
 generations should be noted in estimating heredity as a possible etio- 
 logical factor. 
 
 Length of Time Tumor has Existed. — This part of the clinical 
 history is often indefinite and misleading. A tumor has often existed 
 for years before being accidentally discovered by the patient or the phy- 
 sician. Patients generally fix as the date when the tumor appeared 
 the time when it was accidentally discovered. By relying on the pa- 
 tient's statement in regard to the time the tumor commenced the sur- 
 geon is liable to mistake a benign tumor for a malignant tumor or an 
 inflammatory affection. Due allowance must therefore be made in ref- 
 erence to the statements made by patients or their friends as to the 
 length of time a tumor has existed. 
 
 Location of Tumor. — In eliciting from the patient the clinical his- 
 tory it is very important to ascertain from him, so far as possible, the 
 exact location of the tumor when it was first noticed. The student 
 should be made to appreciate the importance of the questions put to 
 the patient to elicit this part of the clinical history. In investigating 
 the probable starting-point of a large abdominal tumor it is quite im- 
 portant for us to ascertain from the patient whether the tumor was first 
 noticed above the pelvis or about the pelvic brim, and on which side. 
 In a rapidly-growing ulcerating tumor of the neck the patient's state- 
 ments will often render material aid in making a differential diagnosis 
 between secondary glandular carcinoma and lympho-sarcoma. In the 
 absence of an appreciable source of carcinomatous infection the patient, 
 upon questioning him properly, will probably make the statement that 
 the first thing he noticed was a movable, painless tumor under the skin. 
 This information alone from an intelligent patient will exclude a surface 
 carcinoma. An epiblastic surface tumor commences in the skin, and 
 the patient's statement will often impart valuable information in dif- 
 ferentiating between an ulcerating malignant tumor of the epiblast and 
 one of the mesoblast. The relation of the skin or the mucous membrane 
 to the tumor in its early stages must be ascertained from the patient for 
 the purpose of enabling the surgeon to connect the tumor with its matrix , 
 derived from the different germinal layers, in all cases in which any doubt 
 remains as to the histogenetic source of the tumor. 
 
 Rapidity of Growth of Tumor. — The rapidity with which a tumor 
 has increased in size should be taken carefully into account in the dif- 
 ferential diagnosis between a tumor and an inflammatory swelling and 
 between a benign and a malignant tumor. We know how unreliable 
 
90 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the statements of patients are in ascertaining the previous clinical course 
 of a tumor. The patient must be requested to compare the size of the 
 tumor when first discovered with objects familiar to him, such as a 
 hempseed, a pea, a bean, a hazelnut, a walnut, a hen's egg, a plum, 
 an apple, an orange, a cocoanut, a child's head, an adult's head, etc. 
 By comparing the size of the tumor when first discovered with its present 
 size and estimating the time that has elapsed we are in possession of facts 
 which enable us to judge, at least in an approximately correct way, the 
 rapidity of growth of the tumor. As a rule, a benign tumor grows slowly, 
 a malignant tumor rapidly ; the clinical behavior of a tumor is titer ef ore 
 very important in making a differential diagnosis betzveen benign and 
 malignant growtlis. 
 
 Pain. — Spontaneous pain was regarded for a long time as one of 
 the most distinctive clinical witnesses of carcinoma as compared with 
 benign growths. The idea that carcinoma is an exceedingly painful, 
 torturing disease is deeply rooted among the people of all nations. 
 A peculiar lancinating, paroxysmal pain with nocturnal exacerbations 
 has been described since the time of Hippocrates as characteristic of 
 carcinoma. Physicians and surgeons have placed too much stress upon 
 the diagnostic value of this symptom. A lancinating pain at variable 
 intervals and only of a moment's duration is described by many patients 
 suffering from carcinoma of the breast and epithelioma of the lip, but 
 is by no means a constant symptom. The writer is sure that clinical 
 observations will bear him out in making the statement that adenoma 
 of the breast causes more suffeidng than does carcinoma of the same 
 orgaji and of the same size. He has known of numerous cases of car- 
 cinoma of internal organs in which the disease was painless from the 
 beginning to the end. Sarcoma, as a rule, causes less pain than car- 
 cinoma. Benign tumors, with the exception of tumors of the nerves 
 or of their sheaths, produce pain only when, from their location or their 
 size, they cause compression of a sensitive nerve. A small osteoma in 
 the bony canal through which pass certain sensitive nerves will occasion 
 excruciating pain, while a lipoma in the panniculus adiposus, of immense 
 size and meeting with no resistance to its outward growth, will remain 
 a painless affection throughout life. 
 
 Tenderness. — The pain produced by pressure results from com- 
 pression of a sensitive nerve subjected to the pressure. Tumors of 
 the nerves or of the nerve-sheaths most frequently give rise to pain 
 on pressure. The subcutaneous painful tubercle is well known as the 
 most sensitive tumor. Tumors of the nerve-sheaths of the terminal 
 nerves in the subcutaneous tissue, described by Recklinghausen, are 
 not painful on pressure, owing to the looseness of the structures in 
 
DIAGNOSIS OF TUMORS. 
 
 91 
 
 their immediate vicinity. Tenderness in carcinoma and sarcoma depends 
 either on some unusual relation of the tumor to sensitive nerves or to 
 the existence of complications, as pain is absent in the majority of cases 
 of uncomplicated malignant tumors. Tenderness is an exceedingly im- 
 portant symptom in differentiating between a tumor and a7i inflammatory 
 swelling, being usually absent in the former, and almost invariably pres- 
 ent to a greater or less extent in the latter. 
 
 Examination of the Patient. — The surgeon who limits his examina- 
 tion to the tumor does not do his duty to his patient, and is very liable to 
 commit mistakes in diagnosis, prognosis, and treatment. A correct diag- 
 nosis implies more than a mere classification of the tumor for which 
 the patient seeks relief: it includes a careful inquiry into the condition 
 of every important organ, the elucidation of the exact pathological 
 conditions in the tumor itself, and a careful investigation of its environ- 
 ment. A correct diagnosis should furnish all the clinical and patho- 
 logical data required to guide the surgeon in rendering a reliable 
 prognosis and in adopting a safe and judicious course of treatment. 
 Specialists in surgery are very apt to overlook the importance of a 
 thorough and unprejudiced examination of the patient as the first step 
 in seeking reliable evidence upon which to build a correct diagnosis. 
 A careful examination of the clinical history of the case in reference to 
 the possibility of the existence 
 of syphilitic infection should j* 
 
 never be neglected. Sarcoma 
 and syphiloma have often been 
 confounded, to the great detri- 
 ment of the patients and almost 
 chagrin of the attending physi- 
 cian. If there is any doubt as 
 to the differential diagnosis be- 
 tween a tumor and a gumma, 
 the patient should be given the ^ 
 benefit of the doubt by subject- 
 ing him to a vigorous antisyph- 
 ilitic treatment for several weeks. 
 Von Esmarch made recently the 
 statement that more than forty 
 cases of supposed sarcomatous 
 tumors were sent to him for oper- 
 ative treatment, which yielded to 
 the inunction treatment and the internal use of potassic iodide 
 
 f 
 
 i 
 
 / 
 
 - k 
 
 v-~— i 
 
 Fig. 33. — Syphiloma (after von Esmarch). 
 
 the case shown in Fig. 33 five operations were performed, 
 
 In 
 
 ith 
 
92 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 speedy relapse after each. Sprinkling the ulcerated surface daily 
 with potassic iodide resulted in marked improvement, and later a 
 permanent cure was effected by mercurial inunctions. The age 
 of the patient is of some importance in determining the probable 
 character of the tumor, as it has been shown that benign tumors 
 are met with most frequently in persons not past middle life, while 
 malignant tumors, on the whole, attack persons advanced in years. In 
 this respect sarcoma constitutes frequently an exception, as it exempts 
 no age, being sometimes found in children less than ten years of age, as 
 well as in persons far advanced in years. It must not be forgotten, how- 
 ever, that carcinoma occasionally is met with in young persons. The 
 writer has seen carcinoma of the rectum in a boy eighteen years of age, 
 carcinoma of the stomach in a man twenty-seven years old, carcinoma 
 of the breast in a female aged thirty, and carcinoma of the lip in a man 
 thirty-five years old. Sex, as we have seen, predisposes to tumors, both 
 benign and malignant, of special organs. This can also be said of 
 certain occupations. The general appearance of the patient often 
 enables the experienced surgeon at first sight to make a probable 
 diagnosis between a benign and a malignant tumor. The wasting of 
 the subcutaneous adipose tissue and the sallow complexion of the face 
 are familiar to the surgeon as indicating far-advanced malignant disease. 
 CEdema about the ankles and over the sternum is an indication pointing 
 in the same direction. Occasional hemorrhages from different organs, 
 as the kidneys, the bladder, the vagina, and the rectum, frequently call 
 the attention of the surgeon to these organs as the probable seat of a 
 malignant tumor. Mechanical obstruction in the different hollow vis- 
 cera in persons past middle life is caused more frequently by malignant 
 tumors than by all other causes combined. Functional disturbances of 
 all kinds must be investigated carefully and traced to the primary cause. 
 Neuralgic pain caused by tumor-pressure will often lead to the detec- 
 tion of the tumor. Obstruction to the venous circulation, if studied 
 with the same object in view, will frequently reward the surgeon with 
 a similar result. To show the importance of a careful and painstaking 
 examination of the patient before venturing a diagnosis based upon a few 
 probably unimportant local evidences, attention will be called to a few 
 conditions which frequently present themselves to the surgeon. Let 
 us suppose a patient presents himself suffering from a sarcoma of the 
 intermuscular fascia of the forearm. The tumor has attained the size 
 of a cocoanut, is movable, and has no connection with the overlying 
 skin. The patient's general health is not materially impaired. The 
 rapidity of the growth of the tumor, its shape, and its consistence 
 render the diagnosis of sarcoma more than probable. The surgeon 
 
DIAGNOSIS OF TUMORS. 93 
 
 has determined in his own mind that an amputation affords the only 
 chance to effect a radical operation with a view of preventing a recur- 
 rence in the future. Before informing the patient of his intentions he 
 takes the necessary pains to look for contraindications. On further 
 examination he finds a slight convergent strabismus, the liver enlarged 
 and nodular, and traces of albumen in the urine. The result of this 
 additional examination has satisfied him that operative interference of 
 any kind is positively contraindicated, as general dissemination has 
 already taken place, important organs being implicated. The exam- 
 ination into the condition of the important organs has been the means 
 of saving the patient the pain, anxiety, and risks to life incident to a 
 useless operation, and has prevented the infliction of additional reproach 
 upon modern surgery. 
 
 Let us suppose another case : A patient advanced in years presents 
 himself with a lipoma over the shoulder which has given him but little 
 inconvenience, but which he is anxious to have removed. As the 
 patient's general health, upon superficial examination, does not appear 
 to be impaired, the surgeon responds to the request of the patient. 
 The patient is anesthetized and the tumor is removed. Suppression 
 of urine follows the operation. The patient is seized with uremic con- 
 vulsions and dies comatose. A post-mortem examination reveals the 
 existence of a chronic interstitial nephritis. A careful examination of 
 the urine would have furnished a positive contraindication to an opera- 
 tion, and would have been the means of preventing a premature death 
 from the immediate effects of the anesthetic. 
 
 In calling special attention to the importance of searching for con- 
 traindications to radical operations for carcinoma another hypothetical 
 case will be alluded to : A woman about middle life presents herself 
 for the removal of a carcinomatous breast. The disease in the organ 
 primarily affected has advanced to such an extent that the breast is 
 firmly attached to the chest- wall ; infiltration of the axillary glands is 
 moderate ; the patient's general health is not much impaired. She is in 
 the hands of a careful, conscientious surgeon. The breathing attracts 
 his attention ; it is short and frequent. He makes a careful physical 
 examination of the chest, and finds a copious effusion in the pleural 
 cavity on the side corresponding with the diseased breast. If he had 
 any intention whatever to advise operative interference, this will soon 
 be abandoned, as he has satisfied himself that the disease is beyond the 
 reach of an operation, as shown by the existence of a hydrothorax 
 caused by extension of the disease through the chest-wall to the 
 parietal pleura. 
 
 The hypothetical cases cited do not represent imaginary complica- 
 
94 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tions, but illustrate many similar cases which the surgeon is called 
 upon to examine and treat, and they speak for themselves in showing 
 the importance of subjecting tumor-patients to a thorough examination. 
 
 Examination of the Tumor. — The examination of a tumor should 
 be made in a systematic manner. Much information can be gained by 
 the intelligent use of the sense of sight. Ocular examination is ex- 
 tended by the use of the ophthalmoscope, the otoscope, the rhino- 
 scope, the laryngoscope, the urethroscope, the cystoscope, and by the 
 employment of different specula in the examination of tumors in local- 
 ities inaccessible to inspection without the aid of these instruments. 
 Inspection enables the surgeon in the examination to gain information 
 concerning (i) color, (2) size, (3) form and structure of surface, (4) loca- 
 tion, and (5) transmission of light. 
 
 Color. — The color alone often distinguishes the character and struct- 
 ure of the tumor. In angioma of surfaces accessible to inspection the 
 color of the tumor will enable the surgeon to distinguish between the 
 venous and the arterial variety. The venous angioma resembles in its 
 color venous blood ; the arterial angioma, that of arterial blood. The 
 pigmentation of a sarcoma or a carcinoma distinguishes these most 
 malignant of all tumors from the other varieties of malignant tumors. 
 Discoloration of the surface of a tumor is also caused by interstitial 
 hemorrhage and by inflammation. 
 
 Size. — The size of a tumor is significant to the surgeon, because 
 certain tumors never exceed a definite size. Neuromata and osteomata 
 never reach large size. They grow slowly, and when they attain the 
 maximum size they remain stationary throughout life. Very important 
 from a diagnostic standpoint is a sudden variation in size. This is 
 observed in vascular tumors, which under the influence of certain 
 agencies that cause intravascular tension increase in size and become 
 firmer. A naevus in a child becomes more prominent and tense 
 during the act of crying. The volume of a large venous tumor is often 
 materially affected by respiration, the size increasing during expiration 
 and diminishing during inspiration. In following the clinical history of 
 a tumor careful measurements should be taken and recorded from time 
 to time. The eye should not be relied upon in ascertaining the increase 
 in size of a tumor. Fixed anatomical landmarks are readily available 
 guides in following the extension of a tumor toward its vicinity — by 
 recording at fixed intervals the measured distance between them and 
 the margin of the tumor. When the measurements are taken the 
 patient and the part to be examined should always be placed in the 
 same position. 
 
 Form and Structure of Surface. — The shape of a tumor can often 
 
DIAGNOSIS OF TUMORS. 95 
 
 be outlined by inspection, and if the tumor is sufficiently near the sur- 
 face, any irregularities in its contour can be recognized at the same time. 
 The shape of the tumor is determined largely by the structure of the 
 mother-soil, the anatomical locality, and the resistance offered by the 
 surrounding structures to the extension of the growth. Equal resist- 
 ance on all sides determines a globular shape ; later, pressure results in 
 elongation of the tumor ; absence of resistance on one side gives rise 
 to a growth in that direction, followed by constriction at the base of the 
 tumor and by pedunculation. Central tumors of bone usually assume 
 the shape of a spindle. A nodular surface is often presented by carci- 
 noma, but it is also found in all tumors which have perforated organs 
 and tissues and grow free in all directions. The most malignant forms 
 of carcinoma and sarcoma have a smooth surface, owing to the predomi- 
 nance of their cellular elements over the stroma. Nodular projections 
 in carcinoma as well as in other tumors are produced by contraction of 
 the stroma as well as by unequal resistance offered by the surrounding 
 tissues. Ulceration on the surface of a tumor represents from an 
 etiological standpoint different things : Superficial excoriations are 
 usually the outcome of purely local accidental causes, such as trauma 
 or the application of irritating remedies, and commonly heal upon the 
 removal of the cause ; ulcerated surfaces occupied by a fungous mass 
 indicate the existence of a rapidly-growing tumor ; extensive ulceration 
 devoid of massive fungous granulations point to the existence of a less 
 rapidly-growing tumor ; while deep, and especially crater-like, excava- 
 tions are indicative of speedy destruction of the central mass of the 
 tumor. Of special pathological interest is the character of the floor 
 of the ulcer — whether it is clean or ragged, red, gray, dirty, or gan- 
 grenous ; frequently, characteristic parts of the tumor are exposed on 
 the surface of the ulcer. The secretion of the ulcer is of diagnostic 
 value in determining the stage of malignant degeneration and the 
 character of the microbic infection which followed the exposure of the 
 tumor-tissue to the atmospheric air. Suppuration indicates infection 
 with pyogenic microbes ; putrefaction of the secretions points to the 
 presence of putrefactive bacilli in the dead tissue attached to the sur- 
 face of the ulcer. Capillary bleeding from the surface of the ulcer is 
 an indication of the destruction of granulations by the tumor-tissue, 
 by pathogenic microbes, or by an injury; more profuse hemorrhage 
 results from erosion of trie wall of blood-vessels of considerable size. 
 Location. — Ocular inspection often reveals the primary location of 
 the tumor. A unilateral exophthalmos denotes the presence of a 
 retrobulbar tumor ; an unusual prominence of one of the cheeks and 
 the presence of a projecting tumor of the nose on the same side point 
 
g6 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 to the existence of a tumor of the antrum of Highmore. Inspection 
 is also useful in some cases in determining the character of the tumor 
 — as, for instance, in the case of tumors of the lower lip, which tumors, 
 with few exceptions, are epithelial cancers. 
 
 Transmission of Light. — A tumor with clear liquid contents and 
 tumors composed largely of a colorless intercellular substance transmit 
 light to a greater or lesser extent, rendering them translucent or trans- 
 parent — as, for example, hydrocele of the neck, myxoma of the nasal 
 cavities, etc. 
 
 Tactile Examination. — Tactile examination is more important than 
 ocular inspection in the examination of a tumor. The value of ocular 
 examination has been overestimated greatly in the past. In ascertain- 
 ing the exact location and extent of a tumor much more diagnostic 
 information is gained by the employment of the sense of touch than 
 by inspection with the aid of specula, if the tumor is accessible to 
 digital examination. The mania on the part of surgeons and instru- 
 ment-makers to invent new specula for the exploration of channels and 
 cavities accessible to digital exploration has about subsided, and in its 
 place efforts are being made to instruct students more efficiently in the 
 use of the finger in the examination of tumors. The acquirement of 
 the tactus eruditus requires long and careful training. The student 
 should be given an opportunity to handle and examine tumors of all 
 kinds, in order to familiarize himself with their structure and physical 
 characteristics by the sense of touch. Instruction of this kind will 
 impart a thorough knowledge of the nature and extent of the degen- 
 erative changes which occur in the parenchyma and stroma of tumors. 
 The careful digital palpation of the different normal tissues and organs 
 is an exceedingly useful exercise in acquiring a delicate sense of touch. 
 Fluctuation can be studied advantageously by palpating a bladder or a 
 rubber bulb distended by water. In the examination of tumors in the 
 living subject the teacher should inform the student what he is expected 
 to find and to feel before he proceeds to make the digital examination. 
 If the tumor is large, manual examination takes the place of the digital. 
 In bimanual examination both hands are employed. Bidigital exami- 
 nation means the use of one finger of each hand in the exploration of 
 a tumor or other pathological product. The information gained by 
 manual and digital examination is often used to corroborate or to 
 render more accurate what has been learned from inspection. The 
 tactile sense is relied upon in deciding diagnostic points of the greatest 
 practical import to the surgeon, the most important being — I. Connec- 
 tion of the tumor with the mother-soil ; 2. Resistance and consistence ; 
 3. Pulsation; 4. Tenderness; 5. Crepitation. 
 
DIAGNOSIS OF TUMORS. 97 
 
 Connection of Tumor with the Mother-soil. — The kind and extent 
 of the connection of a tumor with the mother-soil have an important 
 bearing on the nature of the tumor and on the selection of appropriate 
 operative measures. The degree of mobility of a tumor and the ease 
 with which it can be displaced are determined largely by the nature of 
 its connection with the surrounding tissues. The wider the base of a 
 tumor and the more projections it sends out into the surrounding 
 tissues, the more pronounced becomes its immobility and the more 
 limited the extent to which it can be displaced. If the tumor is attached 
 only by a pedicle, it is freely movable and can readily be displaced. 
 Such tumors in the abdominal cavity often become displaced in an 
 axial direction, resulting in twisting of the pedicle. If a tumor is sur- 
 rounded on all sides by resisting tissue, it is held firmly in place and 
 cannot be displaced. The immobility of a carcinoma is due to the 
 many prolongations which the tumor sends out into the surround- 
 ing tissues. A carcinoma is movable if it involves a movable organ 
 before the organ becomes attached by the extension of the tumor 
 beyond the limits of the organ primarily affected. Tumors freely 
 movable often become firmly attached to the surrounding tissues by 
 inflammatory adhesions following inflammation of the tumor resulting 
 from direct infection through an ulcerated surface, from auto-infection, 
 or from infection caused by exploratory puncture or by ineffective treat- 
 ment. A branchial cyst is usually attached loosely to the surrounding 
 tissues, and can readily be enucleated, but after ineffectual attempts at 
 radical cure by irritating injections or after incomplete removal by 
 enucleation the whole or a part of the cyst-wall is found firmly attached 
 to important structures, rendering enucleation impossible and the 
 removal by excision a difficult and dangerous procedure. In deter- 
 mining the mobility of a tumor its base should be grasped firmly, when 
 by moving it in different directions the degree of mobility and the ex- 
 tent of its connection with the mother-soil can be determined. If the 
 tumor is immediately under the skin or under the abdominal wall, the 
 existence of attachments to the skin can be ascertained by gliding the 
 superimposed structures overthe surface of the tumor ; adhesions between 
 an abdominal tumor and the anterior abdominal wall can be ascertained 
 by observing the respiratory movements of the abdominal wall, or, if the 
 tumor is not too large, by displacing it by changing the position of the 
 patient or by moving it with the hands. The absence of inflammatory 
 adhesions or of neoplastic attachments of a struma to tissues other 
 than the underlying trachea is demonstrated by the movements 
 imparted to the tumor by the trachea during deglutition. The extent 
 and location of attachments of tumors in some of the cavities — for 
 
 7 
 
98 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 instance, the uterine cavity and the nasal passages — can often be deter- 
 mined only by a careful use of probes and sounds. It can be laid down 
 as a rule that the more limited are the attachments of a tumor with the 
 surrounding tissues, the more favorable is the prognosis and the bet- 
 ter are the results following its operative removal. In the absence of 
 inflammatory processes, attachment of the tumor to the underlying 
 skin indicates that the tumor is malignant. The lymphatic glands in 
 the region occupied by a tumor should always be subjected to a careful 
 examination. Enlargement of the lymphatic glands in the vicinity of 
 a tumor must always be regarded with suspicion. A consensual hyper- 
 plasia of the lymphatic glands may occur in consequence of the intro- 
 duction into the lymphatic channels of pathogenic microbes through 
 the ulcerated surface of a benign tumor. In the absence of a tangible 
 infection-atrium implication of the regional lymphatic glands, with few 
 exceptions, points to a malignant nature of the tumor. As lymphatic 
 infection seldom accompanies sarcoma, when this condition exists inde- 
 pendently of microbic infection the primary tumor in the great majority 
 of cases is a carcinoma. 
 
 Resistance and Consistence. — Resistance and consistence are vari- 
 able qualities of tumors. We seek to ascertain the density of a tumor 
 by fixing its base, and then ascertain its resistance to finger-pressure 
 at different points. To ascertain the density of a deeply-situated tumor 
 or of different parts of the same tumor, Middeldorpf advised the use of 
 acupuncture needles (Fig. 34), and he applied to this diagnostic aid the 
 term akidopeirasty. The writer has found this diagnostic resource of 
 great value in the differential diagnosis of deeply-seated tumors of bone. 
 If the tumor is an osteoma, the needle will be arrested when it reaches 
 the surface of the tumor; if it is a periosteal sarcoma, the needle will 
 penetrate the soft parts of the tumor, and with its point plates or 
 spiculae of bone can usually be detected. If it is a central osteo- 
 sarcoma, the needle can be forced by pressure and by rotatory move- 
 ments through the atrophic 
 compact layer of the bone 
 — © encasing the tumor, after 
 
 Fig. 34.— Acupuncture needles used in exploring tumors by which it Can be forced 
 
 opeirasuc. through the soft tumor-mass 
 
 until the opposite side of the bone is reached without meeting with 
 any appreciable resistance. Exploratory puncture for this and other 
 purposes should be done under strictest antiseptic precautions, other- 
 wise puncturing may become the direct cause of infection. The needle, 
 before being used, should be sterilized by boiling or by heating it for 
 a sufficient length of time in the flame of an alcohol lamp, and the • 
 
DIAGNOSIS OF TUMORS. 99 
 
 surface where the puncture is to be made should be rendered aseptic 
 by thorough washing with warm water and soap, followed by washing 
 with a strong antiseptic solution. After the removal of the needle the 
 puncture should be sealed hermetically with iodoform collodion. The 
 existence of cysts in solid tumors can often be determined by the 
 same method of exploration. Osteoma and chondroma are the benign 
 tumors noted for their density. Fibroma varies greatly in this respect, 
 often being nearly as hard as cartilage, in other instances being as soft 
 as a myxoma. Uterine fibroids present both extremes as to density. 
 A soft fibroma of the uterus usually contains muscle-fibres as the pre- 
 dominating histological element, and is generally much more vascular 
 than the firm variety, in which we find more fibrous tissue and a less copi- 
 ous blood-supply. The density of a malignant tumor is in proportion 
 to its benign tendencies. In soft malignant tumors the parenchyma-cells 
 predominate, the stroma is scanty, and the vascular supply is abundant. 
 The softness of a malignant tumor is in proportion to its malignancy. 
 The stroma in such cases is scanty, and the cells are numerous and are 
 endowed with a maximum capacity of tissue-proliferation ; the new cells 
 find ready access into the surrounding tissues, hence early and exten- 
 sive infiltration determines rapid growth and early regional and general 
 dissemination. Elastic softness is manifested by many fibrous, fatty, 
 O* and sarcomatous tumors. Owing; to the softness of the tumor-tissue 
 " in many cases of very malignant carcinoma and sarcoma, these tumors 
 present on palpation a sense of fluctuation which is exceedingly decep- 
 tive, and which in many instances has led the surgeon to puncture or 
 incise such tumors under the belief that the swelling contained the 
 products of an inflammation. Pseudo-fluctuation is often elicited in the 
 examination by palpation of benign tumors, notably myxoma and lipo- 
 ma. Fluctuation is frequently absent in dense cysts, particularly if the 
 cyst-wall is of unusual thickness. 
 
 The existence of a cystic tumor or swelling and the occurrence of 
 cystic degeneration in solid tumors can often be determined only by the 
 use of an exploratory needle (Fig. 35) or a trocar. The ordinary hypo- 
 
 4»U 
 
 Fig. 35. — Exploratory needle. 
 
 dermic needle answers an excellent purpose in ascertaining the presence 
 of liquid contents in a cyst. Syringes are, however, very liable to get out 
 of order, and this is more particularly the case on occasions when they 
 
IOO 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 are most needed. Another objection to the use of the hypodermic and 
 the exploratory syringe is the difficulty experienced in securing and 
 maintaining them in an aseptic condition ; and, lastly, it is difficult, if not 
 
 Fig. 36. — Senn's exploratory syringe. 
 
 impossible, to hold the needle perfectly steady while the piston is with- 
 drawn in aspirating the contents of the cyst. These objections to the 
 use of the ordinary syringe in withdrawing the contents of tumors or of 
 swellings apply with special force to exploration of the brain, the peri- 
 cardium, and the pleural cavity. The writer, who has for a long time 
 been anxious to do away with the piston as a means of aspiration and 
 in making intra-articular and parenchymatous injections, has succeeded 
 at last in devising an instrument possessing all the merits of the ordi- 
 nary syringe, minus the objections to the piston. This instrument is 
 also used exclusively in making intra-articular and parenchymatous 
 injections. The fluid is withdrawn by aspiration performed by a strong 
 rubber bulb in place of a piston, and in making injections the fluid is 
 propelled by a column of elastic air. The remaining part of this 
 syringe can readily be understood from Figure 36. Some care is neces- 
 sary in preventing serious complications arising from the employment 
 
DIAGNOSIS OF TUMORS. 101 
 
 of this exceedingly useful diagnostic aid. The usual strictly antiseptic 
 precautions should never be neglected, as tumor-tissue is very suscep- 
 tible to infection, and in a great many cases the use of the exploring- 
 needle in the hands of careless practitioners has resulted in serious and 
 fatal complications. The puncture should be made after the skin has 
 been withdrawn to one side, so that after the withdrawal of the needle 
 the puncture in the deep parts will be subcutaneous. Injury to import- 
 ant vessels and nerves should be avoided. In puncturing abdominal 
 tumors and swellings the needle should be inserted, if possible, extra- 
 peritoneally ; if this cannot be done, the puncture in the cyst-wall 
 should be oblique, so that upon the removal of the needle there will 
 be less liability of the contents escaping into the peritoneal cavity 
 through the puncture. In such cases the needle used should be small. 
 The removal of a considerable portion of cyst-contents will diminish 
 tension, and thus prevent leakage through the puncture. The explor- 
 ing-needle can also be used to ascertain the degree of density of the 
 tissues which it penetrates (akidopeirastic). If the contents of a sus- 
 pected cyst fail to escape on making aspiration, the point of the needle 
 is further advanced or withdrawn while aspiration is frequently made 
 until the point of the needle is within the cyst. It may also become 
 necessary to remove the needle and to insert it through the same 
 external puncture in different directions before the cyst is reached. 
 The character of the fluid withdrawn will throw much light upon the 
 nature of the tumor. If no fluid is withdrawn, we often find in the 
 lumen of the needle fragments of tissue, which, when examined under 
 the microscope, will furnish valuable information in reference to the 
 nature of the tumor. The exploratory syringe is a most valuable, and 
 often an indispensable, instrument in the differentiation between a tumor 
 and an inflammatory swelling. 
 
 Pulsation. — Pulsation is felt in certain tumors by placing the palmar 
 surface of the hand against the tumor. Not all pidsating tumors are 
 vascular tumors. A solid tumor resting against a large artery receives 
 the impulse from the artery. In such cases the pulsation can be felt only 
 in one direction, away from the artery. A pulsating tumor, angioma, 
 vascular myeloid sarcoma, diminishes in size under pressure, and the 
 pulsations are not limited to one direction. 
 
 Tenderness. — The causation of pain by finger-pressure over the 
 tumor has already been alluded to as an evidence in the diagnosis of 
 a tumor. Tenderness indicates either that the tumor is intimately con- 
 nected with a sensitive nerve or that the tumor has become infected and 
 is the seat of an inflammation. Under ordinary circumstances pressure 
 over a tumor docs not cause pain. 
 
102 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Crepitation. — Palpation of a tumor occasionally elicits a sense of 
 crepitation. If the crepitation is caused by the presence of chalky 
 masses or bone, it is rough ; if the plates of bone are thin, it is softer, 
 resembling the crepitation produced by the bending of parchment. 
 The " parchment " crepitation is produced by making pressure upon 
 a myeloid sarcoma in which the compact layer of the bone has been 
 reduced to thin plates or scales by pressure from within outward, and 
 in chondroma surrounded by a thin, yielding shell of bone. 
 
 Auscultation and Percussion. — The ear, aided or unaided by the 
 use of the stethoscope, can be utilized in the diagnosis of certain 
 tumors. Percussion is useful in the differential diagnosis of hernia and 
 of tumors occupying localities the most frequent seat of hernia. Per- 
 cussion is also useful in outlining a tumor in the chest and in the 
 abdominal cavity. 
 
 Auscultation is resorted to in the examination of pulsating tumors, 
 in which usually, a distinct bruit can be heard, and in the differential 
 diagnosis of aneurysm and of tumors located in close proximity to a 
 large artery. It must be remembered that a blowing, rasping sound 
 is often produced by the narrowing of the lumen of a large artery 
 from outward pressure caused by a tumor. 
 
 The diagnostic resources which have been described so far are 
 ample, if carefully and thoughtfully applied, to enable the surgeon in 
 the majority of cases to make a correct diagnosis. In obscure cases 
 it is advisable to repeat the examination at intervals of a few days, 
 weeks, or months, and at the same time to observe carefully the clinical 
 course of the tumor. A hasty diagnosis in obscure cases is justifiable 
 only in urgent cases demanding prompt surgical interference. Whenever 
 permissible \ the surgeon should take sufficient time and, if necessary, make 
 repeated examinations, and exhaust all diagnostic resources before he 
 commits himself concerning the nature of the tumor. 
 
 Rontgen Ray. — During the year 1896 the diagnostic resources as 
 applied to tumors were increased by the discovery of the ;r-ray by 
 Rontgen. As bone-tissue is impermeable to this ray, the shadow- 
 pictures obtained by its use show clearly the outlines of bones and 
 pathological formations containing bone. The Rontgen ray will be 
 of great value in locating osteomata and in showing their relations 
 to adjacent joints and other structures; in ascertaining the exist- 
 ence of bone in mixed tumors ; and in demonstrating the early exist- 
 ence, exact location, and size of myeloid and bone-producing periosteal 
 sarcoma. 
 
 It remains to discuss — 
 
DIAGNOSIS OF TUMORS. 103 
 
 The Value of the Microscope as an Aid in the Diagnosis of 
 Tumors. — There is no doubt in the mind of the writer that the value 
 of the microscope as an aid in the diagnosis of tumors has been greatly 
 over-estimated. The greatest blunders in diagnosis and treatment have 
 been committed by surgeons of eminence through placing too great 
 reliance on the microscopic examinations of fragments of tumor-tissue 
 obtained either before operation or from the specimens removed. The 
 late Emperor Frederic of Germany is a case corroborating the truth 
 of this assertion. His attending surgeon, Von Bergmann, made a cor- 
 rect diagnosis, basing his opinion upon the clinical aspects of the case. 
 A part of the tumor was removed and examined by the most dis- 
 tinguished pathologist the world has ever seen. His diagnosis was 
 based upon what he could see under the microscope. In the sec- 
 tion examined he could detect nowhere any evidences of malignancy. 
 The epithelial cells, greatly increased in number, retained their normal 
 relation to the underlying tissues. All the pictures under the micro- 
 scope represented a benign papilloma. The disease, however, pursued 
 its relentless course, notwithstanding the favorable prognosis made, 
 and in a few months destroyed the life of the illustrious patient. The 
 unprejudiced surgeon will readily understand the source of fallacy in 
 the diagnosis made by the pathologist. The part removed and exam- 
 ined represented only one part of the tumor. The attached deep por- 
 tion contained the carcinoma-cells, and it was from this part that the 
 
 Fig. 37. — Warren's harpoon for the removal of tissue from solid tumors for microscopic examination. 
 
 disease extended from one tissue to another. The case is an extremely 
 valuable one in showing the importance of examining different parts 
 of a tumor if the microscope is to be relied upon in making a final 
 diagnosis. The examination under the microscope of isolated cells is 
 not to be relied upon, as all the varieties of tumor-cells have their 
 counterpart somewhere in the normal tissues of the body. Instruments 
 constructed upon the plan of a trocar have been devised by Wintrich, 
 Bouisson, Bruns, Middeldorpf,and J. Collins Warren (Fig. 57), for the pur- 
 pose of removing particles of tumor-tissue for microscopic examination. 
 The objection to this method of obtaining tissue for examination is that 
 by taking the tissue from only one part of the tumor the part removed 
 
io4 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 may not represent tumor-tissue, and may consequently lead to error 
 in diagnosis ; and multiple punctures are objectionable, as they are 
 likely to give rise to considerable hemorrhage and to stimulate tumor- 
 growth. This method of procedure is, however, advisable when all 
 other diagnostic resources have failed and it is essential for the welfare 
 of the patient that a correct diagnosis should be made before an opera- 
 
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 w 
 
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 Fig. 38.— Gumma of the liver (after Karg and Schmorl). In the centre of the field circumscribed foci, 
 miliary gummata : the same are composed of young granulation-tissue, and show in their centre evidences 
 of degeneration. The parenchyma-cells are seen as grayish-black stripes, and are separated from each other 
 by narrower stripes of cellular connective tissue. 
 
 tion is undertaken. Preparations of teased tissue are of but little value 
 for diagnostic purposes. The fragment should be prepared properly, 
 and from it sections should be taken for microscopic examination. 
 Only specimens which represent both cells and stroma in their proper 
 relations enable the microscopist to interpret the character of the tumor. 
 How difficult it is to distinguish the tissue of some tumors from the 
 granulomata by the aid of the microscope can readily be seen by a 
 
DIAGNOSIS OF TUMORS. 
 
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106 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 glance at Figures 38, 39, and 40. All these illustrations represent in 
 the foreground embryonic connective tissue with a very scanty stroma. 
 Without knowing anything about the clinical aspects, it will readily be 
 seen that it would be exceedingly difficult to distinguish between a 
 small round-celled sarcoma, young granulation-tissue, and a gumma. 
 It is in just such cases that we seek additional light from a micro- 
 scopic examination. 
 
 To illustrate still further the danger which may follow the use of 
 the microscope as an exclusive and only means of diagnosis, the writer 
 will relate a case which recently came under his observation. During 
 the World's Fair held in Chicago he was consulted by a Russian 
 gentleman concerning several tumors which had developed in the scar 
 of an operation-wound. He gave the following history : Age, forty ; 
 married ; the father of several healthy children ; merchant by occupa- 
 tion. In 1890 he noticed a swelling in the skin at a point corre- 
 sponding to the supraspinatus fossa of the right scapula. The tumor 
 was movable and painless, but increased quite rapidly in size. He 
 consulted his family physician in Russia, who pronounced the tumor 
 a sarcoma of the skin and sent him to one of the most prominent 
 surgeons in Berlin for operation. The Berlin surgeon made a diag- 
 nosis of gumma, placed the patient on specific treatment, and removed 
 the tumor, more for the purpose of allaying the fears of the patient 
 than with the expectation of any benefit being derived from the 
 operation. The patient followed the treatment faithfully, but in the 
 course of six months a tumor returned in the scar. He consulted the 
 same surgeon, who at the patient's special request removed the tumor 
 a second time, still claiming that it was not malignant. It was now 
 decided to leave the diagnosis in the hands of the most competent 
 pathologists. The surgeon sent a part of the tumor to an eminent 
 Berlin pathologist, and the patient sent the balance to the foremost 
 Paris pathologist. The specimens were subjected to microscopic ex- 
 amination, and each pathologist sent in a written report to the effect 
 that the tumor was a gumma, and not a sarcoma. The patient was 
 now placed on vigorous antisyphilitic treatment, including mercurial 
 inunctions, baths, and the internal use of corrosive sublimate and 
 potassic iodide in large doses. The wound after both operations healed 
 by primary intention. The patient is not aware that he ever con- 
 tracted syphilis, and never showed evidences of secondary or tertiary 
 manifestations. When the writer examined the patient none of the 
 remote consequences of syphilis were discovered. The pale, large scar 
 following the last operation was occupied by four tumors, covered by 
 intact scar-tissue and varying in size from that of a hazelnut to that 
 
DIAGNOSIS OF TUMORS. 
 
 107 
 
 of a walnut, all of them perfectly movable, and with no attachments 
 to the scapula. If ever a case of sarcoma of the skin was seen, this 
 was one. Under the circumstances it was deemed prudent to advise 
 the patient to return to his surgeon for a third operation. The writer 
 does not wish to under-estimate the value of the microscope as an aid 
 in the diagnosis of doubtful tumors, but he must insist that it cannot 
 be relied upon in differentiating between a small round-celled sarcoma 
 and some of the granulomata under circumstances such as those 
 detailed above. In doubtful tumors of accessible surfaces tumor-tis- 
 sue can be selected and removed 
 for microscopic examination. Sec- 
 tions of such specimens are better 
 adapted for diagnosis by means 
 of the microscope than fragments 
 taken from the depths of tumors 
 through the skin with the different 
 forms of harpoons. Another course 
 is sometimes necessary when the 
 surgeon has decided to remove the 
 growth and is in doubt as to its 
 nature. Here the microscope is em- 
 ployed during the operation as an 
 aid in diagnosis. As soon as the 
 tumor is reached, when doubt still remains as to its character, a piece is 
 removed and sections are made with a freezing microtome (Fig. 41) for 
 microscopic examination. The freezing microtome can be purchased at 
 a small expense, and should have a place in the operating-room of every 
 hospital. The result of such an examination frequently settles all doubt 
 as to the nature of the tumor, and serves as a valuable guide to the 
 surgeon in the performance of the operation. The microscope is an 
 invaluable aid in the diagnosis of tumors, but the co7iclusio7ts based upon 
 the re stilts of the examination are not infallible ; hence the importance of 
 a careful study of the clittical aspects of the tumor, followed by a thorough 
 examination of the patient, of the tumor, and of its environments. 
 
 g microtome. 
 
X. PROGNOSIS OF TUMORS. 
 
 A reliable prognosis presupposes a correct diagnosis. To predict 
 correctly the probable termination of a tumor requires an accurate 
 knowledge of its life-history and of its relations to its neighborhood 
 and to the entire organism. The prognosis must therefore rest largely 
 upon a careful study of the clinical history of the tumor, its anatomical 
 location, its influence upon the adjacent tissues, and the general condi- 
 tion of the patient. It is when we are called upon to foretell the future 
 behavior of a tumor that we realize most keenly the necessity of 
 making a searching examination of the patient as well as of the tumor. 
 From a prognostic standpoint it is absolutely necessary to divide all 
 tumors into the two great clinical divisions (i) benign and (2) malig- 
 nant. If we are able in the diagnosis to exclude inflammatory swell- 
 ings, the next duty that presents itself is to differentiate between 
 benign and malignant tumors. This task is easy in some cases, diffi- 
 cult or impossible in others. A carcinoma that has advanced to the 
 stage of ulceration with regional glandular infection is recognized at 
 sight ; a rapidly-growing tumor in bone or in periosteum in localities 
 predisposed to sarcoma is readily identified as such. Under other less 
 obvious circumstances the question as to whether the tumor is benign 
 or is malignant is not so easily decided. Carcinoma of some of the 
 internal organs is often diagnosed only in the post-mortem room. 
 Carcinoma and sarcoma of accessible organs are frequently recognized 
 as such only after their clinical behavior has given unmistakable evi- 
 dence of their malignant character. It is evident that the surgeon 
 who regards his own reputation and the welfare of his patient must be 
 cautious in rendering his verdict as to the probable course the tumor 
 will pursue in the future and the ultimate fate of his patient. The 
 prognosis should be postponed until repeated examinations — and, if 
 necessary, the microscopic examination of tissue from the tumor — have 
 furnished conclusive evidence of the nature of the tumor. It is most 
 humiliating to a surgeon to make a diagnosis of malignant disease, and 
 to render a prognosis in accordance with his views of the nature of the 
 tumor, and to find later, by its clinical course, that it was either a 
 benign tumor or an inflammatory swelling. It is a disregard of a duty 
 imposed upon a surgeon to pronounce a malignant tumor non-malig- 
 
 108 
 
PROGNOSIS OF TUMORS. 109 
 
 nant upon a superficial, hasty examination, as the loss of time may 
 weigh heavily in the balance of failure of a too-long-postponed radical 
 operation. It must be apparent to the student that an intelligent, reliable 
 prognosis must necessarily rest on a correct diagnosis, and that a prog- 
 nosis should consequently be withheld from the patient and his friends 
 until the nature of the tumor has been ascertained by conclusive evidence. 
 A correct diagnosis having been made, the next question that pre- 
 sents itself to the conscientious surgeon is, To what extent should the 
 knowledge gained as to the nature of the tumor be communicated to 
 the patient and his friends ? The prognosis in cases of benign tumors 
 should be freely and candidly expressed to the patient, including the 
 possible risks of an operation and its probable result. A different 
 course should be pursued if the tumor is malignant. Under ordinary 
 circumstances the writer regards it in the light of a cruelty to inform 
 a patient directly that he is suffering from a malignant tumor. The 
 public appreciates our shortcomings in the treatment of malignant 
 tumors, and with few exceptions an intelligent patient regards such 
 a diagnosis as his death-sentence. The mental depression following 
 such a declaration not only destroys all happiness on the part of the 
 patient, but has a disastrous effect on the disease, and is an important 
 factor in detracting from the immediate and remote results of an 
 operation. The surgeon is often placed in a very unenviable position 
 when importuned by the patient in reference to the nature of the 
 growth. The question, " Have I a cancer ?" is often squarely put to 
 him, and the reply will either inspire hope or cause a despondency 
 from which the patient will never recover completely. It has been an 
 invariable rule with the writer to inform the relatives as to the true 
 nature of the tumor, and to discuss with them the propriety of an 
 operation as well as its probable immediate and remote results. The 
 patient is informed that he is suffering from a tumor, and this statement 
 will prove satisfactory in the majority of cases. If asked as to the 
 possibility of a recurrence, the facts are placed as gently as possible 
 before the patient. If " ignorance is bliss," this adage has a special 
 significance in the case of a patient suffering from a malignant tumor. 
 If the patient is not aware that he is suffering from what is regarded 
 almost universally as a fatal malady, an operation inspires hope, and, 
 in place of the despondency often bordering on desperation that 
 attends a knowledge of the true nature of the tumor, the patient 
 looks forward to a complete and permanent recovery. The surgeon 
 should communicate to the patient's //rarest relatives or trie /ids the true 
 nature of the tumor and the probable results of an operation, but such 
 information should be withheld from the patient himself under ordinary 
 
no 
 
 PATHOLOGY AND TREATMENT l OF TUMORS. 
 
 circumstances. There are exceptions to every rule, and circumstances 
 may arise which make it imperative on the part of the surgeon to tell 
 the patient the whole truth. 
 
 From an anatomical standpoint every tumor is benign in proportion 
 to its degree of isolation from the adjacent tissues and from the organ- 
 ism. Benign tumors, as a rule, are encapsulated; consequently they 
 remain permanently as local affections having no connection whatever 
 with the organism. The encapsulation of some forms of sarcoma is 
 more apparent than real, as the capsule does not afford protection 
 to the surrounding tissues against invasion by tumor-cells ; yet when 
 a capsule is present it imparts to the tumor a certain degree of benig- 
 nancy which is not observed in malignant tumors entirely devoid of a 
 capsule, as is the case in carcinoma and in the most malignant varieties 
 of sarcoma. For reasons that have been explained, the soft, vascular 
 tumors belonging to the malignant type of tumors manifest the great- 
 est degree of malignancy. In tumors of this kind the stroma, which 
 always acts more or less as a barrier to local and general dissemina- 
 tion, is always scanty and sometimes is nearly wanting. The cells 
 remain in their embryonic state, possess ameboid movements, and are 
 reproduced with great rapidity. Such tumors resemble inflammation 
 very closely, and the surgeon is familiar with the well-known clinical 
 
 Fig. 42. — Carcinoma of mammary gland, showing numerous leucocytes between tumor-cells and along 
 the course of blood-vessels (Surgical Clinic, Rush Medical College) : a, carcinoma-cells ; b, stroma; c, brown- 
 ish granules of blood-pigment ; d, area of new proliferation ; e, leucocytes. 
 
 fact that the nearer the anatomical and clinical aspects of a tumor 
 correspond with inflammation, the greater its malignancy. In rapidly- 
 
PROGNOSIS OF TUMORS. in 
 
 malignant tumors we find between the tumor-cells and in 
 the course of blood-vessels a picture closely resembling inflammation 
 (Fig. 42). 
 
 The immigration of blood-corpuscles into the parenchyma of a tumor 
 is caused by the imperfect development of the wall of the new blood- 
 vessels and by the favorable local conditions in the interior of the blood- 
 vessel for mural implantation. The imperfect wall of the blood-vessels 
 in the tissues of malignant tumors corresponds to the damaged capil- 
 lary walls in inflamed tissue, and permits the escape of numerous 
 leucocytes, and in some cases of red corpuscles. Rhexis is of frequent 
 occurrence in rapidly-growing carcinoma and sarcoma. The new cells 
 in soft vascular malignant tumors possess ameboid movements in the 
 highest degree, and encounter few obstacles on their way from the 
 tumor into the surrounding tissues with greatly impaired physiological 
 resistance. Cells originating under such circumstances are very liable 
 to lose their connection with the mother-soil and to wander away 
 into the surrounding tissues or to enter the lymphatic vessels or the 
 blood-vessels, thus giving rise to early regional and general dissemina- 
 tion. The intrinsic danger of a tumor consists in its capacity to impli- 
 cate the adjacent tissues and the organism — that is, in its giving rise to 
 regional and general i7ifection. This capacity is possessed to the highest 
 degree by the soft vascular carcinomata and sarcomata — tumors that are 
 in contact with the surrounding tissues from the beginning, without any 
 attempt at the formation of a barrier between abnormal and normal tissue. 
 
 In carcinomatous tumors location plays an important part in deter- 
 mining the degree of malignancy of a tumor. For years it has been 
 believed and taught by authors and teachers that for some unknown 
 reason epithelioma was a less malignant affection than glandular car- 
 cinoma, the so-called " scirrhus." For a long time epithelioma w T as 
 described as a tumor separate from carcinoma proper. It was also 
 asserted that epithelioma remained as a purely local affection — that 
 it did not give rise to regional and general dissemination. A more 
 extended and accurate clinical observation of this form of carcinoma 
 has convinced pathologists and surgeons that an epithelioma eventually 
 becomes diffuse by regional and general dissemination, and destroys 
 life in the same manner as a deep-seated carcinoma. The writer has for 
 years claimed that the greater benignancy of a surface carcinoma as com- 
 pared with a deep-seated carcinoma depends entirely upon its location. 
 In epithelioma of the lip, as well as in the case of any other carcinoma 
 of a free surface, the tumor can grow only in one direction, while a 
 similar tumor located in an organ surrounded by tissues on all sides 
 grows from the very beginning in all directions. The field for local 
 
H2 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 infection of a surface carcinoma is therefore limited as compared with 
 that of a glandular carcinoma. The increased area of tissue in contact 
 with a glandular carcinoma as compared with that of a surface carci- 
 noma will readily account for the more constant and earlier occurrence 
 of regional infection. Another important element determining earlier 
 and more constant regional infection in glandular carcinoma is pressure 
 caused by the tissues encroached upon by the tumor. In surface carci- 
 noma this element in the diffusion of the tumor is absent, and consequently 
 migration of carcinoma-cells into the surrounding tissues is retarded. 
 
 The location of a tumor is also an important factor in estimating 
 the danger to life in the case of all benign growths. An osteoma 
 on the external surface of the skull always remains as a harmless 
 affection, while a similar tumor on the side of the cranial cavity may 
 produce distressing symptoms, and may finally result in death from 
 cerebral compression. A papilloma on the surface of the skin pro- 
 duces no symptoms, while the same kind of tumor in the larynx 
 may destroy life by suffocation. A subserous fibroma of the uterus 
 becomes a source of danger only from its size, while a small sub- 
 mucous tumor is a frequent cause of profuse and even dangerous 
 hemorrhage. In connection with the location, the size of a tumor 
 must also be taken into consideration in estimating its danger to life. 
 Large tumors are prone to undergo various kinds of degenerations 
 which in themselves may become a source of danger. A tumor that 
 has undergone extensive degeneration is also more likely to become 
 infected with pathogenic microbes. Large tumors of the ovary and 
 the uterus by displacing abdominal and pelvic organs may cause fatal 
 complications by pressure. A similar source of danger attends tumors 
 occupying the cranial cavity and the thorax. Large tumors of the 
 thyroid gland and malignant tumors of the lymphatic glands of the 
 neck become dangerous to life from compression of the trachea. 
 
 A few words in reference to what may be expected from operative 
 interference in the treatment of tumors : Complete removal of a benign 
 tumor is never followed by recurrence. The same favorable result will 
 follow a thorough removal of a sarcoma or a carcinoma if the operation 
 is performed before regional infection lias taken place. The removal of 
 a carcinoma or a sarcoma after regional dissemination has taken place 
 is followed sooner or later by recurrence in the great majority of cases. 
 Nothing but palliation can be expected from the removal of the primary 
 tumor in all cases in which the disease has become general by metastasis. 
 
 The partial removal of a malignant tumor with extensive regional 
 dissemination is often followed by aggravation of the local conditions 
 and hastens the fatal termination. 
 
XI. TREATMENT OF TUMORS. 
 
 The treatment of a tumor must necessarily vary according to its 
 nature, structure, and location. The removal of malignant tumors is 
 indicated if this can be done before the disease has passed beyond the 
 reach of a radical operation. The operation in such instances meets 
 an indicatio vitalis, because the intrinsic tendency of a malignant tumor 
 is to destroy life. The removal of a benign tumor for a similar indi- 
 cation is called for only if the tumor occupies a locality where by its 
 presence it produces mechanical conditions incompatible with the func- 
 tion of an important organ. In other cases benign tumors are removed 
 for the purpose of correcting functional disturbances, for cosmetic 
 reasons, and with a view of protecting the patient against the risks 
 of a possible transition into a malignant tumor. The treatment of 
 tumors divides itself into (i) medical, (2) surgical, and (3) palliative. 
 
 It is superfluous in this connection to make the assertion that a 
 rational treatment must be based on a correct diagnosis. It is the 
 recognition of the nature, location, and clinical tendencies of tumors 
 that distinguishes the honest and competent surgeon from the char- 
 latan. The cancer-quack calls every swelling a tumor, and his influ- 
 ence among the people is not due to the success he scores in the 
 treatment of carcinoma, but is gained by subjecting benign tumors, 
 retention-cysts, and inflammatory swellings to a similar barbarous 
 treatment, and claiming the results thus obtained as so many victories 
 over cancer. We have reason to believe that many of the alleged 
 permanent results following operations for malignant disease were cases 
 of mistaken diagnosis. Many a gumma and tuberculous ulcer has 
 been removed by honest, able surgeons under the belief that they were 
 operating for carcinoma. Gummata of bone have frequently been mis- 
 taken for sarcoma. The number of permanent results claimed for rad- 
 ical operations for malignant disease would be greatly decreased if we 
 could eliminate all cases of mistaken diagnosis. Professor von Esmarch 
 years ago called attention to the frequency with which tubercular ulcers 
 and gumma are mistaken for carcinoma. 
 
 Medical Treatment. 
 Since we have learned to distinguish between true tumors and infec- 
 tive swellings the indications for medical treatment have almost disap- 
 
 8 118 
 
114 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 peared. No kind of internal medication has any influence whatever in 
 limiting tumor-growth, much less in causing the disappearance of a tumor. 
 It is interesting for the student to know what has been done in the past 
 in the way of internal administration of medicines in the treatment of 
 tumors. Mercury was recommended by Boerhaave, and the effects of its 
 different preparations were praised by Gama, Akenside, Mariot, Gooch, 
 Gmelin, Buchner, Tauchnow, and many others. Rust and his pupils 
 had great faith in the use of Zittmann's decoction. Arsenic was intro- 
 duced in 1775 by Lefebure in the form of arsenious acid. Fowler's solu- 
 tion found many admirers, among them Desault, Klein, Rust, Wenzel, 
 Hill, Walshe, Thomson, and more recently Washington Atlee. The 
 last-quoted authority had great faith in the internal use of arsenic after 
 operations for carcinoma, as he believed the drug had a positive influ- 
 ence in retarding, if not preventing, a recurrence. He invariably admin- 
 istered this drug after an operation for cancer, and gradually increased 
 the dose until it produced slight intoxication, when the use of the drug 
 was not suspended, but the dose was diminished. He insisted that if 
 patients could not take a drop of Fowler's solution they should be 
 given a fraction of a drop ; that is, that the use of the drug should 
 be continued under all circumstances and for a long time. Preparations 
 of gold were used by Duportail and Duparcque ; the salts of copper, 
 by Gauret, Gerbier, Solier, and De la Romillais ; chloride of barium, by 
 Crawford and Mittag. Mineral waters, especially those containing prep- 
 arations of iodine, enjoyed a good reputation for a long time, and were 
 recommended in the highest terms by such men as Wagner, Travers, 
 Walshe, Flinsch, Klaproth, Ullmann, Littre, Friese, Copland, and 
 Demme. Preparations of iron were regarded with favor by Carmichael 
 and Daniel Brainard. Animal charcoal was recommended by Weise 
 in 1829. The highest praise was conferred upon conium maculatum 
 in its day in the treatment of carcinoma. It was used first for this pur- 
 pose in 1 76 1 by Stork; after him it was recommended in terms of the 
 highest praise by Recamier, Neuber, Gunther, Camper, Baudelocque, 
 Trousseau, and Solon, and it is extensively prescribed even at the pres- 
 ent day by N. S. Davis of Chicago, De Haen, Andree, Fothergill, 
 and Alibert. Almost all the narcotics have had their advocates in 
 the treatment of carcinoma. The fame of condurango was of short 
 duration. Introduced by Bliss of Washington, it soon reached great 
 popularity among both laymen and the members of the medical pro- 
 fession. Men like Andrews of Chicago and Eichhorst of Zurich ex- 
 tolled its merits. Like all other famous cancer remedies, it soon fell 
 into well-deserved " innocuous desuetude." Some of the surgeons of 
 fifty and a hundred years ago resorted to rigid antiphlogistic treatment. 
 
TREATMENT OF TUMORS. 115 
 
 Valsalva, Broussais, Brechet, Poteau, Dzondi, and Lisfranc claimed that 
 they could eliminate the cancerous material by copious and frequently- 
 repeated venesection. Local abstraction of blood was recommended 
 by Velpeau. More recently, surgeons aimed to remove the virus of 
 cancer by derivatives. After operative removal of the growth setons 
 were inserted at different parts of the body. Other surgeons used the 
 moxa and blisters to meet the same indication. 
 
 As a matter of historical interest, it should be known that Auzias 
 Turenne suggested syphilization to counteract the carcinoma virus. 
 We can readily understand why the different mercurial preparations 
 commanded the attention and received the approbation of the most 
 influential members of the profession for the longest time. Gummata 
 diagnosed as carcinoma disappeared under this treatment, and the 
 results thus obtained gave the remedy its great reputation. We have 
 no authenticated proof that mercury or any of its preparations has ever 
 been instrumental in retarding the growth of a tumor. The same can 
 be said of all other internal remedies. The internal administration of 
 medicines at the present time receives consideration only in the treat- 
 ment of some of the complications that may arise and in improving 
 the general health of the patient. 
 
 Radical Operation. 
 
 The complete removal of a benign tumor furnishes the best illus- 
 tration of what is meant by a radical operation. A radical operation 
 for the removal of a tumor has for its object the complete removal of 
 tumor-tissue. If this object is attained, the tumor, whether benign or 
 malignant, will not return. The removal of a benign tumor generally 
 constitutes a radical operation, owing to the structure of the tumor 
 and to its complete isolation from the adjacent tissues by a limiting 
 capsule. Incomplete removal of a benign tumor is followed by recur- 
 rence, in which event the operation does not deserve to be called 
 radical, because it failed to accomplish what is understood by the term 
 radical. A radical operation undertaken for the removal of a carci- 
 noma is radical in the estimation of the surgeon who in dealing with 
 the tumor has made every effort to comply with the meaning of the 
 word; but in the majority of cases he has been deceived, as is subse- 
 quently shown by a local recurrence. The term radical means more 
 and more to the surgeon as he becomes more familiar with the path- 
 ways and the extent of local and regional infection of malignant tumors. 
 
 Radical operations include — 1. Ligation of the principal blood- 
 vessels nourishing the tumor; 2. Galvano-puncture ; 3. Parenchym- 
 atous injections; 4. Injection of erysipelas toxines ; 5. Cauterization; 
 
Ii6 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 6. Ligation ; 7. Galvano-caustic wire ; 8. Ecrasement lineaire ; 9. Avul- 
 sion ; 10. Extirpation. Most of the modern surgeons resort almost 
 exclusively to the use of the knife in undertaking the radical operation 
 in the removal of tumors both benign and malignant. The bloodless 
 procedures are seldom resorted to, but they deserve a brief description, 
 as cases not adapted to extirpation may present themselves, or patients 
 may positively object to the use of the knife, and under such circum- 
 stances it is wisdom on the part of the surgeon to yield to their request 
 rather than to give them an opportunity to seek the services of char- 
 latans as devoid of a moral sense of responsibility as of a knowledge 
 of the science and art of surgery. 
 
 Ligation of the Principal Blood-vessels Nourishing- the Tumor. 
 — It has been stated in the section on the Etiology of Tumors that 
 a tumor can grow only if it receives an adequate quantitative and 
 qualitative blood-supply. Sudden or progressive anemia of a tumor 
 determines degeneration of the tuntor-tissue. Surgeons have made a 
 practical application of this knowledge, and have resorted to meas- 
 ures calculated to deprive the tumor of the necessary blood-supply 
 by ligating the principal arteries nourishing the tumor. This method 
 of treatment was first introduced in 165 1 by Harvey. It has been 
 most frequently resorted to in the treatment of tumors of the thyroid 
 gland. 
 
 Wolfler has recently revived and improved the operation. It has 
 been shown that ligation of the superior and inferior thyroid arteries 
 on both sides has a curative effect in the treatment of non-malignant 
 tumors of the thyroid gland. 
 
 In inoperable cases of malignant tumors of the pharynx and the 
 upper part of the neck the primitive carotid artery has been tied 
 repeatedly without even temporary benefit. 
 
 Ligation of the uterine arteries has recently been proposed as a 
 conservative operation in the treatment of bleeding fibroids of the 
 uterus. The results so far obtained are not conclusive as to the merits 
 of the operation. It is possible that in the future benign tumors of 
 other organs will be treated successfully upon the same principles. 
 Ligation of the principal arteries nourishing a tumor is occasionally 
 resorted to advantageously as an operation preliminary to a subsequent 
 extirpation. 
 
 Galvano-puncture. — Electricity was used in the treatment of tu- 
 mors by De Haen. Galvanism came next in use. In a case of a large 
 sarcoma of the neck in which Liicke resorted to galvanism the tumors 
 appeared to become smaller and more movable under its use, but care- 
 ful observation showed that the reduction in size and the temporary 
 
TREATMENT OF TUMORS. 117 
 
 improvement followed the subsidence of an accompanying inflamma- 
 tion, and that the treatment had no effect whatever on the tumor. 
 This has been the uniform experience of surgeons in the external 
 application of electricity in the treatment of tumors. Electro-puncture 
 and galvano-puncture have found special application in the treatment 
 of cystic tumors. At the International Medical Congress held in 
 Philadelphia in 1876, Semeleder of Mexico read a paper on this sub- 
 ject, from which it appeared that electricity was destined to supplement 
 the knife in the treatment of ovarian cysts. Apostoli made similar 
 claims for this agent in the treatment of myofibroma of the uterus at 
 the International Congress held in the city of Washington. It is now 
 generally conceded that electro-puncture and galvano-puncture occa- 
 sionally bring about improvement, but the results have not been 
 such as to entitle this therapeutic resource to be included among the 
 radical measures in the treatment of tumors. The application of the 
 electrolytic action of the galvanic current was first made use of by 
 Nelaton. As the electrolytic action is attended by gas-formation, Bill- 
 roth did not resort to electrolysis in the treatment of vascular tumors, 
 as he feared that the gas evolved might enter the blood-vessels and 
 produce dangerous if not fatal gas-embolism. Electrolysis has a lim- 
 ited sphere of application in the treatment of superficial naevi. 
 
 Parenchymatous Injections. — Injections of solutions of perchlo- 
 ride of iron have had an extensive application in the treatment of 
 vascular tumors. The use of coagulating substances as injections into 
 a vascular tumor is attended by great risks, and should entirely be 
 abandoned. Fatal embolism has attended this procedure by the separa- 
 tion of a fragment of the blood-clot, with the result of causing sudden 
 death. In other instances the injection was followed by suppuration, 
 thrombo-phlebitis, and pyemia. Thiersch injected into carcinomatous 
 growths a solution of nitrate of silver, with the object of bringing 
 about speedy degenerative changes. This treatment proved a com- 
 plete failure. Broadbent used for the same purpose dilute acetic acid, 
 with similar negative results. Carbolic acid and other antiseptic sub- 
 stances have been used in the treatment of malignant tumors, but none 
 of them have answered the expectations of those surgeons who regard 
 with favor the microbic origin of malignant tumors. The use of ani- 
 line dyes, introduced by Mosetig von Moorhof, has had an extended 
 trial, but so far no positive results have been realized. The employ- 
 ment of parenchymatous injections in the treatment of inoperable 
 tumors should be encouraged, as it is within the range of possibility 
 that there may be found a substance which, when brought in con- 
 tact with the tumor-tissue, may prove beneficial either by its destructive 
 
Il8 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 effects on the new cells or by effecting a change in the type of tissue- 
 proliferation. 
 
 Injection of Erysipelas Toxines. — It has been known for a long 
 time that an intercurrent attack of erysipelas frequently retarded the 
 growth of a sarcoma, and in exceptional cases resulted in a permanent 
 cure. Billroth and others have reported such cases. Since the dis- 
 covery of the microbe of erysipelas by Fehleisen patients suffering 
 from inoperable malignant tumors have been inoculated with pure 
 cultures of the streptococcus of erysipelas. Some of the cases sub- 
 jected to this treatment improved, others received no benefit, and in 
 some the symptoms were aggravated and the treatment hastened the 
 fatal termination. Coley and Bull have recently made use of sterilized 
 cultures of the erysipelas microbe, and have obtained equally good, 
 if not better, results than were obtained with the active cultures. This 
 treatment is certainly preferable to the employment of active cultures, 
 as it is not attended by the risks incident to an attack of erysipelas. 
 These authors have found that the employment of the sterilized cult- 
 ures was followed by better results in the treatment of sarcoma than 
 in that of carcinoma. It has also been ascertained that the culture 
 made of the streptococcus of erysipelas and the bacillus prodigiosus 
 is more effective than the culture of the streptococcus alone. As in 
 the case of Koch's lymph, the injections are followed by a rise in the 
 temperature. The diluted sterilized culture as sold in the shops is used 
 in doses of from 5 to 30 minims. The treatment should be commenced 
 by injecting 5 minims every alternate day, increasing the dose gradu- 
 ally. Koch's syringe (Fig. 43) should be employed for this purpose. 
 The writer has given this treatment a fair trial in twelve cases, but so 
 far no permanent beneficial results have been obtained. 
 
 Fig. 43. — Koch syringe. 
 
 The author has given this treatment an extensive trial, with invari- 
 ably negative results ; and Drs. L. A. Stimson, A. G. Gerster, and B. F. 
 Curtis, at a recent meeting of the New York Surgical Society, sub- 
 mitted the following report upon the use of erysipelas toxins in the 
 treatment of malignant disease : " We believe that in the instances of 
 apparent cure or marked improvement the correctness of the diagnosis 
 is open to doubt. We therefore submit: 1. That the danger to the 
 patient from this treatment is great. 2. Moreover, that the alleged 
 successes are so few and doubtful in character that the most that can 
 
TREATMENT OF TUMORS. 
 
 119 
 
 be fairly alleged for the treatment by toxins is that it may offer a very 
 slight chance of amelioration. 3. That valuable time has often been 
 lost in operable cases by postponing operation for the sake of giving 
 the method of treatment a trial. 4. Finally, and most important, that 
 if the method is to be resorted to at all, it should be confined to the 
 absolutely inoperable cases." 
 
 Cauterization. — The destruction of tumors by caustics and by the 
 actual cautery is one of the most ancient resources of the surgeon in 
 the bloodless removal of tumors. The actual cautery was preferred 
 by the surgeons of ancient times, because it not only destroyed the 
 tumor quickly, but at the same time also acted as a hemostatic. The 
 use of the actual cautery has had an extended application also as a 
 supplement to the knife in effecting the destruction of remnants of 
 tumor-tissue and in arresting hemorrhage. The actual cautery is occa- 
 sionally used now in the removal of small surface carcinomata in 
 patients who show an unconquerable objection to the use of the knife, 
 and in the palliative treatment of inoperable ulcerating malignant 
 tumors. The instrument employed almost universally for this purpose 
 is Pacquelin's cautery (Fig. 44). The bulb- or knife-point is used most 
 frequently in the treatment of malignant tumors, while the needle-point 
 is used almost exclusively in the treatment of angiomatous tumors. 
 The employment of the potential cautery — chemical caustics in differ- 
 ent forms — has found a more varied and extended application than that 
 of the actual cautery. It is to be regretted that this method of treat- 
 ment has fallen almost entirely into the hands of charlatans. The 
 ignoramus fears blood ; the public always has had, and always will 
 have, faith in bloodless procedures ; hence the great popularity which 
 chemical caustics have en- 
 joyed in the treatment of 
 tumors. The war between 
 caustics and the knife has 
 been a long and bitter one, 
 and it is by no means ended. 
 The cause of caustics is de- 
 fended by a great army of ig- 
 norant, irresponsible, money- 
 loving quacks, supported 
 and cheered by an admiring 
 misled public. On the side 
 of the knife stands the hon- 
 est surgeon who holds out 
 only guarded promises, confronted by patients suspicious of his skill 
 
 Fig. 44. — Pacquelin cautery. 
 
120 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and in great dread of a bloody operation. The ultimate victory of the 
 knife must rest on earlier and more thorough operations. The quack 
 has been educating the people to the effect that the caustic he uses de- 
 stroys only cancer-tissue, and he takes special pains to point out to his 
 patient that the remedy has not only succeeded in removing the cancer, 
 but has also followed its roots. The patient, with the specimen care- 
 fully preserved in alcohol, returns to his home happy and hopeful, and 
 exhibits the specimen cancer, roots and all, with satisfaction and a cer- 
 tain feeling of pride as a signal triumph of quackery over regular 
 medicine. In the face of such a state of things it is no wonder that 
 the surgeon who has regard for his own reputation is slow in substi- 
 tuting caustics for the knife. Chemical caustics have had an exten- 
 sive trial at the hands of the regular profession. Their merits and 
 disadvantages have been studied by competent and honest surgeons. 
 They occupy at the present time a limited and special field in the 
 treatment of tumors. 
 
 The value of different caustics depends on the manner of their 
 action : the more potent its action, the less the liability to hemorrhage ; 
 the less the pain it inflicts, the more useful it is. The treatment of 
 small benign tumors by the application of caustics often results in a 
 permanent cure. In the treatment of carcinoma this is seldom the 
 case. The difficulty encountered in this method of treatment is that 
 one application is seldom sufficient to destroy all the tumor-tissue, 
 and that repeated applications cause so much suffering and distress 
 that few patients will endure them long enough to effect a radical cure. 
 Some of the caustics which have been used may become absorbed in 
 amount sufficient to produce poisoning, and on this account should 
 never be used : this is the case with arsenical preparations. When fluid 
 caustics are employed the surrounding tissues should be protected 
 carefully against their action. If the caustic is to be repeated, the 
 second application is postponed until the eschar has separated. Pain 
 is to be subdued by the application of cold and by hypodermic injec- 
 tions of morphine. In the selection of the caustic we must be guided 
 by the depth to which it is desirable to penetrate, as well as by the 
 location to which liquid caustics are adapted. 
 
 Caustic Potash. — Caustic potash is a very energetic caustic. The 
 rapid liquefaction which it undergoes when applied to the tissues 
 detracts somewhat from its advantages, and it must be watched care- 
 fully and the tissues beyond its desired range of action must be pro- 
 tected thoroughly. It cannot be employed safely in the treatment of 
 tumors located in cavities. Its hemostatic action is not reliable. This 
 substance is often mixed with caustic lime, the mixture constituting 
 
TREATMENT OF TUMORS. 121 
 
 the famous Vienna paste, which is not much inferior to the caustic 
 potash as a caustic. 
 
 Chloride of Zinc. — This article, in the form of a paste known as 
 Canquoin's paste, has been used quite extensively as a caustic. To 
 increase its action in paste form it is necessary that it should receive 
 a certain amount of moisture, and it must therefore be applied under 
 the skin. If the skin over the tumor is intact, it should be made per- 
 meable to the caustic by macerating it for some time with a dilute 
 solution of caustic potash or by making multiple superficial incisions. 
 It is a reliable hemostatic, which fact is an additional recommendation 
 for its employment in the removal of vascular tumors. The eschar it 
 produces is very dry and corresponds in size to the cubic volume of the 
 mass of paste inserted. In a few days the eschar can readily be re- 
 moved with the knife, when the cauterization is repeated. The caustic 
 arrows of Maisonneuve are composed of a paste of flour and chloride 
 of zinc in the proportion of 3:1. Landolfi, a famous Italian cancer- 
 doctor, used a mixture of chloride of zinc, chloride of gold, and chlo- 
 ride of bromium. 
 
 Arsenic. — The arsenical preparations, especially the paste of Frere 
 Come, were popular for a long time, and proved useful in the removal of 
 small epiblastic carcinomata about the face and the lip. Arsenic is an 
 energetic caustic, but its action is slow. Intoxication from the absorp- 
 tion of arsenic has repeatedly been observed. For some time arsenic 
 was regarded as a specific in the treatment of carcinoma, but this delu- 
 sion no longer prevails, as it has been found that its beneficial action 
 when applied as a caustic depends entirely upon the depth to which 
 tissue is destroyed, as is the case with all other caustics. 
 
 Chromic Acid. — This acid inflicts less pain than any other liquid 
 caustic, and has proved successful as a superficial caustic. It is used 
 in the form of crystals or as a concentrated solution. 
 
 Nitric Acid. — Of all the acids, nitric acid has been used most fre- 
 quently as a caustic in the treatment of tumors. The eschar is of a 
 yellowish color, and the resulting scar is small. Nitric acid is also 
 a good hemostatic. 
 
 Instead of resorting to cauterization from without, French surgeons 
 devised a method by which caustics are inserted into the tissues of the 
 tumor through punctures from different points, which method they 
 termed " linear cauterization." The first attempts in this direction were 
 made in 1700 by Deshaies Gendrou. His method consisted in intro- 
 ducing pieces of caustic paste under the base of the tumor, with the 
 expectation that the deep cauterization from different points would 
 eventually separate the tumor from the tissues, when it would be cast 
 
122 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 off as a whole with the eschar. Under the name of " cauterisation 
 en fleches " Maisonneuve in 1857 developed this procedure. He in- 
 
 Fig. 45. — Cauterisation en rayons (after Maison- 
 neuve). 
 
 Fig. 46. — Cauterisation en faisceaux (after Maison- 
 neuve). 
 
 serted arrow-shaped pieces of chloride-of-zinc paste into the substance 
 of the tumor after puncturing it at different points with a bistoury. 
 He described three methods of procedure : First, the arrows are intro- 
 duced on the same level in such a way that their points meet in the 
 centre of the tumor (Fig. 45) ; second, the arrows are inserted from the 
 surface like posts driven in the ground (Fig. 46) ; third, an arrow was 
 inserted into the centre of the tumor, so that cauterization should pro- 
 ceed from the centre toward the periphery — " cauterisation centrale " 
 
 (Fig. 47)- 
 
 In the • removal of tumors of small size surface cauterization must 
 be resorted to. If the tumor is large, Maisonneuve's procedures are 
 preferable. They are, however, not devoid of danger. It has hap- 
 pened in the practice of Maisonneuve that the caustic destroyed the 
 walls of large blood-vessels, and upon the separation 
 of the eschar troublesome and even fatal hemorrhage 
 occurred. The writer recollects a case of carcinoma 
 in the parotid region that was treated by a charlatan 
 by caustics. Before the patient left the institution 
 profuse hemorrhage occurred after separation of the 
 last eschar. The patient was informed that the cure 
 was completed, and was advised to return to his 
 home. Soon after he left the institution there oc- 
 curred another hemorrhage, which nearly proved fatal. 
 Greatly debilitated and almost exsanguinated, he was 
 brought to the Presbyterian Hospital, Chicago. The 
 dressings were saturated with blood. An anesthetic was administered, 
 the dressings were removed, the neck was disinfected, and the common 
 carotid artery was tied. Upon examination of the large surface partly 
 
 Fig. 47. — Cauterisation 
 centrale (after Maison- 
 neuve). 
 
TREATMENT OF TUMORS. 
 
 123 
 
 covered by granulations and partly by fungous carcinoma-tissue, a 
 large opening in the external carotid artery was found near the bifur- 
 cation of the common carotid. The surface was disinfected and the 
 opening in the vessel was tamponed with iodoform gauze. The hem- 
 orrhage did not return, and the patient left the hospital in the course 
 of a week. 
 
 Immediate and complete removal of a tumor is accomplished by 
 the employment of the ligature, the ecraseur, the galvano-caustic wire, 
 and the knife. The complete removal of a tumor is effected in the 
 safest manner and most expeditiously by the use of the knife, but, as 
 all the procedures enumerated above are still endorsed by eminent 
 surgeons, and as all of them are occasionally resorted to, they merit 
 a brief description. 
 
 Ligature. — The ligature is an ancient surgical resource in the treat- 
 
 Fig. 48. — Maisonneuve's constrictor. 
 
 ment of tumors. Ambrosius Pare and De Saliceto removed with it 
 polypoid growths from the nasal cavities and from the cervix of the 
 uterus. Mayor described this procedure, under the name of ligature 
 en masse, as a new discovery, improved the technique, and extended its 
 use to different parts of the body. The ligature 
 was used in two ways : 1. It was tied so firmly 
 that it strangulated all blood-vessels, producing 
 rapid necrosis of the tumor ; 2. It was tightened 
 from time to time, in order to cut its way more 
 slowly through the tissues. The single ligature 
 
 was used in tying off pedunculated growths. 
 Its use was extended to the removal of tumors 
 with a wide base, with the introduction of the 
 double and multiple ligatures. The ligatures 
 were either tied on the surface of the skin or 
 inserted with needles around and under the 
 base of the tumor. Whenever possible a ped- 
 icle was made artificially by making traction 
 upon the tumor before inserting and tying the 
 ligatures, or by dissecting off the skin around 
 the base of the tumor. The percutaneous ligature has been employed 
 
 Fig. 49. 
 
 -Koderik's rosary instru- 
 ment. 
 
124 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 extensively in the treatment of angioma. Recently absorbable lig- 
 atures of catgut and kangaroo tendon have been sustituted for the 
 silk and metallic ligatures in the subcutaneous ligation of vascular 
 growths. Various instruments have been devised for the progress- 
 ive constriction of the base of the tumor by the ligature. Maison- 
 neuve's (Fig. 48) is constructed upon the same plan as Chassaignac's 
 ecraseur. In Koderik's instrument (Fig. 49) the ligature is tightened at 
 intervals over a row of perforated shot. Manec contributed largely 
 toward the perfection of the technique of the subcutaneous ligature. 
 He devised a needle for this special purpose, the manner of use of 
 which is well shown in Figure 50. Fergusson's method (Fig. 51) 
 is simpler and does not require a needle of special construction. The 
 great objections to the use of the ligature are the pain it causes 
 and the liability to infection that attends its use. The ligature is used 
 at the present time only in exceptional cases of angioma. The aseptic 
 ligature should be used, attended by all necessary antiseptic precautions. 
 
 Fig. 50. — Manec's method of percutaneous ligation of a tumor (after Manec). 
 
 Galvano-caustic "Wire. — Recognizing the disadvantages of the silk 
 and metallic ligatures in the removal of tumors, Middeldorpf in 1852 
 
TREATMENT OF TUMORS. 
 
 125 
 
 substituted for ligation the galvano-caustic wire. Like the ligature, it 
 has been used in severing the tumor from the body by cutting its way 
 
 Fergusson's percutaneous ligature (after Fergusson). 
 
 from the surface and by destroying the tumor-tissue subcutaneously. 
 The latter method of application has proved very useful in the treat- 
 ment of subcutaneous angioma, as the overlying skin is protected 
 against cauterization by insulating the platinum wire at the points of 
 entrance and exit. The galvano-caustic wire has been a great improve- 
 ment over the ligature, as it completes its work almost as quickly as 
 the knife and leaves a wound much less liable to infection. One great 
 objection to the use of the galvano-cautery is the well-known fact that 
 the apparatus is very liable to get out of order, often necessitating a 
 resort to other measures. With few exceptions it has been superseded 
 by the needle-point of the Pacquelin cautery. 
 
 Bcrasement Lineaire. — The removal of tumors by linear crushing 
 was devised by Chassaignac. The parts included in the chain or wire 
 of the ecraseur are divided slowly and, if no large vessels are present, 
 bloodlessly. Chassaignac was an enthusiast in the use of his ecraseur 
 
 Fig. 52. — Chassaignac's chain ecraseur. 
 
 (Fig. 52). In his practice it almost displaced the knife. According to 
 Chassaignac's own directions, the tissues should be divided very slowly, 
 
126 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 for the purpose of guarding more efficiently against hemorrhage. That 
 hemorrhage is not always prevented even by exercising the greatest 
 caution is well known. The writer has seen profuse hemorrhage from 
 both lingual arteries after amputation of the tongue by the ecraseur. 
 Rhinologists and laryngologists have invented minute ecraseurs upon 
 which they rely almost exclusively in the removal of polypoid growths 
 from the nasal cavities and the larynx. The general surgeon at the 
 present time seldom resorts to the ecraseur. Mr. Hutchinson prefers 
 
 Fig. 53. — Wire ecraseur. 
 
 it to the knife or the scissors in removing the tongue, but few surgeons 
 could be induced to follow his example. 
 
 Avulsion. — The removal of a pedunculated tumor by torsion is 
 accomplished by grasping the pedicle, as close to its attachment as pos- 
 sible, with a pair of strong forceps and twisting it around its axis until 
 the tumor is torn from its bed. This has been a favorite method of 
 removing polypoid growths of the nose and the uterus. If the tumor 
 is soft, the removal is often incomplete, and a return of the growth is 
 the rule ; if the pedicle is large and firm, unnecessary damage is often 
 inflicted upon the organ to which the tumor is attached. Avulsion 
 should give way to the galvano-caustic wire, to the ecraseur, or to 
 enucleation. 
 
 Extirpation. — The general surgeon, with few exceptions, removes 
 all tumors by extirpation. This method of eradicating tumors has 
 precision. The knife can be made to include any tissue that may pre- 
 sent a suspicious appearance, and it enables the surgeon to examine 
 the tissues as he proceeds with the operation, and thus to outline more 
 accurately the limits of the tumor. The operation can be performed 
 painlessly by placing the patient under the influence of an anesthetic, 
 and the wound can be made to heal by primary intention. The con- 
 trast between the speedy and painless removal of a tumor by excision 
 and the slow and painful destruction by caustics is great. The wound 
 left after the use of caustics has to heal by a slow process of granula- 
 tion, and, as so often happens, incomplete removal transforms a subcu- 
 taneous into an open ulcerating cancer, with all the risks and incon- 
 veniences incident to such a condition. Incomplete removal by caustics 
 invariably results in -aggravation of all the local conditions, as the 
 inflammation which follows cauterization imparts a new stimulus to 
 
TREATMENT OF TUMORS. 127 
 
 tumor-growth. The risks of hemorrhage and infection are much greater 
 after cauterization than after excision. The removal of benign tumors, 
 carcinoma, and sarcoma by extirpation should be made the rule, and 
 the use of caustics be reserved for exceptional cases of carcinoma. 
 
 The idea that the results after extirpation of malignant tumors are 
 better if the wound suppurates and heals by granulation is wrong both 
 in theory and in practice. Inflammation is one of the most influential 
 factors in effecting a speedy recurrence if the tumor has not been 
 removed completely. In extirpation of tumors it should be the aim of 
 the surgeon to secure healing of the wound by primary intention. If the 
 margins of the wound cannot be brouglit into apposition by suturing, 
 owing to the removal of an extensive area of skin with the tumor, the 
 margins should be approximated as far as possible by tension-sutures, 
 and the remaining surface be covered with a Wolfe skin-graft or with 
 a mosaic of Thiersch skin-grafts. For the purpose of preventing wound- 
 complications, and with the view of securing speedy healing of the wound 
 and of obtaining an ideal functional and cosmetic result, it is absolutely 
 necessary to resort to the strictest antiseptic precautions in the extirpation 
 of a tumor, irrespective of its size or its location. 
 
 The instruments should be sterilized by boiling for at least ten 
 minutes in a 1 per cent, solution of carbonate of soda. Sterile liga- 
 tures, sutures, and gauze sponges should be used. The field of opera- 
 tion and the hands of the operator and of his assistants should be 
 disinfected thoroughly by scrubbing with warm water and potash soap 
 for at least five minutes, followed by washing in a 1 : 1000 solution of 
 corrosive sublimate. If the tumor occupies any of the large cavities, the 
 patient must be prepared thoroughly for the operation by preliminary 
 treatment continued for several days. The external incision should be 
 amply large, to facilitate deep dissection. The danger of a wound is 
 no longer estimated by its size. The attempt to remove tumors 
 through small incisions is attended by greater risks of injury to 
 important structures than when the parts we wish to avoid are well 
 exposed by a large incision. The incision should be made in a loca- 
 tion and direction which will render the tumor most accessible and 
 which will not implicate important structures. It must be remem- 
 bered that tumors often displace important vessels and nerves, and on 
 this account special care is necessary to avoid these structures when 
 displaced. In operating upon the extremities the incision should be 
 made parallel with muscles. In extirpating tumors of the neck an 
 incision in the direction of the sterno-cleido-mastoid muscle is usually 
 made. A transverse incision is preferred by some operators in the 
 removal of tumors of the thyroid gland. Submaxillary growths should 
 
128 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 be approached through a slightly-curved incision below the border of 
 the lower jaw. In amputations of the breast the incision is prolonged 
 behind the border of the pectoralis major muscle to the apex of the 
 axilla. Tumors of the groin are laid bare by making an incision 
 parallel with and a little below Poupart's ligament, and joining it by 
 a vertical incision over the femoral vessels extended to the apex of 
 Scarpa's space. A slightly-curved incision affords more room than 
 a straight one. If the skin or the mucous membrane over the tumor 
 is implicated, it is included between two elliptical incisions and is 
 removed with the tumor. After a benign tumor has been reached, 
 cutting instruments are laid aside and the tumor is removed by enucle- 
 ation, using for this purpose the finger, Kocher's director, or blunt- 
 pointed scissors. Extirpation of osteoma and chondroma requires the 
 use of the chisel or the saw. Some cysts have such firm attachments 
 that enucleation is impracticable, in which event their removal is effected 
 by careful dissection. If the extirpation of a tumor requires a prelim- 
 inary myotomy, the muscle should be united by buried absorbable 
 sutures before the external wound is closed. If a nerve or a tendon 
 is accidentally or intentionally cut, it is united in a similar manner. 
 If an important fascia has been divided, it is separately sutured. As 
 benign growths are aseptic pathological conditions, the external wound 
 can be closed throughout by sutures and sealed. The after-treatment 
 should include rest of the part operated upon, which can be secured 
 by rest in bed, bandages, splints, etc. Operations for carcinoma and 
 sarcoma are attended by great difficulties, as with the tumors the sur- 
 geon must include a zone of tissue surrounding them, and must usually 
 extend the operation far into apparently healthy tissue to reach and 
 remove the products of regional infection. Two great difficulties con- 
 front the surgeon during the course of the operation. In the absence 
 of any limiting structures he is often in doubt concerning the amount of 
 tissue he should include with the tumor, and, again, to what extent he 
 should invade the vicinity in his attempts to eradicate the disease. No 
 definite rules can be laid down to guide the surgeon in deciding these 
 most important points of the operation. He must take pathological 
 anatomy as his guide. It is well known that sarcoma follows connec- 
 tive tissue, blood-vessels, nerve-sheaths, and muscles. The surgeon 
 must therefore include as much tissue in the direction of these pathways 
 as is permissible with the importance of the structure involved. The 
 amount of tissue to be included must necessarily vary with the character 
 of the tumor, its location, and the importance of the structures in its 
 vicinity. The farther the tumor is away from important vessels and 
 nerves, and the more tissue can be included, the better will be the 
 
TREATMENT OF TUMORS. 129 
 
 results. As a rough estimate the writer would say that the incisions 
 should be made at least an inch away from the periphery of the tumor. 
 Sarcoma of bone usually demands amputation, although recently suc- 
 cessful local operations have been made in cases of circumscribed 
 myeloid sarcoma. If amputation is performed, the entire bone should 
 be removed ; that is, amputation should be made through or above the 
 proximal joint. In the removal of a malignant tumor enucleation must 
 never be attempted : the tumor must be excised. Extirpation here means 
 the removal not only of the tumor, but also of all infected tissues in its 
 vicinity or in the same region. The knife or the scissors must be used 
 from the beginning to the end of the operation. The extirpation of a 
 carcinoma, unless the tumor involves a free surface and is recent and 
 localized, must be follozved by excision of the lymphatic glands of the 
 same region, whether enlarged or not enlarged. The tumor and the string 
 of lymphatic glands should be removed in one continuous piece by 
 thorough and clean excision. It has been shown that carcinoma fre- 
 quently selects the connective tissue as pathways for local infection ; hence 
 as much of the connective tissue as possible in the vicinity of the tumor 
 shoidd be included in the excision. Muscles are often divided or removed 
 in operations for malignant tumors. Partial removal for malignant dis- 
 ease of organs not essential to life is bad surgery. In operating for 
 malignant disease parts and tissues must be removed regardless of the 
 cosmetic result. The surgeon who operates with a view of securing a 
 good cosmetic result is very liable to perform an incomplete operation. 
 The primary indication in the extirpatioii of a malignant tumor is to re- 
 move all infected tissues ; the cosmetic result is of secondary consideration, 
 and can be improved immediately or later by plastic operation. After 
 operation it is advisable to watch the patient carefully, and in case of 
 recurrence to repeat the operation. By following this course there is 
 no doubt that the patient is made more comfortable and life is pro- 
 longed, and occasionally a radical cure is effected by repeated opera- 
 tions for local recurrence. 
 
 Contraindications to radical operations for malignant disease are — 
 1. Metastasis; 2. Extreme old age; 3. Regional infection beyond the 
 reach of complete removal of diseased tissue without imminent danger 
 to life ; 4. Very extensive local infection, as in cases of diffuse cancer 
 en cidrasse. 
 
 Palliative Treatment. 
 
 Palliative treatment is indicated in cases of inoperable malignant 
 tumors. It consists in protecting the tumor against irritation, and, in 
 open ulcerating tumors, in partial removal, antiseptic applications, and 
 
130 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the use of anodynes to subdue pain. If the tumor is on the surface, 
 it should be protected against friction by the clothing by a compress 
 of aseptic absorbent cotton held in place by a bandage or by strips of 
 adhesive plaster. As soon as indications of ulceration appear, the sur- 
 face should be disinfected thoroughly and be protected by an antiseptic 
 dressing, so that when the tumor-tissue is exposed the ulcerated sur- 
 face will be protected against infection. If the ulcer or fungous mass 
 has become infected, it is necessary to correct the fetor by the employ- 
 ment of strong antiseptic applications. Chlorine-water, solution of per- 
 manganate of potash, saturated solution of acetate of aluminum, and 
 solution of chlorinated soda (Labarraque's solution) are most efficient 
 in correcting the putrefactive processes. A 10 per cent, solution of 
 chloride of zinc, carefully applied with a camel's-hair brush to the dried 
 surface of the ulcer, is one of the best disinfectants. The writer has 
 found a solution of hydrate of chloral (2 : 100) not only a good anti- 
 septic, but also a local anodyne. The stronger antiseptics, creosote, 
 carbolic acid, and corrosive sublimate, must be used with caution, as 
 the prolonged use of even a weak solution might result in intoxication. 
 Vegetable charcoal has been popular for a long time as a deodorizer. 
 Great benefit often follows the removal of fungous granulations with 
 a sharp spoon, followed by an energetic use of the actual cautery. 
 This treatment is frequently resorted to with decided temporary im- 
 provement, so far as the local conditions are concerned, in the palliative 
 treatment of inoperable carcinoma of the uterus. Bleeding from the 
 ulcerated surface, commonly of capillary origin, is best controlled by 
 applying a few layers of gauze saturated with liquor, ferri sesqui- 
 chlorati, over which an antiseptic tampon is applied, and the whole kept 
 in place with the dressing applied to the ulcer by broad strips of ad- 
 hesive plaster. If a large vessel is the source of hemorrhage, and can 
 be tied neither in loco nor at a distance, the antiseptic tampon will have 
 to be relied upon. Very little is to be expected in the way of allevi- 
 ating pain from local anodynes ; of these, cocaine has proved the most 
 useful. A strong solution (10 per cent.) of cocaine applied to ulcerating 
 carcinomata of the cavity of the mouth has done much to relieve pain 
 and dysphagia. Arnott derived great benefit from cold applications. 
 The cold coil or the ice-bag deserves a trial as a local anesthetic. Sub- 
 cutaneous injections of morphia have to be relied upon to allay pain 
 and to procure sleep. The smallest dose possible should be com- 
 menced with ; the dose must be increased rapidly as the pain increases 
 in severity and the patient becomes habituated to the use of the drug. 
 
XII. CLASSIFICATION OF TUMORS. 
 
 A rational, systematic classification of tumors is to the surgeon 
 what the analytical key is to the botanist. A uniform system of classi- 
 fication of tumors is one of the great wants of modern pathology, and 
 all attempts in this direction have proved failures. New classifications 
 are being introduced from time to time, but each of them invariably 
 represents the individual author's own views regarding the origin and 
 nature of tumors. A classification which will be intelligible to the 
 student and of practical utility to the surgeon must be based on the 
 histogenesis and the clinical aspects of tumors. As the histologist 
 traces the normal tissue to its embryonic origin, so the pathologist must 
 follow the tumor-cells to the embryonic matrix which produced them, 
 in order to trace tumors to their primary histogenetic origin and to 
 classify them upon a histological basis. The botanist includes in the 
 same class wholesome and poisonous plants from their morphological 
 resemblance, and the pathologist groups together tumors which have 
 a common embryonic origin ; but in making a classification he must 
 make a subdivision according to their clinical aspects, which means 
 their relation to the surrounding tissues and the organism. To Virchow 
 belongs the honor of having attempted the first systematic classifica- 
 tion of tumors on a histological basis. 
 
 Virchow's Classification. 
 
 1. Histioid; 
 
 2. Organoid ; 
 
 3. Granulomata; 
 
 4. Teratoid ; 
 
 5. Combination tumors ; 
 
 6. Extravasation- and exudation-tumors ; 
 
 7. Retention-cysts. 
 
 Among the histioid tumors he included all tumors composed of one 
 kind of cells. 
 
 The class of organoid tumors he made to include all tumors com- 
 posed of several kinds of tissue-elements with a definite typical arrange- 
 ment of the component parts. 
 
 131 
 
132 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Among the infective swellings he included carcinoma and sarcoma, 
 calling this group " granulomata." " Teratoma " was the term applied 
 to tumors composed of a system of organs arranged in an imperfect 
 manner, of course, and representing different parts of the body, and 
 sometimes a perfect body, such as dermoid cysts and fcetus in fcetii. 
 
 " Combination tumors," as the term implies, are tumors composed 
 of different kinds of tumor-tissue representing two or more histioid 
 tumors, such as adeno-chondroma, myofibroma, etc. 
 
 The extravasation- and exudation-tumors include swellings con- 
 taining blood, serum, or inflammatory products. 
 
 A pure histioid tumor, according to Klebs, could be found only in 
 a very small epithelioma and a small sarcoma. In large tumors it is 
 represented by angioma. 
 
 The term "organoid " as applied to tumors is incorrect and mislead- 
 ing, because even the most perfectly-developed adenoma, as well as all 
 the rest of the tumors, lacks physiological function. 
 
 Compound tumors occur in consequence of degenerative changes 
 or of change in the type of tissue-growth in a primary simple tumor. 
 
 The granulomata and the extravasation- and exudation-swellings, 
 which should no longer be classified with tumors, will be eliminated 
 from our classification. 
 
 Retention-cysts are not tumors, but have so much in common with 
 tumors, and occupy such a conspicuous place in the differential diag- 
 nosis, and require so frequently the same treatment as tumors, that 
 they will be treated under a separate head in this book. 
 
 Cohnheim's Classification. 
 
 Fibroma ; 
 
 Lipoma ; 
 
 Myxoma ; 
 | Chondroma ; 
 i. Connective-tissue type. { Osteoma; 
 
 Angioma ; 
 
 Lymphangioma ; 
 
 Lymphoma ; 
 
 Sarcoma. 
 
 Epithelioma ; 
 
 Onychoma ; 
 
 Struma ; 
 
 Cystoma ; 
 I Adenoma ; 
 v Carcinoma. 
 
 2. Epithelial type. 
 
CLASSIFICATION OF TUMORS. 
 
 135 
 
 3. Myomata. 
 
 1. Archiblastic neoplasms. < 
 
 f Myoma laevi-cellulare ; 
 \ Myoma stri-cellulare. 
 
 , T f Neuroma ; . 
 
 4. Neuromata. | ^.^ ^^ 
 
 5. Teratomata. { (Virchow). 
 
 The classification of tumors as prepared by a committee of the 
 College of Physicians and Surgeons of London is very defective, as 
 among tumors it includes swellings the product of other pathological 
 conditions. 
 
 Williams's Classification. 
 
 Lowly organized : 
 
 c Squamous ; 
 
 Epithelioma. < Cylindrical; 
 (. Glandular. 
 Highly organized : 
 
 Adenoma ; 
 
 Cystoma (neoplastic) ; 
 
 Papilloma. 
 Lowly organized : 
 
 Sarcoma ; 
 
 Myxoma. 
 Highly organized : 
 
 Fibroma ; 
 
 Lipoma ; 
 
 Chondroma ; 
 
 Osteoma. 
 
 Williams and Klebs classify tumors into archiblastic and parablastic, 
 in accordance with the division by His of tissue in the embryo. For 
 the sake of simplifying the location of tumors anatomically in the diag- 
 nosis, as well as in pointing out the differences of structure and func- 
 tion of the cells of the epiblast and hypoblast, we shall retain the 
 distinction between epiblastic and hypoblastic tumors. 
 
 Virchow from a practical standpoint divided all tumors again into — 
 1. Homologous ; 2. Heterologous — terms which have been used wrongly 
 as synonymous with the designation " benign " and " malignant." All 
 malignant tumors are heterologous, but not all heterologous tumors arc 
 malignant. According to Virchow, a heterologous growth is a tumor 
 which in its histological structure deviates from the type of tissue from 
 which it grows, while a homologous tumor is one which reproduces 
 the type of tissue of the part or organ in which the tumor is located. 
 The innocent tumors histologically very closely resemble normal tissue ; 
 
 2. Parablastic neoplasms. 
 
134 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 no such resemblance can be seen in the malignant tumors. The former 
 are homologous, the latter heterologous ; but there are instances where 
 an innocent tumor is heterologous (chondroma), and malignant tumors 
 present a homologous appearance during the earliest stages of their 
 development. A familiar illustration of what is meant by the term 
 " homologous " is furnished by a myofibroma of the uterus, because it 
 contains all the tissue-elements of that part of the uterine wall with 
 which it is in contact. A chondroma in any of the glands — as the paro- 
 tid, mammary, and testicle — represents a benign heterologous tumor, 
 because cartilage is not a normal histological constituent of these 
 glands. According to Cohnheim, all chondromata are heterologous 
 tumors, as they never spring from cartilage where it normally exists, 
 but occur in bone and soft tissues where cartilage has no legitimate 
 physiological existence. Using the term " heterologous " in a strictly 
 practical sense, the only tumors that are destructive are those which 
 are heterologous in their origin and location. The homologous tumors 
 may become destructive only by accident. Heterotopic tumors are 
 heterologous tumors. " Heteroplasty " is another term introduced by 
 Virchow, and in its strictest sense it takes in the malignant tumors. 
 According to the views of this author as to the origin of malignant 
 tumors, in cases of sarcoma and carcinoma during the earliest stages 
 we meet with indifferent cells which, according to the nature of the 
 initiative, assume an epithelial or connective-tissue type. It must be 
 remembered that Virchow entertained the belief that carcinoma and 
 sarcoma have a common origin in connective tissue, and that during 
 a later stage the new products differ as their cellular elements reach 
 various degrees of development. 
 
 Robin and Waldeyer showed conclusively that epithelial tumors are 
 never developed from a connective-tissue matrix. Lancereaux, Klebs, 
 and others have excluded from the mesoblastic tumors endothelioma, 
 as being a separate type closely resembling epiblastic and hypoblastic 
 tumors. Lancereaux described endothelial tumors of the lymphatics 
 of the peritoneum ; Robin, of the arachnoid and peritoneum ; Gaucher, 
 of the spleen from the endothelia of blood-vessels and lymphatic 
 glands ; Monod and Arthraud, of the retina from the vascular endo- 
 thelia. 
 
 Sutton claims that the same relation exists between sarcoma and 
 endothelioma as between carcinoma and epithelioma. We shall include 
 endothelioma among the malignant mesoblastic tumors, and thus 
 adhere strictly to the classification made in accordance with the division 
 of embryonic tissue into the three germinal layers. We shall also 
 endeavor to show that the endothelial cells are capable of being trans- 
 
CLASSIFICATION OF TUMORS. 135 
 
 formed into ordinary connective tissue, and vice versa, and that their 
 close histological and pathological relationship to the connective-tissue 
 tumors would, a priori, tend to prove that they are subject to tumor- 
 formation of the same type as the common connective tissue of similar 
 histogenetic origin. From a practical standpoint, the division of tumors 
 according to their clinical aspects manifested by their relations to the 
 adjacent tissues and to the organism has always been, and always will 
 be, of the greatest importance to the surgeon. Clinically, tumors have 
 been divided into— 1. Benign; 2. Malignant; 3. Suspicious. We have 
 explained elsewhere why the third class should be abolished. A tumor 
 is either benign or malignant. The tumors classified heretofore as sus- 
 picious are tumors which from their structure or location present con- 
 ditions not favorable for thorough removal by the usual operations 
 made for the removal of benign tumors. Such tumors as chondroma 
 and myxoma, about which there has always lingered a suspicion as to 
 their benign nature, from a practical standpoint have been regarded 
 as innocent growths, and incomplete removal is responsible for many 
 relapses after operation. The sudden change in the clinical behavior of 
 tumors which have been pursuing a benign course for perhaps a long time 
 is no evidence of a semi-malignant nature of the tumor, but is an evidence 
 that a benign tumor has undergone transition into a malignant stage, or 
 that the tumor was malignant from its incipiency, and has passed from 
 a latent into an active condition. All the embryonic germinal layers 
 furnish matrices for benign and for malignant tumors. The clinical type 
 of the tumor depends upon the stage of arrest of development of the cells 
 composing the matrix derived from the embryo or from embryonic cells 
 of post-natal origin. • 
 
 The cells composing the tumor-matrix produce a tumor that is either 
 benign or malignant. We shall speak of benign and malignant tumors 
 of the epiblast and hypoblast and the mesoblast. A benign tumor is 
 one which never extends beyond the germinal layer in which it had its 
 origin, while a malignant tumor extends to and involves tissues derived 
 from germinal layers other than the one from which it had its origin. 
 The extension of a tumor to adjacent tissues irrespective of their structure 
 or their embryonic oi r igin has been regarded for a long time as the most 
 reliable clinical proof of the malignant nature of the tumor. 
 
 We shall classify tumors with special reference to their origin from 
 the different germinal layers — the epiblast, the hypoblast, and the meso- 
 blast — and to the stage of arrest of development of the cells composing 
 the tumor-matrix. The lowly-organized tumor-tissue will represent the 
 malignant tumors, and tumors composed of highly-organized cells will 
 include all benign growths. In the description of the different varieties 
 
136 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 of tumors the benign tumors will be considered first, as the tissues of 
 which they are composed bear a closer resemblance to normal tissue 
 than do the tissues of malignant tumors, and hence the deviation from 
 the laws governing normal growth and nutrition is less marked. 
 
 Author's Classification. 
 f Papilloma ; 
 I. Epiblastic and hypoblastic J Adenoma; 
 
 tumors. 
 
 2. Mesoblastic tumors. 
 
 I Cystoma ; 
 L Carcinoma. 
 
 Fibroma ; 
 
 Lipoma ; 
 
 Myxoma ; 
 
 Chondroma ; 
 
 Osteoma ; 
 
 Angioma ; 
 
 Lymphangioma ; 
 
 Lymphoma ; 
 
 yr ( Lsevi-cellulare ; 
 
 1 Stri-cellulare ; 
 
 at f Neuroma,-] ^ ,. .' 
 
 Neuromata, J \ Amyelmic; 
 
 Glioma (Klebs); 
 
 Sarcoma. 
 Teratomata. 
 
 Epiblastic, hypoblastic, and 
 
 mesoblastic tumors. 
 Swellings caused by reten- "^ 
 
 tion of physiological se- f Retention-cysts. 
 
 cretion. J 
 
XIII. PAPILLOMA AND ONYCHOMA. 
 
 Papilloma. 
 
 A papilloma is a non-malignant epithelial tumor of the cutaneous or 
 mucous surface. The essential part of the tumor is composed of epithe- 
 lial cells ; the framework is furnished by the connective tissue under- 
 neath the epithelial proliferation. The tumor-tissue proper is outside 
 the limits of the vascular area, being separated from it by the mem- 
 brana propria. The tissues of the epiblast and the hypoblast possess 
 no independent organ-producing power, as their blood-supply is derived 
 from the mesoblast. Epithelial cells in the normal mesoblast have no 
 power to proliferate, hence in cases in which we find them multiply- 
 ing here the mesoblast has undergone changes. The epithelial cells 
 receive their nourishment from the blood-plasma and the leucocytes. 
 As the stroma of an epithelial tumor is derived from the mesoblast, an 
 epithelioma is a mixed tumor, in which, however, in accordance with the 
 law of the legitimate succession of cells, the epithelial cells are derived 
 from the epiblast or the hypoblast, and the connective tissue from the 
 mesoblast. The development of new tissue from these sources is usu- 
 ally unequal : sometimes the product of one, and sometimes that of the 
 other, predominates. The unequal representation of the two different 
 tissue-elements, epithelial cells and connective tissue, in this form of 
 tumor has given rise to a great deal of confusion in classification. As 
 papillary formations are found in many tumors not belonging to this 
 variety, and as in many specimens fibrous tissue predominates, Virchow 
 objected to papilloma as a separate variety of tumors. Rokitansky 
 also treated papilloma as a variety of fibroma. Virchow proposed 
 the name fibroma papillare. However, in most tumors which deserve 
 the designation " papilloma " the epithelial elements predominate and 
 impart character to the tumor — the reticulum, if it predominates, being 
 an accidental product. It is the intention of the writer to show, as far 
 as possible, in connection with every variety of tumors, the counter- 
 part in the normal tissues of the body. A papilloma of the skin under 
 low power presents in a hypertrophic condition all the tissues of which 
 the skin is composed. 
 
 Histology and Pathology. — Papilloma of the skin, as shown in 
 Figures 54 and 55, represents the same papillary structure as the skin, 
 
 137 
 
138 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the number of papillae depending on the size of the tumor. In papil- 
 loma of the hypoblast the villi correspond with the papillae of the 
 epiblastic papilloma. The connective tissue and the vessels occupy 
 the centre of the papillae (Fig. 55, a), and present, on vertical section 
 of the tumor, finger-like projections conical in shape, the base corre- 
 sponding with the base of the tumor, and the apex with the summit 
 of each papilla. The epiblastic papilloma is covered by stratified layers 
 of squamous epithelial cells. The new cells are produced near the 
 vascular territory (Fig. 55, b). As the cells become older they lose the 
 liquid part of their contents by exposure on the surface and by more 
 
 Fig. 54. — Section of human skin (after Piersol) : a, stratum corneum ; b, stratum Iucidum; c, stratum 
 granulosum; d, stratum Malpighii ; e, f, papillary and reticular layers of corium ; g, stratum of adipose tis- 
 sue ; h, i, spiral and straight portions of duct of sweat-gland ; k, coiled portion of sweat-gland ; /, vascular 
 loops occupying papillae of corium. 
 
 distant removal from the vascular supply, forming the horny layer of the 
 papilloma (Fig. 55, c). The papilloma of the hypoblast is composed of 
 a connective-tissue stroma, usually softer and more vascular than that 
 of epiblastic papilloma, and of cells corresponding in type to the cells 
 of the mucous membrane in which the tumor is located. The pave- 
 ments of cells which constitute the essential part of the tumor are made 
 up of cylindrical cells. As hypoblastic tumors are constantly exposed 
 to maceration by the contents of the hollow organs in which they are 
 located, the epithelial cells become cedematous and are very liable to 
 undergo myxomatous degeneration. Even by excluding the papillo- 
 
PAPILLOMA AND ONYCHOMA. 1 39 
 
 mata of inflammatory origin, we have, so far as the texture of the 
 tumor is concerned, two varieties — (i) hard and (2) soft. The density 
 of a papilloma depends on the amount and character of the stroma and 
 the location of the tumor. If the stroma is abundant and compact, 
 
 r'?M 
 
 I : 
 
 ■7. 
 
 Fig. 55.— Papilloma of skin ; X 50 (Surgical Clinic, Rush Medical College, Chicago) : a, connective tissue; 
 b, embryonic epithelial cells ; c, old squamous epithelial cells. 
 
 and if the tumor is not exposed to maceration by constant moisture, 
 the tumor is firm ; on the contrary, if the stroma is scanty, if the con- 
 nective-tissue fibres are loosely arranged and vascular, and if the 
 epithelial cells, by constantly imbibing moisture from their environ- 
 ment, become ©edematous, the tumor is soft. The former conditions 
 are most frequently presented by tumors of the skin and of mucous 
 membranes derived from the epiblast, and the latter condition by tumors 
 of mucous membranes lining hollow viscera and paved with columnar 
 epithelium. In some instances a papilloma is covered by columnar 
 epithelia if the tumor occupies a location surrounded by squamous 
 epithelia. Hard papillomata are found most frequently in the skin and 
 in the mucous membrane of the lip, mouth, soft palate, nose, larynx, 
 urethra, vagina, and cervix uteri. The soft variety is found most fre- 
 quently in the mucous membrane of the intestinal canal and oi~ the 
 bladder. If a number of papillomatous tumors develop simultaneously 
 
140 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 or in succession in the same neighborhood, they form tumor-masses 
 of greater or less circumference with a mushroom-like surface. The 
 papillary excrescences are often branched, producing the so-called 
 " dendritic vegetations." This condition is often found upon mucous 
 surfaces. If the papilloma is not subjected to injury and is otherwise 
 surrounded by favorable conditions for rapid growth, it often elongates 
 into a delicate filamentous tumor, as is frequently seen in the bladder. 
 The connective-tissue core conveys vessels and nerves to each papil- 
 lary growth, the vessels forming loops as in the papillae of normal 
 skin and in the villi of the intestinal mucous membrane. In papillary 
 growths in joints the vessels are absent. In benign epithelial tumors 
 of the skin we often find epithelial cells in concentric layers arranged 
 in pearl-like masses, a proof of the independent proliferation of the 
 epithelial cells. A papilloma never attains great size, large tumors of 
 this kind being met with only as a result of the confluence of a number 
 of tumors. By the aggregation of numerous tumors, masses the size 
 of a fist are observed in the rectum and upon the prepuce and the labia 
 majora. An individual tumor seldom exceeds the size of a cherry. The 
 growth of a true papilloma is always very slow, papilloma manifesting 
 in this respect much less activity than infective papillomatous growths. 
 Among the degenerative processes which most frequently affect papil- 
 lomatous tumors are cretefaction, myxomatous degeneration, and ulcer- 
 ation. Cretefaction often arrests the further growth of a papilloma of 
 the skin. Myxomatous degeneration most frequently attacks tumors 
 of hypoblastic origin. Ulceration is the result either of mechanical 
 irritation or of infection with pathogenic microbes through an abrasion 
 or a fissure of the surface of the tumor. If in a pedunculated papil- 
 loma the principal artery becomes thrombosed, either in consequence 
 of an injury, such as twisting of the pedicle or traction, or as one of 
 the results of an accidental inflammation, gangrene of the tumor is 
 produced, usually resulting in a permanent cure. Psammoma is very 
 prone to undergo calcification which limits tumor-growth — a fortunate 
 occurrence, considering the importance of the locality occupied by such 
 tumors. 
 
 Transformation into Malignant Tumors. — Of all tumors, papillo- 
 mata are most liable to undergo malignant transformation.. The irrita- 
 tion to which such tumors are frequently exposed by their location upon 
 a surface will account satisfactorily for this well-established clinical fact 
 This transition is observed most frequently in tumors which occupy local- 
 ities most exposed to irritation. We seldom hear of a papilloma of the 
 cavity of the mouth undergoing such a transformation, while carcinoma 
 frequently originates in a papilloma of the lip. Papilloma constitutes 
 
PAPILLOMA AND ONYCHOMA. 141 
 
 a more frequent starting-point of a carcinoma than of a sarcoma. The 
 deepest stratum of epithelial cells is composed of young cells which 
 are in touch with the membrana propria, which, so long as the tumor 
 remains benign, constitutes an impermeable partition between the essen- 
 tial tumor-elements and its stroma, the subcutaneous or submucous 
 connective tissue. If, in consequence of prolonged irritation or other 
 exciting causes, this partition is damaged, the embryonic cells have 
 access to the vascular part of the tumor, and, once there, the trans- 
 formation from a papilloma into a carcinoma takes place. If, on the 
 contrary, fetal " rests " or post-natal embryonic cells in the connective- 
 tissue part of the tumor become environed by causes favoring tumor- 
 growth, the papilloma is transformed into a sarcoma. Such a trans- 
 formation was observed by Simon in a papillary growth of a joint. 
 Sarcoma of the skin has occasionally a similar origin. 
 
 Topography. — Papilloma is met with in various parts of the body, 
 but some parts are more predisposed to it than others. It is most fre- 
 quent in localities most exposed to irritation. We shall not include 
 papilloma of an infective origin — as warts, condylomata, and molluscum 
 contagiosum, all of which are inflammatory swellings and not true 
 tumors — in the discussion of the topographical distribution of papil- 
 loma. Warts (verruca) come and disappear mysteriously. They increase 
 in size much more rapidly than papilloma, and they often disappear 
 spontaneously. Condyloma, another papillomatous inflammatory swell- 
 ing resembling in its structure papilloma, almost always appears mul- 
 tiple in places where skin and mucous membrane meet and are bathed 
 with infective discharges, usually of a gonorrheal origin. The vulva, 
 the prepuce, and the anal region are the parts most frequently affected 
 by condyloma. The removal of the primary causes usually results in 
 a speedy cure. Molluscum (Bateman) or epithelioma contagiosum 
 (Virchow) is now generally recognized as an inflammatory swelling. 
 Its contagiousness is the best possible evidence that it is not a tumor. 
 Haab succeeded in producing it artificially in animals by inoculation. 
 Austrian and English dermatologists have traced its starting-point to 
 sebaceous glands. The papillary growths of non-infective origin, the 
 true benign epithelial tumors, do not disappear spontaneously ; their 
 growth is limited by an inherent limitation of tissue-proliferation or by 
 degenerative changes. These tumors have a very wide distribution, 
 and the more important localities inhabited by them, and the different 
 clinical varieties, will now be discussed. 
 
 Skin. — Papilloma of the skin occurs in two principal forms: 1. 
 Cornu cutaneum ; 2. Fibrous papilloma. In the former variety the 
 tumor is composed almost exclusively of epiblastic tissue ; in the latter 
 
142 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the connective tissue derived from the mesoblast is present in varying 
 proportions. 
 
 Cornn Cutaneum. — The cutaneous horn represents a form of pap- 
 illoma in which the tumor is composed almost exclusively of desic- 
 cated epithelial cells corresponding with the horny layer of the skin. 
 The old cells, instead of becoming desquamated, remain attached to 
 the tumor-matrix, forming projections varying in length from half an 
 inch to twelve or more inches. Such horns are found most frequently 
 on the scalp, temple, forehead, eyelid, nose, lip, cheek, shoulder, arm, 
 elbow, thigh, leg, knee, toe, axilla, thorax, buttock, loin, penis (Fig. 56), 
 
 ^iMs w$^^^^ 
 
 Fig. 56. — Cornu cutaneum of penis (after Pick). 
 
 and scrotum. The matrix of such tumors is very vascular. Horny 
 tumors of the skin can readily be enucleated, and they seldom return 
 after removal. A post-natal matrix for cutaneous horns is furnished 
 most frequently by scars. Cruveilhier described a specimen of cornu 
 cutaneum which originated from a scar following a burn of the forearm, 
 the tumor reaching such an enormous size that amputation became 
 necessary (Fig. 57). The tumors in this case were multiple. 
 
 That desiccation is not the sole cause in the production and fixation 
 of such an enormous mass of epithelial cells is shown by the fact that 
 papillomata of a similar structure are occasionally found in dermoid 
 
PAPILLOMA AND ONYCHOMA. 143 
 
 and sebaceous cysts. The matrix of a cutaneous horn undoubtedly 
 not only possesses the inherent capacity of producing epithelial cells 
 very rapidly, but also furnishes the cement-substance which fixes the 
 old epithelial cells, thus preventing their removal by desquamation. 
 There is no reason why papillomata should not develop as secondary 
 formations in epithelial tumors of either a benign or a malignant type. 
 
 Fig. 57. — Cornua cutanea from the scar of a burn (after Cruveilhier). 
 
 Not infrequently we find in the interior of an adenoma, a cystoma, or a 
 carcinoma papillary growths which resemble in every respect the surface 
 papillomata, and which impart to the tumor additional pathological 
 and clinical characteristics. Papillomatous cysts of the ovary (Fig. 58) 
 are regarded with special interest by the surgeon. A semi-malignant 
 nature was assigned to them long ago. There can be no doubt that 
 in many instances such tumors are malignant from the beginning, 
 but in other instances the papillomata are benign and remain so. The 
 desquamated epithelial cells furnish here a part of the contents of the 
 
144 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 cysts (Fig. 58, d). As in surface tumors, the epithelial cells are strati- 
 fied. Tumors of large size are formed by the aggregation and coales- 
 cence of numerous smaller tumors. 
 
 The fibrous papUlomata of the skin occupy most frequently the region 
 
 Fig. 58. — Papillomatous cyst of ovary; X no (Surgical Clinic, Rush Medical College, Chicago) : a, in- 
 terpapillary space; b, stroma; c, epithelial lining; d, amorphous, non-staining detritus with a few detached 
 epithelial cells ; e, proliferating areas. 
 
 of the face, scalp, and hands ; they are of slow growth and never 
 attain large size. 
 
 Respiratory Organs. — The larynx is the most frequent seat of papil- 
 lomata. Morgagni's pockets are their favorite locations. They appear 
 as isolated affections or as multiple tumors closely aggregated, giving 
 to the mass a cauliflower-like appearance. The symptoms will vary ac- 
 cording to the size and the location of the tumor. Hoarseness, cough 
 harassing in character, and difficult breathing alternating with tempo- 
 rary attacks of dyspnea, are some of the leading clinical features. Not 
 infrequently, papilloma of the larynx undergoes transformation into car- 
 cinoma, as was probably the case in the instance referred to in the sec- 
 tion treating of the Transformation of Benign into Malignant Tumors. 
 
 Digestive Tract. — The mucous membrane of the cavity of the mouth 
 is derived from the epiblast and is frequently the seat of papilloma. 
 The favorite localities are the mucous membrane of the cheek, the 
 prolabium of the lip, the tongue, the soft palate, and the pharynx. The 
 naso-pharyngeal space is frequently studded with papillomatous vegeta- 
 tions. The stomach is almost exempt from this affection. The fre- 
 quency with which the mucous membrane of the intestinal canal is 
 affected increases in a downward direction. Papillomata are rare in the 
 intestines, while in the rectum they are most frequent, and are either 
 
PAPILLOMA AND ONYCHOMA. 
 
 145 
 
 Fig. 59. — Papilloma of the rectum (alter Lucke) : 
 a, submucous connective tissue ; b, papillae, some 
 of them branching, covered by columnar epithelia. 
 
 sessile or pedunculated, constituting a frequent form of polypus of this 
 organ. The writer has repeatedly seen the mucous membrane of the 
 lower part of the rectum studded with papillary tumors varying in size 
 from a hempseed to a cherry (Fig. 
 59). The symptoms which attend this 
 affection of the rectum are hemor- 
 rhage, usually slight, tenesmus, and 
 a glairy discharge. 
 
 Urinary Organs. — The urinary 
 tract is very often the seat of papil- 
 loma, and no part of it is exempt. 
 Papillomata are frequently located in 
 the urethra, and especially around the 
 margin of the meatus in the female. 
 In this locality they are often multi- 
 ple, and they are a source of great 
 distress to the patient. The tumors 
 are very vascular, are extremely sen- 
 sitive to touch, and are the source of 
 great pain during micturition. Papil- 
 lomata of the male urethra are more 
 frequent than was formerly supposed, and their presence can now be 
 ascertained and their removal be facilitated by the use of the urethro- 
 scope. They simulate, and have usually been mistaken for, stricture. 
 
 Papilloma of the bladder is a frequent affection of this organ. The 
 connective tissue is usually abundant and carries with it one or more 
 vessels of considerable size. The main stem of the tumor usually gives 
 off branches which in turn again become branched, giving to the tumor 
 an arborescent structure (Fig. 60). As the connective-tissue core of the 
 tumor is often covered by only one layer of epithelial cells, and the ulti- 
 mate branches are often exceedingly delicate, it is easy to understand that 
 such tumors frequently give rise to hemorrhage. If the principal artery 
 of such a tumor is eroded or torn, the hemorrhage may become alarm- 
 ing and even fatal, Sometimes small fragments of such a tumor are 
 voided with the urine or are removed in the eye of the catheter, afford- 
 ing the surgeon an opportunity to make a correct diagnosis, by the aid 
 of the microscope, in what was before an obscure case. The cysto- 
 scope renders valuable assistance in ascertaining not only the existence, 
 but also the exact location and character, of the tumor. The liability 
 of such growths to become transformed into malignant tumors is well 
 known and generally recognized. A very interesting case of papil- 
 lomatous tumors of the pelvis of the kidney is reported by Murchison 
 10 
 
146 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and quoted by Sutton. The pelves of both kidneys were similarly 
 affected, and the bladder contained two similar tumors, one on each 
 side near the ureteral orifice. Sutton believes that in this case the 
 tumors in the bladder were secondary, and were caused by the implan- 
 tation of tumor-cells from the primary tumors upon the mucous mem- 
 brane of the bladder. While this mode of origin is possible, it is more 
 likely that the tumors developed from so many different tumor-matrices 
 independently of one another. Multiple papilloma of the same surface 
 or organ is not of rare occurrence. 
 
 Fig. 60. — Papilloma of the bladder (after Perls). 
 
 Female Organs of Generation. — The external genitals, the uterus, 
 and all its appendages represent conditions favorable to the origin 
 and development of papillomatous tumors. We shall, of course, ex- 
 clude infective papillary swellings, which are of such frequent occur- 
 rence upon the external genitals of gonorrheal patients and syphilitics. 
 The labia (Figs. 61, 62) and the fringes of the hymen are frequently 
 the starting-points of such growths. The tumors may be either single 
 
PAPILLOMA AND ONYCHOMA. 
 
 H? 
 
 Fig. 6i. 
 
 -Papilloma of right greater labium (after Winckel) : a, minor labium; b, dilated meatus of the 
 urethra ; c, papilloma. 
 
 " . 
 
 or multiple, sessile or pedunculated. In the absence of irritating dis- 
 charges they occasion but little inconvenience, and they are usually 
 accidentally discovered in examinations for 
 other affections. 
 
 The so-called " erosions " of the mucous 
 membrane of the cervix uteri present under 
 low power the typical structure of a papil- 
 loma. Many of the small polypoid growths 
 of the cervical canal are papillary tumors. 
 The uterine mucous membrane is often the 
 seat of multiple papillary tumors which may 
 produce profuse menstruation and other 
 symptoms simulating chronic endometritis or 
 malignant disease (Fig. 63). Papilloma of 
 the Fallopian tubes has been described by 
 Hennig in 1876. Doran first described a 
 true papilloma of the tube in 1879, whilst 
 Sutton is of the opinion that this tumor is an 
 adenoma. Landau, Kaltenbach, and Eberth, 
 however, support the papilloma theory, as 
 they find that in its earliest stage the growth i 
 
 Fig. 62. — Papillomata of lesser 
 labium (after Winckel) : a, clitoris; 
 /', orifice of urethra ; c, papillomata ; 
 d, fimbriated hymen. 
 
 papillary elevation or 
 
148 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 villus, and not a glandular structure. On the other hand, it is quite 
 possible that the tumor described by Sutton is a distinct affection from 
 papilloma, and is developed, if his theory be correct, from his normal 
 tubal glands ; if incorrect, from Recklinghausen's Wolffian relics. The 
 same theory may explain the occurrence of tubular cells found by 
 Doran in primary tubal carcinoma. 
 
 r.. f \ V'A g 
 
 r*««a 
 
 W 
 
 Fig. 63. — Papillary excrescences of the mucous membrane of the cervix uteri, vertical section; X 22 
 (after Karg and Schmorl). The papillae, as well as the remnants of glandular tissue, are covered by cylin- 
 drical epithelia. This section was taken some distance from a carcinoma, and two of the papillae at b are 
 infiltrated with epithelial cells, indicating the beginning of carcinomatous degeneration. 
 
 Papillomata may develop upon the surface of the ovary, but more 
 frequently from the wall of glandular cysts (Fig. 58). Papillary tumors 
 upon the surface of the ovary have been observed by Gusserow, Klebs, 
 Birch-Hirschfeld, and Winckel. The intraglandular papilloma of the 
 ovary will be described more fully in connection with proliferating 
 papillary cysts of the ovary. 
 
PAPILLOMA AND ONYCHOMA. 149 
 
 Brain. — The brain is developed from the epiblast, but papillary 
 tumors of this organ are exceedingly rare. The choroid plexuses are 
 fringed with tufts of epithelium-covered villi which occasionally become 
 the seat of papillary tumors. Douty describes a case of this kind in 
 which the tumor attained the size of a bantam's egg. The patient was a 
 boy seventeen years old, and the tumor produced focal symptoms which 
 enabled the medical attendant to localize the tumor accurately during 
 life. Sutton is of the opinion that psammoma is an epithelial tumor, 
 but the majority of pathologists assign to it an endothelial origin, and 
 it will be discussed more fully in connection with epiblastic tumors. 
 
 Diagnosis. — The greatest difficulty encountered in the diagnosis of 
 papilloma is to differentiate from it inflammatory papillary swellings 
 and carcinoma. Inflammatory swellings usually grow rapidly and 
 appear as a multiple affection. The microbic cause can often be ascer- 
 tained. The swellings frequently present signs and symptoms of in- 
 flammation which are lacking in papilloma. The difficulty would be 
 greatly increased if a papilloma were at the same time in a condition 
 of inflammation. Inflammatory papillary swellings may occur at any 
 time of life, the only essential cause being the presence of pathogenic 
 microbes in quantity sufficient to produce either a subacute or a chronic 
 inflammatory process. Papilloma is most frequent in adults and in 
 persons past middle life. Age is an important factor in the differential 
 diagnosis between papilloma and carcinoma. Carcinoma affects most 
 frequently persons past middle life. A papillary carcinoma almost with- 
 out exception is indurated at its base — a condition absent in papilloma. 
 In doubtful cases the microscope will decide the diagnosis. The part 
 of the tumor that it is most important to subject to microscopic ex- 
 amination is the base. If sections from this part of the tumor show 
 no epithelial cells on the vascular side of the membrana propria, the 
 tumor is benign ; the presence of even a limited number of epithelial 
 cells in the subcutaneous or submucous connective tissue is a positive 
 evidence of malignancy. Papillomata of the meninges of the brain 
 and of other inaccessible organs which produce no symptoms cannot, 
 of course, be recognized during life ; if they produce symptoms, these 
 must be studied carefully and be referred, if possible, to their proper 
 source. Papillomata of the larynx, urethra, bladder, uterus, and rectum 
 must be seen before they can be recognized, and for this purpose the 
 different instruments that render them accessible to sight must be em- 
 ployed. 
 
 Prognosis. — Papillomata never attain a large size, consequently they 
 only become a source of danger to life if, by causing compression o\ an 
 important organ or by blocking an important passage, the function oi~ 
 
150 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 an organ is impaired or abolished. A papillary tumor at the base of 
 the brain may result in fatal cerebral compression. A papilloma of the 
 larynx may be caught in the rima glottidis, and produce death from 
 suffocation. Another element of danger is hemorrhage. A papilloma 
 of the bladder has often been the source of serious and even fatal 
 hemorrhage. The liability of a papilloma to undergo transformation 
 into a malignant tumor must also be taken into consideration, and 
 should be regarded as a forcible argument in favor of early operative 
 treatment. 
 
 Treatment. — The only treatment of a papilloma is a radical opera- 
 tion. The tumors being usually small, they can be destroyed by the 
 energetic use of the needle or the knife-point of the Pacquelin cautery, 
 or be removed by excision. The cauterization or excision should in- 
 clude the entire tumor-matrix ; if this is not done, a recurrence will 
 almost surely follow the operation. Incomplete removal of a papilloma 
 will also favor transformation of the balance of tumor-tissue into a 
 malignant tumor. Laryngeal papillomata can be removed with a 
 snare, aided by the use of the laryngoscope, or by laryngotomy. 
 Laryngo-fissure is the preferable method if there is any question 
 concerning the benign nature of the tumor. Small papillomata of 
 the uterine cavity and the cervical canal can be removed with a sharp 
 spoon followed by the use of the Pacquelin cautery (cervix) or of 
 a safe caustic (uterine canal). Papillomata of the urethra require in 
 their removal the urethroscope. When the tumor has been thor- 
 oughly exposed to sight it can be removed by torsion or by linear 
 crushing. Papillomata of the bladder can be rendered sufficiently 
 accessible to operative removal only by a suprapubic incision. The 
 Trendelenburg posture will greatly facilitate the operation. The tumor 
 is removed either by torsion, by the wire ecraseur, or, if broad and flat, 
 by scraping it away with a sharp spoon or a finger-nail. If the bed 
 of the tumor can be exposed sufficiently well to sight and touch, it 
 should be cauterized lightly with the actual cautery for the purpose 
 of arresting hemorrhage as well as to destroy remnants of the tumor, 
 which, if left, would give rise to a speedy recurrence. 
 
 Onychoma. 
 Virchow described a papillary tumor of the matrix of nails under 
 the name of onychogry pilosis (Fig. 64), and distinguished it from an inflam- 
 matory hyperplasia occupying the same locality, which he called onycho- 
 mycosis. A papillary tumor of that part of the cutaneous surface occu- 
 pied by the nails resembles in structure and in physical appearance the 
 cornu cutaneum. Such a tumor is composed almost exclusively of the 
 
PAPILLOMA AND ONYCHOMA. 
 
 151 
 
 product of epithelial proliferation, and it has a vascular base. A true 
 nail-horn usually appears clinically as a single tumor, while the inflam- 
 matory swelling, onychogryphosis, is a multiple affection attacking at the 
 same time or in succession a number or all of the nails of both hands. 
 
 Fig. 64. — Onychogryphosis of toes ; natural size (after Ziesing). 
 
 The inflammatory form of onychoma is extremely common in the toes 
 of bedridden patients, especially old women and those who are filthy. 
 The true onychoma occurs in persons in perfect health and under the 
 best sanitary and hygienic conditions. The nail often reaches several 
 inches in length and becomes curved, resembling a ram's horn. The 
 writer removed a nail of this kind which was three inches in length. 
 A recurrence of the tumor can be prevented with certainty only by 
 extirpation of the whole matrix of the nail. 
 
XIV. ADENOMA. 
 
 Adenoma is a benign epithelial tumor which in structure resembles 
 the glandular tissue of the organ in which the tumor is located. Ade- 
 noma is the second variety of benign tumors of the epiblast and the 
 hypoblast. The relation of the epithelial cells to the basement membrane 
 is the reverse of that of papilloma ; that is, the basement membrane is on 
 the outside of the parenchyma of the tumor, instead of on the inside, as 
 is the case in papilloma. In papilloma of the cutaneous a?td mucous 
 surfaces the cellular elements of the tumor often become detached and 
 permanently lose their connection with the tumor ; in adenoma the cells 
 are confined in hollow spaces bounded by the basement membrane } and 
 they or the imabsorbable products of their regressive metamorphoses 
 remain permanently as a part of 'the tumor. These differences in the 
 anatomical structure of the tumor will go far to explain why a papil- 
 loma never attains a large size, and why the size to which a rapidly- 
 proliferating adenoma may attain is unlimited. In reference to the 
 relation of the tumor-cells to the subcutaneous or submucous connec- 
 tive tissue, there exists a great analogy between papilloma, epithe- 
 lioma, adenoma, and glandular carcinoma. An adenoma, as its name 
 implies, is a glandular tumor. Broca included under the term " ade- 
 noma " all circumscribed glandular swellings. Cornil and Ranvier 
 embraced in this class only glandular tumors composed of new gland- 
 ular tissue. In the strictest etiological and pathological sense the term 
 should be limited to glandular tumors containing adenomatous tis- 
 sue produced from a tumor-matrix independently of the pre-existing 
 glandular tissue. As adenoma is present in all the glandular organs, 
 the cells of which it is composed resemble the type of cells of the 
 gland or duct in which the tumor is located. Glandular tumors, how- 
 ever, are found in localities where glands do not normally exist. In 
 such instances the tumor develops either from a matrix of embryonic 
 cells displaced and isolated during fetal life — the so-called " rests " — or 
 from a matrix of embryonic cells in a supernumerary or accessory 
 gland. Such accessory glands are found in the vicinity of nearly all 
 the glandular organs, notably the thyroid, pancreas, spleen, liver, kid- 
 neys, and mammary gland. Adenomata are found quite often in the 
 
 152 
 
ADENOMA. 
 
 *53 
 
 axillary space unconnected with the mammary gland. A fetal matrix 
 in the vicinity of the umbilicus, derived from the intestinal tract, may 
 give rise to adenomata representing intes- 
 tinal glands. Tumors of this kind were ob- 
 served by Kustner and Heukelem, and were 
 freely supplied with unstriped muscular fibres. 
 Glandular tumors springing from a post-natal 
 matrix of embryonic cells are necessarily 
 confined to normal or accessory glands. 
 
 The histological similarity between an 
 adenoma and the normal tissues in which 
 such a tumor may be located is well shown 
 in Figures 65 and 66. The difference be- 
 tween an adenoma and normal gland-tissue, 
 from a physiological standpoint, is best shown by tumors of glands 
 in continuous physiological activity, such as the liver and the kidneys, 
 from the absence of gland-ducts and the presence of an atypical in 
 place of a typical circulation. 
 
 Fig. 65. — Transverse section of 
 follicles of large intestine of dog : the 
 individual tubules are separated by the 
 fibrous stroma of the mucosa (after 
 Piersol). 
 
 Fig. 66. — Polypus (adenoma) of rectum, showing the glands of the tumor; X 35° (after D.J. Hamilton): 
 a, gland lined by columnar epithelium ; b, stroma of the tumor. 
 
 Histology and Pathology.- — The histogenesis of adenoma has been 
 referred either to a congenital matrix of embryonic cells in glandular 
 organs, accessory glands, or displaced islets of embryonic cells (hetero- 
 topic), or to embryonic cells of post-natal origin in glands and acces- 
 sory glands. Like the papilloma, it receives its stroma and its blood- 
 supply from the mesoblast. The glandular part of a tumor remains 
 in an adenoma permanently. The most important distinctive feature 
 between a localized or diffuse hyperplasia of a gland and an adenoma 
 
i54 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 is the absence of function in the latter in common with all other tumors. 
 The absence of ducts prevents the escape of the products of cell-pro- 
 liferation, frequently resulting in the formation of cysts the contents 
 of which vary according to the nature of the degenerative processes 
 which occur in the cells of the parenchyma of the tumor. Tumors in 
 the interior of internal organs, as a rule, attain greater size than tumors 
 of the cutaneous or the mucous surfaces. Adenoma of the breast 
 seldom exceeds the size of a walnut. The essential structure of an 
 
 Fig. 67. — Adenoma of mammary gland ; X 50 (after Karg and Schmorl) : a, epithelial cells lining gland-space ; 
 
 b, glandular space ; c, stroma. 
 
 adenoma is the stroma of fibrous or myxomatous connective tissue 
 containing newly-formed glands of either the acinous or the tubular 
 variety. A central space between the epithelial cells can invariably be 
 found, representing the glandular spaces in normal glands. 
 
 Most of the myxomatous polypoid growths are glandular tumors. 
 Adenoma containing tubular glands presents on section under the 
 microscope the appearance of tubular glands. The cells are arranged 
 in a single layer or in stratified layers ; the centre of each tubule shows 
 a space toward which the unattached parts of the cells converge. 
 
ADENOMA. 
 
 155 
 
 Adenoma composed of acinous glandular tissue shows on section 
 under the microscope spaces lined by flat epithelial cells (Fig. 67). The 
 stroma varies in amount : if abundant, the tumor is hard ; if scanty, soft. 
 The blood-vessels follow the stroma and supply each tubule or acinus 
 of the tumor with an irregular network of capillary vessels. The cells 
 of an adenoma are subject to fatty, mucoid, and colloid degeneration. 
 The stroma frequently undergoes myxomatous degeneration. The 
 progressive accumulation of the degenerated products of cell-prolifera- 
 tion leads to cyst-formation. Such cysts vary in size from micro- 
 scopical spaces to cavities which contain many quarts of fluid. The' 
 largest cysts are found in, or in the vicinity of, the ovary. The fetal 
 remains of ducts in the vicinity of the ovary give rise to the formation 
 of adenoma containing tubular structures the vegetative power of 
 which is much greater than that of the Graafian follicles. The liability 
 of an adenoma to become transformed into a glandular carcinoma is 
 perhaps greater than that of papilloma. In fact, according to D. J. 
 Hamilton, carcinoma is preceded by an adenomatous stage (Fig. 68), 
 an opinion advanced years ago by Gouley of New York. The earliest 
 evidences that such an occurrence has taken place are a more active 
 multiplication of epithelial cells 
 and their migration through the 
 basement membrane into the con- 
 nective tissue outside the limits 
 of the tumor (Fig. 68, b). 
 
 Etiolog-y. — The essential 
 cause, the matrix of embryonic 
 cells, has been referred to in the 
 introductory remarks of this sec- 
 tion. Of the exciting causes, 
 trauma, irritation, and inflamma- 
 tion are the most influential. 
 Adenomata are found most fre- 
 quently in organs the seat of pe- 
 riodical congestion, such as the 
 mammary and prostate glands, 
 the uterus, and the ovaries. They 
 are common also in mucous pas- 
 sages the seat of catarrhal affec- 
 tions, such as the nasal cavities 
 and the rectum. Adenoma is met 
 with most frequently in the young and in persons not beyond middle 
 life. The greater frequency of adenoma of the ovary as compared 
 
 Fig. 6S.— Development of a cancer of the mamma : 
 a set of adenomatous acini becoming cancerous ; X 35o 
 (after D.J. Hamilton): a, an adenomatous swelling 
 of an acinus ; b, the cells of a similar swelling which 
 have broken out and are invading the surrounding 
 stroma; c, part which is cancerous. 
 
156 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 with that of the testicle is explained by Klebs upon the ground that in 
 the testicle the structures retain their fetal arrangements, while in the 
 
 Fig. 69. — Isolated sebaceous adenomata (after Demme). 
 
 ovary they are transformed into isolated structures, the Graafian folli- 
 cles. During the rearrangement of the structures of the ovary in the 
 
 
 Fig. 70. — Sebaceous adenoma from the skin of the left side of the neck : upon the summit of the separate 
 nodules the dilated outlets of the ducts can be seen (after Demme). 
 
 embryo tubular remnants not utilized in the formation of the Graafian 
 follicles are set aside, and remain as fetal rests, from which later the 
 large adenomatous cysts take their origin. 
 
 Topography. — The topographical distribution of adenomata fur- 
 nishes an interesting proof of the importance of exciting causes in the 
 
ADENOMA. 157 
 
 production of tumor-growth. We shall find that benign glandular 
 tumors frequent localities and organs the seat of prolonged vascular 
 fluxions and exposed to intercurrent affections which are calculated to 
 diminish the physiological resistance of the tissues. 
 
 Skin. — Adenoma of the skin is represented by the two kinds of 
 glands found in this structure, the sebaceous and the sudoriparous 
 glands. Retention-cysts of these glands are, of course, excluded from 
 present consideration. True adenomata of the skin are very rare. 
 
 Adenoma Sebaceum. — Sebaceous glands found in other tumors, such 
 as dermoid cysts, are not tumors, but hyperplastic glands. Lucke 
 removed an ulcerating sebaceous tumor from the nose of a man eighty 
 years old. He suspected that the tumor was a carcinoma, but micro- 
 scopic examination showed only convolutions of sebaceous glands and 
 interglandular connective tissue — no trace of carcinoma. The tumors 
 when small assume the shape of sebaceous glands. In larger tumors 
 the glandular tubules form a convoluted mass. Demme described a 
 large sebaceous adenoma of the skin of the scrotum. The few cases 
 of sebaceous adenoma that have been reported appear to show that this 
 tumor is found almost exclusively in the aged, and that the face and 
 the scrotum are its favorite localities. Anatomically, this tumor is dis- 
 tinguished from a retention-cyst by the presence of numerous tubules 
 instead of one cavity, as is the case in retention-cysts (Figs. 69, 70). 
 
 Adenoma Sudoriparum. — Sudoriparous adenoma was first described 
 by Verneuil. Virchow's doubts regarding the existence of such a tumor 
 have not been confirmed by later investigations. Lotzbeck observed a 
 case in which the tumor was congenital. In Thierfelder's case the 
 tumor occupied the diploe, but communicated with the skin, in which 
 it undoubtedly had its origin. The growth of the tumor takes place 
 from the deeper part of the tubule, which elongates and becomes more 
 convoluted than normal sweat-glands (Fig. 71). According to Verneuil 
 and Demarquay, these tumors may reach the size of a fist, and may 
 manifest a great tendency to ulceration ; they have been mistaken for 
 angioma. The growth of the tumor is slow. Sweat-gland adeno- 
 mata have been observed most frequently upon the skin of the face. 
 Demarquay saw such a tumor the size of an egg in the axillary space; 
 Verneuil, one upon the sternum and one upon the back. 
 
 Digestive Tract. — Adenomata of the cavity of the mouth are rare. 
 In the stomach adenoma occupies most frequently the pyloric part, and 
 may attain the size of a hen's egg and cause pyloric obstruction. It is 
 more frequent in the intestinal mucous membrane, and is often the 
 direct cause of invagination. The mucous membrane of the rectum is 
 more frequently affected by adenoma than is the remaining part of the 
 
158 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 whole intestinal tract. The majority of cases of polypus in this local- 
 ity have an adenomatous structure. Port has recently collected 13 
 cases of multiple adenoma of the intestinal tract which terminated in 
 carcinoma. The patients ranged in age from 10 to 30 years. In a 
 number of the cases more than one member of the family was similarly 
 affected. The prognosis is grave, even in the event an operation is 
 performed, as out of the 13 cases 9 died. Only in 4 cases did the 
 
 FlG. 71.— Sudoriparous adenoma from skin of frontal region of a woman ; transverse section of tubule, 
 X 650 (after Liicke) : a, hair-follicle ; b, adipose tissue ; c, sweat-glands in longitudinal section; d, d" , the 
 same in transverse section. 
 
 operation result in relief for a considerable length of time. In Helfe- 
 rich's case the pyloric end of the stomach was the seat of a similar 
 affection, and the disease led to extensive glandular metastasis. Nearly 
 all the adenomata of the mucous membrane lining the gastro-intestinal 
 canal present in section under the microscope a tubulated appearance. 
 Adenoma of the rectum (Fig. 72) is more frequent in children than in 
 adults. The tumor increases slowly in size, and in the course of time 
 
ADENOMA. 
 
 J 59 
 
 becomes pedunculated. Adenomata in this locality usually vary in 
 size from that of a cherry to that of a walnut. At the base of the tumor 
 or pedicle the mucous membrane of the tumor is continuous with that 
 of the rectum. The symptoms are the same as in papilloma. 
 
 Nasal Cavities. — Many of the polypoid growths of the nasal cavi- 
 ties are adenomata. Billroth was the first to discover gland-follicles 
 
 - ■ 
 
 
 ,: 
 
 
 Fig. 72. — Adenoma of the rectum ; X 48 (after Karg and Schmorl). The tumor is composed of glandular 
 spaces and, between them, a stroma infiltrated by small cells. The structure of the tubules corresponds with 
 that of the normal glands of the rectum. The glandular spaces are lined with columnar cells with basal 
 nuclei surrounded by the membrana propria. Between the columnar cells here and there can be seen goblet- 
 cells (c). Some of the glands are enlarged and are supplied with lateral buds ; others are transformed into 
 larger hollow spaces (a). At b dilated blood-vessels are seen in the stroma. 
 
 in the myxomatous polypus of the nose. The connective tissue sur- 
 rounding the adenomatous growth and the epithelial cells of the mu- 
 cous membrane covering the tumors are in a hyperplastic condition, 
 caused by an increased blood-supply. Adenoma of the nasal mucous 
 membrane often appears as a multiple affection. Catarrhal inflamma- 
 tion often precedes, and frequently attends, adenoma of the nose. 
 
 Uterus and its Appendages. — The uterus is the organ most frequently 
 
i6o 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 affected by adenoma. The development of the tumors in this locality- 
 is usually preceded by catarrhal inflammation. The inflammation evi- 
 dently acts as an exciting cause in diminishing the physiological resist- 
 
 Fig. 73. — Adenoma of the posterior wall of the uterus (after Winckel). 
 
 ance of the tissue in the vicinity of the embryonic matrix. The fungous 
 vegetations which so often cover the cervix uteri and its canal — the 
 so-called " erosions " — are either papillomata (see Fig. 63) or adenomata. 
 
 Fig. 74. — Uterine cavity entirely filled with adenomatous vegetations (after Winckel). 
 
 In the uterine cavity adenoma is found as a single tumor or in the form 
 of diffuse vegetations covering the entire surface. Adenoma of the 
 uterine cavity (Figs. 73, 74) or of the cervix seldom increases beyond 
 the size of a walnut. The tumor appears first as a small nodule, 
 pushes the mucous membrane before it, and, if it increases to the 
 
ADENOMA. 161 
 
 size of a cherry, becomes pedunculated. Multiple adenomata of the 
 uterine mucous membrane usually remain sessile. Menorrhagia, a pro- 
 fuse glairy discharge, and dysmenorrhea are some of the most promi- 
 nent symptoms which point to the existence of adenomata of the 
 mucous membrane lining the uterus. 
 
 Adenoma of the Fallopian tubes is a very rare affection. Ascites 
 is sometimes produced by tumors in this locality, as the increased 
 secretion provoked by the tumor escapes into the peritoneal cavity. 
 
 Adenoma of the ovary, according to Waldeyer, Thierfelder, and 
 Klebs, does not originate from the Graafian follicles so frequently 
 as was formerly believed. In the majority of cases the tumor starts 
 from an embryonic tubular matrix, a remnant of Pfliiger's ducts. 
 Glandular tumors of the ovary appear as globular, nodular tumors of 
 widely different form and size. Some of these tumors become so large 
 that they exceed the weight of the patient. They develop beneath the 
 columnar epithelial cells of the surface of the ovary, within a strong 
 layer of connective tissue in which are imbedded the blood-vessels. 
 In the centre of this vascular connective-tissue layer a small space 
 lined with cylindrical cells marks the beginning of the adenoma and 
 the incipient formation of a cyst. Waldeyer claimed that the glandular 
 spaces are lined by only one layer of epithelial cells, while Rindfleisch, 
 Bottcher, and others found several layers. Into a space thus formed 
 other tubules project and open, forming secondary cysts. If the walls 
 of the secondary cysts, by distention and growth, come in contact, the 
 joint septum formed breaks down and a communication between the 
 cysts is established. Coalescence of many cysts in this manner may 
 result in the formation of enormous spaces. Cruveilhier and Virchow 
 found in the jelly-like, structureless contents of such cysts blood- 
 vessels, the remnants of the broken-down septa. For this kind of 
 glandular cysts Waldeyer proposed the name " myxomatous cysts." 
 In typical adenoma of the ovary the cysts do not reach such great 
 size. Constant friction on the surface of the tumor destroys the epithe- 
 lial layer and leads to adhesions, which in cases of glandular cysts are 
 often very extensive and firm. From the cyst-wall form buds covered 
 by cylindrical epithelium, projecting into the cyst and presenting the 
 appearance of placental villi (see Fig. 58). These papillary intracystic 
 growths carry with them large vessels and take a very active part in the 
 proliferation of tumor-tissue. By perforation of the cyst-wall these 
 papillary excrescences reach the peritoneal cavity, and undoubtedly 
 have much to do with the production of ascites, which so often attends 
 this form of ovarian tumor. The small cysts contain a jelly-like, homo- 
 geneous substance. The larger the cyst the more liquid its contents, 
 it 
 
162 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Waldeyer and Spiegelberg ■ found in all cysts of the ovary paral- 
 bumin. 
 
 Thyroid Gland. — The thyroid is one of the ductless glands. It is 
 only recently that its physiological importance has been ascertained 
 d :fmitely. Clinical observation and experimental research have demon- 
 strated that the complete destruction of the gland by disease or its 
 removal by extirpation results in myxedema and cretinism. It is a 
 compound tubular gland, whose excretory duct, the thyro-glossal duct, 
 in the early stages of the organ connects the tubules with the mucous 
 surface, where its opening corresponds to the foramen caecum. It is 
 along this tract that remnants of the gland are occasionally found, as 
 well as accessory glands in the vicinity of the organ, which may become 
 the seat of adenomata resembling the structure of the thyroid gland. 
 This gland in its normal condition contains the product of one of the 
 retrograde tissue-metamorphoses — colloid material. It would appear 
 
 that this tendency of the cells to degen- 
 eration into colloid material in a normal 
 condition would naturally predispose 
 adenomata of this organ to the forma- 
 tion of cysts. Virchow divided the 
 benign tumors of the thyroid gland 
 into — (i) Struma hyperplastica ; (2) 
 struma gelatinosa ; (3) struma cystica. 
 This classification is no longer tenable, 
 as the gelatinous and cystic varieties 
 represent only an advanced stage of 
 adenoma. 
 
 The ordinary bronchocele, mias- 
 matic struma, is not a true tumor, but 
 an infective swelling caused by an unknown microbe. Enlargement of 
 the- gland from this cause is an endemic affection. The true glandular 
 tumor of the thyroid is produced, like other tumors, from a matrix 
 of embryonic cells. It is in this gland that the essential cause of 
 tumor-formation has been actually demonstrated. Wolfler has found, 
 in the substance of the gland, cell aggregations which did not appear to 
 belong to the gland-structure and which he regarded as remnants of 
 embryonic tissue. From these develop the adenomata. He formulates 
 adenomata as " epithelial new formations which develop from embryonal 
 gland-matrices with atypical vascularization." Wolfler has shown that 
 the true benign tumor of the thyroid gland is an adenoma. The 
 greater prevalence of adenomata in districts inhabited by miasmatic 
 struma is an important proof of the part taken by the surrounding 
 
 Fig. 75. — Section of thyroid body exhibiting 
 detail of acini, which are cut in various direc- 
 tions (after Piersol) : c, colloid material distend- 
 ing the larger acini ; i, interacinous connective 
 tissue; v, blood-vessels. 
 
ADENOMA. 
 
 l6 3 
 
 tissues in tumor-formation. The physiological resistance of the tissues 
 is diminished by the infective process, and matrices of embryonic cells 
 which have remained in a latent state until then assume active tissue- 
 proliferation and produce a true glandular tumor. 
 
 The difference between an infective swelling of the thyroid gland and 
 a true tumor has already been pointed out. A miasmatic swelling 
 yields to the internal and external use of iodine preparations ; a true 
 tumor is not affected by this treatment. Early treatment of a miasmatic 
 struma is a prophylactic measure against tumor-formation , as it restores 
 the physiological resistance impaired by the microbes which produced the 
 struma. The glandular tumors are always imbedded in the substance 
 of the gland or in the miasmatic struma, and are encapsulated. Fre- 
 quently they are multiple. Small recent cysts always contain a colloid 
 substance. Multilocular cysts are formed in the same manner as in 
 cystic adenoma of the ovary, by coalescence of two or more cysts. In 
 
 Fig. 76. — Enormous tumor of the thyroid gland (after Bruns). 
 
 old cysts the contents become more liquid, and are often changed other- 
 wise by hemorrhage into the cyst and by the formation of numerous 
 cholesterin-crystals. Other forms of regressive metamorphosis are 
 
1 64 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 amyloid, cheesy, and fatty degeneration and calcification. The tumors 
 often attain great size. Rose has shown that death from sudden suffo- 
 cation is caused by atrophy and softening of the tracheal rings resulting 
 from pressure of the tumor. The trachea in such cases has been found 
 flattened, resembling a sabre-sheath. Pressure-atrophy and flattening 
 of the trachea do not take place in proportion to the size of the tumor. 
 A small tumor, not larger than a hen's egg, of the middle lobe of the 
 gland will do more damage to the trachea than will a large tumor, such 
 as that shown in Figure 76. When a tumor has attained this size 
 pressure-symptoms are often relieved by the weight of the tumor 
 making traction away from the trachea. Retro-sternal tumors give rise 
 to the most distressing symptoms, as the outward growth of the tumor 
 is opposed by the unyielding sternum. Retro-tracheal tumors or 
 tumors encircling the trachea are also the source of great suffering, and 
 demand operative treatment. It is generally known that adenoma of 
 the thyroid gland shows no tendency to increase in size after the patient 
 has reached his fiftieth year. Numerous cases of congenital tumors of 
 the thyroid gland have been recorded. They are most likely to occur 
 in localities where bronchocele is endemic. 
 
 If, in a person past middle life, a struma that has been stationary 
 for years suddenly and without any special provocation commences to 
 increase in size, it is very probable that the tumor has undergone 
 transformation into a carcinoma or a sarcoma. Malignant disease of 
 the thyroid gland is more likely to originate in a pre-existing tumor 
 than in a normal gland. Tumors of the thyroid gland always receive 
 a rich blood-supply. The gland is so abundantly supplied with blood 
 from the four thyroid arteries that excessive vascularization of the 
 tumor invariably occurs. The veins of the capsule of the gland, if 
 the tumor is large or multiple, often attain the size of the little finger ; 
 the superficial veins in such instances are also enormously dilated (see 
 Fig. 76). 
 
 The differential diagnosis in tumors of the thyroid gland has for its 
 object to distinguish between infective swelling, adenoma, cyst, carci- 
 noma, and sarcoma. A miasmatic bronchocele presents itself as a 
 smooth swelling involving usually the entire gland. It is endemic in 
 certain districts in some countries (Switzerland and Austria), and it 
 appears usually during childhood or at the age of puberty. A few 
 weeks' treatment with preparations of iodine will make an impression 
 on the swelling. Adenoma commences as a small nodule in the sub- 
 stance of the gland, and follows the movements of the gland during 
 deglutition. Adenoma is often multiple from the beginning, or addi- 
 tional nodules appear in different parts of the gland in succession. 
 
ADENOMA. 165 
 
 Sarcoma and carcinoma develop in preference in a gland affected pre- 
 viously by infective swelling or by adenoma, and occur, as a rule, in 
 adults and in persons of advanced age. The malignant tumors grow 
 rapidly in size, and soon render the tumor immovable by extension to 
 the surrounding tissues. Cysts frequently mark an advanced stage 
 of an adenoma. Unless the cyst-wall is very tense, fluctuation can be 
 elicited without difficulty. If any doubt exists, an exploratory puncture 
 will furnish the desired information. A miasmatic swelling or an ade- 
 noma of the thyroid gland is prone to become the seat of microbic infec- 
 tion during an intercurrent infective disease. Tavel studied this subject 
 very exhaustively from a bacteriological aspect, and reported a number 
 of cases of strumitis in which he found in the inflamed tumors microbes 
 similar to those which caused the general infective disease, notably 
 typhoid fever. 
 
 Treatment. — Owing to the importance of the operative treatment 
 of tumors of the thyroid gland, this subject will be discussed separately. 
 The most efficient treatment of miasmatic bronchocele is by the internal 
 and external use of iodine. The parenchymatous injections of iodine 
 so extensively used by Lucke are no longer popular. It has been fol- 
 lowed by disastrous results in a number of instances. Paralysis of the 
 recurrent laryngeal nerve, great swelling, and suppuration are some of 
 the immediate complications occasionally caused by this method of 
 treatment. The late Professor Gunn used parenchymatous injections 
 of a 5 per cent, solution of carbolic acid, repeated once or twice a week, 
 with great success, and this method has remained in constant use in 
 the clinic of Rush Medical College, and is yielding excellent results. 
 It is perfectly safe, almost painless, and the carbolic acid appears to 
 neutralize the primary microbic cause. The iodine treatment is em- 
 ployed at the same time. The injection should be made into different 
 parts of the tumor, and should be repeated at least twice a week. 
 
 Extirpation of the thyroid gland for tumor is a comparatively recent 
 operation. J. Collins Warren of Boston extirpated one lobe of the thy- 
 roid gland, after preliminary ligation of the common carotid artery on 
 the same side. He believed that the operation was impracticable with- 
 out resorting first to tying of the common carotid artery. Green prac- 
 tised rapid removal of the tumor, and ligated the bleeding vessels later. 
 Rose tied each vessel before cutting, proceeding very slowly. The 
 writer in 1878 witnessed one of his operations, which lasted for four 
 hours. The operative technique of strumectomy has been perfected 
 chiefly by the teachers of surgery in the universities of Switzerland — 
 Billroth, Lucke, Julliard, Reverdin, Socin, and Kocher — men who 
 were frequently called upon by patients from localities in which 
 
166 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 bronchocele prevailed as an endemic affection. Kocher was the first 
 to call the attention of the profession to the evil results following 
 complete removal of the thyroid gland. He observed, in a number of 
 cases in which he removed with the tumor the entire gland, a condition 
 which he termed cachexia strumipriva, which resembled what was later 
 discovered to be myxedema. This subject then received careful ex- 
 perimental investigations which corroborated Kocher's observations. 
 Zesas found in his experiments on dogs that if only a part of the gland 
 is extirpated the remaining part undergoes compensatory hypertrophy ^ 
 and that complete removal of the gland resulted sooner or later in the 
 death of the animal. Similar experiments with the same results were 
 made by Bardeleben and Horsley. The experiments have taught sur- 
 geons that complete extirpation of the thyroid gland except for malig- 
 nant disease is an unjustifiable operation. A part of the gland must be 
 allowed to remain in order to prevent the probable occurrence of serious 
 remote complications. 
 
 Partial extirpation of the thyroid gland is still in use in the removal 
 of benign growths, and complete strumectomy is absolutely necessary 
 in the extirpation of malignant tumors. The external incisions selected 
 for this purpose must be made in accordance with the size and location 
 of the tumor. An incision along the margin of the sterno-cleido- 
 mastoid muscle will secure good access for the removal of tumors or 
 for extirpation of the lateral lobes. A median incision will reach tumors 
 of the isthmus most directly. In large tumors or in tumors involving 
 both lobes a transverse incision over the most prominent part of the 
 tumor, with the concavity directed upward, is preferable. So far as pos- 
 sible, the vessels should be ligated or be secured with pressure-forceps 
 before being cut. This ligation is especially necessary when the thyroid 
 arteries are reached. The isthmus of the gland is included in a ligature 
 en masse. The operation should be performed slowly and carefully, and 
 all tissues should be identified before being cut, to avoid injury to the 
 recurrent branch of the pneumogastric nerve. Accidental section of 
 this nerve is followed by paralysis of the vocal cords on the same side, 
 which paralysis will in all probability remain as a permanent disability. 
 
 Extirpation of parts of the thyroid gland has largely given way to 
 'enucleation, an operation devised by Socin and strongly endorsed by 
 Julliard. It is the ideal operation, as it leaves the gland-tissue intact. 
 This operation is not limited to the removal of small growths, as the 
 enormous tumor depicted in Figure 76 was successfully removed by 
 the same procedure. All glandular and cystic tumors of the thyroid 
 gland are enclosed by a thick connective-tissue capsule which can be sep- 
 arated from the surrounding tissues with ease and without much heritor- 
 
ADENOMA. 167 
 
 rhagc. The great secret in the successful removal of glandular and 
 cystic tumors of the thyroid gland is to find the exact place, between cap- 
 sule and tissues, at which to commence the enucleation. The dissection 
 down to the capside must be made with the utmost care, and no attempts 
 at enucleation should be made until the proper place is found. As soon 
 as the capsule is reached the knife must be laid aside and the tumor 
 be enucleated by the use of the finger or of blunt instruments. The 
 parenchymatous hemorrhage generally yields to pressure and hot water, 
 or, in case it is not controlled in this way, to the aseptic tampon. If 
 the aseptic tampon is not used, the mantle of thyroid tissue which was 
 cut in exposing the tumor should be sutured with absorbable material 
 separately before closing the external wound. If the tampon is em- 
 ployed, it is removed at the end of the first day and the wound is closed 
 by secondary sutures. If more than one tumor is found, all the tumors 
 can be removed through the same external incision by approaching 
 them through separate incisions through the capsule or veil of gland- 
 tissue which invariably covers them. The great advantages of enucle- 
 ation over extirpation are greater ease of operation, less liability to 
 troublesome hemorrhage, less deformity, and, lastly, that it does not 
 deprive the patient of any normal gland-tissue, which has been found 
 of such enormous importance in the preservation of health. 
 
 Wolfler revived the operation of ligating the thyroid arteries in the 
 treatment of tumors of the thyroid gland. This operation, of course, 
 can attain what is claimed for it only in parenchymatous tumors. Cysts 
 should invariably be enucleated unless calcification of the capsule has 
 so far advanced as to render this procedure impracticable. Adenomata 
 should be dealt with in the same manner unless the capsule of the 
 tumor has become firmly attached to its surrounding tissues by an 
 antecedent inflammation. Extirpation should be limited to tumors that 
 cannot be enucleated, and it should never include the entire gland except 
 in the removal of malignant tumors. 
 
 Mammary Gland. — The benign tumor most frequently met with in 
 the mammary gland is the adenoma. Until quite recently it was gen- 
 erally conceded that the firm tumors of the mammary gland were in 
 the majority of cases fibromata. Careful study under the microscope 
 of sections from such tumors has shown that glandular elements 
 are absent only in exceptional cases, and consequently that most of 
 the benign tumors of the gland are not fibromata, but adenomata. 
 Schimmelbusch has shown that the tumors of the breast heretofore 
 designated as fibromata are in reality tumors in which the adeno- 
 matous structures predominate — an opinion strongly supported by 
 Haeckel. In order to realize the true nature and structure of such 
 
i68 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumors it is absolutely necessary to examine sections from different 
 parts of the tumor. Some sections from the same specimen will often 
 show epithelial cells almost exclusively, while other sections exhibit 
 only fibrous tissue. The presence of epithelial cells in different parts 
 of the tumor, however, leaves the impression that they take the essen- 
 tial part in the production of the tumor. Billroth denied that epi- 
 thelial cells took any part in the origin and growth of tumors of the 
 breast, which he designated as fibroid tumors. The adenoid structure 
 is well marked in the tissues of young tumors, while in old tumors 
 the epithelial cells are found arranged in an irregular manner in the 
 
 :^=^^' iff P'- ''■'■■ ^ ^ W .<\\f '///--w^.SA. 
 
 ^-6 
 
 Fig. 77. — Adenoma of mamma (after Haeckel) : a, fibrous tissue; b, epithelial cells. (Zeiss, Obj. A., Oc. 2.) 
 
 connective-tissue spaces. Figure J J shows that the connective tissue 
 has separated the acini, but the glandular appearance is well preserved. 
 The fibrous tissue is increased by active proliferation of the interacinous 
 connective tissue, and the new elements impart to the tissues a grayish- 
 red or yellowish color instead of the pearly-white color of old connec- 
 tive tissue. At some points in the older portions of the tumor the 
 
 fibrous tissue is pale and firm, at others 
 cedematous or myxomatous. 
 
 It is a question whether pure fibromata 
 ever occur in the mammary gland. Un- 
 mixed adenomata are also exceedingly rare. 
 Haeckel had an opportunity to remove and 
 examine a pure adenoma of the breast, and 
 he gives the accompanying illustration (Fig. 
 78) to explain its histological structure. The 
 tubules were lined by at least twenty strata 
 of epithelial cells. 
 
 The writer removed a tumor the size of a 
 hazelnut from the breast of a young lady, and from its firmness 
 
 Fig. 78. — Pure adenoma of the 
 mammary gland (after Haeckel). 
 (Zeiss, Obj. D., Oc. 2.) 
 
ADENOMA. 
 
 169 
 
 was led to believe the tumor to be a fibroma. The macroscopical 
 appearance of a section of the tumor showed wavy bundles of connec- 
 tive tissue, thus confirming the opinion formed. Under the microscope 
 the tumor revealed itself as a genuine adenoma. The microscopic ap- 
 pearance of the tumor-tissue and the relative proportion of glandular 
 and connective tissue are shown in the accompanying illustration (Fig. 
 79). It will be seen from this illustration that, although the tumor had 
 existed for several years, the tubules are lined by a number of layers 
 of epithelial cells and that the glandular spaces are small. We have 
 
 ' ■ : " y - ■' ~- - - ... - ■ - < - 
 
 :■■■ 
 
 SPSBr & 
 
 
 'W* 
 
 
 ■' 
 
 -v: ?S., ^ ' : 
 
 >■■*&#>■■:■■ 
 
 C' :y ' 
 
 
 Fig. 79.— Adenoma of breast ; X 115, reduced one-fifth (Surgical Clinic, Rush Medical College, Chicago) : a, 
 shrinkage due to hardening ; b, proliferating ducts ; c, fibrous tissue. 
 
 reason to believe that during the future growth of such a tumor the 
 stroma would increase more than the parenchyma, and so render 
 the fibrous structure more apparent. Adenomata without cyst-forma- 
 tion never attain a large size. Usually they range 
 in size from that of a pea to that of a walnut ; 
 99 per cent, of them occur in females. Adeno- 
 mata occupy more frequently the superficial and 
 peripheral than the deep and central parts of 
 the gland. They are often multiple in one breast, 
 seldom in both breasts. They often cause great 
 pain and are quite tender on pressure. These 
 symptoms are much less prominent in the early 
 history of carcinoma of the breast. Adenoma of the breast (Fig. 80) 
 is always well encapsulated. Adhesion to the skin and retraction are 
 
 Fig. 80. — Adenoma of the 
 breast, showing capsule (after 
 Astley Cooper). 
 
170 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 therefore never observed. The existence of a well-defined capsule is 
 of great assistance to the surgeon in doubtful cases after he has exposed 
 the tumor to make a positive diagnosis of its non-malignant nature. A 
 section of the tumor (Fig. 81), if the fibrous tissue predominates, very 
 much resembles in its naked-eye appearances fibroma of the uterus. 
 The surface of the section appears as though the tumor were composed 
 of separate parts, each of which indicates a different centre of growth. 
 Cystic adenoma often attains great size. The contents of the cysts are 
 variable. Colloid degeneration seldom takes place. The serous fluid is 
 
 Fig. 8i. — Large adenoma of breast, cut surface resembling fibroma of the uterus (after Astley Cooper). 
 
 often stained a dark color, owing to the presence of blood and cholesterin- 
 crystals. The writer has found cystic degeneration most frequent in 
 women advanced in years. In the diagnosis it is important to remem- 
 ber that carcinoma seldom, if ever, occurs in the breast as a multiple 
 affection, while this is frequently the case in adenoma. Retraction of 
 the nipple and the skin may follow inflammatory affections of the 
 breast, but is never present in uncomplicated adenoma, and is of fre- 
 quent occurrence in carcinoma. Adenoma resembles more closely 
 sarcoma than carcinoma. Sarcoma, however, grows much more rapidly 
 than carcinoma, and is usually attended by dilatation of the superficial 
 veins. Adenoma and sarcoma occur frequently in young adults, while 
 carcinoma is seldom met with in women less than thirty-five years 
 
ADENOMA. 171 
 
 of age. The prognosis must always be guarded, as adenoma of the 
 breast undergoes transformation into malignant tumors — carcinoma and 
 sarcoma — perhaps more frequently than any other benign tumor. Early 
 operative removal should be recommended, as an operation brings 
 mental as well as physical relief, and protects the patient against the 
 possibility of the occurrence of malignant disease caused by the transi- 
 tion of a benign into a malignant tumor. 
 
 Prostate Gland. — The prostate is a glandular organ and part of 
 the genital apparatus. It was until recently supposed that the en- 
 largement of this gland in . men past fifty years of age was a tumor 
 resembling myofibroma of the uterus. This idea, in the light of recent 
 investigations, has been abandoned, and the enlargement is now regarded 
 as a glandular swelling or tumor. White of Philadelphia ascertained 
 by his experiments on dogs that castration resulted almost uniformly 
 in great diminution in the size of the prostate. Surgeons have made 
 use of the knowledge thus gained, and in a few instances have resorted 
 to castration for the relief of enlargement of the prostate gland. Ramm 
 of Christiana reports two cases in which this operation afforded perma- 
 nent relief and was followed by progressive diminution in the size of the 
 gland. Harrison of London reports a case of hypertrophy of the pros- 
 tate greatly benefited by subcutaneous section of the spermatic cord on 
 both sides. The patient begged to have castration performed, and as 
 a compromise Harrison made subcutaneous section of both cords. 
 Should future operations produce similar results, they would prove 
 that in the majority of cases enlargement of the senile prostate is not 
 a tumor, but a swelling. The writer is firmly convinced that in most in- 
 stances this is the case. There is, however, a tumor of the prostate 
 that is glandular in structure and that appears as a single or a multiple 
 affection involving any or all of the lobes of the gland. The general 
 enlargement of the gland consists of a hyperplasia of the glandular 
 and connective-tissue part of the gland ; the isolated nodules are ade- 
 nomata. Adenomata are found almost exclusively in hyperplasic glands, 
 in this respect bearing a strong resemblance to adenomata of the thy- 
 roid gland. The hyperplasia of the organ occurs as one of the many 
 pathological conditions incident to old age, in the production of true 
 tumors taking the same part as the miasmatic struma. The prostate, 
 like the uterus and the thyroid gland, is an organ in which and around 
 which complicated developmental changes take place ; consequently 
 there is here, as in the other organs mentioned, great liability of the 
 deposition of unutilized embryonic cells which later become the essen- 
 tial tumor-matrix. So long as the physiological resistance of the tis- 
 sues around the matrices remains unimpaired, tumor-growth does not 
 
172 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 take place, but when this resistance becomes diminished by senile debil- 
 ity, and particularly by the changes which the prostate undergoes 
 during advanced age, the embryonic cells assume active tissue-prolifer- 
 ation which results in the formation of a tumor. Billroth asserted that 
 he never observed an adenoma in the prostate gland, and he attributed 
 the senile enlargement to dilatation of the acini and hyperplasia of the 
 epithelial cells. It took a long time for pathologists to make a distinc- 
 tion between hyperplasia of the thyroid gland and the adenomata, and 
 the same confusion has prevailed in regard to the two entirely different 
 kinds of enlargement of the prostate gland. The extirpation of the 
 hyperplasic prostate in toto has not yielded encouraging results, and 
 will never become a feasible surgical procedure ; on the contrary, enu- 
 cleation of adenomata of this organ from the perineum through Zucker- 
 kandl's incision or through the bladder above the pubes has a promis- 
 ing future. 
 
 Lachrymal Gland. — Adenoma of the lachrymal gland has been 
 studied by P. Becker and others. It appears as a lobulated, nodular 
 tumor of moderate size, and it is very liable to undergo hyaline degen- 
 eration. The tumor increases in size very slowly, and the formation 
 of small cysts is of frequent occurrence. Enucleation of the tumor 
 should be done in preference to extirpation of the whole gland. 
 
 Parotid Gland. — According to C. O. Weber, the parotid gland is very 
 rarely the seat of adenoma. Billroth maintained that adenoma of this 
 organ, when it does exist, is only a part of a compound tumor. It cannot 
 be denied that compound tumors of the parotid gland, such as adeno- 
 chondroma, adeno-cystoma, and adeno-carcinoma and adeno-sarcoma, 
 are frequently met with in the examination of tumors of this organ. 
 Pure adenoma of the parotid gland has, however, been found, and it 
 resembles in structure similar tumors of the thyroid gland. Glandular 
 tumors occur most frequently in young adults. Cystic degeneration 
 often takes place at different points, large cavities being formed by the 
 coalescence of smaller cysts. The cyst-wall, lined by epithelial cells, 
 often projects into the cysts at different points in the form of papillary 
 excrescences. The tumor is well encapsulated, and it can be enucleated 
 very readily without serious damage to the gland. The incision should 
 be made with special reference to the location and direction of Sten- 
 son's duct and the branches of the facial nerve. A thin veil of gland- 
 tissue has to be divided before the capsule of the tumor is reached, and 
 the operation occasionally results in the formation of a temporary 
 salivary fistula. 
 
 Testicle. — The relative proportion of true tumors of the testicle to 
 inflammatory swellings is unusually small. Adenoma of the testicle 
 
ADENOMA. 173 
 
 has only recently been described. Liicke called attention to its 
 existence in connection with cystic disease of the testicle. Eve has 
 examined a large number of cysts, including adeno-cystoma, sarco- 
 mata, myxomata, and carcinomata ; they were lined with columnar, 
 stratified, or ciliated epithelium ; some were papillomatous, and car- 
 tilage and unstriated muscular fibres were occasionally present in 
 the stroma. The adeno-myxomata were characterized by slit-like 
 tubes or solid rods of gland-tissue surrounded by a zone of trans- 
 parent tissue. Eve and Sutton believe that the majority of gland- 
 ular tumors of the testicle originate in the remnant of the Wolffian 
 body lying between the globus major of the epididymis and the 
 testicle proper. This remnant of the Wolffian body is known as 
 the "paradidymis." 
 
 Adenoma of the testicle is characterized by the existence of numer- 
 ous small cysts. The cyst-spaces are lined with columnar or stratified 
 epithelium. If the tumor attains large size, it causes atrophy of the 
 testicle by pressure. The tumors are encapsulated, but in the few cases 
 that have come under the observation of the writer their enucleation 
 has been found quite difficult. The tumors varied in size from a 
 hickory-nut to a walnut, and on section presented a honeycomb appear- 
 ance, owing to the presence of numerous cysts, the largest of which 
 did not exceed the size of a hempseed. 
 
 The differential diagnosis of adenoma of the testicle must take into 
 consideration tuberculosis, gumma, carcinoma, sarcoma, and circum- 
 scribed hydrocele of the tunica vaginalis. In the removal by enucleation 
 great care is required in preventing injury to the cord and the testicle. 
 
 Liver. — Adenoma of the liver during the last year or two has 
 become a more interesting topic to the surgeon from the fact that in 
 several cases tumors of this kind have been removed successfully by 
 excision. Keen and Von Bergmann have each reported a successful 
 case. The earliest communications on adenoma of the liver were made 
 by Hoffmann and Lancereaux. Gruber, Wagner, and others have 
 found detached portions of liver-tissue, often very numerous, in the 
 peritoneal folds supporting the liver and in the portal fissure ; these 
 fragments may be a possible source of cysts and tumors. Friedreich 
 found in the liver itself groups of cells which did not appear to form 
 part of the parenchyma, as they were isolated from it by a capsule. 
 These embryonic remnants are undoubtedly the matrices from which 
 adenomata originate. Isolated tumors may be no larger than a marble ; 
 larger tumors are formed by a collection of multiple tumors. In some 
 parts of the tumor the seat of active proliferation, metaplastic condi- 
 tions of the parenchyma-cells are developed, as in a case reported by 
 
174 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Rindfleisch-Griesinger : the nodules in the acini of this specimen were 
 
 Fig. 82. — Adenoma of the liver (after Paul) : a, section of blind duct filled with green fluid: b, liver-cells; 
 
 c, connective tissue. 
 
 made up of columnar epithelial cells. Small adenomata, consisting of 
 cylinders lined by columnar epithelium and imbedded in fibrous tissue, 
 
 Fig. 83. — Papillary adenoma of kidney ; X 250 (after Karg and Schmorl) ; hollow spaces lined by cylindrical 
 cells ; stroma scanty and moderately cellular ; papillary proliferations project into the glandular spaces. 
 
 occur (Fig. 82). The acini may be solid and hard, or they may consist 
 of large cells and may resemble the acini of the pancreas. A slow- 
 
ADENOMA. 
 
 175 
 
 growing tumor in the substance of the liver in a non-syphilitic subject 
 would indicate the necessity of making a careful investigation with a 
 view of determining the propriety of an abdominal section to make 
 a positive diagnosis, and, if the tumor is found to be an adenoma, to 
 attempt its removal In the cases thus far operated upon a positive diag- 
 nosis was made only after the tumor was rendered accessible to direct 
 examination by abdominal section. 
 
 Kidney. — The frequency with which the kidney is now subjected to 
 operative treatment adds renewed interest to everything pertaining to the 
 pathology of the numerous affections of this organ that have recently 
 been brought within the reach of successful surgery. Very little is 
 known of benign tumors of this organ. Occasionally small cystic 
 adenomata are found, some of which are undoubtedly derived from 
 retention-cysts, but it is also probable that Wolffian-body rests may be 
 a cause. Shattock maintains, with good reason, that remnants from the 
 mesonephros (Wolffian body) and the metanephros (true kidney) often 
 serve as matrices for tumor- 
 formation. The papilloma- 
 tous projections into the cysts 
 of renal adenomata as well as 
 the cyst- wall are covered with 
 columnar epithelium which 
 bears no resemblance to the 
 epithelial cells lining the 
 uriniferous tubules (Fig. 83). 
 
 Adenomatous tumors of 
 the kidney sometimes reach a 
 considerable size in case the 
 cysts are large and numerous, 
 as in Mr. Edmunds' case (Fig. 
 84). The kidney represented 
 in Figure 84 was successfully 
 removed by Mr. Edmunds 
 from a girl eighteen years old. 
 Such a tumor might easily 
 be mistaken for a sarcoma. 
 
 Diagnosis. — The differen- 
 tial diagnosis between ade- 
 
 , . , , 11 Fig. 84. — Adenoma of the kidney (after Edmunds). 
 
 noma and other glandular 
 
 affections is of great practical importance, often is exceedingly difficult 
 owing to the location of the organ affected, and is frequently rendered 
 more perplexing by misleading statements on the part of the patient. 
 
176 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Chronic infective swellings, tuberculosis, and gumma are most likely 
 to be mistaken for adenoma. Mistakes of this kind have sometimes 
 been made by careful and competent surgeons. Search for additional 
 evidences of the primary cause of infection will frequently furnish valu- 
 able information. In gumma of the testicle the presence of other less 
 apparent tertiary lesions and the existence of tuberculosis in other 
 organs are points upon which the surgeon often rests his diagnosis in 
 differentiating between an adenoma and an infective swelling. The 
 central part of an infective swelling frequently degenerates and liquefies, 
 still further complicating the diagnosis between a cystic adenoma and 
 an infective swelling. An exploratory puncture is often of great value 
 in ascertaining the character of the contents of a doubtful swelling. 
 Primary tuberculosis does not often attack the organs which are the 
 favorite seat of adenoma. Tuberculosis of the mammary, thyroid, and 
 prostate glands is a comparatively rare affection. Carcinoma of a 
 gland differs from adenoma by the absence of any attempts at encap- 
 sulation of the tumor and by the presence of regional dissemination 
 through the lymphatics. Metastasis never attends adenoma. Cohnheim 
 claimed to have found metastasis in a case of adeno-myxoma of the 
 thyroid gland. The tumor perforated a vein-wall, and fragments were 
 detached and reached the pulmonary vessels, where the secondary 
 tumors were found. It is more than probable that in this case, the only 
 one of the kind on record, the tumor was malignant, the strongest 
 proof of this being the manner in which the tumor reached the lumen 
 of the vein. Sarcoma in its earlier stages resembles adenoma, but its 
 more rapid growth and the local and often general infection are the 
 most important points upon which to base a correct diagnosis. 
 
 Prognosis. — Adenoma without cyst-formation never grows beyond 
 certain limits, so that it seldom interferes with important functions by 
 its presence. Adeno-cystoma of the ovary often reaches an immense 
 size. Adenoma of the middle lobe of the prostate and of the isthmus 
 of the thyroid gland of moderate size gives rise to serious symptoms 
 of obstruction. With the exception of adenoma of the prostate, gland- 
 ular tumors seldom originate in persons advanced in years, and usually 
 they become stationary at the age of fifty. Adenoma not infrequently 
 undergoes transformation into carcinoma or sarcoma. Malignant 
 tumors of the thyroid gland frequently have such an origin. The 
 transition into carcinoma is observed oftener than a resulting sarcoma. 
 
 Treatment. — Most of the adenomata can be removed successfully 
 by enucleation. In adenoma of the breast the surgeon is often in doubt 
 as to whether the tumor is benign or malignant when the operation is 
 undertaken. A positive diagnosis can be made after the tumor has 
 
ADENOMA. 177 
 
 been reached. If the tumor is an adenoma, it is supplied with a perfect 
 capsule, and can be shelled out from its bed without any difficulty ; if it 
 is a carcinoma, all evidences at limitation of the growth are absent, the 
 tumor infiltrates the surrounding tissues, and the operation is incomplete 
 unless the entire breast and all of the axillary glands are removed. If 
 any doubt exists in the mind of the operator in cases of glandular 
 tumors of the breast, the patient should be informed beforehand that 
 conditions might be revealed by the operation which would necessitate 
 removal of the entire breast. In the enucleation of benign tumors of 
 the breast the incision should be made in the direction of the milk- 
 ducts, and the capsule of the gland should be sutured separately after 
 the removal of the tumor. 
 
 Adenomata of the uterus and cervix are usually removed by the use 
 of the sharp curette. Preliminary rapid dilatation of the cervical canal 
 and thorough disinfection of the parts are essential in effecting com- 
 plete removal of the diseased tissue and in preventing septic infection. 
 Tamponade of the uterine cavity with iodoform gauze and rest in bed 
 for at least a week will add to the beneficial effects of the operation and 
 will minimize the liability to complications. 
 
 Cystic adenoma of the kidney does not justify nephrectomy, as the 
 opposite organ is frequently found similarly affected. If the kidney has 
 been exposed by a lumbar incision and the nature of the tumor has 
 been determined, enucleation or partial nephrectomy is preferable to 
 complete removal of the organ. 
 
 Adenoma of the liver may become an object of operative treatment 
 if the abdomen has been opened for the purpose of determining the 
 nature of an obscure tumor of that organ. The hemorrhage after 
 removal of the tumor by enucleation or excision should be arrested by 
 the employment of the aseptic tampon, which is brought out at the 
 upper angle of the wound, by the application of the actual cautery, or 
 by suturing Glisson's capsule, as advised by Von Bergmann. 
 
 12 
 
XV. CYSTOMA. 
 
 The term " cystoma" in this book will be used in the most restricted 
 histogenetic sense, and will be applied only to those cysts in which both 
 cyst-wall and contents are formed anew and independently of pre-existing 
 gland-structures. A sharp etiological distinction must be made between 
 a cyst, in the ordinary sense in which this word has been used, and 
 a cystic tumor or cystoma. The word " cyst " has been used very 
 indiscriminately to indicate the existence in a closed cavity of various 
 solid and liquid contents. It has been, and is still, used to designate 
 the existence of the products of extravasation, inflammation, and re- 
 tained secretions in a closed cavity. We shall limit the term " cystoma," 
 cystic tumor, to cystic formations in which the cyst-wall is produced 
 from a matrix of embryonic cells, and the contents are the products of 
 tissue-proliferation of the cells lining the cyst-wall. Used in such a 
 limited sense, a cystic tumor is a hollow tumor, the interior of the cyst- 
 wall being lined by epithelial or endothelial cells. The cells lining the 
 cyst-wall are the essential tumor-cells. Retention-cysts and cysts 
 caused by extravasation or inflammation will be excluded from this 
 section. The epithelial lining of the cyst-wall is derived either from the 
 epiblast or the hypoblast or is composed of endothelial cells. We have 
 already described adeno-cystoma and proliferating adeno-cystoma in the 
 section on Adenoma. In adeno-cystoma the glandular structure of the 
 tumor predominates, the cystic part being accidental and usually limited. 
 Proliferating cysts may attain great size, but the glandular part pre- 
 dominates permanently. The epithelial cells correspond in shape and 
 structure to that part of the epiblast or the hypoblast from which the 
 matrix is derived. In cysts representing mucous membrane and ducts 
 the cells are usually columnar ; in cysts of epiblastic origin the cells are 
 flat, corresponding to the pavement epithelium of the skin (Fig. 85). 
 Cysts composed exclusively of mesoblastic tissue are lined by endothe- 
 lial cells. Heterotopic cysts are cysts lined with epithelial cells and entirely 
 disconnected with tissues or organs of epiblastic or hypoblastic origin. 
 Mesoblastic cysts are never heterotopic, as connective tissue can be 
 transformed into endothelial cells and endothelial cells into connective 
 tissue, and connective tissue is present in the body everywhere. 
 
 178 
 
CYSTOMA. 179 
 
 Sterile cysts are cysts in which the epithelial or endothelial lining has 
 disappeared by degeneration of its cells (Fig. 85, d). 
 
 Growth of a cyst will continue so long as the cells lining the interior 
 of the cyst-wall continue to proliferate. When the cells are destroyed 
 by degeneration or otherwise the contents of the cyst cease to increase, 
 and the cyst remains stationary or diminishes in size. In Figure 85 
 the cystic spaces at b and c, being lined by proliferating epithelial cells, 
 
 a _=_ _.. , .; . .. —^~*r~ 
 
 Fig. 85. — Adeno-cystoma of thyroid gland ; X 5°, reduced one-third (Surgical Clinic, Rush Medical 
 College, Chicago): a, stroma; b, acinus filled with colloid material and lined by epithelial cells ; c, epithelial 
 lining; a?, acinus from which all epithelial cells have disappeared, constituting a sterile cyst. 
 
 would increase in size by the addition of new colloid material to the 
 contents of the cyst, while the space at d would remain stationary in 
 size, because all the epithelial cells have been destroyed by degenera- 
 tion, and with the destruction of the epithelial cells the cyst has been 
 deprived of any further source of colloid material. The framework of 
 the cyst-wall to which the epithelial or endothelial cells are attached 
 is composed of connective tissue. The connective tissue in a true 
 cystoma is derived from the pre-existing connective tissue, which at 
 first is condensed by compression caused by the gradual enlargement 
 of the cyst, and later becomes increased in thickness by the production 
 of new connective tissue. The cyst-wall may be exceedingly thin and 
 delicate if it contains only a small amount of connective tissue, or in 
 the course of time it may become enormously thickened by the pro- 
 duction of new connective tissue. If the cyst is surrounded by tissue 
 on all sides, this tissue gradually becomes more and more isolated 
 from the external surface of the cyst-wall, so that finally only the 
 vascular connections remain — a condition exceedingly favorable for the 
 removal of the cyst by enucleation. The cyst-wall may also become 
 
180 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 firmly attached to the surrounding structures by inflammatory adhe- 
 sions, as is so often the case in ovarian cysts and in cysts in other parts 
 of the body subjected to partial extirpation or to other inadequate 
 methods of treatment. 
 
 The cyst-contents will vary according to the type of the cells which 
 produced them. Cysts lined by epiblastic epithelial cells usually 
 contain the products of fatty degeneration, an atheromatous material, 
 or, if the fatty degeneration has progressed still further, pure oil. 
 Cysts lined by columnar epithelial cells analogous to those found 
 in the gastro-intestinal canal usually contain mucus. Cysts of the 
 thyroid gland contain most frequently colloid material, or, if the col- 
 loid material has disappeared by liquefaction, a serous fluid. Meso- 
 blastic cysts generally contain a serous fluid. The cyst-contents are 
 modified by hemorrhage into the cyst and by the addition of choles- 
 terin-crystals — a frequent occurrence, especially in cysts of an epiblastic 
 origin. A simple, single cyst is called a monolocular cyst. A cyst in 
 which we find different compartments from the beginning, or produced 
 later by coalescence of several cyst-walls or by proliferation from the 
 cyst-wall, is called a multilocular cyst. The cyst-wall often undergoes 
 calcareous degeneration, and sometimes ossification, particularly in cases 
 in which the epithelial lining has been destroyed by degeneration. 
 
 Etiolog-y. — Cystoma very frequently appears as a congenital affec- 
 tion. The tumor-matrix proliferates during intra-uterine life, and at 
 the time of birth the activity of proliferation can be calculated by the 
 amount of contents of the cyst. Congenital cystic tumors of the neck 
 are of frequent occurrence. Although cystic tumors may occur at any 
 time after birth, they are met with most frequently at the age of puberty. 
 Sublingual epiblastic tumors make their appearance most frequently at 
 this time of life. The great physiological activity of the organs derived 
 from the epiblast plays an important part in stimulating a latent matrix 
 to active tissue-proliferation, and if this matrix is of such a structure 
 or nature that its product is not arranged in glandular form, cystic 
 dilatation of its primary central space will follow. The growth of the 
 cyst will depend on the amount of essential tumor-elements and the 
 activity of their proliferation. Other exciting causes are trauma and 
 prolonged irritation and inflammation in the immediate vicinity of the 
 tumor-matrix. 
 
 Diagnosis. — A cystic tumor usually grows more rapidly and attains 
 a larger size than a papilloma or an adenoma. A central hollow space 
 is present from the very beginning, and does not appear later, as is 
 the case in adeno-cystoma. If the cyst-wall is not too tense or thick, 
 fluctuation can be elicited by careful palpation. If the cyst-wall is thin 
 
CYSTOMA. 181 
 
 and near the surface, the tumor is translucent if it contains clear serum. 
 In uncomplicated cases of hydrocele of the neck the tumor is trans- 
 lucent. An exploratory puncture will often prove of great value, not 
 only in showing the cystic nature of the tumor, but also in demon- 
 strating the nature of its contents. This diagnostic resource must be 
 employed with caution in the examination of abdominal tumors if the 
 free peritoneal cavity cannot be avoided. Exploratory puncture through 
 the free peritoneal cavity is ordinarily attended by more danger than 
 an exploratory incision. In locating the tumor an effort should be 
 made to ascertain its primary anatomical starting-point and to bring it 
 in connection with the organ in which it originated. If the cyst occu- 
 pies the pelvis, it should be ascertained whether it is connected with 
 the ovary, the Fallopian tube, or the uterus. If it occupies the abdom- 
 inal cavity and is not connected with the pelvic viscera, the relation of 
 the tumor to the different abdominal organs must be studied with care 
 to determine the organ with which the tumor is connected or to which 
 it has become attached. Inflation of the stomach and the intestinal 
 canal will often prove an invaluable diagnostic aid in such cases. 
 
 Prognosis. — Cystoma is a benign tumor. A proliferating cyst of 
 the ovary may perforate the cyst-wall and invade the peritoneal cavity, 
 but aside from this a cystic tumor does not extend beyond the limits 
 of the organ primarily affected. Cystoma, if in close contact with im- 
 portant organs, may give rise to dangerous complications by causing 
 harmful pressure. Cysts of the neck and of the pelvis may become a 
 source of danger from pressure. Large cysts of the abdominal cavity 
 ultimately interfere with digestion and respiration and become a source 
 of danger from their size. Adhesions between pelvic and abdominal 
 tumors and the surrounding organs may become a cause of intestinal 
 obstruction. Infection of a cystic tumor with pyogenic microbes may 
 result in suppuration and sepsis. Torsion of the pedicle of a cystic 
 tumor of the pelvis or of the abdomen has often resulted in gangrene, 
 septic peritonitis, and death. Malignant transformation is not as often 
 observed in cystoma as in papilloma and adenoma. 
 
 Topography. — Cystic tumors are met with most frequently in 
 organs and parts of the body in which during intra-uterine life the 
 most complicated tissue-changes occur. The favorite localities are the 
 ovaries, the base of the tongue, the neck, and the region of the orbits. 
 
 Traumatic Epithelial Cysts. — The accidental or intentional dis- 
 placement of a small island of skin into the mesoblastic tissues brings 
 about a condition closely resembling the relations of an epiblastic tumor- 
 matrix to the surrounding tissues. A few cases have been reported in 
 which epithelial cysts had such an origin. The difference between such 
 
i8a 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 an artificial matrix and a genuine tumor-matrix is the limited prod- 
 uct of the epithelial proliferation. Kaufmann studied the behavior of 
 attached buried epithelial cells by resorting to a procedure which he 
 terms enkatarrhophy . He selected for this purpose the cock's comb. 
 By two elliptical incisions an island of skin was circumscribed ; it was 
 then buried by suturing over it the margins of the wound. In some 
 of the successful cases the result was followed until the 210th day. 
 Examination of the specimens obtained at variable periods after the 
 operation showed that at the margins of the buried skin the epithelial 
 cells proliferated, resulting in the formation of a cyst-wall lined 
 throughout by epithelial cells. The cysts formed in this manner con- 
 tained a material which resembled the contents of an atheromatous 
 
 'WmBmMk 
 
 
 Fig. 86 — Traumatic epithelial cyst of finger (after Garre) : a, skin ; b, subcutaneous tissue ; c, epithelial cyst. 
 
 cyst. The growth of the cysts continued until they reached a certain 
 limited size, when it ceased and the cysts remained stationary. 
 
 Garre recently reported two cases of traumatic epithelial cysts of 
 the fingers. In both cases the injury which preceded the cyst-forma- 
 tion was a punctured wound. The cyst developed soon after the injury. 
 In one case the cyst was 12 millimeters in length and 7 to 8 millimeters 
 in width. A section through the centre of the tumor showed a central 
 cavity (Fig. 86). The implanted fragment of skin could readily be 
 identified by its characteristic anatomical structure. The epithelial cells 
 at the margins produced new cells which converted the piece of skin 
 into a globular mass well supplied with blood-vessels. The cyst con- 
 tained exclusively epidermic cells arranged in wavy stratified layers. 
 In the other case the cyst had reached the size of a hempseed and 
 showed a similar structure. The opinion of Chavasse that such cysts 
 
CYSTOMA. 
 
 183 
 
 Fig. 87. — Manner of production of traumatic epithe- 
 al cyst (after Garre) : a, skin ; b, subcutaneous tissue ; 
 dislocated fragment of skin. 
 
 E- - — b 
 
 are produced by the sweat-glands contained in the implanted skin is 
 contradicted by Garre. The process of cyst-formation as explained by 
 Garre can readily be understood by a glance at Figures 87, 88, and 
 89. He did not find any evidences of the formation of a cyst-wall as 
 described by Kaufmann. 
 
 Reverdin believes that epithelial cysts can originate from the dis- 
 placement of detached mature epithelial cells into the mesoblastic 
 tissues. Garre's second case was 
 one in point. In this case only 
 cells were forced into the subcu- 
 taneous tissue before the point 
 of a needle, and from them a 
 globular mass of epithelial cells 
 developed, but no trace of a 
 cyst-wall could be found. Rizet 
 reported a case in which the 
 epithelial cells that originated 
 from a displaced fragment of skin 
 became the seat of a calcareous 
 degeneration. In other instances 
 the cells have frequently been 
 eliminated by suppurative inflam- 
 mation. 
 
 Tatum observed on the scar of 
 a scalp wound an atheroma-cyst 
 which undoubtedly was caused 
 by a dislocated particle of skin. 
 A conclusion of the greatest eti- 
 ological moment that can be 
 drawn from the experiments of 
 Kaufmann and the clinical ob- 
 servations of Garre and others 
 is this, that a dislocated fragment of skin does not possess the same 
 intrinsic capacity of continued progressive tissue-proliferation as an epi- 
 blastic tumor-matrix. Epithelial cysts of a similar origin are found 
 more frequently in the scars following burns than after trauma. Epi- 
 thelial pearls in scar-tissue, the product of buried epithelial cells, are 
 not of rare occurrence. Traumatic epithelial cysts must be removed 
 by thorough extirpation, otherwise a recurrence will almost surely take 
 place. 
 
 Deep-seated Atheroma. — A retention-cyst of the sebaceous glands 
 resembles a true atheroma so perfectly in the structure of the cyst-wall 
 
 
 Fig. 88. — Beginning of healing of the skin-defect 
 and commencing proliferation from the margins of the 
 implanted skin (after Garre). 
 
 Fig. 89. — Wound entirely healed, and the buried 
 skin-graft enlarged by proliferation from the surface 
 and margins of the graft (after Garre). 
 
1 84 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and in its contents that we must distinguish between them etiologically 
 and clinically according to their location. Retention-cysts of the seba- 
 ceous glands result from obstruction to the escape of the secretions, 
 and always retain their relations with the skin. They are superficial, 
 being covered only by the skin. The deep-seated atheroma has no con- 
 nection with the glandular apparatus of the skin, and it always originates 
 from a displaced matrix of embryonic epiblastic cells. It should be dis- 
 tinguished from a dermoid cyst by the character of its contents. An 
 atheroma contains only epithelial cells as its characteristic morphologi- 
 cal cellular element, while the cyst-wall of a dermoid cyst represents 
 skin with its appendages in the simplest cases, and in more complicated 
 cases systems of organs in various degrees of perfection. The displace- 
 ment of the matrix of an atheroma occurred at a time prior to the differ- 
 entiation of the epiblastic cells into the organs representing the appendages 
 of the skin, while the matrix of a dermoid cyst points to a later displace- 
 ment of the matrix. Atheroma is met with most frequently in the 
 ovaries, in the region of the orbits, especially the superciliary arch, and 
 at the base of the tongue. In all these localities it is most frequent 
 at the age of puberty. In the superciliary region it occurs occasion- 
 ally as a congenital affection. In this locality it seldom exceeds 
 the size of a walnut, while tumors at the base of the tongue the size 
 of a cocoanut are not uncommon. Superciliary atheromata frequently 
 
 ^ -. — _ - — - contain pure oil which will ignite 
 
 and burn like ordinary lamp-oil. 
 When this stage of degeneration 
 is reached further growth is gen- 
 erally arrested. In the majority 
 L ^ of cases the tumor contains a 
 
 substance resembling in every 
 respect the contents of a reten- 
 /fi? tion-cyst ofthe sebaceous glands. 
 
 :.::• The granular detritus is com- 
 
 posed of epithelial cells which 
 have undergone fatty degenera- 
 tion suspended in a serous fluid 
 in varying proportions. Cho- 
 lesterin-crystals are often very 
 abundant in old cysts. Cysts 
 at the base of the tongue pro- 
 ject toward the cavity of the 
 mouth, and when they have reached a certain size they form a swelling 
 in the submaxillary region, causing great disfigurement, and by press- 
 
 t 
 
 Fig. 90. — Sublingual dermoid cystomj 
 
CYSTOMA. 
 
 185 
 
 ure against the tongue interfering with speech and often also with deg- 
 lutition (Fig. 90). The differential diagnosis between such a tumor and 
 a branchial cyst is often difficult, and sometimes can be made only by 
 resorting to an exploratory puncture. A branchial cyst usually con- 
 tains either mucus or a serous fluid ; an atheroma contains the product 
 of fatty degeneration of epithelial cells. 
 
 An atheroma may occur in almost any part of the body, and in the 
 differential diagnosis of cysts in unusual localities this fact should be 
 taken into consideration. The cyst-wall of an uncomplicated atheroma 
 is loosely attached, and can readily be removed by enucleation. 
 
 Mucous Cysts. — Cystic tumors with mucoid contents are compara- 
 tively rare if we exclude from this category retention-cysts with similar 
 contents. They are analogous to atheroma in their etiology, except 
 that the matrices are derived from the hypoblast and that the interior of 
 the cyst-wall is lined by columnar epithelium. In place of atheroma- 
 tous material the cysts contain mucus, which in old cysts is usually 
 transformed in the course of time into a serous fluid. If the cyst is 
 derived from a matrix representing squamous or ciliated epithelia, it 
 is lined by cells representing the part or organ from which the epi- 
 blastic or hypoblastic matrix was derived. Frequent locations of these 
 cysts are the orifice of the cervical canal of the uterus and the mucous 
 membrane of the lips, mouth, phar- 
 ynx, and intestinal canal. Mucous 
 cysts seldom attain the size of a 
 walnut, as, owing to the delicate 
 structure of the cyst-wall, rupture 
 takes place usually before the tu- 
 mor reaches this size. The epithe- 
 lial cells are generally arranged in 
 a single layer, and are not stratified 
 as in epiblastic epithelial cysts — an 
 additional cause for the early rup- 
 ture of these cysts that so fre- 
 quently takes place. Many of the 
 so-called "hydatid" cysts are mu- 
 cous cysts, the mucoid substance 
 having become transformed into a 
 transparent serous fluid. Among 
 the morphological elements in the 
 contents of a mucous cyst are epi- 
 thelial cells, free nuclei, cholesterin- 
 crystals, colloid masses, and sometimes concretions. The mucous cysts 
 
 91 
 
 Congenital cervical cyst extending into 
 the axilla (after T. Smith). 
 
 ^m 
 
1 86 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 are usually globular in shape ; owing to the fragility of the cyst-wall, 
 they seldom become pedunculated. Extirpation and the complete 
 destruction of the epithelial lining of the cyst by cauterization are the 
 only two operative procedures which can be relied upon in preventing 
 a recurrence. With very few exceptions, enucleation is impractical, 
 owing to the great fragility of the cyst-wall. 
 
 Cysts lined by ciliated epithelial cells always have their origin from 
 an embryonic matrix derived from parts and organs supplied with 
 ciliated epithelium in the fetal state. Cysts of this kind have been 
 found in the brain, the external ear, the liver, and the testicles. 
 
 Mesoblastic Cysts. — Cysts composed exclusively of tissue of meso- 
 blastic origin are found most frequently in the region of the neck, where 
 they have been described by the German authors as " hygroma " and 
 by the English surgeons as " hydrocele of the neck." This form of 
 cyst is always of congenital origin ; it occupies the deep tissues of the 
 neck in front of the large vessels, and often extends from the hyoid 
 bone down to the clavicle and even as far as the axillary space (Fig. 
 91). Congenital cysts of the neck often shrivel soon after birth and 
 disappear spontaneously; at other times they increase rapidly in size. 
 In a few instances they reappeared later in life, such a case being 
 reported by Birkett. They are usually unilocular, but sometimes 
 they are divided in part or completely into a number of compart- 
 ments with similar contents. If the cyst is large and contains a 
 clear serous fluid, it is translucent. The histology of these cysts has 
 not been investigated sufficiently. The very fact that in the majority 
 of cases they disappear spontaneously is sufficient proof that epi- 
 thelial cells do not enter into their construction. Some authors have 
 suggested that these spaces are ectatic lymph-spaces. If the cyst per- 
 sists, the wall of the space would be sure to become lined by endothe- 
 lial cells, as under such circumstances the connective-tissue cells on the 
 surface would become transformed into endothelial cells. Such trans- 
 formation of connective-tissue cells into endothelial cells is frequently 
 observed in the formation of accidental bursae and in the formation of 
 false joints in ununited fracture. The attempt to remove such cysts 
 by extirpation is attended by danger, and often has to be abandoned 
 before the completion of the operation. The injection of irritating 
 solutions has also been followed by disastrous consequences. Repeated 
 evacuation by tapping, followed by the injection of a 5 per cent, solu- 
 tion of carbolic acid under strictest antiseptic precautions, is the safest 
 and most efficient method of treatment. Cysts developing from an 
 embryonic mesoblastic matrix after birth are formed in the same way 
 as epithelial cysts. The central space in the matrix becomes lined by 
 
CYSTOMA. 187 
 
 endothelial cells ; serous contents accumulate and distend the space. 
 The spontaneous disappearance of endothelial cysts is of frequent 
 occurrence, as the endothelial cells may at any time revert into their 
 former condition, and the cyst-contents are more amenable to absorp- 
 tion than are the products of epithelial cells. If the cyst is emptied by 
 absorption of its contents and the endothelial cells lining the cyst-wall 
 are brought in contact, permanent obliteration of the space will follow. 
 Thyroid Gland. — A true cyst of the thyroid gland commences as 
 such. The formation of the cyst is not preceded by any considerable 
 production of glandular tissue. The glandular tissue is scanty. In 
 
 /■>M k 
 
 Fig. 92. — Adenocystoma of thyroid gland; X 85 (Surgical Clinic, Rush Medical College, Chicago): 
 a, a, stroma; b, follicles of gland slightly enlarged ; c, colloid cyst ; d, two colloid cysts separated by a thin 
 septum. 
 
 cystic degeneration of an adenoma of the thyroid gland cyst-formation 
 takes place usually at different points, and the glandular part of the 
 tumor predominates (Fig. 92). The cysts enlarge by the breaking 
 down of the thin compartments between smaller cysts, and the cystic 
 nature of the tumor becomes clinically apparent only after the larger 
 part of the glandular structure has been destroyed by degeneration. 
 In a true cystoma the cavity is formed by expansion of the epithelial 
 cells from a central point of the tumor-matrix, and the tumor is more 
 
 H 
 
1 88 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 frequently unilocular than multilocular. Of course, a number of cysts 
 may form simultaneously and coalesce into one common cavity, but 
 this occurrence is rare as compared with adeno-cystoma. A cystoma 
 of the thyroid gland can usually be recognized without difficulty, but 
 if any doubt exists, this can be set aside effectually by an exploratory 
 puncture. Enucleation is the proper treatment for cystic tumor of the 
 thyroid. If this operation cannot be done on account either of calcareous 
 degeneration of the cyst-wall or of firm adhesions with the surround- 
 ing tissues, a partial thyroidectomy is indicated. Laying open of the 
 cyst freely by incision, followed by vigorous application of the actual 
 cautery so as thoroughly to destroy the cellular lining of the interior 
 of the cyst-wall, will also effect a radical cure, but this treatment 
 consumes more time and will leave a more unsightly scar than either 
 enucleation or extirpation. 
 
 The writer has recently treated successfully a cyst of the thyroid 
 gland the size of a hen's egg by a single tapping, followed by the 
 injection of 2 drams of a 10 per cent, emulsion of iodoform in 
 glycerin. 
 
 Mammary Gland. — Retention-cysts and adeno-cystoma of the mam- 
 mary gland occur much more frequently than true cysts. In both 
 instances the cysts are frequently multiple, and seldom do they attain 
 great size. Bryant divides cysts of the mammary gland into three 
 varieties : I . Cystic degenerations of the breast, met with in the aged as 
 well as in glands which have long ceased to be active — " involution- 
 cysts," as they are called ; 2. Cystic tumors of the gland, single or 
 multiple, of glandular, duct-, or connective-tissue formation, without 
 intracystic growths ; 3. Cystic tumors of the breast, of whatever kind, 
 in which papillomatous, adenomatous, sarcomatous, or carcinomatous 
 intracystic growths are present. 
 
 A true cystic tumor commences, like all true cystomata, in the centre 
 of a matrix of embryonic epithelial cells, the epithelial cells becoming 
 attached to the surrounding connective tissue, which becomes the 
 stroma of the tumor. The products of epithelial proliferation accumu- 
 late in the central space and form the contents of the cyst. Serum, or 
 serum altered by the presence of blood or cholesterin-crystals, is usu- 
 ally found as the characteristic contents of such a cyst. The tumor 
 grows slowly in size, displaces the surrounding tissues, and often 
 reaches an enormous size. Paget refers to a case in which the tumor 
 contained nine pounds of serous fluid. He remarks, very correctly, 
 that tumors which contain the simplest fluids and which have the 
 simplest walls are apt to grow to the largest size. Thickening of cyst- 
 walls and, much more, their calcification are here, as elsewhere, signs 
 
CYSTOMA. 
 
 189 
 
 of degeneracy and of loss of productive power. A true cystoma of 
 the mammary gland is characterized clinically by its progressive growth, 
 its simple contents, and the thinness of the cyst-wall. 
 
 Another form of cyst of the mammary gland is described as " pro- 
 liferous cyst," in which, from the cyst-wall, papillary excrescences 
 project into the cyst, resembling the same kind of cyst in the ovary. 
 This kind of cyst, however, more frequently occurs associated with 
 adenoma or sarcoma of the breast than as a distinct anatomical variety 
 of cystoma. 
 
 Enucleation is the proper treatment of cystic tumors of the breast ; 
 if this operation does not succeed on account of firm adhesions or of 
 degeneration of the cyst-wall, the excision of a small zone of gland- 
 tissue with the cyst will ensure a radical cure. 
 
 Ovary. — As cysts of the ovary have so many different histogenetic 
 sources from which they take their origin, and as the different localities 
 correspond with so many structures of different embryonic origin, the 
 student must familiarize himself with the development of the ovary in 
 the embryo in order to enable him to trace the different kinds of cysts 
 to their proper embryonic matrices (Fig. 93). 
 
 aa 
 Fig. 93. — Schema of tubo-ovarian apparatus, to show the various points of origin of cystic growths 
 (after Doran) : aa, multilocular glandular cyst, developed in a, ovarian parenchyma ; c, papillary cyst, devel- 
 oped in b, tissue of the hilum of the ovary; d, unilocular cyst of the broad ligament, free from the parova- 
 rium, k; e, unilocular cyst of the broad ligament, situated just above the Fallopian tube, but not united to 
 it ; f, similar cyst nearjf, utero-ovarian ligament ; h, hydatid of Morgagni, which is never the starting-point 
 of a large cyst ; i, cyst developed at the expense of the horizontal canal of the parovarium ; /, cyst devel- 
 oped at the expense of the vertical tube (according to Doran, these are the papillary cysts of the broad liga- 
 ment) ; in, n, course of the obliterated canal of Gartner : papillary cysts may be developed at any portion 
 of this canal (Coblenz), and these cysts may be the origin of papillary cysts connected with the uterus, ;/. 
 
 The size of the cyst will depend on the vegetative capacity of the cells 
 of the tumor-matrix. The nature of the contents of ovarian cysts is 
 determined by the histological character of the tumor-cells and by the 
 type of degenerative changes which these cells undergo. The hydatids 
 
190 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 of Morgagni consist of an exceedingly delicate cell-wall and a trans- 
 
 Fig. 94. — Cystic disease of the ovaries : serous and myxomatous multiple follicular cysts (after Pozzi) : 
 a, a', small myxomatous cysts ; b, b' , large myxomatous cysts ; e, e' , follicular cysts with fluid contents ; c, 
 g, g 1 , follicular cysts with caseous contents ; o,f,f, ovarian tissue containing small follicular cysts. 
 
 parent clear serum as contents, and they seldom exceed the size of an 
 
 Fig. 95. — Papillary cyst starting from the hilus of the ovary (aftor Doran). On the 1-eft lower extreme 
 of the picture is the ovary, which is almost intact. The cyst is developed within the broad ligament, which 
 is opened so that we may see above a portion of the Fallopian tube. An opening has been made in the cyst- 
 wall to show the papillary vegetations within. 
 
 ordinary marble. They are usually pedunculated, and are discovered 
 only in opening the abdomen for other indications. 
 
CYSTOMA. 
 
 I 9 I 
 
 The multiple cysts with serous contents that characterize the cystic 
 ovary as described by Rokitansky hardly ever exceed in size a cherry- 
 stone (Fig. 94). 
 
 Ovarian cysts of this variety are always complicated by sclerosis 
 of the interstitial tissue. In a very instructive paper on ovarian papillo- 
 ma Coblenz gives an accurate histogenetic account of this variety of 
 ovarian cysts. The author comes to the conclusion that the Pfliiger- 
 Waldeyer epithelial sacs, as well as the medullary tubules of Kolliker, 
 may give rise to the formation of cysts, but that from the former the 
 glandular, and from the latter the papillary, variety are produced. At 
 any rate, the papillary cysts are genetically and anatomically analogous 
 to the papillary formation of the mucous membranes, whether they are 
 in the interior of cysts or whether they spring from the surface of the 
 ovary. In the latter case the tumor may have developed from the sur- 
 face of the ovaiy or may have reached this locality from the interior of 
 a cyst. Proliferous cysts spring either from the surface of the ovary 
 or from rests of fetal tubules in the ovary (Fig. 95). The cystic spaces 
 are usually small, and the proliferating masses in their interior are large. 
 
 Papillary growths on the surface of the ovary, and similar vegeta- 
 tions reaching the surface after perforation of a proliferous cyst, spread 
 
 Fig. 96. — Papillary tumor of ovary covering the whole of both broad ligaments (after Pozzi). 
 
 to the surrounding parts, often imbedding ovary, tube, ligament, and 
 uterus (Fig. 96). The histological structure of a papuliferous tumor 
 of the ovary is well shown in Figure 97. 
 
 Proliferous cysts of the ovary are more likely to return after opera- 
 tion than are any of the other benign tumors. If the tumor develops 
 from the surface of the ovary, or if the operation is postponed after a 
 proliferous cyst has been perforated, fragments of the tumor frequently 
 remain, and it is from these fragments that the recurrence takes place. 
 Recurring tumors have no pedicle and are usually extensively adherent, 
 
 ■M 
 
193 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 
 1 
 
 S; 
 
 & 
 
 i = 
 
 </) o 
 
 u 
 
 « 8 
 
 « >> 
 
CYSTOMA. 
 
 J 93 
 
 rendering their removal difficult and sometimes impossible. If the 
 tumor-tissue comes in contact with the peritoneal surface, ascites sets 
 in, still further complicating the case. 
 
 L 
 
 Fig. 99. — Adeno-cystoma of right ovary (after Winckel). In the anterior wall of the large cyst a number 
 of small prominences indicate the location of smaller cysts. 
 
 Glandular cysts of the ovary always occur as a multiple affection 
 (Fig. 98). By breaking down of the septa the cavities enlarge (Fig. 
 99). The contents undergo various regressive changes and vary 
 
 Fig. 100. — Follicular cysts of ovary (after Barnes). 
 
 greatly in different cysts of the same tumor. Some cysts contain a 
 jelly-like, amorphous mass, others a clear serum, and still others a 
 serous fluid stained by the admixture of blood. 
 13 
 
 M 
 
i94 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The origin of simple cysts of the ovary has been the subject of care- 
 ful investigation, but has not definitely been settled. The so-called "fol- 
 licular cysts " are dilated Graafian follicles. All the histological elements 
 of a normal follicle are found in such cysts. The cysts are numerous 
 and are separated by septa of connective tissue (Fig. ioo). The spaces 
 are lined by columnar epithelium, and ova have been found in their 
 interior by Ritchie, Webb, Tait, and Rokitansky. The cysts contain 
 usually clear serum ; occasionally the serum is of a yellowish color, 
 and sometimes it is otherwise stained by the admixture of blood. 
 Sometimes the epithelial cells undergo myxomatous degeneration 
 (Fig. 101). 
 
 Hydrops of the follicles of the ovary is usually a symmetrical affec- 
 tion occurring in both ovaries at the same time. Follicular cysts of the 
 ovary seldom result in the formation of large tumors. It was formerly 
 believed that most of the simple ovarian tumors resulted from disten- 
 tion of pre-existing Graafian follicles by proliferation of the epithelial 
 lining. That this is not the case is now generally admitted, but that 
 occasionally an ovarian cyst may have such an origin cannot be denied. 
 
 Fig. ioi.— Follicular cyst of ovary with myxomatous degeneration; X 5° (after Pozzi) : A, A, loose myxo- 
 matous tissue toward the interior of the cyst ; B, B, dense myxomatous tissue toward the external surface. 
 
 If in a Graafian follicle a matrix of embryonic epithelial cells should 
 
CYSTOMA 
 
 195 
 
 exist, we can readily understand that the follicle would become the 
 cyst-wall, while the matrix would furnish the contents. Neumann ex- 
 amined a monolocular ovarian cyst which contained four liters of fluid, 
 and found that the cyst had developed from a Graafian follicle. The 
 deposit which formed in the fluid after standing for some time contained 
 epithelial cells of the membrana granulosa and innumerable ova with 
 a distinct zona pellucida. Neumann estimated the number of ova at 
 many thousands. The majority of simple ovarian cysts undoubtedly 
 originate from embryonic tubular rests. 
 
 Cysts of the corpus luteum were ascribed by Rokitansky to preg- 
 nancy, but Gottschalk found them also in nullipara. The contents of a 
 
 Fig. 102. — Corpus luteum ; X 350. 
 
 corpus luteum of the ovary without cystic degeneration are shown in 
 Figure 102, which shows the epithelial cells of the follicle and rem- 
 nants of the blood-clot. Cystic degeneration of a follicle may lead to 
 the formation of cysts as large as an apple. Nagel has seen them as 
 large as an adult's head. Cysts of the corpus luteum (Figs. 103, 104), 
 as well as follicular cysts, are not cystic tumors, but are retention- 
 cysts. 
 
 The parovarium (Fig. 93, k) is frequently the seat of cyst-formation. 
 
 ^^m 
 
196 
 
 PATHOLOGY AND TREATMENT OF TUMORS, 
 
 This structure is an embryonic remnant, and consequently it frequently 
 contains the essential tumor-matrix. Cysts of the parovarium (Fig. 
 105) are also called "cysts of Rosenmiiller's organ,'"' because their 
 origin in the broad ligament, in which they are situated, corresponds 
 to the seat of these embryonic remains. Verneuil, De Sinety, and 
 
 Fig. 103. — Cyst of the corpus luteum ; natural size (after Nagel). 
 
 Doran believe that these cysts are developed in the connective tissue 
 independently of the parovarium. Supernumerary ovaries must also 
 be remembered as a possible source of such cysts. 
 
 According to the structure of the cyst-wall and the character of 
 
 Fig. 104.— Cyst of the corpus luteum; X 50 (after Nagel) : a, connective tissue of the internal surface, 
 epithelium removed; b, yellow layer of corpus luteum ; c, normal tissue of the ovary near the hilum. 
 
 the contents, cysts originating from the parovarium or in its immediate 
 vicinity are divided into — I. Hyaline cysts ; 2. Papillary cysts ; 3. Der- 
 moid cysts. Cysts developing from this locality do not reach a large 
 size, and they contain a serous fluid. Their removal is attended by 
 difficulty, owing to the absence of a pedicle. 
 
 Morgagni's hydatids (Fig. 106) are small, translucent, pedunculated 
 
CYSTOMA. 197 
 
 cysts attached to the fimbriated extremity of the Fallopian tubes. 
 According to Waldeyer, these cysts are caused by partial distraction 
 of Miiller's canal by fixation of a part of this structure to the diaphrag- 
 matic band of the primary kidney. These cysts are perfectly harmless, 
 and never exceed in size a hazelnut. 
 
 Intraligamentous cysts of the broad ligament often attain the size 
 of a fetal head, contain a clear serous fluid, and are lined by squamous, 
 ciliated, or columnar epithelial cells, according to the origin of the 
 tumor-matrix. In diagnosis they are often mistaken for ovarian cysts 
 and for the different varieties of retention-cysts of the Fallopian tube. 
 
 Fig. 105. — Unilocular parovarian cyst of the broad 
 ligament (after Doran). To the left and above is the 
 incised ovary, which is seen to be free. The elongated 
 Fallopian tube is spread over the surface of the cyst. Fig. 106.— Morgagni's hydatid (after Winckel). 
 
 Their removal by enucleation is one of the most difficult of all pelvic 
 operations. Tapping these cysts is not attended by much risk, and the 
 operation has occasionally resulted in a permanent cure. 
 
 Treatment. — The proper treatment of an ovarian cyst, irrespective of 
 its origin and size, is removal by abdominal section. If no contraindi- 
 cations exist, the operation should be performed as soon as the diagno- 
 sis can be made. Under strict antiseptic precautions the abdomen is 
 opened to the requisite extent through the linea alba. After removal 
 of the contents of the cyst by tapping the tumor is drawn forward into 
 the wound and its pedicle is ligated after transfixion by a double liga- 
 ture of silk, and the cyst is severed at a safe distance from the liga- 
 tures, in order to prevent hemorrhage from slipping of the ligatures. 
 The stump should be dusted lightly with iodoform, after which it is 
 returned into the abdomen and the external incision is closed in the 
 usual manner. If the adhesions are firm, it is advisable to leave the 
 peritoneal covering attached to the adherent organs to prevent visceral 
 
198 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 injuries. In aseptic cases drainage may usually be dispensed with 
 unless made necessary by hemorrhage, when a Mikulicz drain should 
 be employed. In closing the abdominal incision the peritoneum and 
 the fascia of recti muscles should be sutured separately. The silk-worm 
 gut should embrace all tissues except peritoneum. 
 
 Vagina. — Kossmann attempts to prove that Gartner's ducts are 
 identical with Wolff's ducts ; that, therefore, where they remain they 
 open into the sinus urogenitalis between the urethral orifice and the 
 introitus vaginae ; that as a rule they usually obliterate, but that in 
 some mammalians, and abnormally in man, the obliteration of a part 
 may not take place, and that, therefore, we may in the human female 
 find their remnants in the anterior vaginal wall down toward the 
 urethral orifice. Nagel, on the other hand, seems to prove by his and 
 other excellent researches that Wolff's ducts have no part in the devel- 
 opment of the vagina, which proceeds from the lowest points of the 
 united Miiller's ducts. Islets of epithelial cells, which subsequently 
 become hollow and constitute the beginning of cyst-formation, have 
 been seen by Ackeren and Schueller in early embryonic life. Vaginal 
 cysts, except those resulting from retention of secretions, arise from 
 embryonic remnants of the distal part of Gartner's duct. The writer 
 has removed two such cysts, as large as a hen's egg, filled with mucus. 
 These cysts are lined with stratified epithelium. Their enucleation from 
 the vagina is not attended by any special difficulty. 
 
 Testicle. — Cysts of the testicle were described by Astley Cooper as 
 "hydatids," and Curling included them under the general term "cystic 
 disease of the testis." Cystic tumors of the testicle are cysts which are 
 developed independently of pre-existing glandular structures, in con- 
 tradistinction to spermatocele, which forms in consequence of a 
 mechanical obstruction interfering with the escape of the physiological 
 secretion of this organ. From the category of cystoma of the tes- 
 ticle must also be excluded the different varieties of hydrocele. The 
 Wolffian body enters largely into the composition of the testicle, and 
 is without doubt the source of many cystic formations ; simple exam- 
 ples are the cysts of the organ of Giraldes. The hydatids of Mor- 
 gagni and other rests of Midler's duct are possible starting-points 
 of cysts. The cyst-wall is composed of an abundant new growth 
 of connective tissue lined by columnar, ciliated, or rarely by strati- 
 fied epithelium. How far the simple stratified cysts are derived 
 from adult spermatic tubes, how far from spermatic tube-rests which 
 have failed to unite with Wolffian-duct tubes, it would be difficult to 
 decide. That some of the sperm-containing cysts owe their origin to 
 these rests seems very probable ; indeed, Paget suggested that in these 
 
CYSTOMA. 
 
 199 
 
 cysts spermatozoa were secreted by the lining membrane. Not long 
 ago the writer removed a cystoma of the testicle, and found in the 
 contents of the cyst numerous spermatozoa and a few epithelial cells. 
 The tumor was perfectly encapsulated, with no connection whatever 
 with the glandular apparatus of the testicle, and was enucleated with 
 ease. Occasionally, cystic tumors of the testicle are multilocular. 
 
 Enucleation is the proper treatment. During the operation the 
 same precautions must be observed as in the removal of adenomata 
 of this organ, to prevent injury to the spermatic cord or the testicle. 
 After enucleation the visceral layer of the tunica vaginalis should be 
 sutured by a buried row of catgut sutures. 
 
 Bye. — The iris and the cornea are the most common localities of 
 cysts of the eyeball. In the iris they occur most frequently upon the 
 anterior surface as sessile or pedunculated cysts containing a serous 
 fluid or a sebaceous material. Mr. Hulke collected 21 cases of cysts 
 of the iris, and found that in 17 cases the cyst-formation was pre- 
 ceded by an injury. He suggests that some of these cysts originated 
 from portions of Descemet's membrane that may have been torn from 
 the cornea and implanted on the iris. 
 
 Corneal cysts (Figs. 107, 108) are caused most frequently by implanta- 
 tion of corneal tissue resulting from 
 operations or injuries. This cause 
 of cyst-formation has been studied 
 carefully by Treacher Collins. 
 
 Fig. 107.— Large implantation-cyst of the cor- 
 nea following an injury (after Collins). 
 
 Fig. 108. — Section of the cyst in Figure 107 
 (highly magnified), showing the laminated epithelium 
 (after Collins). 
 
 The cysts of the cornea following an injury are produced in the 
 same manner as the traumatic epithelial cysts described in the begin- 
 ning of this section. They arise from transplantation of conjunctival 
 epithelium into the deep tissues of the cornea. 
 
 Cysts of the Vitello -intestinal Duct. — The profession is greatly 
 indebted to J. Bland Sutton for a more thorough understanding of 
 cysts of the vitello-intestinal duct and cysts of the urachus. His 
 investigations have done the most toward enabling surgeons to refer 
 
200 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 hitherto obscure cysts in these localities to their origin from remnants 
 of embryonic life. Cysts of the vitello-intestinal duct connected with 
 the umbilicus of babes and young children, and varying in size from a 
 pea to a cherry, are of frequent occurrence. They are usually pedun- 
 culated, and are composed of unstriped muscle-fibre, mucous mem- 
 brane, Lieberkuhn's follicles, and columnar epithelium collected in a 
 mass. These cysts may enlarge, rupture spontaneously, and leave a 
 sinus from which escapes a watery discharge. In rare cases that part 
 of the vitello-intestinal duct connected with the ileum becomes the seat 
 of cyst-formation. Such a case was reported by Roth. Occasionally 
 the entire duct remains patent, when part of the intestinal contents 
 escape from its opening at the umbilicus. Sutton has traced imper- 
 forate ileum to the vitello-intestinal duct. 
 
 Allantoic (Urachus) Cysts. — The urinary bladder of man presents 
 at its apex an impervious cord, known as the urachus, which passes to 
 the umbilicus. The duct is obliterated at birth, and in the adult lies in 
 the subperitoneal tissue in the middle line of the anterior abdominal 
 wall. If the urachus does not become obliterated in any part of its 
 course, it becomes dilated, and the cyst is found outside the peritoneum 
 and in close relation with the bladder. The whole of the intra-abdom- 
 inal part of the urachus may remain patent and form a large urinary 
 bladder. Shattock observed such a case. If the entire urachus remains 
 open, urine escapes at the umbilicus. Tait reported a case in which he 
 found a large cyst of the urachus beneath the abdominal wall. The 
 surgical treatment of such cases is not well settled, and must be deter- 
 mined largely by the size and location of the cyst. 
 
 Cysts of the vitello-intestinal duct and the urachus are not cysto- 
 mata, but are retention-cysts resulting from faulty development. 
 
 Bone. — True cystoma of bone is exceedingly rare. Engel describes 
 the case of a female fifty-five years of age, the mother of six. healthy 
 children, who died of an acute affection and who had never exhibited 
 symptoms indicative of any bone-lesion. At the post-mortem the 
 entire skeleton was found occupied by cysts varying in size from that 
 of a pea to three inches in diameter. The cysts contained a clear or a 
 bloody serum. The cyst-walls consisted of a layer of connective tissue. 
 In a few cases isolated cysts of considerable size have been found in 
 different bones. 
 
 Bone-cysts developing from a displaced matrix of embryonic epithe- 
 lial cells are most frequently met with in the maxillary bones. 
 
 Single cysts of the jaws are usually developed in connection with 
 displaced or diseased teeth, and consequently are met with most fre- 
 quently in young persons. 
 
CYSTOMA. 20I 
 
 Malassez has made careful researches concerning the origin of cysts 
 of the jaws, which have led him to the conclusion that they start from 
 what he calls " debris paradentaires epitheliaux," which he was able to 
 demonstrate in embryos as well as in the adult. Such epithelial nests 
 are formed during intrauterine life by the mucous membrane covering 
 the alveolar margin projecting into the tissues, where by constriction 
 
 
 
 
 N- 
 
 P ifr^r;^ 
 
 l\#?A^ 
 
 
 r v V\\\> -~, . ' '■ '^*m^f$*<<r':>'h>-~c 
 
 *m^ S* 
 
 JM'* 
 
 ck /« . ;■ - - — ^— " ,i.r ■-; „,*v 
 
 m 
 
 <t * 
 
 f t * 
 
 % J jfJJ!*%i*?$X*i*r*;#X<l t !k ¥:•&, '^ .■.jF**':*' M& 
 
 * m\ ••' 2SW c *! " . • ' '» ' S .**» #;, : : * v f i .£ ~ « ' „•■ /* , * />£. 
 
 44^ — a 
 
 ^ 
 
 * * • »■ * - »»« V. ' i " • ; i *«** »** v ,V s .- \ ** . : - V* 
 
 -t~^ s^ 
 
 
 i? SB •• w-> .;^ fi: » » > t#^Sr — Pk 
 
 Fig. 109.— Multilocular cystoma of the lower jaw ; vertical section through tumor, X 176 (after Becker) : 
 C, cylindrical cells ; P, polygonal cells ; PI, flattened polygonal cells ; S, stellate cells ; V, vacuoles ; Cy, cyst ; 
 Pk, pearl-globe (Kugel) ; K, granular contents of cyst ; Ca, capillary from stroma into alveolus ; Ck, colloid 
 mass ; Si, stroma. 
 
 at the surface isolation takes place, forming the tooth-germs, and from 
 which buds may form, which serve later as the starting-point of 
 cystoma. Allgayer and Grasse are of the same opinion. Such cysts 
 are lined with epithelial cells, and contain usually a viscid yellowish 
 fluid. 
 
 Multilocular cysts of the jaws (Fig. 109) are a great rarity. Re- 
 
202 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 cently two such cases from the clinic at Bonn were described by Becker. 
 This author found in literature sixteen additional cases. The lower 
 jaw is more frequently the seat of this tumor. From this fact alone 
 it is evident that displaced dental germs are not the cause of these 
 cysts, as most authors claim. In the upper jaw such cysts may rup- 
 ture into the antrum of Highmore. They are found more frequently 
 in the region of the molar and bicuspid than in that of the other teeth. 
 The youngest patient was twelve years, the oldest seventy-two years 
 of age. The growth, which commences during childhood and puberty, 
 is slow. Trauma and inflammatory affections are the exciting causes. 
 According to the location of the matrix the cyst will project either 
 from the outer or the inner side of the jaw. 
 
 The crackling sensation (bruit de parchemin) as a diagnostic sign 
 in the examination of multilocular tumors of the jaw was described by 
 Runge in 1775, and later by Dupuytren. Fluctuation appears when the 
 bony wall has been absorbed, and is consequently a later sign. Ulcer- 
 ation of the gums does not take place. Such tumors often attain an 
 enormous size. Falkson and Bryk describe a case in which the tumor 
 weighed one and a half kilograms and reached from the zygomatic arch 
 to the sternum. On section through the tumor a system of hollow spaces 
 was disclosed. Some of the cysts communicated with others. The 
 septa are usually membranous. These cysts contain a viscid fluid some- 
 times mixed with blood. The size of the cysts varies from minute 
 spaces to that of a hen's egg. The inner surface of the cysts is smooth. 
 In the study of these cysts three stages are apparent : 1. Cellular cords ; 
 2. Alveoli ; 3. Cysts. 
 
XVI. CARCINOMA. 
 
 The subject of carcinoma is one of immense etiological and clinical 
 interest. The etiology has been investigated and discussed for cen- 
 turies, and, although great progress has been made in tracing the histo- 
 genetic origin of carcinoma to its proper source, the explanation of the 
 real cause awaits discovery. The etiology has recently received renewed 
 interest from the bacteriological researches that have been made to prove 
 the microbic origin of carcinoma. As we shall see farther on, no posi- 
 tive proof has been furnished so far that carcinoma is a microbic disease. 
 The clinical interest of carcinoma arises from the prevalence of this 
 affection and the inadequacy of the present surgical resources to cope 
 with it successfully. To what fearful extent carcinoma figures as a cause 
 of death can be learned from the fact that in England and Wales during 
 ten years (1860-1870), 2,379,622 persons above the age of twenty died, 
 and that this number includes 81,699 deaths from carcinoma, the deaths 
 from this cause constituting to all others a ratio of 1 : 29. There can 
 be but little doubt that this disease is on the increase. The dread of 
 carcinoma is almost universal. Its terrors have been described in prose 
 and in poetry. Shakespeare alludes to it in Hamlet : "And is't not to 
 be damned, to let this canker of our nature come in further evil ?." 
 Not only the profession, but also the public, is aware of the great 
 shortcomings of surgery in its treatment. The impression prevails 
 among the people that it is incurable. The great mass of the people 
 have abandoned all hope of the receipt of permanent benefit from the 
 recognized surgical craft for this affection, and seek aid from so-called 
 " cancer specialists " that exist everywhere and fatten on the credulity 
 of an army of despondent, almost desperate, cancer patients. This sad 
 condition of affairs, and with it the remunerative occupation of this 
 horde of pretenders, will cease to exist when the discovery of the real 
 cause of carcinoma is made and when successful therapeutic measures 
 are established upon such basis. The writer has great confidence in 
 future investigations in this direction. A great number of tireless, 
 honest investigators are at work, and the prophesied results will be 
 realized in time. 
 
 Definition. — Carcinoma is an atypical proliferation of epithelial cells 
 from a matrix of embryonic cells of congenital or post-natal origin. 
 
 203 
 
204 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 This definition includes what is known of the histogenetic origin of 
 carcinoma. It refers the tumor to its primary location in mesoblastic 
 tissue, and the origin of its cellular elements to a matrix of embryonic 
 epithelial cells. The heterotopic location of the epithelial cells distin- 
 guishes carcinoma from all the benign epithelial tU7nors. Atypical pro- 
 liferation of epithelial cells means their growth and multiplication in 
 a locality where epithelial cells have no legitimate citizenship. The 
 matrix may occupy such a location from the very beginning when 
 embryonic cells have been displaced into mesoblastic tissue during the 
 development of the embryo in the case of congenital matrices ; or 
 when in a burn or a wound or an inflammatory process embryonic cells 
 become buried in the mesoblast after destruction of the membrana 
 propria in matrices of post-natal origin ; or, finally, if the matrix is 
 confined to the epiblastic or hypoblastic tissues, the carcinoma dates 
 back to the time when the embryonic cells passed through and beyond 
 the membrana propria into the vascular mesoblastic tissues. 
 
 Views Past and Present regarding the Origin and Nature of 
 Carcinoma. — The old authors were familiar with the gross appearances 
 and the clinical aspects of carcinoma. The division into open and sub- 
 cutaneous carcinoma was made at an early day ; the former was de- 
 scribed as cancer apertus, and the latter as cancer occultus. Celsus 
 understood under the term " cancer " the several forms of gangrene. 
 Galen insisted on an early diagnosis, which he based almost exclusively 
 upon its clinical course. ^Etius gave an accurate description of carci- 
 noma of the uterus. The classical description of cancer by Soranus 
 would be no discredit to a modern work on general pathology. All 
 malignant growths were included under the head of cancer. The first 
 attempt to describe tumors upon an anatomical basis was made by 
 Johannes Miiller in his work on The Structure of Morbid Growths, 
 published in 1838. Virchow traced the tumor-cells to their histological 
 origin, and thus laid the foundation for a rational classification. He 
 was also the first to describe the alveolar structure of carcinoma, and 
 he called attention to the resemblance of carcinoma-cells to epithelial 
 cells. He believed that both stroma and the epithelial cells were pro- 
 duced by the connective tissue. 
 
 The microscope was made available as a means of investigating the 
 structure of tumors by Schleiden and Schwann. Miiller in 1836, in a 
 preliminary communication, divided tumors into "benign" and "malig- 
 nant," by which terms he meant tumors that were curable or incurable 
 by operation. Bichat described carcinoma as a subepithelial tumor, and 
 distinguished a stroma which he believed consisted of degenerated con- 
 nective tissue and of cells derived from the epithelial layer. Laennec 
 
CARCINOMA. 205 
 
 divided tumors into " homologous " and " heterologous," and among 
 the latter included tubercle, encephaloid, melanosis, and scirrhus. Lob- 
 stein, while admitting the correctness of this division, believed that the 
 difference between the two kinds of tumors was due to a species of 
 lymph, which, according to the character of the tumor, is either euplastic 
 or cacoplastic. Miiller maintained that the structure of benign and 
 malignant tumors was identical, and that the classification into homol- 
 ogous and heterologous tumors was based on ignorance of their micro- 
 scopical structure. He, however, recognized a neoplastic form of cell- 
 elements, and in the examination of tumor-tissue under the microscope 
 he speaks of normal tissue, granules, cells, "and new connective tissue. 
 From that time dates the description of a morphologically specific 
 caudate cancer-cell which was regarded as the essential element of 
 cancerous infiltration — an opinion which prevailed at his time, but 
 which was not shared by Miiller. Lebert and Hannover revived again 
 the theory of the existence of a specific cancer-cell, but, instead of the 
 caudate cell, described a more primitive structure. Lebert separated 
 carcinoma of the skin from carcinoma of internal organs, and called it 
 cancroid. About the same time Ecker examined microscopically three 
 specimens of carcinoma of the lip, and, finding no foreign heteroplastic 
 cells, declared them to be a simple hypertrophy of the papillae. Mayo 
 discovered general infiltration in a similar tumor, and therefore classified 
 it with what was then generally recognized as cancerous tumors. 
 
 Rokitansky classified carcinoma of the skin with glandular carci- 
 noma, and regarded it as a variety of medullary fungus, differing from 
 carcinoma proper only by the form and aggregation of its cells. Lebert 
 modified his views regarding the structure and nature of cancroid after 
 he discovered that in some cases it gave rise to glandular and general 
 infection, and after having found in it the cell-forms which he regarded 
 as characteristic of carcinoma. In 1845 he- distinguished three kinds 
 of carcinoma of the skin: 1. Papillary excrescences with inflamed, 
 indurated base and superficial ulceration ; 2. Papillary proliferations of 
 the cauliflower kind with enlargement of the sebaceous glands ; 3. Epi- 
 thelial neoplasms consisting of a fibrous framework, its meshes filled 
 with epithelial cells. Ecker, Mayo, and Lebert referred the origin of 
 the new epithelial cells to proliferation from pre-existing mature epithe- 
 lial cells, while Virchow, Rokitansky, and Neumann claimed that they 
 were the product of metaplastic proliferation of the connective tissue. 
 The glandular origin of carcinoma of the skin was studied by E. H. 
 Weber, and later by Gluge. Ecker, Mayo, Lebert, and Rokitansky 
 believed that carcinoma resulted from tissue-proliferation of the papillae 
 of the skin. Virchow applied the term cancroid to surface carcinoma 
 
206 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 in which, in the tumor-tissue, spaces are formed and are occupied by 
 epithelial cells. Fiihrer called attention to the possible influence of 
 irritation caused by the hair in the production of carcinoma of the lip 
 in men. Robin believed that carcinoma of the skin originated in the 
 sebaceous glands. 
 
 Hannover originated the term epithelioma for carcinoma of the skin 
 and mucous membranes — a term which has caused a great deal of 
 confusion in distinguishing a benign from a malignant epithelial tumor. 
 He asserted that carcinoma of the skin originated from the rete Mal- 
 pighii, and not in the glandular appendages of the skin. Verneuil and 
 Forster observed cases of carcinoma of the skin that originated in 
 sweat-glands. A parallel to the history of surface carcinoma is that of 
 a form of ulceration of the skin that was called ulcere cancroide by 
 Lebert, ulcus rodens by Paget, and ulcus phagedcenicum by Von Bruns. 
 Many English authors adhere to the term rodent ulcer, and describe 
 under it something which is supposed to be different from true carci- 
 noma. Modern writers, with few exceptions, look upon rodent ulcer as 
 a variety of carcinoma of the skin. Forster observed fatty degeneration 
 of the tissues in carcinoma of the skin, besides a mucous metamorphosis 
 of the cell-masses in the alveoli. Colloid degeneration was found only 
 in exceptional cases. It was ascertained later that the cylindroma of 
 Billroth also represents only a secondary change occurring in surface 
 carcinoma. In but a few instances was a primary carcinoma found 
 away from the epiblastic or hypoblastic tissues. Virchow reports a 
 primary cancroid in the tibia ; O. Weber, in the inferior maxilla ; Paget, 
 in the inguinal glands. In all these and in similar cases the prolifer- 
 ation had its origin from a displaced matrix of embryonic epiblastic or 
 hypoblastic tissue. Cohnheim went a step farther, and claimed that 
 carcinoma did not originate by proliferation from mature epithelial cells, 
 but that it was produced, independently of mature pre-existing tissue, 
 from a matrix of embryonic epithelial cells, and he advanced the theory 
 which assigns to the origin of all tumors a matrix of embryonic tissue. 
 This theory has been upheld strongly by Waldeyer and a number of 
 modern writers. It goes farther toward explaining the origin of tumors 
 than any other theory heretofore advanced. Until quite recently car- 
 cinoma was regarded as a local manifestation of a general dyscrasia. 
 It was supposed that the essential cause existed in the blood, and that 
 the tissues the seat of tumor-formation were acted upon by a specific 
 virus. Virchow assumed the existence in the tissues of a primary 
 carcinoma of a seminium which, by being brought in contact with 
 lymphatic and other tissues, reproduced the disease in other localities, 
 and which by its action upon the adjacent tissues gave rise to local 
 
CARCINOMA. 207 
 
 infection. He asserts that in the primary formation no doubt there is 
 produced a contagious material which acts upon the tissues with which 
 it comes in contact in the same manner as does the lymph in lymph- 
 glands. The more anastomoses the affected parts have, the more such 
 a result may be expected. Cartilage is almost exempt from local infec- 
 tion of a malignant growth, owing to the absence of blood-vessels and 
 lymphatics. In malignant tumors in the epiphyseal region of the long 
 bones the articular cartilage is often found completely separated, and 
 shows the effect of pressure-atrophy rather than of direct implication 
 by the tumor. He believes that local infection from a malignant growth 
 takes place by the action of an infective fluid brought in contact with 
 cells without the intervention of vessels or nerves. He admits that it 
 is not known whether distant parts are infected in a similar manner or 
 whether metastasis takes place by transportation of cells. He believes 
 that the occurrence of metastatic carcinoma of the liver without carci- 
 noma of the lung speaks against cellular transportation as a cause of 
 metastatic tumors. W. Miiller and Creighton believe that the virus 
 produced in a carcinoma affects the tissues with which it is brought in 
 contact like the spermatozoa affects the ovum, the cell-impregnation 
 giving rise to tissue-proliferation. 
 
 Mr. Simon in a recent discussion on 'carcinoma took this standpoint. 
 He attempted to show that the mere wandering of cancer-cells to parts 
 distant from the primary tumor, and their overgrowth in their new loca- 
 tion, did not explain the facts as observed in these tumors. He 
 maintained that the essence of the specific force of malignancy is an 
 impregnative or spermatic one, whereby the part primarily affected 
 exercises on the tissue receiving its juices an influence which causes 
 the latter " to fructify in conformity with its own deranged pat- 
 tern." But then, again, holding these views, he still is able to 
 see two functionally distinct classes of disease in cancerous and non- 
 cancerous tumors. It is difficult to conceive how a modern path- 
 ologist could hold such views in the face of the numerous and con- 
 clusive proofs of dissemination of carcinoma by migrating and trans- 
 planted cells. 
 
 More recent researches have been made with a view of demonstrat- 
 ing the microbic origin of the primary and secondary tumors, but so 
 far no conclusive proof has been furnished of the microbic origin of 
 carcinoma. Our present knowledge concerning the origin and growth 
 of carcinoma warrants us in making the statement that carcinoma is the 
 result of an atypical proliferation from a matrix' of embryonic cells, and 
 the local and general infections are caused by the local and general 
 dissemination of carcinoma-cells. 
 
208 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Histogenesis. — In discussing the histogenesis of carcinoma we shall 
 take it for granted that all carcinomatous tumors spring from a similar 
 matrix — that is, that they all have a similar histogenetic origin. It has 
 been stated elsewhere that the histological structure of the tumor and 
 its behavior to the surrounding tissues are modified by the type of the 
 cells of which it is composed and the nature of its environment ; but 
 all cancerous' tumors bear a resemblance to one another anatomically 
 and manifest the same clinical tendencies. The idea that the old authors 
 entertained in regard to the parasitic nature of tumors of all kinds, but 
 especially of carcinoma, presents plausible features. Even normal cells, 
 as Virchow says, live a parasitic life. In a stricter sense the term 
 parasitic can be applied to cells which, when detached from their 
 mother-soil, retain under favorable circumstances their vitality when 
 transplanted into other localities, such as epithelial cells and cartilage- 
 cells. If a piece of connective tissue should become detached and 
 should engraft itself upon living tissue in some other place, it would 
 have to be regarded as a parasite, as its existence would depend upon 
 the abstraction of nutritive material from the new soil. The parasitic 
 nature of malignant tumors is more marked than that of the benign 
 growths, because a carcinoma or a sarcoma from its very commence- 
 ment destroys pre-existing tissues, besides robbing the part in which 
 it is located of a part of its nutritive supply. 
 
 Parasitism of tumors, in the sense in which the expression is 
 used to-day, is much more limited in its significance than formerly. 
 When used in its modern sense, the term signifies the presence 
 in the body of growths which have no existence in the normal 
 body. We now regard a tumor as an integral part of the organ- 
 ism, the product of tissue-proliferation from a matrix of embryonic 
 cells. 
 
 The first attempt to trace tumors to their proper histogenetic source 
 was made by Virchow, who believed that the carcinoma-cells, like the 
 cells of nearly all tumors, were derived from the connective tissue. 
 He found cells in carcinoma far away from normal epithelial cells, and 
 from their resemblance to epithelial cells he called them epithelioid cells. 
 He believed that these cells were produced in the localities in which 
 he found them. Forster believed that the cells of the cylinder-celled 
 epithelial cancroid of the gastro-intestinal canal and the squamous 
 epithelioma of the skin were produced by the pre-existing connective 
 tissue of the part in which the tumor originated. Neumann supported 
 Virchow's views in reference to the histogenetic source of the carci- 
 noma-cells. Koster, a pupil of Recklinghausen, asserted that in carci- 
 noma of the skin and the stomach the carcinoma-cells were derived 
 
CARCINOMA. 209 
 
 from the endothelial cells of the lymphatic vessels. Virchow describes 
 cell-formation in carcinoma as follows : "A portion of a large granular 
 cell becomes uniformly transparent, possibly beginning with a degener- 
 ating nucleus. This portion shows from the first a definite wall, which 
 becomes thickened and similar in appearance to cartilage-cells. During 
 this change the remainder of the old cell becomes more homogeneous 
 and frequently disappears entirely." He considers the cavities, or vacu- 
 oles, in carcinoma-cells and in cartilage-cells identical. This condition 
 seems to be the first step to overcome morphologically the apparently 
 great differences between epithelial and cartilaginous structures. As 
 illustrations of their close relation, instances of two tumors, one of 
 the parotid gland and the other of the testicle, are given, in which 
 tumors a portion was of epithelial and the remainder of cartilaginous 
 structure. 
 
 Virchow's views prevailed until Remak established the doctrine of 
 the independence of the different histological elements and founded the 
 law of the normal succession of cells. His supported Remak's teach- 
 ing in a most positive manner. The same author added to our know- 
 ledge of the histogenesis of epithelial tumors by excluding from them 
 endothelial tumors. He regarded the endothelial cells as a variety of 
 connective-tissue cell derived from a histogenetic source entirely differ- 
 ent from the epithelial cells. In the light of recent embryological in- 
 vestigations, the doctrine of metaplasia as expounded by Virchow is no 
 longer tenable. Connective tissue cannot produce epithelial cells, and 
 epithelial cells cannot produce connective tissue. The law of the legiti- 
 mate succession of cells holds true in the growth of tumors, both benign 
 a7id malignant, as well as in the production of normal tissue. The 
 origin of carcinoma-cells from mature pre-existing epithelial cells was 
 accepted by Billroth, Liicke, Rudnow, Thiersch, Klebs, Rindfleisch, 
 and others. Waldeyer went a step farther in explaining the difference 
 between the origin of benign and malignant epithelial tumors when he 
 defined a carcinoma as "an atypical epithelial tumor." With this defini- 
 tion he wished to draw a line between a benign and a malignant epithelial 
 tumor. By an atypical proliferation of epithelial cells is meant a condition 
 in which the new cells produced originally within the limits of epithe- 
 lial tissue extend beyond the limits of the physiological type — that is, 
 beyond the basement membrane. An adenoma (Fig. no) as compared 
 with a carcinoma (Fig. 1 1 1) is a typical tumor because the epithelial 
 cells remain within their normal physiological boundary-line, the mem- 
 brana propria. 
 
 By contrasting Figures 1 10 and 1 1 1 it will be seen at a glance what 
 is meant by a " typical " and an " atypical " tumor. Adenoma of the 
 
 14 
 
210 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 A2i 
 
 i ii 
 
 
 
 E 5 .S 
 
 2S _g 
 
 •of- 
 < 3 vT 
 
CARCINOMA. 211 
 
 breast is a typical epithelial tumor because the epithelial cells have at 
 no place lost their normal relations with the connective tissue ; the 
 cells and the connective tissue are separated by the membrana propria. 
 Carcinoma of the tongue is an atypical epithelial tumor because the new 
 epithelial cells have passed beyond the membrana propria and are 
 beginning to infiltrate the connective tissue. The proliferation here is 
 atypical because the epithelial cells are produced in a tissue of a differ- 
 ent type and in a place distant from that in which they normally 
 originate. 
 
 To make, the point between typical and atypical proliferation of 
 epithelial cells still stronger the atypical proliferation will be defined 
 as the presence, growth, and multiplication of epithelial cells in the meso- 
 blastic tissues. Klebs defines this process very correctly as " a meta- 
 stasis of epithelial cells." 
 
 Cohnheim believed in the epithelial origin of carcinoma, but asserted 
 that mature epithelial cells are not capable of producing a tumor. He 
 claimed that all tumors originate from a congenital matrix of embryonic 
 cells. For carcinoma he assumed either a matrix of epithelial cells in 
 localities in which epithelial cells normally exist, or a displaced matrix. 
 From this standpoint all tumors are atypical. We shall, however, use 
 the word " atypical " in the sense in which Waldeyer applied it. We 
 shall hold fast to Cohnheim's theory regarding the histogenesis of car- 
 cinoma. If a carcinoma always originates from epithelial cells, primary 
 carcinoma in mesoblastic tissue is impossible from a histogenetic stand- 
 point unless a matrix of embryonic epithelial cells has become displaced 
 during the development of the embryo, or when epithelial cells have become 
 buried in mesoblastic tissues, after birth, by injury or by disease. Primary 
 carcinoma of mesoblastic tissues is due to the presence of a displaced 
 matrix of embryonic epithelial cells. It is from such matrices that 
 primary carcinoma is occasionally observed in bone, in lymphatic glands, 
 and in other mesoblastic tissues. Deep-seated carcinoma of the neck 
 occurring independently of infection from another source originates 
 either from branchial structures — branchiogenous carcinoma (Volk- 
 mann) — or from an accessory or supernumerary thyroid gland — struma 
 carcinomatosa accessoria (Guttmann). 
 
 The origin of carcinoma in accessory organs must be taken into 
 consideration in the diagnosis of primary carcinoma in unusual localities. 
 A post-natal matrix of embryonic epithelial cells is more frequently the 
 starting-point of carcinoma than was formerly supposed. Such a matrix 
 is created in ordinary scar-tissue in scars following deep burns, in 
 ulcers, and by the traumatic displacement of fragments of epithelial 
 tissue. 
 
212 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Histology. 
 All carcinomatous tumors are composed of epithelial cells and an 
 alveolated stroma of connective tissue. One of the strongest argu- 
 ments against the microbic origin of carcinoma is the histogenetic 
 source of the carcinoma-cells. Pathogenic microbes act upon the 
 tissues with which they are brought in contact, and the proliferation 
 results in cells which correspond in type with the cells acted upon 
 by the microbes. Carcinoma-cells multiply by karyokinesis. Soon 
 after Flemming published the result of his observations on karyo- 
 
 Fig. ii2.— A celi-nest from a cancer of the lip ; X 300 (after D. J. Hamilton) : a, the stroma of the alve- 
 olus in which the cell-nest is contained ; b, small germinal cells of the periphery ; c, prickle-cells ; d, com- 
 pressed squamous cells; e, degenerated cells in the centre. 
 
 kinesis, Filbry observed the same structural changes in carcinoma-cells. 
 All preparations showed, without exception, the indirect mitotic seg- 
 mentation of the nucleus. The best figures were seen in the marginal 
 zone of the epithelial projections, while in sarcoma they were about the 
 same throughout the tumor. The epithelial cells are derived from the 
 essential tumor-matrix ; the stroma consists of pre-existing connective 
 tissue. The several varieties of carcinoma formerly separately described 
 — epithelioma, scirrhus, encephaloid, colloid, glandular carcinoma — differ 
 only in their structure from their location, the type of cells, or the kind 
 and degree of degeneration of the tumor-tissue ; the general plan of 
 their histological structure is the same. For the purpose of avoiding 
 
CARCINOMA. 213 
 
 confusion the different histological forms of carcinoma will be described 
 separately. 
 
 Squamous-celled Carcinoma. — The characteristic histological feat- 
 ure of every carcinoma is the alveolation of the stroma and the group- 
 ing of cells in its meshes (Fig. 112). 
 
 In carcinoma of the skin the squamous epithelial cells are arranged 
 in concentric layers in the alveoli, forming the so-called " cancer-nests " 
 or " epithelial pearls." The young cells occupy the periphery of the 
 nest, the oldest cells being in the centre. Cell-degeneration always 
 begins in the oldest cells in the centre of the nest. The alveolated 
 structure of the stroma was first described by Virchow. The alveoli 
 are formed by the colonies of cells which form in the connective-tissue 
 spaces, each colony the offspring of a single epithelial cell which has 
 found its way into the connective tissue. As the cell-mass increases im 
 size the connective-tissue fibres are separated and form the alveolus., 
 The epithelial cells act the part of a foreign body and increase the 
 blood-supply to the tissues, thus increasing the vegetative capacity of 
 the connective-tissue cells, which in turn results in increase of the 
 stroma. 
 
 Klebs believes that the epithelial cells which have undergone carci- 
 nomatous degeneration are gradually transformed into connective tis- 
 sue and form a part of the stroma. If such a transition occurs, the 
 increase of stroma-tissue during the growth of the carcinoma could 
 easily be explained. Hatschek and 
 Rabl claim that mesoblastic cells are - 
 
 derived from epithelia. Reckling- '- ^ 
 
 hausen and Koster have observed , , >" - 
 
 metaplastic tissue-changes in meta- - > ; ; ■ -- -^ a 
 
 static lymphatic carcinoma, where - ' :. - . ''F-i 
 
 v.,X 
 
 endothelial cells were transformed '* "'■ -,- r >-£&v'~ 
 
 into epithelial cells. These views can v - ' : ~ . 
 
 no longer be held, as more recent 
 
 researches have established upon a '&^-- 
 
 firm basis the law formulated by Fig. 113.— Artery from connective-tissue stro- 
 
 T> „ 1 1 r 11 t t • j a ma °f secondary carcinoma of the lower jaw : 
 
 Remak and confirmed by His, that endarteritis deformans et obliterans . x 54 ; Sur . 
 
 Cells invariably produce their OWn § ical Clinic, Rush Medical College, Chicago): 
 , . j , , - T7 . . a, thickened proliferating intima ; b, internal 
 
 kind, and no Other. We mUSt there- elastic lamina; c, tunica media. 
 
 fore assign to the pre-existing con- 
 nective tissue the function of stroma growth. 
 
 The stroma is always infiltrated by leucocytes and young carcinoma- 
 cells (Fig. 113, a). In rapidly-growing soft carcinoma the stroma is 
 scanty, the alveoli is large, the cells are numerous, and the local infection 
 
214 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 is early and extensive. A well-developed, firm stroma renders the 
 tumor hard and retards its growth and local infection. The vessels and 
 lymphatics of a carcinoma are distributed through the stroma. The 
 arteries in the carcinomatous tissue frequently undergo degenerative 
 changes, which have not been studied with sufficient care since Thiersch 
 first called attention to them. 
 
 Proliferating endarteritis has been found a rather frequent accompani- 
 ment of carcinoma in the laboratory of Rush Medical College, when 
 there were no indications of the existence of the same condition of the 
 
 ■■ ; . %a . . :-.v. 
 
 % ' 
 
 Fig. 114. — Carcinoma of the skin; X 4$o (Surgical Clinic, Rush Medical College, Chicago) : a, stroma 
 infiltrated by leucocytes and young carcinoma-cells; b, epithelial nest; c, colloid degeneration in centre of 
 pearl; d, new cancer-nest. 
 
 arteries in any other part of the body. The existence of this form of 
 arterial degeneration on a large scale cannot but give rise to serious 
 nutritive changes of the tumor-tissue (Fig. 114). It is a subject that 
 calls for further investigation. 
 
 Cylindrical-celled Carcinoma. — In carcinoma of the mucous mem- 
 brane derived from the hypoblast the parenchyma of the tumor is 
 composed of cylindrical cells arranged in the form of tubules in resem- 
 blance of tubular glands. The tubules correspond with the cell-nests of 
 •squamous-celled carcinoma (see Fig. 25, p. 66). The columnar epithelial 
 
CARCINOMA. 
 
 215 
 
 
 cells are arranged in a somewhat atypical manner in the crypts, forming 
 a cellular lining of differing depths (Fig. 115). The tubules vary in size 
 and shape, constituting in this respect a contrast to adenoma of the same 
 part, in which symmetry of the tubules is pre- 
 served (Fig. 116). The stroma of the tumor 
 is infiltrated with leucocytes and young carci- 
 noma-cells (Fig. 1 16, c). The cells and stroma 
 of cylindrical-celled carcinoma are prone to 
 undergo mucoid and colloid degeneration. 
 
 Glandular Carcinoma. — Carcinoma of the 
 acinous glands presents the same alveolation of 
 the stroma as squamous-celled carcinoma. The 
 morphology of the cells being similar, the gland- 
 ular spaces correspond with the connective-tissue 
 spaces, in which, in the latter variety, the epithe- 
 lial cells establish centres of growth and form 
 the alveoli. In glandular carcinoma the acini a carcinoma of the rectum, show- 
 
 ing multiplication of cells in its 
 
 constitute the alveoli, and the interacinous lining; x 170. At a, shrinkage 
 connective tissue constitutes the stroma (Fig. ^Tm^Ip ( ,f rgic r a ; ciini ^' 
 
 V o Rush Medical College, Chicago). 
 
 117). In hard, slow-growing glandular carci- 
 noma the stroma is abundant and the alveoli are small. In soft, 
 rapid-growing carcinoma, formerly called " encephaloid," the stroma 
 
 
 Fig. 
 
 ;5-- 
 
 -A single tubule from 
 
 -^&0^^^iB 
 
 
 Fig. 116. — From carcinoma of the rectum; X no (Surgical Clinic, Rush Medical College, Chicago): 
 a, atypical tubule; b, intratubular growth of cells; c, extratubular infiltration. 
 
 is scanty and the alveoli are large. A strong reticulum imparts to 
 the tumor benign qualities. 
 
 Malignancy. 
 The clinical interest of carcinoma centres on its malignancy. 
 Malignancy depends not upon the progressive increase in the size 
 of the tumor, as is the popular belief, but upon the extension of the 
 
2i6 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumor to near or distant parts and organs. The intrinsic tendency of 
 carcinoma is to destroy life. For the lack of a better word, the pro- 
 cess by which the tumor diffuses itself in its immediate vicinity, in the 
 same region, and throughout the entire body, is termed " infection." 
 
 • If V, -- - 
 
 I 
 
 b 
 
 Fig. 117.— Glandular carcinoma of mamma; X 85 (Surgical Clinic, Rush Medical College, Chicago): a, con- 
 nective-tissue stroma; b, alveoli packed with epithelial cells. 
 
 By the term " infection " as applied to malignant tumors is meant the 
 intrinsic capacity of their cells to leave the primary tumor, and by 
 wandering into the surrounding healthy tissue to establish new centres 
 of growth, or by being transported through pre-existing channels to 
 reproduce the disease in the same region or in distant parts of the 
 body. It is this cell-migration, and the intrinsic capacity of the cells to 
 reproduce themselves in new and strange localities, that distinguish malig- 
 nant from benign tumors, arid upon which depends their malignancy. 
 
 Local Infection. — The power of epithelial cells to penetrate into 
 the apparently healthy tissue, as seen and described by Waldeyer and 
 Thiersch, is evidenced in the local diffusion of every carcinoma, but it 
 does not explain the malignancy of the tumor, as normal epithelial 
 cells do not possess the same power to proliferate in mesoblastic tissues 
 as do the epithelial cells of a carcinoma. The epithelial cells have 
 
CARCINOMA. 
 
 217 
 
 therefore undergone a change, the true nature of which is unknown, 
 which endows them with a greatly augmented vegetative capacity. In 
 the present state of our knowledge we must attribute this increase of 
 their formative power, not to a change in the cells themselves, but to* 
 an altered condition of the tissues which they inhabit. This latter 
 condition we have described as a diminution of physiological resistance. 
 An anomalous location of epithelial cells under certain conditions 
 may cause carcinoma ; this anomaly, however, does not constitute the 
 real cause, but is only an additional factor, and not an essential ante- 
 
 FlG. 
 
 -From an epithelial carcinoma of the clitoris : epithelial nests imbedded in a stroma infiltrated 
 by small cells; X 250 (after Perls). 
 
 cedent condition. Ribbert does not believe that the first changes in 
 the growth of a carcinoma consist in infiltration of the underlying 
 connective tissue. He claims that inclusion of epithelial cells takes 
 place by an outward growth of connective tissue. He has observed as 
 the first thing an active increase of the cellular elements of the sub- 
 epithelial connective tissue. This causes a lifting up of the epithelial 
 layer, which becomes irregular and convoluted. The increased con- 
 nective tissue grows up among the epithelial cells, and causes irregular 
 separation of the cells from their normal relations, so that they become 
 divided into groups and islands surrounded by the new connective 
 tissue. As the cells are now disconnected from the superficial cells, 
 they cannot proliferate upward, and so must grow where the connec- 
 tive tissue will allow. They proceed in the direction of the least resist- 
 
2l8 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 ance — namely, into the intercellular spaces and lymph-channels, and in 
 this manner the carcinoma develops. 
 
 Every carcinoma has a benign stage. No matter where the matrix 
 may be located, the cells composing it are at first isolated from the vas- 
 cular tissues, and the carcinomatous stage begins with cell-migration. 
 Local infection — that is, the growth of the tumor as a whole — is the 
 result of cell-migration. The new epithelial cells, like the ameba and 
 leucocytes, possess the power of independent locomotion. The ameboid 
 
 Fig. 119.— Colloid carcinoma of the colon: section through the margin of the tumor; X 21 (after Karg 
 and Schmorl). The tumor (c), which started in the mucous membrane (a), has perforated the muscular 
 coat (6) and presents an adenomatous structure. 
 
 movements of carcinoma-cells were studied in 1872 by Carmalt in 
 Waldeyer's laboratory. Cells of carcinoma of the breast obtained im- 
 mediately after amputation constituted the material used. The cells 
 were detached by scraping the cut surface of the tumor, and were kept 
 immersed on the thermal object-table of Strieker. The isolated young 
 cells manifested active ameboid movements, while the deeper cells in 
 fragments of tissue remained motionless. 
 
CARCINOMA. 
 
 Plate 4. 
 
 
 
 1. Beginning carcinoma of the lower lip ; border of the tumor; X 160: it, hypertrophic epidermis ; !\ mem- 
 brana propria, continuity disturbed. 
 
 2. Beginning carcinoma of the lower lip ; center of the tumor; X >6° '• «, membrana propria still intact: 
 /'.engorged lymphatic; c, leucocytes ; d, membrana propria ruptured; wandering ofepithcli.il cells into the 
 connective tissue. 
 
CARCINOMA. 
 
 219 
 
 In the stroma of every carcinoma small young epithelial cells 
 besides leucocytes are found (Fig. 118). This infiltration of the tissues 
 around a carcinomatous tumor was called by Waldeyer the " inflam- 
 matory zone." Leucocytes escape through damaged capillary walls and 
 are present in large number in rapidly-growing carcinoma, but among 
 them young carcinoma-cells can always be seen. All these young 
 epithelial cells, as soon as they have isolated themselves from the 
 primary tumor, assume an individuality of their own and establish 
 independent centres of tumor-formation. In cylindrical-celled carci- 
 noma the membrana propria of the tubules is often absent, bringing 
 thus the carcinoma-cells in direct contact with the vascular connective 
 tissue, which they infiltrate, increasing thereby the size of the tumor and 
 the area of tissue-proliferation. The glandular tubules are irregularly 
 branched, are devoid of the membrana propria, and are lined in places 
 by three layers of columnar cells (Fig. 1 19). To the right of the tumor 
 
 Fig. 120.— Rapid-growing carcinoma of the breast ; X "5 (Surgical Clinic, Rush Medical College, 
 Chicago) : a, vascular stroma ; b, b, alveoli packed with large epithelial cells. 
 
 is to be seen a second carcinomatous nodule (d) which is undergoing 
 colloid degeneration. Only at the periphery can carcinoma-cells be 
 seen, while the centre of the space is occupied by colloid material and 
 degenerated detached cells. The space is enclosed by the muscularis (e). 
 In glandulai carcinoma ,e infiltration takes place in all directions, and 
 the tumor is surroundec >n all sides by a zone of new alveoli, the con- 
 tents of each alveolus being the product of proliferation of a single cell. 
 New alveoli are also found in the stroma, especially in rapid-grow- 
 
220 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 ing tumors, rendering the tumor softer by diminishing its stroma 
 (Fig. 1 20, b,b). 
 
 The local infection of carcinoma takes place in the direction of pre- 
 existing connective-tissue spaces, and consequently spreads most rap- 
 idly and becomes most extensive in cases in which the primary tumor 
 is surrounded by an abundance of loose connective tissue. It is in 
 such cases that the tumor attains the largest size. The local infection, 
 however, does not remain limited to the connective tissue. Carcinoma 
 involves by local extension all tissues and organs, irrespective of their 
 anatomical structure. This is the most conspicuous pathological and 
 clinical feature of all carcinomatous tumors. Johannes Miiller called 
 special attention to this property of carcinoma, and surgeons have always 
 regarded this feature as of the utmost diagnostic value in the differen- 
 tiation between benign tumors and carcinoma. Neumann described 
 and illustrated carcinomatous infiltration of muscular tissue, euided 
 by the belief that the carcinoma-cells were produced by the inter- 
 muscular connective tissue. The tissues and organs the seat of local, 
 regional, and general dissemination remain passive in the growth of 
 carcinoma ; the increase in the size of the tumor is due exclusively to 
 tissue-proliferation of wandering displaced carcinoma-cells. The cells 
 of the regional and metastatic tumors are derivatives from the primary 
 or maternal tumor. Diffuse local infection favors early regional and 
 general infection. It is on this account that glandular carcinoma is 
 followed more constantly and at an earlier stage by regional and gen- 
 eral infection than is squamous-celled or cylindrical-celled carcinoma. A 
 carcinoma of the cutaneous or mucous surfaces has only one direction in 
 which to infiltrate the tissues, while a glandular carcinoma is surrounded 
 by mesoblastic tissues o?i all sides, with a correspoiidingly increased area 
 of infiltration. 
 
 The progressive growth of a carcinoma is due to the establishment 
 of independent centres of growth in the periphery of the tumor. It is 
 for this reason that spontaneous sloughing of the tumor and its destruc- 
 tion by caustics is not followed by a cure, as is the case in benign growths. 
 
 Regional Infection. — It is a well-known clinical fact that a carcinoma, 
 wherever it may be located, gives rise to infection of the lymphatic 
 glands of the same region. Simon and Paget were of the belief that 
 carcinoma extends from the primary tumor, not through any active 
 part of the interposed lymphatic channels, but through the lymph. 
 They explained regional infection as follows: 1. The disease in the 
 lymphatic glands resembles the primary tumor, the deviation being 
 dependent on the structures surrounding the carcinoma in the lym- 
 phatic gland ; 2. It appears about midway in the course of the disease 
 
CARCINOMA. 
 
 221 
 
 toward death ; 3. Usually the primary tumor makes more rapid prog- 
 ress, but occasionally the reverse is the case ; 4. The disease extends 
 along the lymphatics in the direction of the thoracic duct ; distant lym- 
 phatics are rarely affected. Paget believes that minute fragments of 
 the protoplasm of the cancer-cells, mingled with the blood, may be as 
 effectual as whole cells in reproducing the disease. 
 
 The migrating young epithelial cells find their way into the lym- 
 phatic vessels within or near the primary tumor, are carried by the 
 lymph-stream to the nearest lymphatic gland, which serves as a filter, 
 arresting their further progress, and as soon as they become localized 
 they establish new centres of growth in the lymphatic gland. There 
 must exist in the primary tumor or in its vicinity favorable conditions 
 for the entrance of the cells into the lymphatic channels. 
 
 Langhans made a careful study of injected preparations of the 
 mammary gland, with the special object of ascertaining the relations of 
 lymphatics to the acini and ducts of the gland. He found the acini 
 
 Fig. 121. — The internal lymphatics of the mammary gland injected, and terminating in two trunks in the 
 
 axilla (after Astley Cooper). 
 
 and ducts surrounded by a delicate network of lymphatic vessels, but 
 in none of the specimens did the lymphatic vessels reach the interior 
 of the acini or ducts, or even the membrana propria. Such a direct 
 communication between these structures is claimed by Ludwig Tomsa. 
 The abundance of lymphatic vessels in the mammary gland is well 
 
222 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 shown in Figure 121. The lactiferous tubes are also partially injected, 
 and may be seen under the network of lymphatics. It is more than 
 probable that normal lymphatic vessels are impermeable to emigrating 
 epithelial cells, and that their entrance is effected by destruction of the 
 wall of pre-existing lymphatics or through the defective walls of new 
 lymphatic channels in the tumor-tissue. This subject is well worthy 
 of a most careful investigation. Gussenbauer maintained that second- 
 ary carcinoma of the lymphatic glands results from the transportation 
 of minute infective corpuscular elements which are carried from the 
 primary tumor through the lymphatic channels into the lymphatic 
 glands, where they infect pre-existing glandular tissue, bringing about 
 a heterologous change in the tissue-elements resembling the structure 
 of the primary tumor. He found in sections of glands recently infected, 
 on staining with picro-carmine, minute granules of an intense red color 
 in the cells of the infected gland-territory. The cells thus infected then 
 presented various changes in their structure. This theory was in accord 
 with views expressed by Virchow and Creighton, that cancer-cells are 
 produced by the action of a virus or seminium upon mature cells. We 
 have shown conclusively that the cells of which the primary tumor is 
 composed are derived not from mature tissue, but from a matrix of 
 embryonic epithelial cells, and we shall now proceed to prove that all 
 
 metastatic tumors, local, regional, 
 and distant, owe their origin and 
 growth to cells derived from the 
 primary tumor. 
 
 Afanassiew made some very 
 interesting investigations in Rud- 
 new's laboratory at St. Petersburg 
 concerning the growth of second- 
 ary carcinoma in the lymphatic 
 glands. Inflammatory enlarge- 
 ment of the glands is observed 
 only when the carcinoma has ul- 
 cerated, and is then caused by the 
 entrance into the lymphatic sys- 
 tem of pathogenic microbes or of 
 chemical irritants. Enlargement 
 of the lymphatic glands under 
 other circumstances denotes the 
 regional dissemination of the dis- 
 
 Fig. 122. — Secondary carcinoma of lymphatic 
 gland; X 480, reduced one-third (Surgical Clinic, 
 Rush Medical College, Chicago) : a, groups of carci- 
 noma-cells ; b, lymphoid corpuscles and reticulum. 
 Each one of the epithelial nests is the product of 
 tissue-proliferation of a single carcinoma-cell. 
 
 ease. The first changes observed 
 
 in such glands are the presence of carcinoma-cells from the primary 
 
CARCINOMA. 
 
 223 
 
 tumor in the lymphatic channels, and irritation of the connective-tissue 
 reticulum caused by the invaders. The lymphoid corpuscles take no 
 active part in the process. As the carcinoma increases in size by pro- 
 liferation of the transplanted carcinoma-cells new connective tissue is 
 formed from the granulation-elements. The parenchyma of the gland 
 is subjected to pressure and is gradually destroyed, its place being 
 occupied by carcinoma-tissue. The carcinoma-cells that reach the 
 interior of the lymphatic channels are conveyed with the lymph- 
 current to the nearest lymphatic gland, in the meshes of which their 
 onward course becomes arrested. As soon as a wandering carcinoma- 
 cell has reached its destination it undergoes karyokinetic changes, and 
 the product of tissue-proliferation constitutes the secondary gland- 
 ular tumor, the connective tissue of the gland becoming its stroma 
 (Fig. 122). 
 
 The stroma of the carcinoma is derived from the pre-existing retic- 
 ulum of the gland, which reticulum is increased in consequence of the 
 stimulation caused by the carcinoma-cells, which act the part of a for- 
 eign body. Simultaneously or in succession additional centres of growth 
 may become established in different parts of the gland by new cells 
 emerged from the primary tu- 
 mor to the lymphatic gland. 
 New centres of growth are, 
 however, exhibited also by the 
 migration of young epithelial 
 cells from the first glandular 
 focus along the lymph-spaces 
 into other parts of the gland 
 (Fig. 123,4 
 
 The local infection of sec- 
 ondary tumors is as marked 
 as that of the primary tumor, 
 and takes place in the same 
 manner. The cells corre- 
 spond in shape, size, and 
 manner of grouping to those 
 of the primary tumor. The 
 stroma is modified by the 
 character and amount of 
 connective tissue in the new 
 locality. It has been known 
 frequently grows much more 
 
 R— b 
 
 Fig. 123. — Secondary carcinoma in the lymph-spaces of 
 a lymphatic gland, from a carcinoma of the abdominal wall ; 
 X 480, reduced one-third (Surgical Clinic, Rush Medical Col- 
 lege, Chicago) : a, lymph-spaces ; b, groups of carcinoma- 
 cells ; c, carcinoma-cells in the parenchyma of the gland ; d, 
 leucocytes. 
 
 for a long time that a secondary tumor 
 rapidly than the primary tumor. This 
 fact can readily be explained by assuming that the pre-existing connec- 
 
224 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tive tissue surrounding the secondary tumor is more scanty and of a 
 looser structure than the stroma of the primary tumor. As the local 
 infection in the lymphatic gland increases, the parenchyma of the gland 
 disappears until its capsule becomes distended by carcinomatous tissue. 
 During this time the capsule of the gland has become thickened in a 
 vain attempt to limit further extension of the disease. As soon as the 
 capsule is reached by the carcinoma-cells infiltration takes place, the 
 capsule itself becomes carcinomatous, and the zone of infiltration 
 extends now to the loose paraglandular connective tissue. Until now 
 the gland has remained movable, but as soon as the disease reaches the 
 surrounding tissues the gland becomes immovably fixed. 
 
 From what has just been said in reference to the local infection of 
 lymphatic secondary carcinoma it will be seen that enucleation of car- 
 cinomatous glands is bad practice. Such practice prevails still to a 
 large extent, and is responsible for the local recurrence that invariably 
 follows such a procedure. Not only the paraglandular zone of infiltra- 
 tion remains, but also the connecting lymphatic channels. 
 
 Carcinoma of the lymphatic channels has not received the attention 
 it deserves. The writer is firmly convinced that many of the second- 
 ary glandular tumors that have invariably been regarded as infected 
 lymphatic glands were carcinomatous nodules which developed in the 
 lymphatic vessels. There is no reason to doubt that carcinoma-cells 
 may by mural implantation become arrested in lymphatic vessels and 
 produce the same results as in a lymphatic gland. The number of 
 nodules removed from the axillary space in operations for carcinoma of 
 the breast frequently exceeds by far the number of normal lymphatic 
 glands in that locality. For the purpose of removing the zone of infil- 
 tration around carcinomatous glands, as well as with a view of removing 
 all the connecting lymphatic channels, the radical operation for regional 
 carcinoma should consist in the removal by clean excision of the entire 
 lymphatic apparatus in that locality, with the surrounding connective and 
 adipose tissue. 
 
 Regional infection is always progressive. Epithelial cells from the 
 first secondary tumor reach the efferent part of the lymphatic vessel 
 and are conveyed to the second lymphatic gland, where the same pro- 
 cess repeats itself, until finally, if the disease is allowed to pursue its 
 course and the patient lives long enough, the last of the chain of 
 glands is reached, when the cells from this tumor reach the thoracic 
 duct and from there the general circulation, producing metastatic tumors 
 in distant organs. Regional infection through the deep lymphatic 
 glands begins near the primary tumor, and extends from there, from 
 gland to gland, until the last filter is passed, when general infection 
 
CARCINOMA. 225 
 
 takes place. Regional infection retards, and frequently prevents, general 
 infection. Surgeons are aware of the fact that in the most rapidly fatal 
 cases the lymphatic infection is either entirely absent or, at any rate, 
 not well marked. Usually the lymphatic affection occurs in the same 
 region as that occupied by the tumor. For instance, in carcinoma of 
 the breast the axillary glands on the same side, in carcinoma of the 
 rectum the retro-peritoneal glands behind the rectum, and in carcinoma 
 of the lip the submental and submaxillary glands, are affected. The 
 writer not long ago observed a case of carcinoma of the breast with 
 extensive regional infection of the axillary glands. Local recurrence 
 soon after the operation was followed by enlargement of the inguinal 
 glands first on one side and then on the other. Microscopic exam- 
 ination of sections taken from these regions showed typical gland- 
 ular carcinoma. 
 
 Local infection through the superficial lymphatics of the skin travels 
 as often against as with the lymph-current. The extension of carcinoma 
 through the superficial lymphatics of the skin, as observed in cases of 
 lenticular carcinoma, always reminds one of thd manner of spreading 
 of erysipelas. In such cases the lymphatic vessels take an important 
 part in the diffusion of the disease. Lymphatic channels become 
 blocked, the lymph-current is arrested, and consequently the direction 
 of the dissemination of the disease is no longer governed by the lymph- 
 stream. The original infection takes place in all directions. The swell- 
 ing of the arm in extensive regional infection of the axillary glands 
 is the combined result of lymphatic obstruction and pressure of the 
 glandular tumors upon the large axillary vessels. 
 
 General Infection. — General infection in carcinoma consists in the 
 appearance of carcinomatous tumors in organs or tissues of the body 
 that have anatomically 710 connection with the region occupied by the 
 primary tumor. Such tumors are called " metastatic tumors," and the 
 process by which they are produced is termed " metastasis." Klebs 
 speaks of a " cell-metastasis " in local and regional infection of a carci- 
 noma, but we shall restrict the term " metastasis " to tumor-formation 
 anatomically disconnected with the primary tumor. Carcinoma-cells 
 retain their vitality and intrinsic power of tissue-proliferation during their 
 journey through the lymphatic vessels and blood-vessels, and as soon 
 as they become arrested by mural implantation or embolism they begin 
 to proliferate and to produce tumors identical with the primary tumor. 
 Metastatic carcinomatous tumors always occur in connection with a 
 blood-vessel on the arterial side of the circulation. The process of 
 distribution of tumor-tissue resembles embolism. Generalization of car- 
 cinoma takes place in consequence of the entrance into the general circu- 
 
 15 
 
226 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 lation of carcinoma-cells or fragments of tumor-tissue, which, when 
 arrested anywhere in the arterial system, constitute carcinomatous emboli 
 from which the metastatic tumors grow. The entrance of carcinoma- 
 cells into the general circulation is effected in two ways: I. Direct 
 entrance by perforation of a vein-wall by the tumor; 2. Migration of 
 cells through the lymphatic system. In the first instance isolated 
 tumor-cells may be washed away from the projecting tumor-mass, or 
 fragments may be broken off and conveyed into the general circulation. 
 In the second manner of general dissemination isolated cells reach the 
 venous circulation through the thoracic duct by migration of cells 
 through the lymphatic channels and glands from the primary tumor 
 without causing lymphatic carcinoma ; or, what is usually the case, carci- 
 noma-cells enter from the last gland of the chain of lymphatic glands in 
 the region occupied by the primary tumor, reach the thoracic duct, and 
 from there the venous circulation. The location of the metastatic tumors 
 is determined largely by the size of the carcinomatous emboli. Isolated 
 small epithelial cells can pass through the pulmonary capillaries, reach 
 the arterial circulation, and become arrested in the minute capillaries 
 of some distant organ as minute emboli ; or they adhere to the intima 
 of the arterioles or capillaries, mural implantation takes place, and the 
 cell becomes the starting-point of a metastatic tumor. Large tumor- 
 fragments become arrested as emboli in the branches of the pulmonary 
 artery (see Fig. 28, p. 77). 
 
 General dissemination by isolated cells frequently gives rise to miliary 
 carcinosis ; the fragments of tumor-tissue, to embolism of the pulmonary 
 artery. A metastatic tumor of the lung becomes a distributing-point of 
 carcinoma-cells, which from here reach the general circulation, becom- 
 ing the direct cause of more remote metastatic tumors or, perchance, 
 of miliary carcinomata. All histological varieties of carcinoma may give 
 rise to metastatic carcinoma, and all vascular organs of the body may be- 
 come the seat of a metastatic carcinoma. The type of cells of the primary 
 tumor is reproduced in the metastatic tumors ; that is, a squamous- 
 celled carcinoma produces a squamous-celled metastatic tumor; a colum- 
 nar-celled carcinoma, a columnar-celled metastatic tumor, etc. It seems 
 that this reproduction of tissue of a similar structure is a strong proof 
 against the microbic origin of carcinoma, and a convincing argument in 
 favor of the doctrine that carcinoma is the result of erratic growth of epi- 
 thelial cells, and that local, regional, and general dissemination is caused by 
 the migration and transportation of cells derived from the primary tumor. 
 
 The lungs and the liver are the organs most frequently the seat of 
 metastatic carcinoma. 
 
 Wagner of Chicago has collected fifteen cases of metastatic car- 
 
CARCINOMA. 227 
 
 cinoma of the choroid, and has made some interesting observations 
 in reference to the manner of local 
 diffusion of the metastatic tumors in 
 this locality. Rapid local dissemina- 
 tion of the tumor in this locality ap- 
 pears to be one of its main clinical 
 features. In the case that came under 
 Wagner's observation, and illustrated 
 by Figure 124, the primary tumor was 
 a carcinoma of the stomach. If a large 
 branch of the pulmonary artery is ob- 
 structed by a carcinomatous embolus, 
 hemorrhage around the infarct is of 
 
 r ci 1 J Fig. 124. — Metastatic carcinoma of choroid 
 
 frequent occurrence. Skrzeczka de- (after Carl Wagrer) 
 
 cribes such a case. The entire lung 
 
 was the seat of hemorrhagic infiltration. Lebert examined twelve cases 
 of colloid carcinoma of the gastro-intestinal canal, and found meta- 
 stasis in eleven of them. Hauser made a special study of metastatic 
 carcinoma of the liver to determine whether the pre-existing liver- 
 substance takes an active part in the growth of the tumor. He found 
 that the parenchyma-cells in the vicinity of the carcinomatous nodules 
 were destroyed and took no part whatever in the growth of the tumor, 
 thus confirming the observations made by Thiersch and Waldeyer. 
 It will be seen from Figures 125 and 126 that the glandular structure 
 of the metastatic tumors corresponds with the type of the epithelial 
 cells and the structure of the primary tumors. 
 
 If a carcinomatous embolus becomes impacted in an artery or in a 
 branch of the portal vein, the metastatic tumor first fills the lumen 
 of the vessel — that is, a carcinomatous thrombus forms around the 
 embolus (Fig. 127). As soon as the pre-existing space in the lumen 
 of the vessel becomes completely blocked by the endovascular meta- 
 static carcinoma, the wall of the vessel becomes infiltrated and is soon 
 incorporated in the tumor. After this time the paravascular tissues 
 become successively involved, and on examining such tumors all traces 
 of the original vessel-wall have disappeared and nothing remains to 
 indicate the endovascular origin of the tumor. 
 
 Carcinoma of bone, with very rare exceptions in which the tumor 
 develops from a displaced epiblastic matrix, is the result of metastasis. 
 Metastatic carcinoma of bone (Fig. 128) is a frequent cause of so-called 
 " spontaneous fracture." Fractures occurring under such circumstances 
 should be called " pathological fractures," to distinguish them from 
 fractures resulting from trauma. The writer has observed metastatic 
 
228 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 carcinoma of bone most frequently in aged women suffering from latent 
 carcinoma of the breast with moderate or no regional infection. 
 
 In metastatic carcinoma of bone spontaneous fracture usually occurs 
 before any external swelling has developed. If life is sufficiently pro- 
 longed, a tumor appears later at the site of fracture. As Rokitansky 
 
 • 0& 
 ■y - 
 
 II 
 
 
 r^ a 
 
 Fig. 125. — Metastasis of a rectal carcinoma in the lungs ; X 36 (after Karg and Schmorl). The nodule 
 in the lung resembles in structure the primary tumor. It is composed of tubules lined by a single layer of 
 columnar epithelium imbedded in a delicate stroma of fibrillated connective tissue. The emphysematous pul- 
 monary tissue in the upper part of the picture is sharply defined against the border of the nodule. 
 
 says : " Cancer of the bone appears sometimes in the form of a nodule, 
 of about the size of a walnut or a hen's egg, which is developed mostly 
 in the medullary canal of the long bones ; it displaces the bony tissue, 
 and, producing atrophy of it by pressure, is frequently the cause of one 
 or more spontaneous fractures of the bone which occur as the result 
 of the most trifling causes." Union of the fracture by bony callus, 
 despite the growth of the carcinoma, occasionally takes place. 
 
 In patients suffering from advanced carcinoma the bones often 
 become so brittle that fracture occurs upon the application of slight 
 force without metastatic carcinoma. Paget remarks : " But some of 
 
CARCINOMA. 
 
 229 
 
 the spontaneous fractures in cancerous patients are due to the wasting 
 and degenerate atrophy which the bones undergo during the process 
 of cancer, and which seems to proceed to an extreme more often than 
 in any other equally emaciating and cachectic disease." There is, how- 
 ever, reason to believe that in most cases of spontaneous fracture with- 
 
 
 ■•:■•■ .::.-: ■■■■■■ 'v.. : ' 
 
 up 
 
 Fig. 126. — Metastasis of a carcinoma of the breast in the liver; X 4° (after Karg andSchmorl). The 
 carcinomatous nodule (a), which is quite sharply separated from the parenchyma of the liver (3), consists 
 of narrow cellular cords imbedded in a coarse reticulum of connective tissue. 
 
 out tumor-formation, in which it was believed the fracture occurred 
 without implication of the bone, the fracture was the result of the 
 secondary bone-carcinoma, which was overlooked, life not being suf- 
 ficiently prolonged for the appearance of a swelling. In favor of this 
 view is the fact that pathological fractures under such circumstances 
 are seldom multiple, which would be the case if the marasmus of car- 
 cinoma produced general atrophy of the bones. The carcinomatous 
 material is previously deposited in the Haversian canals, along which it 
 infiltrates the bone, producing enlargement of the canals. 
 
 Miliary carcinosis very closely resembles miliary tuberculosis. 
 
230 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 *:*$&*&& 
 
 
 
 
 
 ^*» » >« °"- - fife- t . 5 
 
 'A 
 
 Fig. 127. — Carcinomatous embolus in a branch of the portal vein after primary carcinoma of the breast; 
 X 250 (after Karg and Schmorl). The branch of the portal vein (a) is dilated and filled by a plug of carci- 
 noma-celis ; b, bile-duct. The surrounding liver-tissue is normal. 
 
 Demme reported seven cases of miliary carcinosis, and, basing his 
 
 Fig. 128. — Metastatic carcinoma of bone (after Hickmann) : enlarged Haversian canals filled with carcino- 
 matous tissue. 
 
 opinion regarding its etiology upon a study of the clinical history of 
 these cases, came to the conclusion that it is most frequently produced 
 
CARCINOMA. 
 
 231 
 
 by trauma. The diffuse general dissemination of carcinoma is usually 
 initiated by a rise in temperature and by other febrile disturbances that 
 
 Fig. 129.— Carcinomatous capillary embolism of the choroid; X 320 (after Perls): b, capillary net dilated 
 and filled partly with red blood-corpuscles and partly with carcinoma-cells ; c, large nuclei. 
 
 closely simulate the general symptoms which inaugurate and attend 
 miliary tuberculosis. In almost all organs of the body, and more par- 
 ticularly upon the serous surfaces, innumerable nodules, from the size 
 of a mustard-seed to that of a hempseed, appear. The nodules are 
 produced by capillary emboli composed of carcinoma-cells (Fig. 129). 
 Miliary carcinosis is a rapidly fatal affection. It is probably produced 
 most frequently by perforation of a vein-wall by the primary or a 
 secondary carcinoma, the epithelial cells of the projecting and rapidly- 
 proliferating endovascular part furnishing the material for the diffuse 
 
 embolic process. 
 
 Etiology. 
 
 Remaining true to the theory that all tumors originate from a matrix 
 of embryonic cells of congenital or post-natal origin, we necessarily 
 must regard the presence of a matrix of embryonic epithelial cells as 
 the essential cause of carcinoma. In the absence of such an essential 
 histological basis, no exciting cause or combination of exciting causes 
 will result in the production of a carcinoma. The matrix of embryonic 
 cells furnishes the essential material for the construction of a carcino- 
 matous tumor ; the exciting causes simply set in motion the machinery 
 which increases the building material. We took it for granted that 
 non-malignant epithelial tumors spring from a similar matrix. The 
 question naturally arises, What influences or agencies determine the 
 difference in the character of the tumors springing from a similar 
 matrix ? Two leading thoughts present themselves in answering this 
 question : I . The epithelial cells in the matrix of carcinoma are arrested 
 
232 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 in their development and are set aside at an earlier stage, and the prod- 
 uct of their tissue-proliferation will therefore be less specialized than 
 that of epithelial cells which have reached a higher degree of differen- 
 tiation. 2. The environment of a carcinoma-matrix offers less resistance 
 to ingrowing of epithelial cells than does that of a papilloma or an 
 adenoma. It is more than probable that the matrix of carcinoma is 
 composed of cells of a lower degree of differentiation than that of a 
 papilloma or an adenoma, and it is almost certain that the conditions 
 under which a carcinoma-matrix assumes active tissue-proliferation 
 result in a diminution of physiological resistance of the tissues in the 
 immediate vicinity of the tumor-matrix. It remains for us to discuss 
 more in detail the exciting causes concerned in awakening a dormant 
 tissue-matrix to active tissue-proliferation. 
 
 Heredity. — In the majority of cases the tumor-matrix is congenital. 
 In the remaining cases it is of post-natal origin, formed in pathological 
 products in which some of the young epithelial cells fail to reach 
 maturity and are buried in the scar-tissue following the healing of a 
 wound or the repair of an inflammatory lesion. Friedreich records a 
 case in which a carcinomatous mother gave birth to a child affected by 
 carcinoma. A few cases of congenital carcinoma have been reported. 
 
 An hereditary disposition, predisposition, or aptitude, local or gen- 
 eral, for carcinoma-growth is generally recognized. It is a difficult 
 task to obtain accurate information concerning the frequency with 
 which carcinoma occurs in the offspring of carcinomatous parents. 
 In this respect statistics as well as many family histories are exceed- 
 ingly unreliable. Mr. Cripps wishes to exclude from such statistics all 
 cases bearing upon distant relatives, excluding even grandparents. In 
 this way he reaches opposite conclusions from those of Sir James Paget, 
 who recognizes heredity as a fruitful cause of carcinoma. Figuring on 
 the cases from Paget's practice, Mr. Baker makes the statement that 
 22.4 per cent, of the cancerous patients were of one or more relatives 
 with the same disease. He then gives a table of 103 cases in which 
 one or more relatives were affected. These 103 cases representing only 
 22.4 per cent, of the total number examined, the whole number must 
 have been 460. In these 103 cases, among the relatives are included 
 aunts, uncles, first, second, and third cousins, great-aunts, and a great- 
 uncle. Among the parents of cancerous patients the death-rate from 
 cancer is — (1) According to Paget, 1 in 24.8; (2) according to Baker, 
 1 in 22.4 ; (3) according to St. Bartholomew's Hospital, 1 in 28. Accord- 
 ing to Mr. Cripps, among the whole community over twenty years of 
 age the death-rate is 1 in 29. 
 
 In studying the influence of heredity it is not fair to exclude from 
 
CARCINOMA. 233 
 
 the statistics distant cancerous relatives, as has been done by Cripps, 
 because it is well known that congenital deformities, physiognomy, 
 and mental peculiarities frequently reappear several generations apart 
 and in distant relatives. There is no reason to doubt that an aptitude 
 for cancer is transmitted in a similar manner. In certain families the 
 heredity of carcinoma has been shown in a marked manner. Paget 
 relates a case in which a lady, two of her daughters, and eight of her 
 grandchildren died of carcinoma. A still more marked and far-reaching 
 hereditary influence has been referred to in the section on the Etiology 
 of Tumors. Lebert relates two cases of colloid carcinoma of the rec- 
 tum in which one of the parents in each case was similarly affected. 
 To ignore the existence of an hereditary predisposition to carcinoma 
 would be to ignore such a predisposition to the acquirement of all 
 other pathological processes. 
 
 What such an hereditary predisposition consists of is not known. 
 We regard it as a diminution of the physiological resistance of the 
 tissues adjacent to the matrix. Such a resistance diminished or abol- 
 ished, the tumor-matrix is no longer held in check, but assumes active 
 tissue-proliferation, and the new cells infiltrate the tissues weakened by 
 local or general causes. 
 
 Traumatism. — Injuries of various kinds have been regarded from 
 time immemorial as a fruitful cause of carcinoma. Without the presence 
 of the essential tumor-matrix no amount or kind of injury will produce 
 a carcinoma. Injury of a part inhabited by the tumor-matrix will act 
 as an exciting cause by diminishing the physiological resistance of the 
 tissues adjacent to the matrix. Paget asserts that about one-fifth of 
 those who have cancer ascribe it to injury. In some the cancer follows 
 almost immediately after the injury; in others it follows as a more 
 remote effect. In another and more frequent class of cases repeated 
 injuries are necessary to produce this result. 
 
 Billroth maintains that in about 20 per cent, of all cases of carci- 
 noma that came under his notice the growth of the tumor could be 
 traced to an injury of some kind. Boll's statistics show a traumatic 
 origin in 14 per cent, and Cohnheim in 350 cases estimated trauma 
 as the principal exciting cause in about 20 per cent. Injuries to plants 
 are quite frequently followed by tumor-formation. The immediate cause 
 of tumor-growth under such circumstances is attributed by some 
 authors (Williams) less to the injury itself than to a change in the 
 nutrition of the tissues in the locality. Galls are produced by the 
 instillation of the virus of gall-wasps into the tissues of oak-leaves. 
 The virus comes in contact with only a few cells, and the new forma- 
 tion is due to proliferation of the infected cells. The structure of the 
 
234 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 gall depends more on the kind of vulnerating insect than on the par- 
 ticular variety of oak. In the plant buds may form in any place where 
 undifferentiated cells are present. The stimulants which determine the 
 nutritive flux may be either intrinsic or extrinsic. It is well known 
 that in plants injuries frequently result in the formation of a large 
 number of adventitious buds. The initial cause of such variations is 
 probably to be found in perversions of the secretions of the affected 
 part. Injury to a part inhabited by a tumor-matrix alters normal nutri- 
 tion, which must result in a diminished physiological resistance of the 
 tissues to infective diseases as well as to tumor-growth. 
 
 Physiological resistance is illustrated by allowing one plant out of 
 a number to go without water. Insect-stings in the w r eakly plant 
 produce definite changes not produced in well-nourished plants. Local 
 influences — and among them we must include trauma — which pervert 
 nutrition diminish the physiological resistance of the tissues, and by 
 doing so they become an exciting cause of carcinoma. 
 
 Age. — Carcinoma is most prevalent in persons of middle and past 
 middle life. The tumor-matrix present at the time of birth or acquired 
 later remains in a latent condition until the tissues undergo certain 
 changes incident to advanced age, when there are created the local 
 conditions necessary to enable the matrix-cells to resume their latent 
 vegetative function and to assume active tissue-formation. That these 
 senile tissue-changes are something different from ordinary marasmus 
 caused by disease or by insufficient nourishment becomes evident from 
 the fact that persons debilitated by disease or by starvation are not 
 more liable to carcinoma than persons of the same age otherwise in 
 perfect health. If carcinoma develops in a young person, it is a proof 
 that the cells of the tumor-matrix possess more than the ordinary degree 
 of vegetative power, or that the person is unduly adapted to cancer- 
 formation, or, finally, that the part which contained the tumor-matrix 
 has been subjected to influences which produced changes in the tissues 
 analogous to those found in the tissues of the aged — in other words, a 
 local senility of the tissues. Thiersch has shown that in the lips of 
 old people the fibrous tissue wastes away while the glandular tissue 
 becomes overgrown, this condition favoring the development of cancer. 
 The capacity of a part of the organism to resist a certain amount 
 of pressure and still to preserve its histogenetic function will determine 
 its vitality. If this power of resistance is lost, then the. part becomes 
 subject only to passive changes. This is the case for physiological as 
 well as for pathological conditions, and as a rule the quantity of paren- 
 chymatous fluid is in direct proportion to the capacity of cell-produc- 
 tion. This is the case in the skin of elderly persons as far as pertains 
 
CARCINOMA. 235 
 
 to the stroma. When in this weakened stroma there are present 
 organic parts the histogenetic properties of which are still operative, 
 those parts will proliferate and lead to a hyperplasia of the epithelial 
 tissue which eventually predisposes to the development of carcinoma. 
 It may be objected that the abundance of capillaries and their dilatation 
 are in opposition to the theory of atrophic condition of the stroma as a 
 cause of carcinoma, as claimed by Thiersch. This vascular change is, 
 however, only a result of the rarefaction of the connective tissue with 
 consequent diminished support against intravascular pressure. 
 
 As the blood furnishes a plasma to the tumor, and likely favors 
 development much as a starting plant favors the growth of aphis, it is 
 possible that in the aged there may occur blood-changes which favor 
 the development of carcinoma. 
 
 Walshe has clearly shown that the mortality from cancer — that is, 
 the number of deaths in proportion to the number of persons living — 
 " goes on steadily increasing with each succeeding decade until the 
 eightieth year." His result is obtained from records of deaths, but it is 
 almost exactly confirmed by the tables collected by Paget showing the 
 ages at which the cancers were first observed by the patients or ascer- 
 tained by their attendants. 
 
 Paget's Table showing the Influence of Age in the 
 Development of Carcinoma. 
 
 Under 10 years 5 per cent. 
 
 Between 10 and 20 years 6.9 " 
 
 " 20 " 30 " 21 " 
 
 30 " 40 " 48.5 
 
 " 40 " 50 " 100 " 
 
 " 50 " 60 " 113 " 
 
 " 60 " 70 " 107 " 
 
 70 " 80 " 126 
 
 The influence of age in the production of carcinoma is pronounced ; 
 the tissue-changes enumerated by Thiersch offer the most plausible 
 explanation of this influence, and can be applied with equal propriety 
 to carcinoma of all parts of the body as to carcinoma of the lips and 
 the skin. 
 
 Diet. — Diet appears to exercise some influence in the causation of 
 carcinoma. Legrain states that epithelioma is unknown in Algeria, 
 except as it appears in a European. This may possibly be due to the 
 vegetarian diet without meat, and absolutely without pork. Verneuil 
 and Reclus asserted long ago that the herbivora were much less 
 liable to carcinoma than the carnivora ; and they ascribe the sixfold 
 increase in the number of patients suffering from carcinoma at their 
 
236 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 hospital during the last forty years to the increased consumption of 
 meat by the laboring classes. 
 
 Climate. — Climate and the attending habits of life and state of 
 civilization appear to exert an influence in the causation of carcinoma. 
 Walshe collected evidence that the maximum number of carcinoma 
 patients are found in Europe, and that carcinoma is very rare among 
 the people at Hobart Town and Calcutta and among the natives of 
 Egypt, Algiers, Senegal, Arabia, and the tropical parts of America. 
 Inquiries that have been made relative to the prevalence of carcinoma 
 among the Indians of North America seem to show that they are 
 singularly immune to this affection. Few authenticated cases of carci- 
 noma have been reported among the Indians unaffected by advancing 
 civilization. 
 
 Mental Depression. — A few pathologists have attributed to the ner- 
 vous system an important part in the etiology of carcinoma. Mental 
 depression has often been quoted as one of the causes in the production 
 of carcinoma. While mental anxiety and worry of all kinds may favor 
 the origin and growth of carcinoma by impairing nutrition, and thus 
 diminishing the physiological resistance of the tissues in the vicinity of 
 a tumor-matrix, we have no evidence that nervous influences exert a 
 more direct effect in the causation of carcinoma. It is different with 
 dread or fear of carcinoma. The writer recollects two patients who for 
 no tangible reason whatever were in constant dread of the disease for 
 many years, when finally their fears were realized. Apprehensions 
 of this nature certainly exert a positive influence in the etiology of 
 carcinoma. 
 
 Tuberculosis. — Rokitansky maintained that tuberculosis and car- 
 cinoma never existed at the same time in the same person. Other 
 investigators have convinced themselves of the incorrectness of this 
 assertion. Dittrich states that of one hundred and fifty cases, in only 
 one did tuberculosis and carcinoma exist at the same time. Friedreich 
 was the first to discover tuberculosis and carcinoma in the same 
 organ. Recently there have been reported a number of well-authen- 
 ticated cases in which carcinoma developed in tubercular affections 
 of the skin. Tubercular lesions prepare the soil for carcinoma, and 
 they may even furnish the essential post-natal matrix of embryonic 
 cells. 
 
 Prolonged Irritation and Inflammation. — Long-continued local 
 irritation is frequently the exciting cause of carcinoma. If the irrita- 
 tion is sufficient in intensity to stimulate the mature tissue-cells to pro- 
 liferation, it may also furnish a post-natal matrix of embryonic cells, 
 and consequently constitute both the essential and exciting causes. 
 
CARCINOMA. 
 
 237 
 
 The frequency with which carcinoma is met with in localities exposed 
 to repeated and prolonged irritation points to the fact that the latter is 
 often a cause of carcinoma. Carcinoma is frequently found about the 
 orifices of the body — the lips, the cervix of the uterus, the rectum, and 
 the nose — localities often exposed to irritation. The tobacco-pipe has 
 often been quoted as a cause of carcinoma of the lip, but since the 
 publication of Melzer's statistics the views on this subject have under- 
 gone a change. Carcinoma of the scrotum has been attributed to 
 irritation caused by coal-dust : the effect of this source of irritation has, 
 however, been over-estimated greatly. Abrasions, punctures of the 
 skin, and small wounds have occasionally served as exciting causes. 
 Unskilful shaving must also be enumerated as a possible cause. In 
 one instance the writer saw a carcinoma develop from a small razor-cut. 
 Similarly, insignificant lesions are often referred to as a possible cause 
 of carcinoma. Chronic inflammatory lesions of all kinds and the rem- 
 nants of acute inflammation have more often been starting-points of 
 carcinoma than was formerly supposed or than many are willing to 
 admit at the present time. Inflammation not only diminishes the physi- 
 ological resistance of the tissues, but its product may also furnish a 
 post-natal matrix of embryonic epithelial cells. In a chronic ulcer, for 
 instance, young epithelial cells often become buried in the granulation- 
 tissue, which may serve as a tumor-matrix, and assume active tissue- 
 proliferation at any time when the local conditions are such as to per- 
 mit such tumor-formation. The writer has repeatedly seen carcinoma 
 develop in scar-tissue or upon the surface of a chronic ulcer (Fig. 130). 
 
 Fig. 130. — Extensive carcinoma which developed in the scar-tissue eighteen years after a severe burn involv- 
 ing the gluteal region and posterior surface of the thigh. Inguinal glands extensively involved. 
 
 Langenbeck observed three cases of lupus in which, after healing of 
 the ulcerated surface, carcinoma developed in the scar-tissue. Similar 
 cases have been referred to elsewhere. 
 
238 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Desbonnet has collected from different sources 86 cases in which 
 epithelioma developed either in the scar-tissue following the healing of 
 lupus or in active lupoid ulcerations. The largest number of cases 
 occurred in persons between forty and fifty years of age. The carci- 
 
 Fig. 131. — Epithelioma developing in lupus (after Desbonnet). 
 
 nomatous complications usually set in many years after the beginning 
 of the tubercular process. Fig. 131 furnishes a good illustration of 
 the appearance of an epithelioma upon a tubercular base. 
 
 Goodhart has called special attention to irritation as a cause of 
 ichthyosis of the tongue and of carcinoma. It has been known for a 
 long time that this superficial chronic inflammation of the tongue fre- 
 quently precedes carcinoma of this organ. In more than one instance 
 carcinoma of the tongue and of the mucous membrane of the cheek 
 has been traced to displaced carious teeth and to the sharp margins 
 of normal teeth. 
 
 One of the most instructive evidences of the influence of prolonged 
 irritation and inflammation in the causation of carcinoma is chronic 
 eczema of the nipple, known as " Paget's disease of the nipple." The 
 etiological relation of this affection of the nipple to carcinoma of the 
 breast was first pointed out by Sir James Paget. Mr. Butlin has cor- 
 roborated Paget's views, and has shown that there can be traced struct- 
 
CARCINOMA. 239 
 
 ural changes extending from the diseased part of the skin along the 
 epithelial linings of the gland-ducts in the nipple, and thence along 
 their branches into the acini of the carcinomatous part of the gland. 
 These acini " become dilated and filled with proliferating epithelium, 
 which is at length, so to speak, discharged into the surrounding tissues." 
 Paget says: "The cases of cancer thus following eczema are illustra- 
 tions of a general rule that a part which has long been the seat of con- 
 stant or often-recurrent inflammation, or, if I may write intentional 
 obscurity, of frequent or consta?tt irritation, is apt to become cancerous 
 (the italics are the writer's). Similar instances of the rule are observed 
 in tongues long affected with psoriasis or ichthyosis, in uteri long or 
 often ulcerated, in scars that often ' break out,' in lower lips long 
 cracked or excoriated, in warts often irritated, sore, and scabbed, some- 
 times in old scrofulous or other ulcers or in sinuses." Paget admits 
 that irritation alone and of itself is not enough to produce carcinoma. 
 He continues : " It may therefore be deemed very probable that the 
 chief or sole effect of irritation is, by inducing a degeneration, to render 
 the parts more fit for the invasion of a disease which is essentially of 
 an internal origin." 
 
 Paget still adheres to the humoral etiology of carcinoma, but we 
 assign, as he does, to chronic irritation and inflammatory products an 
 important role in the causation of carcinoma by diminishing the physi- 
 ological resistance and by occasionally at least furnishing at the same 
 time the essential tumor-matrix of embryonic epithelial cells. 
 
 Another inflammatory product very often the starting-point of car- 
 cinoma is the wart. The warts upon the forehead and cheeks of aged 
 persons (verruca senilis) most frequently undergo such a transformation. 
 The only cases in which the writer has seen primary multiple carcinoma 
 were those in which carcinoma had such an origin. The claim might 
 be made that these papillomatous swellings were carcinomatous from 
 the beginning. Examinations of numerous specimens of this kind have 
 furnished pictures showing all stages of transition of an inflammatory 
 swelling into a carcinoma, and there can therefore be no doubt of their 
 primary inflammatory origin. 
 
 Microbes. — The local, regional, and general dissemination of carci- 
 noma is strongly suggestive of the existence of some virus or microbe 
 as the prime etiological factor of the origin and dissemination of carci- 
 noma. In some respects carcinoma resembles several of the infective 
 processes the microbic origin of which has been well established. ' The 
 infectiveness of tuberculosis was recognized a long time before its 
 microbic origin was demonstrated. Pathologists have made numerous 
 experiments to prove the inoculability of carcinoma. Langenbeck 
 
240 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 injected cancer-juice into the jugular vein of dogs, and it is asserted 
 that in one instance the experiment resulted in carcinoma of the lungs. 
 Novinsky in 1876, and later Wehr and Hanau, succeeded in inocu- 
 lating animals, and Hahn and Bergmann have inoculated the human 
 being. 
 
 Carcinoma has frequently been engrafted from one animal into 
 another of the same species, and in some instances the experiment 
 yielded positive results. The writer has made numerous experiments 
 on dogs by implanting carcinoma and sarcoma from man, and the results 
 were always negative. A slight induration around the implanted graft 
 was all that was ever observed. Induration and graft all disappeared 
 by absorption in the course of two or three weeks. The same results 
 followed the implantation of malignant grafts from one animal into 
 another of the same species. In a recent work Adamkiewicz declares 
 that after implantation of a piece of a carcinoma in the brain of a rabbit 
 death always took place in about two hours. In the brains thus inocu- 
 lated were always found disseminated round-celled metastatic deposits of 
 carcinoma which showed a tendency to break down in the centre. The 
 carcinoma-cells nearly all disappeared from the engrafted piece, leaving 
 only the stroma. Adamkiewicz believes that cancer-cells are living, inde- 
 pendent organisms belonging to the class of protozoa. Geissler, who 
 repeated the experiments of Adamkiewicz, found that fragments of 
 carcinoma-tissue imbedded in the brains of rabbits produced no reaction 
 and were absorbed like other aseptic absorbable substances. The views 
 of Adamkiewicz regarding the origin of carcinoma are as fallacious as 
 the hope he entertained of cancroin as a specific therapeutic agent has 
 been shown to be unfounded. The search for a specific microbe dates 
 back to the early days of bacteriology as a science. One of the first 
 efforts in this direction was made in 1881 by Wedopil. 
 
 The excitement which Scheuerlen's alleged discovery of a specific 
 bacillus of carcinoma produced spread over the world and stimulated 
 others to renewed activity in the bacteriological investigation of carci- 
 noma. For a short time Scheuerlen's claims were seriously entertained 
 and considered, and Schill and Frere went to the trouble to dispute his 
 claim to priority of the discovery of the carcinoma bacillus. Later, 
 Darier, Wickham, Malassez, Albarran, and Soudakewitsch described 
 coccidia-like bodies in tumors. These bodies were studied carefully in 
 tumor-tissue by Pfeiffer, Sjobring, Thoma, Podysoski, Delepine, and 
 especially by Ruffer. The last author regarded them as psorosperms, 
 and he studied their behavior to different kinds of staining material. 
 He found them in the protoplasm of cells in all carcinomatous tumors. 
 Stroebe, Steinhaus, O. Israel, Karg, Eberth, Ribbert, Hauser, and other 
 
CARCINOMA. 241 
 
 pathologists entertained more conservative views in regard to the 
 etiological importance of these bodies in the causation of tumors. 
 Many of these pathologists are of the opinion that the bodies which 
 have been described as psorosperms are only the product of cell- 
 degeneration. 
 
 The experiments of Ballance and Shattock in the cultivation of 
 cancer on nutrient media, and the direct inoculation of cancer per- 
 formed by Hanau, Klebs, and others, argue against a microbic origin 
 of carcinoma. The sporozoa which have been found in cancer-tissue 
 by different observers no doubt play their part in irritation, but there is 
 so far no evidence that they are the cause of carcinoma. 
 
 The bacteriological examination of carcinoma tissue continues, one 
 of the most recent efforts in that direction being that of Roncali. This 
 author found in a carcinoma of the ovary numerous intracellular and 
 intercellular blastomycetes in various stages of development, which he 
 regards as the cause of the disease. 
 
 Kurloff considers it very desirable that those engaged in investigating 
 the supposed organism of carcinoma should furnish with each published 
 case the history of the patient and a clinical and pathologico-anatomical 
 account of the tumor. Only by some such plan can we hope to 
 systematize the results arrived at by different investigators. Korotneff 
 discovered in carcinoma an organism which he called rlwpalocephalus 
 canceromatosus. Kurloff found the same parasite in a vacuole within 
 the epithelial cells of a carcinoma of the breast. Ohlmacher of Chicago 
 made very extensive investigations concerning the etiological relation 
 of sporozoa to carcinoma, and in a recent paper on this subject he 
 pointed out that many objects have been described as the parasites 
 of carcinoma because the subject has been treated unscientifically. A 
 great number of reagents have been used, hence the diversity of results. 
 Artificial products are sometimes found by the reagents. It has been 
 found that sporozoa treated by different fixing solutions act differently. 
 Some agents distort the spores and interfere with the subsequent 
 staining. All the present methods of investigation are faulty, and no 
 results are to be looked for until new methods are devised. 
 
 To prove the microbic origin of carcinoma it is necessary for bac- 
 teriologists to demonstrate the presence of the same organism in every 
 carcinomatous tumor. They must isolate the organism and cultivate it 
 outside the body upon artificial nutrient media, and with pure cultures 
 they must reproduce the disease in some of the lower animals. This has 
 so far not been done, and until it is done we have no right to claim for 
 carcinoma a microbic origin. It has been shown elsewhere that the local 
 and general dissemination of carcinoma is effected exclusively by cell- 
 
 16 
 
242 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 metastasis and cell-transportation, and that the secondary and meta- 
 static tumors are the exclusive products of tissue-proliferation of cells 
 derived from the primary tumor. In all infective swellings the cellular 
 elements are derived exclusively from the corpuscular elements of the 
 blood and proliferation from pre-existing tissue. Carcinoma-tissue is 
 derived exclusively from a matrix of embryonic epithelial cells. The 
 pre-existing tissues remain passive in carcinoma as well as in all other 
 tumor-formations. 
 
 De Morgan in 1874 said: "I can see no analogy between new 
 growth, whether as innocent as lipoma or as malignant as cancer, and 
 the products of true general or blood disease. From the first a tumor 
 is a living, self-dependent formation, capable of continued growth by 
 virtue of its own power of using the nutritive materials supplied to it. 
 Nothing like this is seen in any of the blood diseases." Until additional 
 and more positive light is shed upon the microbic origin of carcinoma 
 we must adhere to the theory that carcinoma is an atypical proliferation 
 of cells from a matrix of embryonic epithelial cells of congenital or post- 
 natal origin. 
 
 Pathology. 
 
 The most important aberration of the normal growth in carcinoma 
 consists in the presence of epithelial cells in vascular connective tissue. 
 The epithelial cells retain their vegetative power in the new locality. 
 The stroma is derived from the pre-existing connective tissue, and its 
 abundance depends largely on the amount of connective tissue in the 
 part affected and the intrinsic vegetative capacity of the epithelial cells. 
 If the organ affected is dense and fibrous, the pre-existing material for 
 the stroma is abundant, and the tumor, at least during its earlier stages, 
 will be firm. If the epithelial cells proliferate slowly, the pre-existing 
 connective tissue constituting the stroma is increased by the production 
 of new connective tissue in response to the stimulation created by the 
 carcinoma-cells, which act as an aseptic foreign substance. If the epi- 
 thelial cells possess a maximum power of tissue-proliferation, the stroma 
 is rapidly broken down, and little or no new connective tissue is formed, 
 the resulting tumor grows very rapidly, is soft, and local infection takes 
 place early and in a short time becomes diffuse. In hard carcinoma of 
 the breast, the so-called " scirrhus," the stroma is abundant and the 
 parenchyma is scanty. The same conditions are found in atrophic 
 carcinoma and in cancer en cuirasse. In the so-called " encephaloid " 
 carcinoma the conditions are reversed — a scanty stroma and an abun- 
 dance of rapidly-proliferating cells. 
 
 Carcinoma is distinguished from all other tumors by the irregularity 
 
CARCINOMA. 243 
 
 of its surface and the existence of a wide zone of infiltration. Virchow 
 years ago observed a zone of infiltration extending from three to four 
 lines from the macroscopical boundary-line of the tumor. Waldeyer 
 described this zone as the " inflammatory zone," because he found in 
 the connective tissue numerous small cells. This zone often presents 
 almost a typical appearance of tissue the seat of a chronic inflamma- 
 tion. The infiltration consists of leucocytes and small young epithelial 
 cells which, like the leucocytes, wander by virtue of their ameboid 
 movements into and along the connective-tissue spaces (Fig. 132). The 
 
 
 Fig. 132. — Zone of infiltration around carcinoma; X 330 (Surgical Clinic, Rush Medical College, Chi- 
 cago) : section from near the macroscopical boundary-line of a carcinoma of the abdominal wall : a, young 
 epithelial cells infiltrating the stroma, beginning formation of new alveoli ; b, stroma ; c, wandering leuco- 
 cytes. 
 
 infiltration in rapid-growing carcinoma is so extensive that the con- 
 nective-tissue spaces are packed with small round cells to such an 
 extent as to obscure the stroma completely (Fig. 133, c). 
 
 The leucocytes escape from new imperfect capillary vessels or from 
 vessels damaged by the tumor-tissue, and consequently are present in 
 great abundance in rapid-growing tumors — a condition which exem- 
 plifies the well-known clinical fact that the more closely a carcinomatous 
 tumor resembles an inflammatory product, the greater is its malignancy. 
 The young epithelial cells possess the maximum capacity to change 
 their location by ameboid movements ; hence we find in the zone of 
 infiltration exclusively young epithelial cells which have left the primary 
 tumor and are actively engaged in increasing its area. From the sur- 
 face of the carcinoma there project into the surrounding tissue tumor- 
 masses which render its surface uneven and nodular. These projections 
 of the tumor can be seen to greatest advantage in squamous-celled 
 carcinoma. They appear first as conical or column-shaped infiltrations 
 connected on one side with the primary tumor and projecting into the 
 connective tissue on the other (Fig. 134). These projecting parts of 
 
244 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Fig. 133. — Extensive ground-cell infiltration at the margin of a carcinoma of the lower jaw; extension 
 of disease from the lip ; X 130: a, carcinoma-cells wandering into site of former pearl; b, colloid material; 
 c, round-cell infiltration ; d, young carcinoma-cells. 
 
 
 
 / 
 
 / 
 
 Fig. i 34 .-Carcinoma of the tongue; X 85 (Surgical Clinic, Rush Medical College, Chicago): a, columnar 
 projections of carcinoma-cells ; b, epithelial nests ; c, blood-vessels ; d, submucous connective tissue. 
 
CARCINOMA. 245 
 
 the tumor impart to it from the very beginning a certain degree of 
 immobility and cause the nodulated condition of its surface. 
 
 The stimulation of the tissues caused by the invasion of so many 
 foreign bodies results also in the formation of new blood-vessels, 
 brought about by a process of budding from the pre-existing blood- 
 vessels adjacent to the tumor-matrix. The vascularization, not being 
 
 
 9. 
 
 e 
 
 f e 
 
 
 W 
 
 d 
 
 Fig. 135. — Deep-reaching epithelioma upon the leg, with papillary excrescences. Specimen injected. 
 Section from the part of the tumor which occupied the cavity in the tibia; X 6 (after Thiersch) : a, new 
 vessels composed of numerous loops; b, elongated pedunculated proliferation of vessels; c, large vessel- 
 trunks which suddenly terminate in capillaries ; d, compact masses of epithelial cells arranged in concentric 
 layers, cut transversely or obliquely, and surrounded by vascular stroma ; e, part of a cleft-like cavity con- 
 taining epithelial debris;,/", flat polygonal cells in irregular layers, answering to the horny epithelial cells of 
 the skin ; g, layer of cells representing the rete Malpighii. 
 
 under the normal control of the nervous tissue, and being in a district 
 of planless tissue-proliferation, always assumes an atypical type. The 
 epithelial cells in carcinoma are brought in direct contact with the new 
 blood-vessels (Fig. 135, d). 
 
 Ribbert has recently advanced the theory that the histogenesis 
 of carcinoma is caused by a proliferation of the connective tissue, 
 which isolates the epithelial cells and brings them in contact with 
 vascular tissue. This view has been vigorously opposed by Hauser 
 and Notthafft, who have made observations on the penetration of 
 epithelial cells during the early stage of the development of car- 
 cinoma. 
 
 The atypical vascularization of a carcinoma exerts a potent influence 
 in determining its clinical course. Great vascularity is a prominent 
 
246 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 feature of rapid-growing tumors. In slow-growing hard tumors the 
 blood-supply is scanty. In atrophic carcinoma the vessels are com- 
 pressed and often obliterated by the cicatricial contraction of the massive 
 stroma. Perforation of a vessel-wall by tumor-tissue is apt to be followed 
 by metastatic carcinoma or miliary carcinosis. Thrombosis of a prin- 
 cipal vessel of the tumor results in speedy and extensive degeneration 
 or necrosis of the tumor-tissue. 
 
 Carcinoma-cells retain their embryonic character and never reach 
 maturity. The imperfect development of epithelial cells in carcinoma 
 is one of the distinctive features between them and the mature epithelial 
 cells of benign epithelial tumors. The juvenile condition of the paren- 
 chyma-cells of a carcinoma explains the rapid growth of the tumor 
 and the early degenerative changes which take place in its tissues. 
 
 Thiersch has well said that the tissue of carcinoma is characterized 
 from the start by degeneration. While the degeneration is progressing 
 the parts first affected suffer a retrogressive change, without, however, 
 it being followed by complete absorption. The pre-existing connective 
 tissue is utilized as a temporary scaffolding for the tumor-tissue. The 
 parenchyma-cells of all organs affected by carcinoma are subjected to 
 pressure, undergo fatty degeneration, and are gradually removed by 
 absorption as the tumor advances. The complete removal of glandular 
 tissue in secondary carcinoma of the lymphatic glands furnishes a 
 striking illustration of the gradual substitution of tumor-tissue for 
 the pre-existing glandular structure. The connective tissue of the 
 part affected furnishes the stroma of the tumor ; this stroma is increased 
 under favorable circumstances, but is likewise subject to degenerative 
 changes and to gradual removal by the increasing number of cells. 
 
 The degenerative changes which occur most frequently in carcinoma- 
 cells are — I. Fatty degeneration ; 2. Colloid degeneration; 3. Mucoid 
 degeneration. Fatty degeneration begins always 
 in the centre of the alveoli, in the oldest cells, 
 and in the parts most distant from the vascular 
 supply. The cells in the centre of an epithelial 
 nest (Fig. 136) show first in their protoplasm 
 granules of fat which increase in size and number 
 until the cell breaks up in fragments, leaving 
 minute particles of fat and a granular detritus. 
 
 riG. 136. — .Lpitheual pearl r <=> 
 
 from carcinoma of skin of leg; Fatty degeneration begins at different points in 
 
 X no, reduced one-fourth (Surg- i / • 
 
 icai clinic, Rush Medical college, the same alveolus (Fig. 137). 
 
 Chicago) : a, a. centre of cancer- T1 j i_ r r ^.j. j >_• 
 
 nests, showing fatty degeneration The product of fatty degeneration in squa- 
 
 ts cells - mous-celled and glandular-celled carcinoma in 
 
 its naked-eye appearances resembles very much the contents of an ath- 
 
 
CARCINOMA. 
 
 247 
 
 roma. It is composed, like the latter, of detached dead and degenerated 
 epithelial cells, granules of fat, and a granular detritus. While the centre 
 of an alveolus is undergoing this 
 change the disease extends in its 
 periphery, where cell-proliferation is 
 progressing in the outer layer of the 
 younger epithelial cells. In ulcer- 
 ating carcinoma of the lip and the 
 skin the products of fatty degen- 
 eration, in the form of small plugs 
 presenting the appearance of athe- 
 romatous material, can be squeezed 
 out upon the surface by pressure. 
 The same condition is not met with 
 in any other ulcer, and is ^therefore 
 of the greatest diagnostic importance. 
 In glandular carcinoma the same 
 kind of material can be squeezed 
 from the surface on making a sec- 
 tion through the tumor. Fatty de- 
 generation of the parenchyma of a 
 carcinoma is most marked in slow- 
 growing hard tumors, and must 
 be regarded as a favorable retrogressive change tending to retard the 
 growth of the tumor. 
 
 Fig. 137. — Multiple points of fatty degeneration 
 in the same alveolus ; X 480 (Surgical Clinic, Rush. 
 Medical College, Chicago) : a, highly refractile non- 
 staining area. 
 
 Fig. 138. — Carcinoma of the rectum with extensive colloid degeneration of the cells lining the tubules 
 (after Perls). In the small alveoli, beginning colloid degeneration of the cells ; the larger alveoli are distended 
 by colloid material and are without attached cells. 
 
248 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 
 Colloid degeneration occurs in the parenchyma and stroma of car- 
 cinoma, and is not limited to tumors of any particular type of cells 
 (Fig. 139). Colloid degeneration of the stroma is found in rapid- 
 growing glandular carcinoma. The colloid material is often so abun- 
 dant as to obscure the cellular elements and the stroma — so much so 
 
 Fig. 139. — Colloid degeneration of stroma in carcinoma of the mamma ; X 350 (Surgical Clinic, Rush Medical 
 College, Chicago) : a, stroma ; b, alveoli packed with epithelial cells ; c, colloid masses in stroma. 
 
 as to induce many authors to regard it as a special form of tumor. 
 Lebert showed that what was known as " colloid carcinoma" is a car- 
 cinoma modified by the character of the regressive tissue-metamor- 
 phosis of its cells or its stroma, or both. Colloid degeneration is of 
 very frequent occurrence in carcinoma of the alimentary canal, the 
 favorite locality of what was formerly described as " colloid cancer " 
 
 (Fig- 138). 
 
 Mucoid or myxomatous degeneration may occur in either the cells 
 or the stroma of a carcinoma. Columnar-celled carcinoma is very apt 
 to undergo this form of regressive metamorphosis. It is again the 
 oldest cells that first undergo this change. In cylindrical-celled car- 
 cinoma, in which the cells are arranged in several layers, the layer next 
 
CARCINOMA. 
 
 249 
 
 to the lumen of the tubule is destroyed by the myxomatous process, 
 and the mucoid material accumulates in the glandular spaces, forming 
 cysts of various sizes (Fig. 140). If the areas of degeneration are 
 
 Fig. 140.— Cylindrical-celled carcinoma of stomach ; X 250 (after Perls). The cells in the central part of 
 the alveoli are destroyed by myxomatous degeneration. 
 
 extensive, the consistence of the tumor varies in different places — a 
 matter of importance in diagnosis. Secondary tumors are subject to 
 the same degenerative changes as the primary. Ulceration in car- 
 cinoma of the skin and the mucous membranes is present almost from 
 the beginning. Carcinomatous ulcers of the cutaneous surface are 
 usually covered by a crust formed by inspissation of the secretion, 
 which crust, if detached, uncovers an ulcer which bleeds upon the 
 slightest touch. An nicer once formed remains permanently, increases 
 in size, and manifests no tendency to heal. The differentiation of such 
 an ulcer from lupus and from ulcerating syphilitic affections is always 
 difficult and sometimes impossible. When the tumor involves the skin 
 or when a deep-seated carcinoma has reached the skin, ulceration takes 
 place, the central part, being more abundantly supplied with epithelial 
 cells and being less vascular, becoming the seat of necrotic changes. 
 As soon as the continuity of the surface is destroyed, micro-organisms 
 take a part in the subsequent work of destruction, as the tumor-tissue 
 becomes the seat of suppurative inflammation. A carcinomatous ulcer 
 is characterized by its deep, crater-like cavity, which again may present 
 nodules, as well as by its thickened and indurated margins. The ulcer 
 may also be flat where the thin infiltrations appear to be destroyed by 
 ulceration. These ulcers are always surrounded by steqp, abrupt 
 
250 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 margins, and present a flat floor with few or no granulations, being 
 thus distinguished from many other kinds of ulcers resulting from 
 infective causes. Large ulcers are usually the seat of putrefactive pro- 
 cesses and emit an exceedingly offensive odor. The putrefaction is 
 caused by the presence of putrefactive bacilli which develop in the 
 dead tissue attached to the ulcerated surface. A carcinoma covered 
 by normal intact skin may become infected with pyogenic microbes by 
 localization in the tumor-tissue of floating microbes. Suppurative 
 inflammation of the tumor-tissue under such circumstances is attended 
 by the usual symptoms which accompany acute inflammation. Tem- 
 perature, rapid pulse, and other symptoms of sepsis, with increase of 
 swelling, pain, tenderness, and oedema, are the symptoms to be relied 
 upon in ascertaining the existence of this complication. If the tumor 
 is large and the infection is extensive, a large part of the tumor may 
 slough, leaving a crater-like excavation after the elimination of the 
 dead material. 
 
 It will be necessary to add to the general remarks on the pathology 
 of carcinoma a brief description of the 
 
 Histological Varieties of Carcinoma. 
 
 Squamous-celled Carcinoma. — This variety of carcinoma develops 
 upon the surface of the skin, and is usually described under the term 
 " epithelioma." The term " epithelioma " has given rise to a great deal 
 of confusion, as some authors describe under it a benign, and others a 
 malignant, tumor of the skin or the mucous membranes. The word 
 should be abolished in the nomenclature of tumors. 
 
 A squamous-celled carcinoma contains as the essential tumor- 
 element squamous or pavement epithelium in imitation of the epithelial 
 layers of the skin. The growth usually begins as a small surface 
 defect — a crack or fissure of the skin covered by a crust. With the 
 cancer-formation the epithelial cells dip down beyond the membrana 
 propria into the subcutaneous vascular connective tissue. The tumor 
 then is slightly elevated above the level of the surrounding skin, with 
 a hard base, and with indurated margins from which infiltrations extend 
 into the surrounding tissues. The tumor beneath the skin or under 
 the ulcer appears to the palpating finger as a hard mass, almost of the 
 density of a piece of cartilage. The tumor ulcerates early, as the oldest 
 portion does not receive a blood-supply adequate to nourish its tissues. 
 When the epithelial layer is destroyed the connective tissue furnishes 
 the surface with a layer of vascular granulations ; but an attempt in 
 this direction is only partially successful, as some of the epidermal 
 plugs penetrate deeply into the subcutaneous tissue. If these epidermal 
 
CARCINOMA. 251 
 
 plugs are carefully examined, their connection with the surface epithelia 
 is readily traced by making the section in a right direction : if it is made 
 oblique, the deeper parts of the tumor appear disconnected with the 
 surface. 
 
 In the proper interpretation of the diagnostic significance of these 
 epithelial plugs not only is their net-like branching characteristic, but 
 of greater import are their shape and combination. Benign epithelial 
 proliferations show the same regular form and arrangement of the cells as 
 the normal inversions of the epidermis, and they gradually become nar- 
 rower toward the depth, while in the carcinomatous epithelial prolifera- 
 tion the nature of the growth is revealed by the irregular arrangement 
 of the epithelial cells and their relations to the connective tissue. New 
 epithelial cells which form on the surface of granulations in the healing 
 of a wound or an ulcer do not possess the power to penetrate into the 
 deeper tissues, while penetration of the connective tissue is the most 
 conspicuous pathological feature of carcinoma. The carcinoma-cells 
 first penetrate the entire thickness of the skin, and later the subcutane- 
 ous connective tissue and any other tissue within their reach. Another 
 important differential point is that in non-malignant affections of the 
 skin the normal shape of the different forms of epithelial cells is main- 
 tained, while in carcinoma there is a great similarity in the shape of the 
 cells. Epithelial pearls in non-malignant affections appear in the form 
 of concentric layers of cells, with the oldest cells in the centre ; in car- 
 cinoma the cells of such a pearl are the product of tissue-proliferation 
 of a single cell. In carcinoma the cells are often multinuclear, and 
 only gradually, by flattening and arrangement in concentric layers, form 
 the epithelial nests. 
 
 In ordinary granulation-tissue but few leucocytes are found ; in 
 carcinoma they are abundant, especially near capillary vessels. In 
 chronic ulcer of the leg, if malignancy sets in, young epithelial cells 
 become buried underneath the benign granulations, and a carcinoma of 
 considerable size may be produced by them before its presence would 
 be recognized by surface indications. If a carcinoma of the skin is 
 allowed to run its course undisturbed, regional infection is sure to take 
 place, and other complications, in common with glandular carcinoma, 
 set in sooner or later, furnishing an abundance of clinical evidence to 
 prove the carcinomatous nature of the tumor. 
 
 The favorite localities of squamous-celled carcinoma are the lips, 
 the skin of the face, the mouth, the nose, the ear, the penis, the vulva, 
 and the anus. In the oesophagus it most frequently attacks that part 
 of the tube which lies behind the cricoid cartilage and the bifurcation of 
 the trachea. Carcinoma of the tongue commences most frequently at 
 
252 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the margin and base of the organ, at points irritated by sharp or defect- 
 ive teeth. Carcinoma is also quite frequent in the larynx, the vocal cords, 
 and, as Stork has observed, from polypoid or papillomatous growths, 
 warts, and scars in this organ. The deep, squamous-celled carcinomata 
 originate from an incompletely obliterated branchial cleft (Volkmann), 
 from remnants of the urachus and of dermoid tumors, or from a dis- 
 placed matrix of embryonic cells in any part of the body. Friedlander 
 found in the apex of the lung of a phthisical patient a squamous-celled 
 carcinoma which projected into a principal bronchus. He believed that 
 the columnar cells in this locality had become transformed into squa- 
 mous epithelium, and he refers to the observations made by Griffini and 
 Ziegler, who found pavement epithelium upon ulcerous, tubercular, and 
 syphilitic defects of the trachea. It is, however, more probable that the 
 carcinoma had developed from a displaced matrix of epiblastic tissue. 
 
 Erbse saw a case of squamous-celled carcinoma of the lung after 
 perforation into the trachea of an oesophagus-carcinoma composed of 
 epithelial cells resembling the primary tumor. Klebs thinks that cells 
 entered the lung by aspiration before perforation occurred. 
 
 As compared with glandular carcinoma, squamous-celled carcinoma 
 pursues a chronic course. This, as we have explained elsewhere, is to 
 be attributed not so much to its lesser intrinsic malignancy as to the 
 difference in the anatomical location of the two growths. If left to 
 itself, squamous-celled carcinoma ultimately presents all the clinical 
 features of glandular carcinoma. 
 
 Melanotic carcinoma is a pigmented squamous-celled carcinoma. It 
 develops in structures which are pigmented — most frequently in pig- 
 mented moles. The pigment appears as granules in the protoplasm of 
 the cells. This form of carcinoma is regarded as exceedingly malig- 
 nant, giving rise to early and extensive regional infection and to general 
 dissemination. The secondary tumors show the same structure, and 
 are pigmented like the primary tumor. 
 
 Cylindrical-celled Carcinoma. — The cylindrical-celled carcinoma 
 resembles the squamous-celled in so far that it develops upon a free 
 surface, but it differs from it in the shape and arrangement of its cells. 
 The cells are derived from the hypoblast, are columnar in shape, and 
 are attached in single or multiple layers to the inner surface of imper- 
 fect tubules. The histological structure of a cylindrical-celled carci- 
 noma is an imitation of gland-ducts and of mucous glands of the 
 gastro-intestinal canal. The carcinomatous process begins with an 
 anomalous vegetation of columnar epithelial cells. The membrana 
 propria is defective at points, and permits the cells to escape from the 
 tubules into the surrounding connective tissue, where they continue to 
 
CARCINOMA. 253 
 
 reproduce themselves by indirect cell-division. The connective tissue 
 also proliferates and enters into the formation of the tumor. The dis- 
 connected development of epithelial cells is an important factor in the 
 local extension of the tumor. It marks the first deviation from normal 
 growth, and it is always followed by local and regional infection, and, 
 as Lebert has shown, very frequently by general dissemination. 
 
 Metastatic tumors, especially of the bones, are often associated with 
 a small primary tumor showing greater aptitude for local and general 
 dissemination than does squamous-celled carcinoma. The primary 
 tumor in such cases has often been overlooked entirely. Klebs 
 believes that the extension to bone usually takes place through lymph- 
 glands, especially those in the lumbar region. 
 
 Compared with squamous-celled carcinoma, cylindrical-celled carci- 
 noma is a much more malignant affection. A partial explanation of 
 this difference in their clinical behavior is the presence in the former 
 of an abundance of firm connective tissue to serve the purpose of 
 stroma, and in the latter of a scanty, loose bed of connective tissue. 
 Glandular Carcinoma. — The morphological prototypes of this 
 variety of carcinoma in normal tissue are the acinous glands, some 
 of which are derived from the epiblast and some from the hypoblast. 
 The hard variety of glandular carcinoma has been called " scirrhus " 
 for centuries, and this name still figures prominently in our modern 
 text-books. The texture of the tumor varies according to the amount 
 of stroma present. If the stroma is abundant and firm, the tumor is 
 firm — the so-called " scirrhus ;" if the stroma is scanty and the amount 
 of tumor-cells is consequently increased, the tumor is soft, constituting 
 what was formerly, from its resemblance in consistence and appearance 
 to brain-tissue, termed an encephaloid or medullary cancer. If such 
 a tumor ulcerated and fungous masses appeared on the surface of the 
 ulcer, which bled easily on being touched, it was called fungus hema- 
 todes. Such a distinction between glandular tumors is no longer justi- 
 fiable upon histological or clinical grounds, as the same tissue-elements 
 are present in all varieties, only in different proportions, and all of these 
 varieties result in regional, and frequently in general, infection. The 
 classification of carcinoma should be made upon a histological basis, 
 and if this is done, all malignant epithelial tumors of acinous glands 
 must be brought under one head as glandular carcinoma. 
 
 Glandular carcinoma varies greatly according to the character of the 
 mother-soil and the arrangements of its histological elements, but 
 many of the features of the varieties formerly regarded as distinct 
 types of tumors have so much in common as to constitute a well- 
 defined form of carcinoma. The most distinguishing feature between 
 
254 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 glandular carcinoma and carcinoma of the cutaneous and mucous sur- 
 faces is that the former gives rise to the formation of a large tumor. 
 The reason that a surface carcinoma does not form a large tumor is that 
 it can grow in one direction only, and that, being exposed to frequent 
 irritation of all kinds, and receiving its blood-supply only from one direc- 
 tion, it falls an early prey to ulceration. As soon as a surface carcinoma 
 has ulcerated, the tumor-tissue is exposed to infection with pathogenic 
 microbes, which infection, by producing a suppurative inflammation, aids 
 in the destruction of tumor-tissue. A glandular carcinoma is better pro- 
 tected against irritation, injury, and infection with pathogenic microbes, 
 is surrounded everywhere by tissue, and receives its blood-supply from 
 all sides, and it is for these reasons that the tumor attains larger size 
 and that ulceration sets in later than in a surface carcinoma. 
 
 Carcinoma of the breast is the most familiar representative of the 
 glandular group. In the hard glandular tumor the epithelial cells lose 
 their typical shape sooner than in the soft variety, owing to the pres- 
 sure to which they are subjected on the part of the massive stroma 
 and to the scanty blood-supply. The defective acinous grouping of 
 the epithelial cells (Fig. 141) points to a deeper nutritive disturbance 
 than is the case in adenoma (Fig. 142), and should always be looked 
 for in making a differential diagnosis by the aid of the microscope. 
 The carcinomatous character of the tumor becomes evident when the 
 tissues adjacent to the tumor are examined. If the tumor, for instance, 
 is surrounded by fat, this tissue will be found infiltrated with new 
 epithelial cells, and hence what might have been considered macro- 
 scopically as the most important features, adhesion and infiltration, 
 become corroborated by examination of these tissues under the micro- 
 scope. When the tumor starts in the acini of the gland — or, rather, when 
 the tumor presents an acinous structure — the picture is entirely changed, 
 as the histological arrangement in a hard glandular tumor presents no 
 resemblance whatever to normal gland-tissue : the glandular tissue has 
 given way to a firm, quite homogeneous, fibrous mass ; only numerous, 
 narrow, somewhat deeply-stained stripes indicate the location of the 
 compressed, proliferating epithelial cells. The carcinomatous, tissue pre- 
 sents a peculiarly distinctive histological type. This tissue consists of a 
 mixture of epithelial cells and connective tissue, the mutual topographical 
 and numerical relations of which deviate completely from the normal 
 structure of the mammary gland. 
 
 The highest degree of atypical tissue-proliferation is met with in 
 carcinoma of the mammary gland. The local infection extends along 
 pre-existing connective-tissue spaces, and ultimately extends beyond 
 the limits of the gland to the overlying skin and the wall of the thorax, 
 
CARCINOMA. 
 
 255 
 
 - 
 
 O — u u 
 
 rt >- a 
 
 3 ° 
 
256 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 which is frequently perforated by the growth, either by continuity of 
 growth and successive involvement of the different tissues, or in the 
 course of the lymphatics until the pleura is reached, when the disease 
 spreads rapidly over the serous surfaces, usually resulting in hydro- 
 thorax. The serum in such cases is frequently stained by the admix- 
 ture of blood. Glandular carcinoma is followed at an early stage 
 by regional infection. The lymphatic glands nearest the organ affected, 
 in the direction of the lymph-current, are usually involved first, when, 
 step by step, successive glands are implicated until the entire chain of 
 glands has become infected. General infection at this stage may occur 
 at any time and may hasten the death of the patient. The glands 
 most frequently the seat of carcinoma are the mammary, thyroid, 
 parotid, submaxillary, ovary, testicle, kidneys, pancreas, and prostate. 
 
 Diagnosis. 
 The difficulty in the diagnosis of carcinoma depends on the size and 
 location of the tumor. In advanced carcinoma of the external parts 
 of the body a correct diagnosis can often be made on first sight. The 
 diagnosis of carcinoma of internal organs is frequently made only in 
 the post-mortem room. The successful treatment of carcinoma 
 depends upon an early and a correct diagnosis and prompt and 
 thorough operative interference. The early diagnosis requires a care- 
 ful study of the clinical history of the case, supplemented by a 
 thorough examination of the tumor, and followed by a critical analysis 
 of the signs and symptoms presented. In doubtful cases a correct 
 diagnosis is possible only by differentiating from a supposed carcinoma 
 swellings and tumors which simulate it — that is, by exclusion. Inoc- 
 ulation experiments and the use of the microscope may become neces- 
 sary to make a differential diagnosis between carcinoma and some of 
 the infective swellings. In obtaining the clinical history it is important 
 to inquire into the family history in reference to the possible existence 
 of an hereditary predisposition to carcinoma. To elicit information of 
 value concerning this point it is necessary to trace back the family 
 history for two or three generations, because such an hereditary predis- 
 position does not necessarily occur in the immediate offspring of car- 
 cinomatous parents, but may appear in the second, third, or fourth 
 generation. The writer knows of one family in which both parents 
 died of carcinoma — the husband of carcinoma of the stomach, the 
 wife of carcinoma of the uterus — and yet the children, one of whom 
 has now reached his sixtieth year, have shown no symptoms of this 
 disease. In tracing the family history in the cases of carcinoma that 
 have come under his observation the writer has had patients tell him 
 
CARCINOMA. 257 
 
 repeatedly that one of the grandparents or great-grandparents died of 
 carcinoma. It is also important to elicit the existence of malignant 
 disease among more distant relatives, as the hereditary predisposition 
 may follow with varying degrees of intensity different branches of the 
 same family. . 
 
 The age of the patient is an important element in the diagnosis of 
 doubtful tumors. Carcinoma is a disease that in preference attacks 
 persons of middle or past middle life. The aptitude for this disease 
 increases after middle life. In very rare instances it has been of con- 
 genital origin or has developed during childhood. It is quite rare in 
 persons less than twenty years of age, and is more common during the 
 third decade of life. The writer has seen carcinoma of the rectum" in 
 a boy eighteen years of age, carcinoma of the breast in a girl twenty- 
 five years old, carcinoma of the lower lip in a man twenty-seven 
 years old, and carcinoma of the stomach in a man of thirty. Cases 
 of carcinoma in persons less than thirty years of age are, however, 
 extremely rare. A tumor of the lip occurring in a man less than thirty 
 years of age is in all probability anything else than a carcinoma, while 
 in persons past middle life the probability of its being carcinomatous is 
 greatly increased. If a woman less than thirty years of age is suffering 
 from pelvic distress, menorrhagia, and profuse leucorrhoeal discharge, 
 the probability of these symptoms being caused by carcinoma of the 
 uterus is exceedingly small, while the same complexus of symptoms 
 occurring in a woman at the time of the menopause or later points 
 strongly in that direction. A solid tumor in females less than twenty- 
 five years of age is usually of a benign nature, while its appearance in 
 women past thirty years of age should arouse a strong suspicion of 
 its malignant character. 
 
 Sex exerts a strong influence in determining the location of carci- 
 noma. Pyloric obstruction of the stomach is caused by carcinoma 
 much more frequently in men than in women. Carcinoma of the lip is 
 extremely rare in women. Carcinoma of the breast in the male is an 
 exceptional occurrence. Carcinoma of the genital organs is much more 
 frequent in women than in men. 
 
 Rapidity of growth is a marked feature of carcinoma as compared 
 with benign tumors. A rapid-growing tumor is therefore more apt 
 to be mistaken for an inflammatory swelling than for a carcinoma. 
 Rapidity of growth as a diagnostic evidence, however, must be weighed 
 carefully before conclusions are drawn from it, otherwise the surgeon 
 is very likely to be misled. A carcinoma may remain latent for main- 
 years before manifesting malignant qualities. An inflammatory swell- 
 ing, as a rule, increases in size more rapidly than a carcinoma. Patients 
 17 
 
258 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 have been sent to the writer repeatedly with the diagnosis of carcinoma 
 of the breast, when the clinical history showed that the swelling had 
 reached its maximum size in from four to six weeks — the result of 
 an almost painless subacute suppurative inflammation of the breast. 
 In rapidly-growing tumors particular pains should be taken to ascertain 
 a possible source of infection. If, for instance, a tumor of the testicle 
 attains the size of a hen's egg in a few weeks in a man more than thirty 
 years of age, a suspicion of syphilitic infection should be excited. A 
 gumma of the testicle will increase in size much more rapidly than a 
 carcinoma of the same organ. A rapid-growing carcinoma must be 
 differentiated carefully from infective swellings of all kinds — gumma, 
 ttcberculosis, actinomycosis, and chronic suppuration. 
 
 Tenderness and pain, although present to a more or less marked 
 degree in advanced carcinoma, are symptoms of greater prominence in 
 inflammatory affections. Non-professional men and women have an 
 exaggerated idea of pain as a symptom of carcinoma. They are im- 
 pressed with the belief, handed down for ages, that carcinoma is an 
 exceedingly painful affection, and it is difficult to make them under- 
 stand that carcinoma may occur as a painless affection. Carcinomata 
 of the skin and mucous membranes are not attended by much pain. 
 Patients who have suffered perhaps for a year or more from carcinoma 
 of the rectum generally complain of but little pain, and seek medical 
 advice for what they have regarded all along as piles. Carcinoma of 
 the stomach is a comparatively painless affection, and the suffering 
 caused by it is more from the mechanical obstruction than from the 
 carcinoma per se. The temporary sharp, shooting, lightning pains so 
 frequently described as a characteristic symptom of carcinoma are often 
 entirely absent and are always of an intermittent character. The writer 
 has frequently opened the abdomen for acute intestinal obstruction, and 
 has found carcinoma of the intestine without the patient's having known 
 that there was anything seriously wrong before the symptoms of acute 
 obstruction set in. 
 
 Tenderness, a symptom of the greatest diagnostic importance in 
 inflammatory affections, is usually entirely wanting in uncomplicated 
 carcinoma. Dilatation of the superficial veins is the result of great 
 vascularity or of deep-seated venous obstruction, and is present as fre- 
 quently in infective swellings as in carcinoma. Redness is present in 
 carcinoma when the tumor has reached and implicated the skin and 
 is on the verge of ulceration. It is only under similar circumstances 
 that it is present in infective swellings. CEdema, so significant of the 
 presence of a deep-seated abscess, is present in carcinoma when the 
 regional infection interferes with the lymphatic or venous circulation 
 
CARCINOMA. 259 
 
 or when the tumor has become the seat of infection with pus-mi- 
 crobes. 
 
 Primary multiplicity of the tumor seldom occurs in carcinoma, but 
 is of frequent occurrence in the case of benign epiblastic, hypoblastic, 
 and mesoblastic tumors. Carcinoma as a multiple affection is occa- 
 sionally met with in the aged, when the disease originates by the trans- 
 formation of senile warts into carcinoma. Cases of primary multiple 
 carcinoma have been reported by Liicke, Winiwarter, Klebs, Kaufmann, 
 Bucher, Walter, and Schimmelbusch. Schimmelbusch explains primary 
 multiplicity of carcinoma by a process of implantation of carcinoma 
 cells at a point opposite or some distance from the primary tumor, the 
 latter furnishing the cells for the secondary tumor growth. Bucher 
 attributes the occurrence of multiple carcinoma in the same organ to a 
 multiplicity of points of irritation. Another potent cause for the occur- 
 rence of multiple carcinoma in the same organ or in different parts of 
 the body is the presence of the essential tumor matrix in tissues dis- 
 posed to tumor-formation, and subjected to the same influences which 
 act as exciting causes. Recently there came under the observation of 
 the writer a case in which four carcinomata of the face developed 
 almost simultaneously. One tumor occupied the malar region on the 
 left side ; another, the lobe of the left ear ; a third was situated over 
 the angle of the lower jaw ; and the fourth was a typical ulcerating 
 carcinoma of the lower lip that had given rise to infection of the sub- 
 mental and submaxillary glands. 
 
 Benign tumors are always encapsulated, hence, unless bound down 
 by surrounding tissues, are movable and have well-defined margins. 
 Carcinoma is an infiltrating tumor, and has abrupt, well-defined mar- 
 gins. The infiltration gives rise to nodulation of its surface and to 
 immobility of the tumor. A nodulated fixed tumor is in all probability 
 a carcinoma. To test the mobility of the tumor it should be palpated 
 carefully between the two index fingers to ascertain the points of fixa- 
 tion caused by the infiltration. An adenoma of the breast will slip 
 between the fingers, while a carcinoma of the same size will be more 
 or less fixed in its location by the peripheral parts of the tumor which 
 project into the surrounding tissues. 
 
 Hardness of the tumor is usually recognized as a sign of malig- 
 nancy. A fibro-adenoma could not be differentiated from a carcinoma 
 by this sign. A carcinoma with a scanty reticulum and extensive de- 
 generative changes is a soft tumor, resembling in this respect an 
 adenoma with cystic degeneration. The diagnostic importance of this 
 property of carcinoma has been overestimated greatly. 
 
 Fluctuation, when too much relied upon, leads to frequent mistakes 
 
260 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 in diagnosis and treatment. It is present in cystoma, cystic adenoma, 
 and inflammatory swellings with central softening, as well as in soft 
 carcinoma with extensive regressive degeneration of the centre of the 
 tumor. Pseudo-fluctuation is often present in soft carcinoma without 
 cystic degeneration. This sign has often induced surgeons to puncture 
 a malignant carcinoma under the belief that they were opening an 
 abscess. Such mistakes, in addition to being a source of mortifica- 
 tion to the surgeon, have always resulted disastrously to the patient 
 by transforming a subcutaneous into an open carcinoma, with all the 
 annoyances and dangers incident to such a change. A suspicious fluctu- 
 ating swelling shotdd never be punctured or incised without having ex- 
 cluded the existence of a soft carcinoma, sarcoma, or gramdoma by the 
 use of the exploratory syringe. 
 
 One of the important steps in the diagnosis of a carcinoma is the 
 examination of the lymphatic glands. In suspected carcinoma of the 
 lip, the submental and submaxillary glands ; in tumors of the mam- 
 mary gland, the glands of the axilla ; in ulcerative affections of the 
 cervix of the uterus, the sacral glands, — should be examined carefully. 
 Many conclusions have frequently been drawn from the results of such 
 an examination. In tumors of the breast a diagnosis of their benign 
 nature has often been based upon the absence of palpable lymphatic 
 glands in the axilla. Some excellent modern authorities continue to 
 advise, when no enlarged glands can be felt in the axilla, that this 
 region should not be invaded in operations for carcinoma of the mam- 
 mary gland. This is teaching of a dangerous kind. The writer has 
 frequently failed to find any evidences of regional infection by examina- 
 tion through the intact skin in cases of carcinoma of the breast, when 
 during the operation, upon exposing the deep lymphatics of the axilla 
 by free incision, numerous glands the size of a marble were found. In 
 obese women it is impossible by external palpation to detect glands the size 
 of a pea or even that of a marble, and consequently such an examination 
 cannot be relied upon in determining the extent of the operation before- 
 hand. Carcinoma of the skin does not give rise to early regional infec- 
 tion, and yet when the disease has become quite extensive exposure 
 of the submental and submaxillary glands by a free incision frequently 
 reveals the presence of glands, as large as a pea, which could not be 
 felt through the intact skin. Examination of the retroperitoneal lym- 
 phatic glands in suspected cases of carcinoma of the uterus should 
 never be neglected. In carcinoma of the skin of the extremities the 
 glands in the different regions should be subjected to a scrutinizing 
 examination. Enlarged glands under such circumstances have often 
 been overlooked, and such oversights have been responsible for many 
 
CARCINOMA. 261 
 
 disappointing results. Enlargement of lymphatic glands in the region 
 occupied by the tumor, without ulceration of the surface and without 
 involvement of the glands in other regions, is almost positive proof of 
 the carcinomatous nature of the tumor. Enlargemeiit of the lymphatic 
 glands in the region occupied by an ulcerating tumor may be the result 
 of infection of the lymphatic glands, in which case pathogenic microbes 
 have entered the lymphatic channels through the surface defect. In lymph- 
 adenitis the glands are not so hard as in secondary carcinoma of the 
 lymphatic glands, and are more tender 011 pressure. In ulcerating car- 
 cinoma the lymphatic glands in the region occupied by the tumor may 
 be the seat of both microbic infection and cell-metastasis, when the local 
 signs and symptoms correspond with this double infection. If from 
 other evidences a diagnosis of ulcerating carcinoma can be made, the 
 lymphatic glands should be subjected to treatment as though their enlarge- 
 ment lucre exclusively due to cellular infection. Universal lymphatic 
 hyperplasia is one of the most important indications of syphilitic infection, 
 and a tumor occurring in a person showing such a condition should be 
 examined with the utmost care, to exclude the possibility of its being a 
 gumma. 
 
 The greatest difficulties are encountered in the diagnosis of ulcer- 
 ating tumors. It is in such cases that it is so important to ascertain 
 from the patient's statements the probable starting-point of the tumor. 
 Epithelial tumors, with few exceptions, start in the tissues derived from 
 the epiblast or the hypoblast — that is, in the skin, the mucous mem- 
 brane, or the glandular tissue. If the tumor developed in the skin or 
 the mucous membrane, it appeared first as a surface tumor, and could 
 be moved only by moving the skin or the mucous membrane in which 
 it originated ; that is, it was in the beginning superficial and not covered 
 by skin or by mucous membrane. If it developed in an acinous gland, 
 it could be moved with the gland and was covered by skin or by 
 mucous membrane. All mesoblastic tumors start as subcutaneous or sub- 
 mucous tumors. Infective swellings seldom appear primarily as surface 
 lesions. If they occur as lesions of the skin or the mucous mem- 
 brane, the incipient swellings appeared as nodules covered by skin or 
 by mucous membrane. If they originated in the connective tissue 
 more distant from the skin, as is more frequently the case, the skin 
 or the mucous membrane became involved later as the infection 
 extended toward the surface. 
 
 The lesions most frequently mistaken for ulcerating carcinoma 
 of the skin are tuberculosis, syphilis, actinomycosis, and chronic 
 ulcers of the leg. The greatest diagnostic doubts arise in connection 
 with ulcerating affections of the nose, face, lips, tongue, and cervix 
 
262 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 uteri. It will interest the student to know that primary syphilis of the 
 lip, tonsil, and vulva has repeatedly been mistaken for carcinoma. Such 
 inflammatory swellings have been excised, and a correct diagnosis was 
 only made, if the physician was honest enough to admit his mistake, 
 after the appearance of secondary symptoms. In chancre the swelling 
 appears rapidly upon the expiration of the usual period of incubation, 
 and gives rise to regional infection of the lymphatic glands soon 
 after the appearance of the first symptoms of local infection. Gland- 
 ular infection is unusually severe and extensive in chancre of the lip. 
 Tuberculosis of the nose attacks in preference the alae, while syphilis 
 attacks most frequently the septum. Carcinoma starts most frequently 
 at the junction of the skin with the mucous membrane. 
 
 Tubercular and syphilitic ulcers often heal wholly or in part spon- 
 tanously or under proper local and general treatment. Carcinomatous 
 ulceration may remain stationaiy for a long time, but never heals, and 
 assumes sooner or later a progressive character. Syphilitic ulceration 
 is preceded by gummatous infiltration, and examination of the whole 
 body will usually reveal the marks of antecedent syphilitic lesions or the 
 existence of such in other parts of the body, and among them hyper- 
 plasia of the lymphatic glands in the different regions, notably the post- 
 cervical and cubital glands. With few exceptions carcinoma appears as 
 an isolated affection, while syphilitic and tubercular ulcers often occur 
 as a multiple lesion. Regional infection through the lymphatics is sel- 
 dom present in tuberculosis and syphilis, but is a frequent complication 
 
 in advanced cases of carcinoma of the 
 skin. Actinomycosis seldom presents 
 itself to the surgeon except as a swell- 
 ing connected with the maxillary bones, 
 where it simulates sarcoma more closely 
 than carcinoma. The discovery of 
 actinomyces by the aid of the micro- 
 scope, or the discovery of the fungus 
 by the naked eye in the secretions as 
 minute yellowish-gray particles, will 
 settle the diagnosis. Sections taken 
 from the margins of the ulcer in carci- 
 noma will reveal the characteristic typi- 
 cal structure of the tumor, while the 
 
 tissues from all infective swellings will 
 
 Fig. 143.— Carcinoma of the lower lip and 
 multiple carcinoma of the face. 
 
 exhibit the typical structure of granu- 
 lomata. If the microscope is inadequate 
 to make a positive diagnosis, inoculation experiments will shed addi- 
 
CARCINOMA. 
 
 263 
 
 tional light and dispel doubt. Implantation of carcinoma-tissue and 
 of tissue from a gumma in guinea-pigs and rabbits will yield a nega- 
 tive result, while inoculation with tubercular tissue will reproduce the 
 disease in the animal. 
 
 The diagnosis of carcinoma of internal organs must often be based 
 almost exclusively upon the functional disturbances produced by the 
 tumor. A circular constricting carcinoma of the pyloric end of the 
 stomach often eludes detection by external examination during the 
 lifetime of the patient, but the symptoms produced by pyloric stenosis 
 in men more than thirty years old strongly suggest as the mechanical 
 obstruction a malignant tumor. Progressive intestinal stenosis in per- 
 sons advanced in years points in the same direction. In aged men 
 hematuria not caused by stone in the bladder indicates the probable 
 existence of carcinoma of this organ. (Esophageal obstruction in per- 
 sons past middle life is in the great majority of cases caused by carci- 
 noma. In the absence of urgent indications for prompt operative inter- 
 ference the clinical history of the tumor should be followed carefully. 
 
 ■ .,, '■ - 
 
 1 ~ 
 
 — =r~ 
 
 «wawBg rou i », i ^j,i 111 i iwi i y 1 
 
 :>, 
 
 
 
 
 SSjdHB 
 
 ■>.:,-' 
 
 
 mm 
 
 
 j&£. 
 
 Fig. 144. — Fibro-adenoma of the breast, showing the epithelial cells lining the duct greatly increased 
 in number, but in their normal anatomical locations (Surgical Clinic, Rush Medical College, Chicago) : 
 a, massive stroma of fibrous tissue free from epithelial infiltration ; b, tubule cut longitudinally, lined by 
 several layers of epithelial cells. 
 
 The rapidity of its growth and its extension to tissues irrespective of 
 their anatomical structure should be noted carefully, and the micro- 
 scope should be made use of as a diagnostic aid. 
 
 The first indication of the malignant nature of an epithelial tumor 
 is cell-metastasis, upon which depends the local infection. In non- 
 malignant epithelial tumors the normal relations between the epithelial 
 
264 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 cells and the membrana propria are preserved. The epithelial cells 
 may be increased greatly in number, the layers increased in number, 
 and the cells closely packed and irregularly arranged, but the mem- 
 brana propria remains as an impermeable wall (Fig. 144). 
 
 The most reliable evidence of the malignant nature of the tissues 
 shown on Plate 5 is the infiltration by epithelial cells of the adipose 
 tissue adjacent to the tumor. Normal adipose tissue does not con- 
 tain epithelial cells : their presence in it could have occurred only by 
 migration from a carcinomatous tumor in its vicinity. The presence of 
 young proliferating epitlielial cells in any of the mesoblastic tissues is an 
 unmistakable evidence of carcinoma. In making a diagnosis of carci- 
 noma under the microscope we search for the presence of epithelial 
 cells in mesoblastic tissues, and when we find epithelial cells anywhere 
 in vascular connective tissue in a state of proliferation, the diagnosis of 
 carcinoma can be made with certainty. The student must make him- 
 self perfectly familiar with the morphological appearance of the different 
 kinds of epithelial cells under different circumstances, so that he will be 
 able to distinguish them at a glance from other histological elements. 
 The absence of epithelial cells in abnormal localities in a section from a 
 suspicious tumor is no proof of the non-malignant nature of the tumor. 
 The section may have been taken from a part of the tumor devoid of 
 carcinomatous tissue. If the microscope is to be relied upon as a 
 diagnostic resource in the examination of a tumor, the sections must 
 be taken from parts of the tumor where the growth is most manifest. 
 Carcinoma grows by infiltration : the specimen to be examined should 
 therefore be taken from the base or the periphery of the tumor, near 
 its macroscopical boundary-line. If the first section under the micro- 
 scope presents negative evidence, sections from different parts of the 
 tumor must be examined in order to prove either its malignant or its 
 benign character. In ulcerating surface carcinoma a fragment of tissue, 
 should be clipped with scissors from the indurated margin. In papillary 
 excrescences a papilla is removed and examined. In deep-seated 
 tumors Warren's harpoon is employed in obtaining the material for 
 microscopic examination. From fragments of tissue thus obtained 
 several sections are made and examined. The products of scraping or 
 teasing preparations should not be used for the purpose of making a 
 diagnosis by the aid of tjie microscope. 
 
 Prognosis. 
 The prognosis of carcinoma is greatly influenced by the histological 
 structure and the location of the tumor. Squamous-celled carcinoma 
 is a much more chronic affection than cylindrical- and glandular-celled 
 
CARCINOMA. 
 
 Plate 5. 
 
 ZW/J& 
 
 *'.# 
 
 Tubular carcinoma of mamma (after Klebs) : a, milk-duct with hyaline contents; r, proliferating gland- 
 tissue; c, group of acini, showing tissue-changes; d, adipose tissue with groups of epithelial cells near the 
 tumor-tissue : the cells are not arranged in the form of acini. (Obj. 4l oc. 2.) 
 
CARCINOMA. 265 
 
 carcinoma. The location of a carcinoma influences the prognosis in 
 two ways: (1) If the carcinoma is located on an exposed part of the 
 surface of the body, the patient is soon made aware of its existence ; 
 his friends discover the tumor and remind him constantly of its presence, 
 inducing the patient to seek timely medical advice. A tumor thus 
 located is accessible to a radical operation. (2) In carcinoma of the 
 internal organs the tumor, as a rule, is not discovered by the patient or 
 his physician until extensive regional infection has made its complete 
 removal impossible. A carcinoma of the breast is often only discovered 
 accidentally after the axillary glands have become extensively involved. 
 A patient suffering from carcinoma of the stomach is usually treated for 
 indigestion, dyspepsia, or catarrh of the stomach for weeks and months 
 until the clinical course has demonstrated the malignant nature of the 
 affection long after the disease has passed beyond the reach of a radical 
 operation. Examination of the stomach and the adjacent organs, 
 including the retroperitoneal lymphatic glands, in the writer's fifteen 
 cases of gastro-enterostomy revealed regional infection beyond the 
 limits of a radical operation in all but one case, and in this case the 
 patient had been reduced to a skeleton by the pyloric obstruction 
 caused by a constricting circular carcinoma. 
 
 Women suffering from carcinoma of the uterus console themselves 
 for months with the thought that they are undergoing the ailments 
 incident to the menopause before they seek medical advice ; and when 
 this is finally done, in more than two-thirds of all the cases the disease 
 has passed far beyond the limits of a successful radical operation. In 
 the writer's practice less than 25 per cent, of the cases of carcinoma of 
 the uterus were found within the justifiable limits of a radical operation. 
 The prognosis in operable cases of carcinoma must therefore largely rest 
 upon the location of the tumor and the exteiit and accessibility of the 
 regional infection. 
 
 If the carcinoma involves a part or an organ inaccessible to operative 
 interference — as the pancreas, for instance — the disease will pursue its 
 typical course uninfluenced by treatment, and in the course of a year 
 or two will result in the death of the patient. In carcinoma of the 
 kidney this disease has usually progressed beyond the reach of a suc- 
 cessful operation before its true nature is recognized. Such early 
 operations as Israel's, in which the tumor was not larger than a cherry, 
 would of course promise a permanent result, but diagnosis at such an 
 early stage is possible only in the hands of expert diagnosticians, and 
 will always be considered as an evidence of special skill and training. 
 
 The greatest progress in the treatment of carcinoma will hare been 
 made when we are placed in possession of an infallible means of early 
 
266 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 diagnosis. The extent of the regional infection and the accessibility of 
 the secondary tumors to operative treatment will also greatly modify 
 the results to be expected from operative treatment. Even extensive 
 regional infection of the axilla in cases of carcinoma does not preclude 
 the possibility of a radical cure. On the contrary, limited axillary 
 infection with enlargement of the lymphatic glands in the supraclavic- 
 ular region is an evidence that the disease has passed beyond the reach 
 of a successful operation. The appearance of a metastatic tumor or 
 a miliary carcinosis seals the fate of the patient and furnishes a positive 
 contraindication to local treatment with a view of removing the primary 
 tumor. The average duration of life in carcinoma permitted to follow 
 its own course is from two to three years. Death finally results from 
 metastasis, septic infection, or exhaustion when the primary or any of 
 the secondary tumors interfere with an important physiological func- 
 tion. Favorable indications, so far as the primary tumor is concerned, 
 are hardness, slow growth, and its location in an organ not essential to 
 the maintenance of life. Unfavorable conditions are rapid growth and 
 softness of the tumor. The more a carcinoma resembles in its local 
 behavior an inflammatory process, the greater is its malignancy and 
 the greater the immediate danger to life. The writer has come to 
 regard rapid-growing secondary tumors of the lymphatic glands, re- 
 sembling in their physical properties and clinical aspects suppurative 
 lymphangitis, as a noli-me-tangere. From a prognostic standpoint, 
 imperfect removal of the primary tumor by caustics or by the use of 
 the knife must be regarded as a measure calculated to aggravate the 
 local conditions and to shorten life. Carcinoma grows much more 
 rapidly, and terminates fatally sooner, in young than in old persons. 
 As a rule, the malignancy of carcinoma is in an inverse ratio to the 
 age of the patient. 
 
 Treatment. 
 Every modern writer on carcinoma insists upon the importance of 
 early operative treatment. Carcinoma is no longer regarded as a con- 
 stitutional or blood disease. It has a benign stage, during which it 
 resembles benign epithelial tumors, and it is amenable to successful 
 treatment by thorough removal. Every surgeon knows that complete 
 removal by excision of a carcinoma of the lip during its early stages 
 is seldom followed by local or regional recurrence, and that the opera- 
 tion furnishes almost certain protection against general dissemination. 
 What is possible in these cases is wifhin the reach of successful surgery 
 in the case of cylindrical-celled and glandular carcinoma, provided the 
 operation is performed with the same thoroughness and under similar 
 
CARCINOMA. 267 
 
 favorable conditions. In fact, the writer is of the opinion that the 
 removal of the entire breast at a time when the disease is still local, 
 and the extirpation of the uterus at a time when the disease remains 
 limited to the cervical canal, would yield as satisfactory results as 
 does early excision of carcinoma of the lip. The removal of an 
 entire organ for carcinoma at an early stage of the disease can hardly 
 fail in removing the zone of local infection. What surgery has to con- 
 tend with is late operation. The writer is an ardent advocate of all 
 legitimate attempts to eradicate carcinoma by operation, but is satisfied 
 that the furor operativus has been carried too far at the present time in 
 this department of surgery as well as in nearly all others. 
 
 The successful treatment of carcinoma requires a bold surgeon. A 
 good and safe surgeon is guided by prudence and good judgment in 
 the selection of his cases. Like a good general, he looks over the 
 whole ground and estimates carefully the strength of his enemy before 
 making an attack. The surgeon is too apt to look only upon the 
 tumor, and to ignore the patient, when he decides upon the propriety 
 of an operation. A remunerative fee or the fear that the patient might 
 get into the hands of his competitors often deadens his sense of 
 moral obligation toward his patient when he renders his final judgment 
 concerning the propriety of an operation. For the welfare of the pa- 
 tient, the reputation of the surgeon, and the honor and good standing 
 of the profession it is just as important to look for contraindications to, 
 as for indications for, a radical operation. That the treatment of carci- 
 noma has been marred by many sins of omission and of commission in 
 the hands of competent surgeons goes without saying. The tempta- 
 tions to carry operative procedures to their maximum limits, and beyond, 
 are greater in the treatment of carcinoma than in any other department 
 of surgery. We find patients suffering from incipient carcinoma often 
 averse to the use of the knife, but willing to lose their lives on the 
 operating-table in attempts to secure relief when the disease has passed 
 far beyond the limits of successful surgery. It requires moral courage 
 to refuse an operation when such a patient begs his surgeon to perform 
 it and is willing to shoulder all risks and responsibilities. The surgeon 
 has no moral right to become a legitimate executioner under any circum- 
 stances. 
 
 A radical operation is contraindicated by — 1. Extreme senile maras- 
 mus ; 2. Extensive local infection ; 3. Regional infection beyond the 
 reach of complete removal of all the infected tissues ; 4. General infec- 
 tion ; 5. The coexistence of another disease which in itself will prove 
 fatal in a short time. 
 
 It is difficult to set a limit by age to the operative treatment of car- 
 
268 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 cinoma. The writer has removed successfully from the temporal region, 
 in a lady eighty-five years of age, under partial anesthesia, a fungous 
 carcinoma the size of a large orange. The large wound granulated in 
 the course of two weeks, and healed by the aid of Thiersch's skin-grafts 
 four weeks after the operation. The writer has seen patients not more 
 than fifty years of age so marantic from senile degenerations that the 
 smallest wound would probably have failed to heal. In persons past 
 seventy years of age suffering from a slowly-growing carcinoma in a 
 locality requiring a formidable operation it requires good judgment to 
 decide whether an operation will benefit the patient or whether it will 
 shorten life. It is in such cases that the extent of the operation must 
 be planned carefully and the patient's strength be estimated before an 
 operation is advised. If the local infection has extended so far that 
 there is no prospect of healing the wound by plastic operations or by 
 skin-grafting after the removal of the primary tumor, the patient's 
 interests demand conservative treatment. Usually in such cases the 
 tumor has so far infiltrated the deep tissues that a complete removal 
 of all the infected tissues is impossible, and the wound-surface soon 
 becomes the seat of a diffuse local return attended by conditions much 
 more annoying and disagreeable to the patient than the primary 
 tumor. It is the regional infection that renders the results of opera- 
 tions so problematical in the treatment of carcinoma. Every honest 
 surgeon must confess that the permanent results of operations per- 
 formed after regional infection had occurred are few and far apart. The 
 disease may not return for one, two, or three years, but return it will, in 
 the great majority of cases, sooner or later. The writer has seen local 
 recurrence five and seven years after operation. The time set usually — 
 three years — is therefore not reliable in drawing conclusions as to the 
 permanency of the result after operations for carcinoma. Permanent 
 results will follow the operative treatment of carcinoma if the operation is 
 performed before regional infection lias occurred ; on the contrary, non- 
 recurrence zvill be the exception, and recurrence the ride, if the primary 
 tumor is not reinoved until regional infection lias set in. If the regional 
 infection is extensive, or if it occupies a locality not accessible to thor- 
 ough removal of all infected tissues, the patient will be more comfort- 
 able, and will live longer, if no radical operation is performed. The 
 writer regards the presence of carcinomatous glands in the supraclavic- 
 ular space in carcinoma of the breast, and extensive infiltration of the 
 sacral glands in carcinoma of the uterus, as contraindications to a 
 radical operation. The existence of a metastatic tumor or of diffuse 
 miliary carcinosis is, of course, an absolute contraindication to an 
 attempt to remove the primary tumor. The existence of a carcinoma 
 
CARCINOMA. ' 269 
 
 in an unusual locality should induce the surgeon to make a critical ex- 
 amination for the purpose of detecting the primary tumor, as when the 
 mother-tumor can be located operative procedure is out of the question, 
 as the metastatic origin of the tumor first discovered has then been 
 demonstrated. If a carcinomatous patient is suffering at the same time 
 from an otherwise fatal disease, such as pulmonary tuberculosis, Bright's 
 disease, diabetes, cerebral softening, locomotor ataxia, etc., it is wisdom 
 on the part of the surgeon to withhold the use of the knife and to limit 
 his efforts to palliation. Unfortunately, it is seldom that the surgeon 
 has the opportunity to give the patient his advice in time. In the great 
 majority of cases he has to deal with carcinoma after regional infection 
 has set in, and in cases in which the disease has advanced too far for a 
 successful radical operation he must content himself with resort to 
 palliative measures. 
 
 Palliative Operations. — In inoperable subcutaneous carcinoma it 
 should be the aim of the surgeon to preserve the cutaneous surface 
 over the tumor intact so long as possible, as the misery which attends 
 this condition is much less than in open carcinoma, and life is prolonged 
 by the avoidance of septic infection. The surface of the tumor should 
 be kept covered by aseptic absorbent cotton held in place by a circular 
 bandage or by strips of adhesive plaster. If the skin becomes red and 
 its perforation by the tumor-mass is threatened, the complication should 
 be anticipated by a timely resort to antiseptic precautions, so that when 
 an ulcer forms infection with pathogenic microbes will be prevented. 
 The surface of the tumor should be disinfected in the same manner as 
 in making preparations for an operation, after which it is covered by 
 a few layers of iodoform gauze, over which is applied a thick compress 
 of sterilized gauze, and the whole is covered by a filter of absorbent 
 cotton. After the skin has given way the dressing is changed as often 
 as necessary, and at each change the surface of the ulcer is washed 
 with an antiseptic solution. Should the dry dressing prove a source 
 of discomfort to the patient, it is replaced by a thick gauze compress 
 wrung out of a saturated solution of acetate of aluminum and kept 
 covered by an impermeable fabric like oiled silk, thin rubber sheeting, 
 or mackintosh cloth. Attempts have been made, by covering large 
 carcinomatous ulcers by skin-grafting, to render the condition of the 
 patient more endurable by transforming the open ulcerating tumor into 
 a subcutaneous lesion. These attempts have proved successful in some 
 instances, but it is doubtful if the gain of such short duration will over- 
 balance the pain and inconvenience caused by the scraping and the 
 transplantation of Thiersch's skin-grafts. If the carcinomatous ulcer 
 has become infected with pyogenic and putrefactive microbes, the sur- 
 
270 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 geon has to contend with an additional evil. It is an exceedingly diffi- 
 cult task to render such a surface aseptic by chemical disinfectants. 
 The surface is so irregular, and there are so many inaccessible nooks 
 and corners which the solutions and powders cannot reach, that com- 
 plete disinfection with chemical agents is usually not attained. The 
 remedies which have proved most efficient in correcting the odor in 
 such cases are Labarraque's solution of chlorinated soda, chlorine- 
 water, aqueous solution of iodine and bromine, and iodoform in powder 
 or mixed with boric acid (1 : 5). The strength of the solutions should 
 not be such as to produce pain. If these milder measures do not 
 succeed, a strong solution of chloride of zinc (25 per cent.) should be 
 tried. 
 
 Of the modern deodorants in the treatment of open inoperable 
 cases of carcinoma aristol deserves special mention. If an ointment 
 dressing is indicated, aristol, with vaselin of suitable strength, is among 
 the best (gr. xx to 3ij to §j). This or any other ointment will be more 
 grateful to the patient if spread upon a thick layer of absorbent cotton, 
 instead of lint or gauze. In carcinoma of the uterus, a deodorizing 
 lotion is of the first importance, and one containing eucalyptus is pre- 
 ferable to a plain antiseptic solution. The vagina may also be loosely 
 packed with cotton tampons, saturated with a mixture of aristol in 
 albolin, 5 per cent. A pad of finely picked oakum should be placed 
 over the vulva, as this material is hygroscopic and a good deodorant. 
 
 Temporary benefit is always derived from a vigorous use of Volk- 
 mann's sharp spoon. The necrosed tissue attached to the ulcerated 
 surface is the soil in which the putrefactive bacilli live and multiply : 
 their removal with the sharp spoon, including in the curettage also the 
 fungous, bleeding; masses, removes the culture-medium of the microbes 
 which have caused the putrefaction, and will accomplish more than the 
 use of chemical agents in rendering the ulcer aseptic. The scraping 
 operation should be followed by the use of the actual cautery. The 
 vigorous use of the flat point of the Pacquelin cautery will accomplish 
 a great deal in this direction without the use of the sharp spoon. 
 Scraping and cauterization have proved of great value in mitigating 
 the distress in inoperable cases of carcinoma of the uterus, the breast, 
 and the mouth. 
 
 The removal of a carcinomatous breast as a palliative measure is 
 occasionally indicated when enough skin can be preserved to cover 
 the wound, and in this manner transform an open into a subcutaneous 
 carcinoma. The ligation of* the principal artery to a part the seat of 
 carcinoma is indicated only when hemorrhage is threatened or has 
 actually occurred and cannot be controlled by more conservative 
 
CARCINOMA. 271 
 
 measures. In inoperable carcinoma of the uterus antiseptic vaginal 
 injections should be employed at least once or twice a day. In carci- 
 noma of the mouth an antiseptic gargle or spray is indicated. Trache- 
 otomy in inoperable cases of carcinoma of the larynx, and colostomy 
 in the same condition of the rectum, are exceedingly useful and grate- 
 ful palliative operations. Gastrostomy in impermeable carcinomatous 
 stricture of the oesophagus, gastro-enterostomy in pyloric carcinoma, 
 and suprapubic cystotomy in advanced cases of carcinoma of the 
 prostate gland, afford great relief and should always be suggested in 
 appropriate cases. 
 
 Radical Operations. — Operations which are intended to remove 
 all. the infected tissues, local and regional, are called "radical" opera- 
 tions. A radical operation is indicated in all cases in which general 
 infection has not occurred, and the primary and original tumors are of 
 such size and extent and are so located as to enable their complete removal 
 by an operation not immediately endangering the life of the patient, and 
 leaving a wound which can be closed by suturing or which can be healed 
 by a plastic operation or by skin-grafting, and the patienfs strength is 
 such as to warrant the operation. 
 
 If a radical operation is undertaken, it should be radical. The 
 surgeon must not forget that carcinoma extends in the vicinity of the 
 tumor along pre-existing connective-tissue spaces, and that conse- 
 quently the zone of infiltration can be removed only by including with 
 the primary tumor a wide strip of apparently healthy tissue on all sides. 
 The incisions should be carried from four lines to an inch away from 
 the macroscopical boundary-line of the tumor, according to the charac- 
 ter of the tumor, its size, and its environment not only on one or two 
 but on all sides. If the tumor is near the surface, the overlying skin 
 should be removed. A zone of apparently healthy tissue at the base of 
 the tumor as well as on the sides should be included in the excision. 
 No blunt force should be used in the removal of the primary tumor ; 
 its removal must be effected by a clean dissection. Pressure and tear- 
 ing are liable to give rise to traumatic dissemination. Grasping the 
 tumor with vulsellum forceps is attended by the same danger. If vul- 
 sellum forceps are necessary to bring the tumor near the surface, the 
 instrument should be so applied as not to penetrate the tumor. If the 
 tumor is located in a part of the body from which the circulation can 
 temporarily be excluded by elastic constriction, this should be made 
 use of, as the bloodless procedure enables the surgeon to identify the 
 tissues more accurately, and aspiration of tumor-cells or of fragments 
 of tumor-tissue into the open lumen of cut veins is less likely to occur. 
 If temporary hemostasis is inapplicable owing to the location of the 
 
272 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumor, the hemorrhage should be arrested as the operation pro- 
 ceeds, for if this precaution is not practised projecting parts of the 
 tumor may be overlooked and not again be found after the tumor has 
 been removed. The external incision must be made at a point which 
 affords easy access to the tumor, and in a direction parallel with important 
 muscles, nerves, and vessels. The external incision must be large enough 
 to expose freely the entire periphery of the tumor to sight as well as to 
 touch, and if this cannot be done safely by one straight or curved incision, 
 it is joined at suitable points by cross cuts. The margins of the wound 
 during the operation must be kept out of the way by retractors. The 
 tumor and the surrounding zone of infiltrated suspicious tissue should be 
 removed in one mass. The removal of projecting portions after the 
 removal of the tumor is bad practice and should be avoided. 
 
 The dissection must be made through healthy tissue outside the 
 zone of infiltration from the beginning to the end of the operation. 
 The employment of the dilute nitric-acid test, as suggested by Stiles, 
 to ascertain during an operation whether or not all the diseased tissues 
 have been removed, is not reliable and is of no use to the careful 
 dissector. If the tumor after its removal is immersed in the 5 per 
 cent, nitric-acid solution, the " boiled-egg " appearance upon some parts 
 of the tumor will show that fragments of considerable size have been 
 left behind, but it will fail in demonstrating that cellular remnants of 
 the tumor have not been removed. In small carcinomata of the lip or 
 of the skin presenting no evidences of glandular infection it is sufficient 
 to excise with the tumor a zone of apparently healthy tissue in order 
 to remove the peripheral invisible part of the tumor. In operating 
 upon the lip it is not advisable to plan the details of a subsequent 
 plastic operation, as there is great danger that the surgeon will be 
 guided in the excision of the carcinoma by the plans of the restorative 
 part of the operation. The prime indication of the operation slwidd be 
 to remove all the diseased tissues, regardless of the cosmetic residt. After 
 the carcinoma has been removed the surgeon sutures the wound in 
 such a manner as to secure the best possible cosmetic results, or he 
 resorts at once to a plastic operation. 
 
 In the removal of all carcinomatous tumors the incision or in- 
 cisions should be made in the direction of the lymphatics, because it is 
 in this direction that the local infection becomes regional. In gland- 
 ular carcinoma the entire gland should be removed if the gland so 
 affected does not perform a function essential to the maintenance of 
 health and life. Partial removal of the breast or the parotid or sub- 
 maxillary gland for carcinoma cannot be condemned too strongly. 
 If any doubt exists in regard to the presence of regional infection, 
 
CARCINOMA. 273 
 
 the lymphatic glands through which regional infection would occur 
 should be exposed by an incision, and if any of the glands are found 
 enlarged, the entire chain of glands should be removed in one uninter- 
 rupted piece with the primary tumor. In carcinoma of the breast the 
 axillary region from the margin of the gland to the apex should be 
 cleared of lymphatic glands and connective and adipose tissue, regardless 
 of the condition of the glands. Typical cleaning out of the axillary 
 space is urgently indicated in all cases of carcinoma of the breast 
 The whole chain of glands, with the surrounding connective and adi- 
 pose tissue, must be removed by a clean dissection. The same plan 
 should be pursued in the removal of the external genitals with infection 
 of the inguinal gland. 
 
 Enucleation of carcinomatous glands is invariably followed by recur- 
 rence. Rupture of glands by pressure or traction is apt to be followed 
 by traumatic dissemination. The primary tumor and regional tumors 
 and healthy glands, with the tissues surrounding them, should be 
 removed in one uninterrupted piece : this will ensure the removal of 
 the connecting lymphatic channels which are so often the seat of 
 regional infection. The wound after the removal of a carcinoma should 
 be covered at once by integument : if this cannot be done by the use 
 of sutures, the surface should be covered by a plastic operation or by 
 skin-grafting. Healing of the entire wound by primary intention should 
 invariably be aimed at in the removal of a carcinoma by excision. 
 
 The use of caustics in the radical treatment of carcinoma has a limited 
 field of usefulness. Caustics should be used only when patients object 
 to the use of the knife, and their use should be restricted to small car- 
 cinomata of the skin. Chloride of zinc should be given the preference 
 over arsenic or the mineral acids. The treatment by caustics is more 
 painful than excision under local or general anesthesia, requires more 
 time, and the cosmetic result is less satisfactory. 
 
 Topography. 
 The study of the topographical distribution of carcinoma is an in- 
 teresting one, as it tends to show that carcinoma is most frequently 
 found in localities in which the most active and complicated tissue- 
 changes take place in the embryo, and in situations most exposed to 
 injuries, irritations, and other post-natal influences which result in 
 diminution of the physiological resistance of the tissues. We also find 
 it frequently in localities the favorite seat of benign epithelial tumors. 
 The influence of age, sex, and occupation in determining the origin of 
 carcinoma in certain parts and organs of the body has repeatedly been 
 referred to. 
 
 18 
 
274 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 
 *vr 
 
 'vSR? 
 
 Fig. 145. — Carcinoma of the sweat-glands, showing the tubular arrangement of the tumor parenchyma (after 
 
 Fordyce). 
 
 fsJLi b 
 
 
 Fig. 146.— Carcinoma of skin of nates; X no, reduced one-third (Surgical Clinic, Rush Medical Col- 
 lege, Chicago) : a, hypertrophied stratum corneum ; b, growth of epithelial cells into subcutaneous tissue; 
 c, epithelial nest in vascular connective tissue. 
 
CARCINOMA. 275 
 
 Skin. — Squamous-celled carcinoma occurs most frequently upon 
 the lower lip, the eyelids, the labia, and the glans penis ; it is also fre- 
 quent in the mouth, the oesophagus, the vagina, and about the cervix 
 uteri. When the growth takes its starting-point in the sudoriparous 
 or sebaceous glands, the cells of the carcinoma are cuboidal in shape 
 and the growth presents a tubular structure (Fig. 145). The latter 
 variety is most frequent on the nose and the eyelids, and is least 
 malignant. 
 
 Histological Structure. — The manner of growth and the forms of epi- 
 thelial tissue are varied, and the changes to which a carcinoma is subject 
 are manifold. The stroma supplies the vascular part of the papillary 
 excrescences, yields to the penetrating epithelial cells, surrounds the 
 epithelial nests with a network of vessels, and finally becomes the seat 
 
 / 
 
 Fig. 147.— Vertical section througn carcinoma of the skin ; X 50 (Surgical Clinic, Rush Medical College, 
 Chicago) : a, subcutaneous connective tissue and stroma of tumor; b, proliferation of epithelial cells into the 
 connective tissue ; c, sebaceous gland in a state of active tissue-proliferation ; d, normal tissue not yet affected 
 by the carcinoma. 
 
 of ulcerative destruction. The equilibrium between the hyperplastic 
 masses of epithelial cells and the underlying vascular connective tissue 
 is destroyed with the beginning carcinomatous process. Conditions 
 
276 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 apparently leading to embryonal development of papillary and follicular 
 structures appear to be arrested, and a functionally useless, planless 
 growth supervenes. Generally the preponderant growth of epithelium 
 initiates the change ; this, however, is to be found not so much on the 
 part of the proliferating epithelial cells as in a lessened resistance of the 
 adjacent tissues. The first evidence of the appearance of epithelial 
 cells in the vascular connective tissue underlying the epithelial layer 
 of the skin announces the transition of the benign into the malignant 
 stage of carcinoma (Fig. 146). Vertical section through a carcinoma 
 of the skin in its earliest stages shows thickening of the layer of 
 epithelial cells between the epidermis and the membrana propria 
 (Fig. 146, b). As soon as the epithelial cells have reached the con- 
 nective tissue they form nests. The glands of the skin in the area 
 of carcinomatous infiltration assume more active tissue-proliferation, 
 which results in increased secretion (Fig. 147). The stroma in the non- 
 
 Fig. 148. — Carcinoma of the skin, showing alveolated structure of the stroma and numerous epithelial 
 nests; X 150 (Surgical Clinic, Rush Medical College, Chicago) : a, stroma; b, epithelial infiltration of con- 
 nective tissue ; c, c, epithelial nests. 
 
 ulcerating part of the tumor increases in quantity by proliferation of 
 the pre-existing cells caused by the presence of the numerous epithelial 
 cells, which to them are foreign bodies. The alveoli of the stroma are 
 
CARCINOMA. 
 
 277 
 
 Fig. 149. — Vertical section through carcinoma of the skin, showing hair-follicle and epithelial nests; 
 X 300 (Surgical Clinic, Rush Medical College, Chicago) : a, hair-follicle containing a hair ; b, epithelial infil- 
 tration ; c, stroma; d, large epithelial nest; e, e, beginning formation of epithelial nests. 
 
 
 jlands ; X iS (after Thiersch) : 
 d, convoluted sweat-gland with 
 
 Fig. 150.— Carcinoma of the skin starting from epithelial cells of sweat 
 a, epidermis ; b, cutis; c, normal lanugo-hairs with their sebaceous glands; 
 
 distinct lumen ; e, branched and anastomosing proliferation of gland : lumen can be seen only in part ; /, 
 branched proliferation with terminal and lateral knob-shaped cellular projections ; g, round masses of cells, 
 separate or in several groups, which lie loose in spaces of the connective tissue, and which appear either as 
 terminal knobs or as transverse sections of cellular strings. 
 
278 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 packed with epithelial cells (Fig. 148). The progressive infiltration of 
 the skin from the surface is well shown in Figure 149. 
 
 Thiersch has repeatedly traced the origin of carcinoma of the skin 
 to sudoriparous glands. Carcinomata of such an origin present under 
 the microscope a tubular structure resembling cylindrical-celled carci- 
 noma of the mucous membrane (Fig. 150). 
 
 In superficial ulceration of a carcinoma of the skin the papillary 
 structure of the skin remains, and the surface presents the appearance 
 of an ordinary ulcer (Fig. 151). As soon as a surface carcinoma be- 
 comes the seat of microbic infection the connective-tissue stroma takes 
 an active part in the suppurative process, as elsewhere. Destruction 
 of the stroma by suppuration liberates the contents of the more super- 
 ficial cell-nests, the contents being discharged with the inflammatory 
 product. The progressive destruction of the stroma results in the 
 
 d 
 —g ; _ . 
 
 Fig. 151. — Deep carcinoma of the skin of the heel : vertical section; X 16 (after Thiersch) : a, papillse- 
 of surface of ulcer; b, their epidermal covering ; c, vascular stroma; d, inner surface of a parenchymatous 
 cavity studded with papillae; e, epidermal covering of papillae; _/, masses of cells in concentric layers in the 
 interpapillary spaces ; g, the same, belonging to the free epithelial masses. 
 
 increase in size and depth of the carcinomatous ulcer. In ulcus rodens,. 
 only one of the many varieties of carcinoma of the skin, the stroma is 
 
CARCINOMA. 279 
 
 very scanty; hence progressive increase in the size of the ulcer and 
 slight induration of its base and margins are conspicuous pathological 
 features. 
 
 Regional Infection. — Regional infection, usually a late occurrence in 
 carcinoma of the skin, does not depend upon the size of the tumor or 
 ulcer. The writer has seen glandular infection in connection with a 
 carcinoma of the lip not larger than a pea, and has seen it absent in 
 
 7 
 
 Fig. 152.— Carcinoma of the sole of the foot. The regional infection involved both the deep and superficial 
 lymphatic glands of the leg and the anterior aspect of the thigh. 
 
 cases in which almost the entire lower lip was destroyed by the carci- 
 noma. The occurrence of glandular infection appears to be influenced 
 more by the diminished loss of resistance of the connective tissue than 
 by the proliferation of epithelial cells. Of all the surface carcinomata 
 affecting the skin, carcinoma of the lip is followed more constantly 
 by regional infection than carcinoma of any other part of the body. 
 The submental glands are usually first involved, later the submaxillary, 
 and finally the cervical glands. The writer has seen the most malig- 
 nant form of regional infection develop several years after the removal 
 of a small carcinoma of the lip by using caustics or by employing the 
 knife. 
 
 For some reasons which remain unexplained, the upper lip is very 
 seldom the seat of carcinoma, and in the few cases which have come 
 under the observation of the writer there was no glandular infection. 
 It has already been explained that the late glandular infection in carci- 
 noma of the skin is attributable to the location of the tumor, and not 
 to its lesser degree of malignancy than glandular carcinoma. A carci- 
 noma surrounded on all sides by tissues has an extensive area of infil- 
 tration, while in surface carcinoma infiltration is limited to one direction. 
 In the former instance the tumor is subjected to pressure which must 
 
28o PATHOLOGY AND TREATMENT OF TUMORS. 
 
 favor lymphatic infection, while in surface carcinoma this cause of dis- 
 semination of the tumor-elements is entirely wanting. The probable 
 existence of regional infection must not be lost sight of in the operative 
 treatment of surface carcinoma. 
 
 Degeneration of Tumor-tissue. — Fatty degeneration of the contents 
 of the alveoli is the most frequent form of degeneration of carcinoma 
 of the skin. In the older parts of the tumor the alveoli contain only 
 the product of this form of degeneration, all the epithelial cells having 
 undergone this change. In chronic cases calcification often follows 
 fatty degeneration. Colloid and myxomatous degeneration, such con- 
 stant regressive metamorphoses in glandular and cylindrical-celled car- 
 cinoma, occur less frequently, and never reach the same degree. Early 
 ulceration is the most characteristic feature of carcinoma of the skin. 
 The ulcer forms over the centre of the tumor, and spreads more or 
 less rapidly in the direction of the base of the tumor and toward its 
 periphery. As soon as the tumor-tissue is exposed the connective 
 tissue takes an active part in the ulcerative process. If the resistance 
 of the connective tissue is not much reduced, granulations spring up 
 from the stroma, the base of the tumor as well as the margins of the 
 ulcer become infiltrated with inflammatory product, and for a time it 
 may seem that the inflammatory process has exerted an inhibitory 
 influence on the local extension of the tumor. The inflammatory 
 material, however, serves only a temporary purpose in retarding the 
 extension of the tumor : the connective tissue and the exudation suc- 
 cumb to the combined effects of tumor-growth and microbic infection, 
 and the disease resumes its progressive tendencies. 
 
 Lip. — Clinical Course. — Carcinoma of the lip usually commences at 
 the junction of the mucous membrane with the skin. It seldom starts 
 from the angles of the mouth and the upper lip. In a case of carcinoma 
 of the upper lip that recently came under the observation of the writer 
 the tumor appeared some distance from the margin of the upper lip 
 (PL 6, Fig. 2). The patient was a man forty-five years of age. The 
 tumor was noticed five years ago, when it was not larger than a millet- 
 seed and appeared to be imbedded in the skin ; a year later the tumor 
 commenced to increase in size, an ulcer formed on its surface, and the 
 base became very much indurated. The base of the tumor was of the 
 density of cartilage ; its surface was covered by fungous granulations. 
 The margins of the ulcer were covered by the overlying undermined 
 skin. 
 
 Carcinoma of the lower lip is common in men, but very rare in 
 women. Konig estimates that the proportion of males to females is 
 20:1. Lortet's statistics show the proportion to be 7.6 : I. Warren 
 
CARCINOMA. 28l 
 
 observed 4 cases in women out'of 73 cases, and states that 3 of the 
 women were smokers. In 145 patients suffering from carcinoma Koch 
 (Erlangen) attributed the affection in 15 to an injury. The tumor- 
 formation is frequently preceded by a crack or a fissure or an eczema- 
 tous condition of the margin of the lip. At a very early stage the 
 centre of the indurated area ulcerates, and from the ulcerated surface 
 the atheromatous contents of the exposed epithelial nests can be 
 squeezed out. By extension of the ulcer the lower lip is destroyed 
 (PI. 6, Fig. 1), when the cheek, the chin, the lower maxilla, and the 
 floor of the mouth are successively involved. The submental and sub- 
 maxillary glands, which now have become enlarged, are often firmly 
 attached to the lower jaw, simulating primary malignant disease of the 
 periosteum or the bone. With few exceptions the disease, if allowed 
 
 Fig. i 53.— Secondary carcinoma of the submental and submaxillary lymphatic glands, following carcinoma 
 
 of the lip. 
 
 to pursue its course, terminates fatally within from three to five years. 
 Death results from marasmus, from sepsis, or from general dissemina- 
 tion of the disease. 
 
 Diagnosis. — The superficial diffuse form of carcinoma of the lip is 
 frequently mistaken for eczema. The deeper layers of the skin are 
 exposed, presenting a papillomatous appearance. The raw surface is 
 constantly moistened by a serous transudation. Careful palpation will, 
 however, detect in the skin and the mucous membrane an induration 
 which is absent in eczema of the lip. Chancre of the lip develops 
 rapidly and is attended at an early stage by diffuse glandular infection. 
 Secondary syphilitic lesions of the lip start usually in the mucous 
 
282 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 membrane of the mouth, and reach the lip by extension. Papilloma 
 of the lip appears as a permanent tumor, and its base lacks induration. 
 Primary tuberculosis of the lip is an exceedingly rare affection ; it 
 occurs almost from the beginning as a more diffuse affection than 
 carcinoma, and it lacks the induration so characteristic of carcinoma. 
 Carcinoma of the lip appears as an ulcerating tumor with indurated base 
 and margins, which tumor ultimately gives rise to regional and general 
 infection. If any doubt remains as to the nature of the tumor, a frag- 
 ment of tissue should be taken from the base or margin of the ulcer, 
 from which sections should be made for microscopic examination. 
 
 Pace. — Carcinoma of the skin in other localities usually pursues 
 a course similar to that of carcinoma of the lip. The face is the 
 most frequent seat of carcinoma of the skin. O. Weber found in 
 740 cases of tumors of all kinds subjected to operative treatment 
 133 cases of carcinoma of the face. The ages of the patients vary 
 from forty to eighty. According to Thiersch, carcinoma of the skin 
 appears either as a superficial ulceration {ulcus rodens) or it penetrates 
 the tissues deeply and involves the different structures successively. 
 If the carcinoma starts from the appendages of the skin, the colum- 
 nar epithelial cells are arranged in groups resembling tubules ; if it is 
 composed of squamous cells, it appears from the beginning as an in- 
 filtration with small epithelial cells, which before ulceration occurs 
 fill the alveoli of the stroma. Like carcinoma of the lip, carcinoma 
 of the skin begins as a minute surface defect with a limited area 
 of induration at its base. From this point the ulceration spreads un- 
 equally in different directions, so that the ulcerated surface presents 
 irregular outlines. In the superficial form of carcinoma peripheral 
 extension takes place rapidly, but the destructive process is limited to the 
 skin. In the penetrating or deep variety the ulceration extends at the 
 same time in the direction of the base of the ulcer, involving succes- 
 sively different tissues irrespective of their anatomical character. In this 
 variety the ulceration is generally preceded by a deep infiltration of the 
 skin and the subcutaneous connective tissue. So long as the papillae 
 of the skin remain, the surface of the ulcer presents a papillary appear- 
 ance. When the papillse are destroyed, the epithelial nests are exposed, 
 their contents escape with the inflammatory product, and the surface 
 of the ulcer assumes a honeycomb appearance. The prognosis of this 
 variety of carcinoma of the skin is more unfavorable than that of the 
 superficial variety. The ulceration spreads very rapidly, and results in 
 very extensive destruction of tissue in a remarkably short time. Lym- 
 phatic infection occurs frequently at quite an early stage, and occa- 
 sionally death results from metastatic tumors. Carcinoma of the face 
 
CARCINOMA. 283 
 
 attacks most frequently the eyelids, the nose, and the malar and frontal 
 regions. Carcinoma of the eyelids, if not removed in time, extends to 
 the eyeball and the other contents of the orbit, causing not only loss 
 of the eye, but also producing a frightful disfigurement. 
 
 Diagnosis. — Carcinoma of the face must be distinguished from tu- 
 berculosis, syphilis, suppurating benign growths, and retention-cysts. 
 Tuberculosis of the face, the so-called " lupus," often appears as a 
 multiple affection. The same can be said of tertiary syphilitic lesions. 
 Multiple carcinomatous tumors are exceptional, and they almost always 
 originate from the transformation of senile warts into carcinomata. 
 Tubercular ulcers often heal, in part or completely, spontaneously or 
 under appropriate local treatment — something never observed in carci- 
 noma. The base of the tubercular ulcer presents to the palpating 
 finger a doughy, cedematous sensation ; the base and margins of the 
 carcinomatous ulcer are firm and indurated. Careful examination of 
 patients suffering from tertiary syphilitic affections of the skin usually 
 reveals additional syphilitic lesions in other parts of the body, or traces 
 of former affections that have healed. If any doubt remains, the 
 patient should be given the benefit of the doubt by subjecting him to 
 antisyphilitic treatment for a number of weeks. The differential diag- 
 nosis between carcinoma and tubercular affections of the skin may 
 require the use of the microscope and a resort to inoculation experi- 
 ments. The former will reveal the typical structure of the existing 
 affection, and the latter will yield positive results if the lesion is tuber- 
 cular, and negative if it is a carcinoma. 
 
 Operative Treatment of Carcinoma of the Lip. — The best curative 
 and cosmetic results are obtained by early and thorough excision. 
 If the tumor is small, the operation can be done without anesthesia ; 
 if large and if a plastic operation must follow to correct the defect, 
 partial anesthesia will answer the purpose. The coronary artery should 
 be compressed at both angles of the mouth 
 by compression-forceps or between the 
 thumbs and index fingers of the hands of 
 an assistant. In diffuse superficial carci- 
 noma of the lip involving only the mucous 
 and submucous tissues the entire margin 
 of the lip, from one angle of the mouth 
 to the other, is excised. The incision is 
 made at a safe distance (about half an inch) fig. 154. -Suturing after excision of 
 from the palpable margin of the tumor ; the enti J e ™ rgin °,V he lip for carcU 
 
 1 r & ' noma (after Esmarch). 
 
 the mucous membrane is then carefully 
 
 stitched to the margin of the skin with fine catgut sutures (Fig. 1 54). 
 
284 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The cosmetic and functional results following this operation are entirely 
 satisfactory. The lip is long enough to retain the secretions of the 
 mouth, and there is formed from the mucous membrane a new pro- 
 labium which in the course of a few months resembles the normal 
 prolabium in appearance. 
 
 If the tumor involves not quite one-half of the lip and has pene- 
 trated the tissues deeply, it is included in a V-shaped incision the apex 
 of which must extend to the lower border of the jaw (Fig. 155). The 
 
 Fig. 155.— Wedge-shaped excision of the lip for car- Fig. 156.— Operation completed (after Esmarch). 
 
 cinoma (after Esmarch). 
 
 coronary artery is either twisted or included in one of the deep sutures. 
 The deep sutures of silk or of silkworm gut should embrace all the 
 tissues except the mucous membrane, which should be sutured with 
 fine catgut from the mouth before the deep sutures are tied, in order to 
 prevent the interposition of mucous membrane between the. margins of 
 the wound. The lower lip gradually elongates after the operation 
 (Fig. 156). 
 
 If the tumor involves more than one-half of the lip, it should be 
 excised by a curved incision, with the convexity directed downward, at 
 least half an inch distant from the palpable margin of the tumor. The 
 mucous membrane is then sutured over the surface of the wound to 
 the skin. The semilunar defect, which is quite apparent after the 
 operation, gradually diminishes in the course of time. If the whole 
 or nearly the whole lip is involved, complete excision becomes neces- 
 sary, and a new lip must be made by a plastic operation. Wolfler 
 recently described an operation which yielded excellent results : After 
 excision of the entire lip a curved incision about two inches below 
 the margins of the wound, and extending a little beyond the angles 
 of the mouth, is made through the skin and the subcutaneous con- 
 nective tissue. The quadrangular flap is then so raised that its upper 
 margin will occupy the normal level of the lip, when the flap is sutured 
 to the anterior surface of the jaw with catgut sutures, so as to ex- 
 clude from the wound the cavity of the mouth and to fix the new lip 
 securely in its new place. The flap is retained by a proper dressing 
 
CARCINOMA. 
 
 285 
 
 in this position. After clearing out the submental and submaxillary 
 spaces of lymphatics, the lower margin of the wound is sutured sepa- 
 rately to the jaw and the new lip, and drainage is established through 
 a small buttonhole in the centre, at the most dependent part of the 
 wound. If the whole wound cannot be covered with skin in this man- 
 ner, the remaining surface should be paved with Thiersch's skin-grafts. 
 As soon as the flap is detached the submental and some of the sub- 
 maxillary glands come in view, and should be dissected out carefully 
 with the adjacent connective and adipose tissue. Langenbeck restored 
 the lower lip by taking a flap from the region of the neck (Figs. 157, 
 1 5 8). In this operation it is necessary, after the formation of the flap, to 
 carry the incision downward in the median line to expose and remove 
 infected lymphatic glands. 
 
 The great difficulty in Langenbeck's operation is that the free mar- 
 gin of the new lip cannot be covered with mucous membrane, and a 
 certain amount of cicatricial contraction ensues during the healing of 
 the wound. In Wolfler's operation there can often be preserved a 
 
 Fig. 
 
 . — Operation completed (after Langen- 
 beck). 
 
 Fig. 157.' — Langenbeck's method of restoring the 
 lower lip after excision for carcinoma (after Lan- 
 genbeck). 
 
 narrow strip of mucous membrane with which to line the free margin 
 of the lip and thus to secure in the course of time a normal prolabium. 
 Partial excision of the upper lip is made in the same way as for car- 
 cinoma of the lower lip. If the entire upper lip has to be excised, the 
 defect is restored after the method devised by Bruns (Figs. 159, 160). 
 The two lateral flaps are brought down to the proper level, are united 
 in the median line by a number of sutures, and are stitched to the 
 margin of the wound below the nose ; finally, the wound on each side 
 is diminished in size as far as possible by suturing. In plastic opera- 
 tions a number of superficial sutures of horsehair are always of great 
 service to bring the skin in accurate coaptation. The sutures should 
 
286 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 be removed as soon as the union is firm enough to render them super- 
 fluous, which will be the case in from three to five days. 
 
 Sutures should be tied carefully, and only with firmness sufficient 
 to bring the margins of the wound in contact. Tension from tying the 
 
 Fig. 159. — Cheiloplasty (after Bruns). Fig. 160. — Operation completed (after Bruns). 
 
 sutures too tightly not only gives rise to pain, but also interferes with 
 an ideal healing of the wound. A suture that causes undue linear 
 compression should be removed at once. If the flap in plastic opera- 
 tion does not require an external mechanical support, the writer is not 
 in the habit of applying a dressing in operations upon the lip. The 
 operation should be performed under strict antiseptic precautions, and 
 after its completion the line of suturing should be covered by a thin 
 layer of carbolated vaselin. 
 
 Operative Treatment of Carcinoma of the Face. — The eyelids are 
 quite frequently the seat of carcinoma. An early operation in this 
 locality is of the utmost importance, as the disease always manifests 
 
 Fig. 161. — Blepharoplasty after removal of carci- 
 noma of lower eyelid (after Dieffenbach). 
 
 Fig. 162.— Operation completed (after Dieffen- 
 bach). 
 
 a tendency to extend to the eye and the other contents of the orbit. 
 If the operation is performed before the conjunctiva has become 
 involved, the functional and cosmetic results are satisfactory. The 
 incisions circumscribing the tumor should be made at a safe distance, 
 and the conjunctiva should be preserved carefully. The defect is 
 remedied in a satisfactory manner by Dieffenbach's method (Figs. 161, 
 162). The tumor is included in a V-shaped incision, and the part to 
 
CARCINOMA. 
 
 287 
 
 be removed is carefully dissected away from the conjunctiva. If the 
 tumor has reached the tarsal cartilage, this must be removed with the 
 eyelashes. A square flap is now made by carrying a straight incision 
 from the outer angle of the eye outward and backward, corresponding 
 in length to the length of the eyelid, joined at the outer terminus by 
 an incision extending downward and inward to a level with the apex 
 of the V-shaped incision. The flap is now detached and by sliding is 
 brought into its new location, when the operation is completed by 
 suturing with fine silk, catgut, or horsehair, as shown in Figure 162. 
 The wound-surface which cannot be covered by suturing should be 
 paved by Thiersch's grafts at once. 
 
 If the disease has extended to the conjunctiva, the entire eyelid must 
 be removed. In such cases it is much more difficult to replace the parts 
 lost by disease than those lost by the operation. Dieffenbach's method 
 must be modified so far that the inner surface of the new eyelid should 
 be covered with a Thiersch graft, which should be retained in its proper 
 position by a few fine catgut sutures. Hotz has shown that conjunc- 
 tival defects can be repaired successfully by skin-grafts. The writer has 
 resorted to this expedient a few times in making new eyelids, and the 
 results have been exceedingly satisfactory. The skin grafted soon 
 adapts itself to its new location and serves a useful purpose as a sub- 
 
 Fig. 163.— Partial rhinoplasty by taking a 
 flap from the opposite side of the nose (after 
 Langenbeck). 
 
 Fig. 164. — Partial rhi- Fig. 165. — Partial rhinoplasty 
 noplasty completed (after by taking a pedunculated flap 
 Langenbeck). from the face along the base of 
 
 the nose (after Esmarch). 
 
 stitute for the conjunctiva. A new eyelid lined on both sides by skin 
 is less liable to shrink and to become distorted than when skin-graft- 
 ing is omitted. 
 
 Operative Treatment of Carcinoma of the Nose. — If only a part of 
 one ala of the nose is affected, the carcinoma is excised by removing 
 a wedge-shaped piece the entire thickness of the ala, and the defect is 
 corrected by taking a flap from the opposite side of the nose, as advised 
 by Langenbeck, or from the face near the base of the nose (Figs. 163, 
 
288 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 164). The wound left on the opposite side of the nose after the 
 removal of the flap should be covered by a pavement of Thiersch 
 skin-grafts. The nasal defect after the excision of the carcinoma can 
 also be remedied satisfactorily by taking a pedunculated flap from the 
 face, as shown in Figure 165. If the margins of the nasal apertures 
 are free, and the tumor occupies the bridge of the nose and has in- 
 volved the bony framework, a very extensive operation becomes neces- 
 sary. With knife, chisel, and saw, the tumor and the bony framework 
 are removed to ensure complete removal of all diseased tissue. If the 
 disease has reached the nasal cavities, extensive removal of the mucous 
 lining of the nasal passages often becomes necessary. The resulting 
 defect often presents alarming proportions, but it can be corrected in 
 a very satisfactory manner by Konig's operation (Figs. 166, a, b, c). 
 
 Fig. 166. — Konig's rhinoplasty, a: a, flap for building bridge of nose, including skin, periosteum, 
 and a thin slice of bone; b, flap used to cover flap a and to furnish integument for the entire defect; c, defect 
 caused by excision of tumor, b : a, flap a turned downward ; b, lower end fastened in place with catgut 
 sutures. The skin of the tip of the nose at b is left free, and to it flap b is sutured, c : a, b, defects over 
 frontal bone ; c, flap b, which covers the bony surface of flap a, and furnishes the cutaneous covering for the 
 entire defect, sutured in place. 
 
 The reflected flap a furnishes a bridge of bone which prevents the sink- 
 ing in of the nose. The defect over the frontal region caused by the 
 removal of the flaps should be covered at once by large skin-grafts. 
 If the entire nose has to be sacrificed, owing to the extent of the carci- 
 noma, Thiersch's method of rhinoplasty recommends itself for restoring 
 the lost organ. The new organ is made by taking a flap from each 
 side of the face ; these flaps are turned inward with the cutaneous sur- 
 face downward, and are then united in the middle line with catgut 
 sutures. A large pedunculated flap is then taken from the forehead 
 
CARCINOMA. 289 
 
 and is rotated into position and sutured in place. The two raw sur- 
 faces brought in contact unite rapidly, and as both sides of the alse of 
 the nose are lined by normal skin, the resulting shrinkage is moderate. 
 The defects caused by the removal of the 
 flaps are covered at once by Thiersch 
 grafts. 
 
 Carcinoma of the skin in other parts 
 of the face or the body is excised with the 
 same thoroughness, making the incisions 
 half or three-quarters of an inch away 
 from the palpable margins of the tumor, 
 and covering the defect either by a plastic 
 operation, by skin-grafting, or by a com- 
 bination of both these procedures. In per- 
 forming primary skin-grafting it is very im- Fu; l67 ._ Rhinoplasty (after Thiersch) . 
 portant to diminish the size of the wound 
 
 by suturing its angles and by approximating the remaining margins of 
 the wound by the use of tension-sutures. The best material for this 
 purpose is coarse silk. The skin-grafts should be covered carefully by 
 strips of protective silk over which an antiseptic dressing is applied, the 
 whole being held in place by strips of adhesive plaster or by a plaster- 
 of-Paris bandage, so that the grafts may not subsequently be disturbed. 
 Unless positive indications arise, the first dressing should not be dis- 
 turbed for three days. In place of Thiersch's grafts, it may be advis- 
 able under certain circumstances to use Wolfe's grafts. Grafts not 
 deprived of all adipose tissue should not be used, as this method of 
 skin-grafting, contrary to the assertions of Hirschberg, often results in 
 failure. 
 
 Mouth. — Carcinoma of the mouth has the same structure as carci- 
 noma of the skin, as the glands and the mucous membrane of this 
 cavity have an embryonic origin similar to that of the skin. Before 
 the fourth week in the life of the human embryo there is developed 
 at the lower part of the face a broad transverse cleft : this is the primi- 
 tive mouth. Developed as it is from the face, and carrying with it 
 the covering of the face, the lining membrane of the mouth is derived 
 from the epiblast. The buccal part of the epiblast forms a sac that is 
 at first closed posteriorly. Not until the eighth or the ninth week 
 is a communication established between the mouth and the pharynx. 
 The mouth and the pharynx in the embryo are two separate cavities, 
 the first having its origin in the epiblastic layer, the second in the 
 hypoblastic layer and the visceral mesoblast. The glands in communi- 
 cation with the mouth are developed from the epiblastic lining of the 
 
 19 
 
290 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 mouth. The mouth is covered by pavement epithelium several layers 
 deep, the deeper or attached layer being generally columnar, while the 
 superficial layer presents flattened scales. In the mouth, as in the skin, 
 carcinoma starts either in the epithelial strata of the mucous membrane 
 or in one of its glandular appendages, in the form of a hard nodule. 
 The epithelial cells undergo fatty degeneration, so that when an ulcer 
 has formed an atheromatous mass can sometimes be pressed from the 
 centre of the ulcer. The base of the ulcer is indurated. The ulcer, 
 instead of showing any disposition to cicatrize, enlarges in all directions. 
 
 The superficial variety, as in the skin, manifests no disposition to 
 invade the deep structures. The nodular variety originates in the 
 tubular mucous glands, and presents under the microscope a tubular 
 structure. The tubules are lined with one or more layers of columnar 
 epithelial cells. This form from the very beginning penetrates the 
 tissues deeply after invading one of the maxillary bones at an early 
 stage. As a primary tumor, carcinoma of the mouth is rarely devel- 
 oped in localities other than the lips, the gums, the salivary glands, the 
 tongue, the tonsil, and the palate. The labial glands are much more 
 numerous in the lower than in the upper lip, and they are almost entirely 
 absent about the angles of the mouth ; which absence may tend to 
 explain why carcinoma affects the middle of the lower lip more fre- 
 quently than the upper lip and the angles of the mouth. Carcinoma 
 of the mouth is frequently attributed to smoking, but in the East, where 
 this habit is most common and is carried to excess, carcinoma of the 
 lip and the mouth is very rare. This fact would seem to prove, if smok- 
 ing is an etiological factor, that it is not the traumatism resulting from 
 the pipe, but the heat, that is the active agent, as long pipe-stems are 
 used by the Orientals and the smoke is passed through water before it 
 reaches the mouth. 
 
 Carcinoma of the mucous membrane of the cheek is sometimes 
 preceded by a patch of leukoplakia. The influence of chronic irrita- 
 tion in producing carcinoma is well shown in carcinoma in this locality, 
 as the tumor very often corresponds in its location with the crowns of 
 prominent upper and lower molar teeth. 
 
 Carcinoma of the gum starts often near the stump of a carious tooth. 
 The bone is invaded so quickly that the disease is often mistaken for a 
 primary bone affection. Lymphatic infection is a very early and con- 
 spicuous feature when the carcinoma involves either of the maxillary 
 bones. The primary tumor is sometimes overlooked in such cases. A 
 rapid-growing glandular tumor of the neck should remind the sur- 
 geon of the necessity of a thorough examination of the cavity of the 
 mouth. Carcinoma of the mouth with early and extensive glandular 
 
CARCINOMA. 291 
 
 infection is a very rapidly fatal affection, the average duration of life 
 being not more than six months. 
 
 Radical operations for carcinoma of the mouth always require an 
 external incision. Intra-oral operations cannot be made with the requi- 
 site degree of thoroughness. The incision must be made in a location 
 which affords the best access to the tumor, and in which the operation 
 will leave the least disfigurement. If the upper maxilla is implicated, 
 the same incisions are made as for partial or complete excision of this 
 bone. If the lower jaw has become secondarily affected, the floor of the 
 mouth is usually also extensively involved. In such cases a horseshoe- 
 shaped incision corresponding with the lower border of the jaw from 
 one angle to the other will afford ample space to remove a portion of 
 the bone and to clear out the infected glands and other soft tissues 
 requiring removal. In cases of extensive carcinoma of the mouth recur- 
 rence is very apt to take place even after the most extensive operations,, 
 owing to the early and extensive lymphatic infection. 
 
 Tonsil. — Carcinoma of the tonsil is a comparatively rare affection. 
 Only two or three cases have come under observation in which the 
 writer could satisfy himself that the disease had its primary origin in 
 this gland. In one of the cases the tumor was mistaken for a long 
 time for primary syphilis, and the patient had been subjected to anti- 
 syphilitic treatment for several weeks, with, of course, a negative result. 
 The infiltration spreads very rapidly, and early lymphatic infection is 
 the rule. The disease in the course of two or three months extends to 
 the base of the tongue, the pillars of the soft palate, and the pharynx. 
 Salivation, pain, and dysphagia are early and distressing symptoms. 
 As soon as the disease reaches the entrance of the larynx, hoarseness 
 and difficult breathing set in. As the disease occurs only in persons 
 advanced in years, the diagnosis is not attended by any difficulty. The 
 malignancy of the tumor is pronounced by the clinical course, and all 
 that remains for the surgeon to do is to differentiate between carcinoma 
 and sarcoma. In carcinoma ulceration commences at an earlier stage 
 than in sarcoma, and is more constantly attended by infection of the 
 lymphatic glands, which infection is exceptional in sarcoma. 
 
 Operative Treatment of Carcinoma of the Tonsil. — The removal of a 
 malignant tumor of the tonsil is one of the most difficult operations in 
 surgery. At the time the operation is performed the disease has usually 
 extended far beyond the limits of the organ primarily affected. The 
 tumor must be exposed by an external incision, with or without tem- 
 porary resection of the inferior maxilla. O. Weber recommended 
 temporary resection of the inferior maxilla at a point corresponding 
 with the third molar. The articular end of the bone is then turned 
 
292 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 upward with the soft tissues. The ascending pharyngeal, lingual, facial, 
 and carotid arteries can readily be tied in this incision. Mikulicz advises 
 an external incision extending from the mastoid process to the hyoid 
 bone, after wmich the ascending ramus of the jaw is denuded of its 
 periosteum from the insertion of the masseter muscle as high up as 
 possible, whereupon the ascending ramus of the jaw is enucleated. 
 The tonsillar region is now freely exposed. Langenbeck recommends 
 
 temporary resection of the inferior maxilla 
 (Fig. 1 68). Cheever of Boston, who recom- 
 mends an incision along the anterior border 
 of the sterno-cleido-mastoid muscle from the 
 external ear in a downward direction, reports 
 several cases operated upon successfully by 
 this method. In two cases in which this ope- 
 ration was performed by the writer he resorted 
 to Kocher's incision for the removal of the 
 tongue, and, although both operations proved 
 exceedingly difficult, he was satisfied with the 
 room afforded by the incision. 
 
 Iodoform-gauze drainage should be em- 
 ployed both for the purpose of arresting 
 parenchymatous oozing and to afford a free 
 outlet for the primary wound-secretions. If 
 temporary resection of the inferior maxilla is practised, the intentional 
 fracture is sutured with silver wire or with chromicized catgut after the 
 extirpation of the tumor. 
 
 Tongue. — Carcinoma of the tongue is one of the most distressing 
 of all surgical affections. Unfortunately, the tongue is rather frequently 
 the seat of carcinoma. The 
 lingual glands are distributed 
 at the root of the tongue, on 
 the sides, and at the apex, and 
 it is in these localities that the 
 tumor has most frequently its 
 starting-point. Very frequently 
 the location of the tumor cor- 
 responds with a source of irri- 
 tation caused by a prominent 
 or carious tooth. Mechanical 
 irritation from such a source 
 continued for any length of 
 time is very apt to become an influential exciting cause 
 
 Fig. 168. — External incisions 
 for extirpation of carcinoma of the 
 tonsil : a, after Langenbeck ; b, 
 after Mikulicz. 
 
 Fig. 169. — Carcinoma of the tongue, showing its papillary 
 structure; X 100 (after W. Fairlie Clarke). 
 
 The propor- 
 
<m 
 
 •?,;&, 
 
 
 CARCINOMA. 293 
 
 tion of female to male patients is about 1:7. In the early stages, 
 before ulceration has become extensive, the tumor retains on its sur- 
 face the papillary structure of the tongue (Fig. 169). Infiltration from 
 the surface soon results in the formation of epithelial nests in the 
 underlying vascular connective tissue. The epithelial cells are closely 
 packed in concentric layers in the 
 alveoli of the stroma (Fig. 170). 
 
 Besides chronic irritation, the 
 most frequent exciting causes of 
 carcinoma of the tongue are psori- 
 asis, leukoplakia, ichthyosis, and 
 other chronic inflammatory affec- 
 tions of the surface of the tongue 
 — a strong argument that chronic 
 inflammatory affections are a fre- 
 quent direct and indirect cause of 
 
 TT n • r Fig. 170.— Carcinoma of the tongue : laminated cap- 
 
 carcinoma. Usually carcinoma of 7 sule . x 200 (after w Fairlie Clarke) . 
 
 the tongue is a rapidly fatal dis- 
 ease, resulting in death within two years. Wolfler has called attention 
 to a more chronic form of carcinoma of the tongue in which a small 
 flat carcinomatous ulcer may remain in a latent condition for many 
 years. The tumor makes its appearance at the margin, tip, or dorsum 
 of the tongue, as a firm nodule which soon begins to ulcerate in 
 the centre. The infiltration and induration are well marked from the 
 beginning. The primary tumor seldom or never occupies the posterior 
 third of the organ. Glandular infiltration is an early sequence, and the 
 floor of the mouth becomes involved at an early stage. 
 
 The pain in carcinoma of the tongue is quite severe and of a sharp, 
 stinging character, extending also in the direction of the ear. The 
 surface of the ulcer is either papillary or covered by gangrenous shreds. 
 The induration of the base and margins of the ulcer remains through- 
 out. Profuse salivation and difficulty in swallowing and in speech are 
 conspicuous clinical features. 
 
 In the differential diagnosis tuberculosis, gumma, traumatic ulcer, 
 and actinomycosis must be considered. Tuberculosis of the tongue 
 occurs, with few exceptions, only in persons suffering from pulmonary 
 tuberculosis. The tubercular sputum, coming in contact with some 
 abrasion, results in inoculation. The tubercular ulcer is covered by 
 fungous granulations, and lacks the indurated base and margins of car- 
 cinoma. Syphilitic lesions have frequently been mistaken for carci- 
 noma, and vice versa. Gumma of the tongue is usually associated with 
 other syphilitic manifestations of the tongue or of the cavity of the mouth. 
 
294 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The tongue itself is often deeply fissured. General hyperplasia of the 
 lymphatic glands is an indication of syphilis, while regional infection 
 speaks in favor of tuberculosis. A gumma of the tongue is not infre- 
 quently the starting-point of a carcinoma. This complication must 
 therefore be looked for in syphilis of the tongue. If any doubt exists 
 as to the differential diagnosis of carcinoma and syphilis, examination 
 
 of a section of the tumor under 
 the microscope will clear up the 
 uncertainty. In actinomycosis of 
 the tongue the discovery of acti- 
 nomyces under the microscope 
 will render the diagnosis positive. 
 The prognosis of carcinoma 
 of the tongue is always grave. 
 Many of the reported perma- 
 nent cures effected by operation 
 were undoubtedly cases in which 
 a gumma was mistaken for a 
 carcinoma. Billroth and Kocher 
 claim that the results after op- 
 erations for carcinoma of the 
 tongue are as favorable as those 
 after operations for carcinoma of 
 other organs. Winiwarter's sta- 
 tistics show that the mortality 
 of extirpation of the tongue, 
 which formerly was very great, 
 has been reduced to 17.6 per 
 cent. The diagnosis should be 
 made early, and useless treat- 
 ment by the application of caus- 
 tics, etc. should give way to an 
 early and thorough operation. 
 Radical Operations for Carcinoma of the Tongue. — In all operations 
 upon the tongue it is very important to disinfect the whole cavity of the 
 mouth, as advised by Billroth. The fear of hemorrhage has in the past 
 induced surgeons to substitute for the knife and scissors the ecraseur or 
 the galvano-caustic wire. The employment of these instruments did not 
 always prevent hemorrhage when the tongue was amputated near its base, 
 and for this and other substantial reasons they have almost entirely been 
 abandoned. Mr. Hutchinson continues to use the ecraseur, but he has 
 few imitators. In all operations on the tongue the organ should be 
 
 Fig. 171. — Syphilitic nodule and fissure of the tongue 
 (after W. Fairlie Clarke). 
 
CARCINOMA. 
 
 295 
 
 pierced in the middle line near the tip with a large needle armed with 
 heavy silk. With this thread, which is tied at the end, the tongue can 
 be drawn and held in any direction during the operation. Preliminary 
 ligation of one or of both lingual arteries as a prophylactic measure 
 
 against hemorrhage is seldom prac- 
 tised at the present time, and is 
 not to be recommended. Some sur- 
 geons employ temporary hemostatic 
 
 Fig. 172. — Temporary constriction of one-half of the 
 tongue (after Esmarch and Kowalzig). 
 
 Fig. 173. — Temporary constriction of the whole 
 tongue at its base (after Esmarch and Kowalzig). 
 
 measures during the operation (Figs. 172, 173). In applying temporary 
 constriction the tongue is pierced in the middle at its base with a large 
 needle armed with a long and strong silk suture. If it is the intention 
 to constrict only one side, the needle is liberated and the suture is tied ; 
 if the whole tongue is to be rendered bloodless, the thread is cut near 
 the needle and the two threads are tied on opposite sides. The writer 
 has tunnelled the base of the tongue in the middle line with a small 
 pair of hemostatic forceps, and has drawn through the tunnel a small 
 rubber tube about twelve inches in length, cut it in the middle, and 
 constricted each side by tying the rubber ligatures firmly enough to 
 interrupt both the arterial and the venous circulation. This method 
 of elastic constriction is to be preferred to the use of silk ligatures. 
 If the surgeon has reliable assistants, preliminary elastic constriction is 
 unnecessary, even if the entire tongue is to be removed. 
 
 If the tumor is small and can be removed effectually through the 
 mouth by a wedge-shaped excision, the tongue is rendered accessible 
 by the use of Whitehead's gag. The operation through the mouth is 
 applicable when the tumor occupies the anterior third of the tongue. 
 The line of incision should be made at least three-quarters of an inch 
 distant from the palpable margin of the tumor. The thread with which 
 the tongue is drawn forward is inserted in such a manner that it can be 
 
296 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 used as a suture after excision of the tumor (Figs. 174-177). After the 
 tongue has been drawn well forward the excision is made either with 
 
 Fig. 174. — Insertion of traction-suture 
 (after Esmarch). 
 
 Excision of tumor (after Esmarch). 
 
 the knife or with scissors. The hemorrhage is readily controlled by 
 accurate suturing. The deep sutures should include all the tissues, 
 and if there is any tendency to inversion of the mucous membrane, this 
 
 Fig. 176. — Tying of first suture (after Esmarch). 
 
 Fig. 177. — Operation completed (after Esmarch). 
 
 tendency should be averted by the use of a few superficial fine catgut 
 sutures. 
 
 Whitehead removes the entire tongue through the mouth with 
 scissors, and immediately grasps and ties the lingual arteries. Few 
 surgeons perform Whitehead's operation — not because it is difficult and 
 cannot be done safely, but because cases which require amputation of 
 the entire tongue are complicated by regional infection, the treatment 
 of which requires an external incision. Langenbeck makes an incision 
 from the angle of the mouth downward, and divides the inferior maxilla 
 transversely in the line of the external incision (Fig. 178). The ends 
 of the bone are then drawn apart sufficiently to secure free access 
 to the base of the tongue. After completion of the amputation the 
 bone-ends are brought in apposition and are sutured with silver wire. 
 
CARCINOMA. 
 
 297 
 
 Regnoli devised an operation, later modified by Billroth (Fig. 179), 
 by which the base of the tongue can be made freely accessible without 
 dividing the inferior maxilla. The cavity of the mouth is opened by a 
 horseshoe-shaped incision corresponding with the lower border of the 
 jaw; the cavity of the mouth 
 being opened, the tongue is 
 drawn forward through the in- 
 cision sufficiently to bring its 
 base within easy reach. More 
 recently, Kocher devised an 
 incision by which the base of 
 the tongue is reached from the 
 side without dividing the jaw 
 (Fig. 180). This incision is com- 
 menced below the ear, and is 
 carried along the anterior mar- 
 gin of the sterno-cleido-mastoid 
 muscle about five inches, when 
 it is directed forward, and by a 
 
 small turn upward is made to terminate near the symphysis of the chin. 
 The flap of skin is then raised as far as the lower border of the jaw, and 
 through this space the base of the tongue is reached. The tongue is 
 then drawn through the incision and is amputated in the usual manner. 
 
 Fig. 
 
 78. — Amputation of the tongue by Langenbeck's 
 method. 
 
 Fig. 179.— Amputation of the tongue according 
 to Regnoli-Billroth. 
 
 Fig. 
 
 -Kocher's incision in amputation of the 
 tongue. 
 
 Kocher's incision affords the surgeon an excellent opportunity to remove 
 all the submaxillary and submental lymphatic glands, but does not expose 
 the base of the tongue as freely as the Regnoli-Billroth method. From 
 experience the writer is satisfied that the Kocher method is well adapted 
 for partial removal of the tongue, but when the entire organ is to be 
 
298 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 amputated the Regnoli-Billroth method deserves the preference. After 
 the tongue has been drawn well forward, before making the amputation, 
 it has been the habit of the writer to insert on each side of the base of 
 the tongue an additional traction-suture, with which to control the 
 stump later. This is an exceedingly important precaution. After 
 dividing the tongue by one stroke of the knife as far as the median 
 line, the lingual artery is grasped and tied. The lingual artery on the 
 opposite side is dealt with in a similar manner after the amputation has 
 been completed. The parenchymatous oozing is moderate, and is con- 
 trolled by suturing the stump. It is advisable to remove as much of 
 the floor of the mouth as necessaiy, and all the infected lymphatic 
 glands, before the tongue is amputated. The writer always resorts to 
 partial anesthesia in performing the operation, for the purpose of 
 securing the patient's co-operation in preventing the entrance of blood 
 into the larynx. The two traction sutures are brought out of the 
 mouth, and are used in fixing the stump in proper position for a day 
 or two after operation. The wound is covered with adhesive iodoform 
 gauze or with Whitehead's benzoe mixture. The external wound is 
 closed except at a point best adapted for drainage. If necessary, the 
 patient is nourished for a few days by introducing food into the stomach 
 through an elastic tube or by rectal feeding. A saturated solution of 
 boric acid should be used frequently as a gargle or mouth-wash. Care- 
 ful attention in the after-treatment is of great importance in the preven- 
 tion of acute pulmonary complications. The functional results are 
 satisfactory after complete extirpation of the tongue. It has been 
 ascertained that the criminals in Persia who were formerly punished by 
 cutting out of the tongue recovered speech sufficiently to make them- 
 selves understood. The same has been observed after amputation of 
 the entire tongue for carcinoma. The function of deglutition is pre- 
 served almost to perfection. 
 
 Parotid. — Carcinoma of the parotid gland does not occur in persons 
 less than forty years of age. Carcinoma of the salivary glands is 
 notoriously malignant. The acinous variety begins as a proliferation of 
 the columnar epithelia of an isolated embryonic lobule of the gland 
 (Fig. 181). The stroma is usually scanty in this variety. The tumor 
 grows rapidly and gives rise to early lymphatic infection. Weber 
 described a form of carcinoma of the parotid that closely resembles 
 hard carcinoma of the breast. The tubular variety begins in the distal 
 branches of the salivary duct, in the form of epithelial pearls of colum- 
 nar epithelial cells which arrange themselves in the form of tubules, 
 which multiply and grow into the substance of the gland. A rapid- 
 growing tumor of the parotid gland in a person fifty or more years 
 
CARCINOMA. 
 
 299 
 
 Fig. 181. — Adenomatous stage of a cancer of the 
 submaxillary gland ; X 35° (after D. J. Hamilton) : a, 
 section of a normal acinus ; b, an acinus distended with 
 proliferating epithelium : other parts of the gland were 
 completely cancerous. 
 
 of age is, with very few exceptions indeed, a carcinoma. The capsule 
 of the gland is perforated at an early stage, when the tumor involves 
 the overlying skin and the neigh- 
 boring organs. The external 
 ear, the malar bone, and the 
 ascending ramus of the inferior 
 maxilla are frequently impli- 
 cated. In two cases that have 
 come under the writer's obser- 
 vation paralysis of the facial 
 nerve existed at the time the 
 operation was performed. Re- 
 gional infection extends to the 
 deep lymphatics of the neck. 
 
 Extirpation of the Parotid 
 Gland. — Extirpation of the par- 
 otid gland was first performed in 
 America in 1804 by the father 
 of J. Collins Warren. Brainard 
 of Chicago performed the opera- 
 tion a number of times, and 
 
 strongly maintained its feasibility. Konig advises in the aged a 
 partial excision of the gland, with a view of preventing facial paral- 
 ysis if the tumor is not large. The writer is of the opinion that 
 partial removal of the parotid gland for carcinoma is an unjustifiable 
 and unsurgical procedure, as recurrence is sure to take place, and the 
 recurrent tumor grows more rapidly than the primary growth. Carci- 
 noma of the parotid gland indicates complete removal of the gland with 
 all other infected tissues, and is always followed by permanent facial 
 paralysis. The writer has removed the parotid gland for carcinoma 
 six times without a death, and has never observed serious consequences 
 from the facial paralysis. In one case there was removed, in addition to 
 the tumor, the entire external ear ; in another, the malar bone and part 
 of the superior maxilla ; and in a third, the ascending ramus of the in- 
 ferior maxilla with the parotid. The overlying skin is generally found 
 affected, and must be excised with the tumor. Preliminary ligation 
 of the external or common carotid artery is unnecessary, as the external 
 carotid artery can be ligated in the wound toward the completion of the 
 operation. Liston and Dieffenbach recommended intracapsular enucle- 
 ation. Roser removed the carcinomatous parotid gland piecemeal 
 (morcellement). 
 
 The capsule of the gland should invariably be removed with the 
 
300 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumor. If a large area of skin has to be excised, the part to be 
 removed should be included between two elliptical incisions, the lower 
 angle of the ellipse corresponding with the point where the external 
 carotid artery is to be ligated. The temporal artery is ligated on the 
 distal side and is secured by compression-forceps on the proximal side. 
 The whole mass is carefully dissected all around ; the dissection must 
 be extended to the styloid process of the temporal bone. As soon as 
 the external carotid artery comes in view it is isolated and is grasped 
 with a pair of hemostatic forceps, the tumor is removed, and the arteiy 
 is tied. The wound-surface being large, it is necessary to cover it by 
 a plastic operation, which can be done by taking a pedunculated flap 
 from the forehead or the scalp. The scalp defect is then covered with 
 Thiersch's grafts. In the case in which the writer had to remove the 
 external ear with the parotid a little opening was made in the large 
 skin-flap, this opening corresponding with the location of the external 
 meatus, and thus the function of hearing was preserved almost to 
 perfection. 
 
 If the skin over the tumor can be preserved, the writer exposes the 
 parotid gland by a curved incision, with the convexity directed down- 
 ward, extending from the mastoid process to near the malar prominence, 
 turns this flap upward, and then proceeds to remove the tumor as has 
 been described. The results after this operation compare favorably 
 with those of removal of the breast for carcinoma. If the deep cervical 
 glands are infected, the incision must be extended downward along 
 the anterior border of the sterno-cleido-mastoid muscle. Carcinoma 
 of the parotid gland should be removed as early and as thoroughly as 
 possible, and the patient must be made to understand that the price he 
 pays for a radical operation includes invariably a permanent facial 
 paralysis. 
 
 Thyroid. — Carcinoma of the thyroid gland is very rare in the 
 United States. Malignant disease of this gland is usually associated 
 with adenoma or with miasmatic struma, and is consequently more 
 prevalent in localities where these affections are endemic. Carcinoma 
 of the thyroid gland presents an additional interest from the fact that 
 such tumors are by no means limited to the thyroid gland. Accessory 
 thyroid glands are quite frequently found in the neighborhood of the 
 thyroid, but thyroid tissue has a much more diffuse distribution in 
 different parts of the body. It has been found in the bronchial glands, 
 in the lungs, and in the bones in cases where the thyroid was enlarged, 
 and its presence in these situations has been regarded as an example 
 of metastasis. According to Piana, thyroid tissue occurs close to the 
 aortic arch in the dog. The hyoid glands of Zuckerkandl and Kadyi, 
 
CARCINOMA. 
 
 301 
 
 Fig. 182. — Microscopical ap- 
 pearance of pulsatile tumor of the 
 skull (after Morris). 
 
 which are well described by Streckeisen, consist of remains of the 
 thyroid duct and of gland-tissue, and may become the seat of malig- 
 nant as well as benign tumors. 
 
 Heterotopic tumors composed of thyroid tissue are excessively rare. 
 Morris in 1880 described a case of pulsatile tumor of the skull in which 
 it was shown under the microscope that the 
 tumor was composed of thyroid tissue (Fig. 
 182). Coats reported a similar case. Gussen- 
 bauer found such a tumor in the vertebrae. 
 That such a matrix should occasionally serve as 
 a starting-point of carcinoma should be remem- 
 bered when a primary carcinoma is found in 
 tissues normally devoid of epithelial cells. 
 
 Carcinoma of the thyroid gland is met with 
 most frequently in persons from thirty to fifty 
 years of age. The tumor infiltrates the gland- 
 tissue, and soon perforates the capsule and 
 extends to the surrounding tissues, rendering 
 
 the tumor immovable. Extension in the direction of the trachea gives 
 rise to hoarseness and dyspnea. Destruction of the recurrent laryngeal 
 nerves results in paralysis of the vocal cords. Wolfler describes a 
 malignant adenoma of the thyroid gland — a tumor which under the 
 microscope exhibited the same appearances as an adenoma, but which 
 clinically pursued the same course as carcinoma. Histologically he 
 recognizes three varieties : 1. Alveolar carcinoma; 2. Cylindrical-celled 
 carcinoma; 3. Squamous-celled carcinoma. 
 
 Carcinoma of the thyroid usually proves fatal within a year. It 
 starts most frequently in a pre-existing miasmatic struma or adenoma. 
 If a goitre that has remained stationary for a long time commences to 
 increase rapidly in size without any apparent cause, it is more than prob- 
 able that it has become the seat of a carcinoma, either by the tissues 
 composing the pre-existing pathological product having undergone malig- 
 nant transformation, or from the development of a carcinoma from a 
 separate matrix of embryonic cells within or in the immediate vicinity of 
 the infective swelling or the benign tumor. Kaufmann recommended as 
 a means of early and positive diagnosis puncture of the tumor and exam- 
 ination under the microscope of fragments of tissue removed in this way. 
 
 Extirpation of the Thyroid Gland for Carcinoma. — The only surgical 
 treatment of carcinoma of the thyroid gland is early and thorough excis- 
 ion. The removal of a carcinomatous tumor of this gland is a much 
 more difficult task than the enucleation of an adenoma or a cyst, as the 
 tumor has usually perforated the capsule of the gland before the opera- 
 
302 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tion is undertaken, 
 necessitates 
 
 The excision of a carcinoma of the thyroid gland 
 
 A 
 
 ligation of numerous and large veins (Figs. 183, 184) 
 
 Fig. 183. — Tumor of the right lobe of the thyroid 
 gland, showing ramification of superficial veins 
 (after Kocher). 
 
 Fig. 184. — Schema showing points of ligation of 
 large veins in extirpation of thyroid tumors (after 
 Kocher). 
 
 curved transverse incision with the convexity directed downward will 
 
 afford the best access to the base of the tumor. The large veins should 
 
 be divided between a double ligature. A very useful instrument in 
 
 making the dissection is Kocher's director (Fig. 185). 
 
 Venous hemorrhage is more to be feared than arterial 
 
 hemorrhage, and is more difficult to control. Injury to 
 
 the recurrent laryngeal nerve has frequently happened 
 
 during operations for malignant disease of the thyroid. 
 
 Permanent paralysis of the vocal cord on the same side 
 
 is a constant result of this accident. If the trachea 
 
 has become involved, it is generally opened during the 
 
 operation, and a tracheal cannula should be inserted at 
 
 once. 
 
 The results of operations for malignant disease of the 
 thyroid gland have not been very encouraging. Local 
 recurrence is the rule, even if the infected lymphatics are 
 carefully removed with the tumor. The operation, how- 
 ever, is one of great palliative value, and is the only means 
 of preventing death from suffocation. In operating for 
 malignant disease of the thyroid the whole gland should 
 be removed, as it is much better for the patient to run the risk of 
 
 Fig. 185.— Kocher's 
 director. 
 
CARCINOMA, 
 
 3°; 
 
 becoming later the subject of cachexia strumipriva than to take the 
 chances of an early local recurrence. 
 
 Mammary Gland. — The greatest interest centres in carcinoma of the 
 mammary gland, owing to the great frequency with which this organ is 
 
 Fig. 186. — From carcinoma of mammary gland, showing infiltration of connective-tissue spaces with 
 carcinoma-cells : connective-tissue endothelia can be seen in places lining the connective-tissue spaces ; 
 X 250 (after Ziesing). 
 
 affected. The frequency of carcinoma as compared with other tumors 
 of the breast is very great, as Billroth found in 440 tumors of the breast 
 that only in 1 8 per cent, were the tumors of a non-malignant character. 
 
304 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Fig. 187. — Acinous carcinoma of mammary gland ; X no, reduced one-third (Surgical Clinic, Rush 
 Medical College, Chicago) : a, connective-tissue stroma; £, tumor-parenchyma ; c, blood-vessels in stroma; 
 d, wandering carcinoma-cells ; e, area where recent hemorrhage has occurred ; f, blood-pigment ; g, shrink- 
 age in hardening. 
 
 Histological Varieties. — The histological structure of a carcinoma of 
 the mammary gland depends on the type of cells of which it is com- 
 
 «?/ 
 
 
 ff^lPW 
 
 Fig. 188. — Alveolar carcinoma of breast (after Kbnig) : a, alveoli filled with epithelial cells; b, empty alve- 
 oli ; c, stroma infiltrated in places by small round cells. 
 
CARCINOMA, 
 
 305 
 
 posed and the amount and arrangement of its stroma. The embryonic 
 matrix from which it develops is always derived from the epiblast, but 
 
 Fig. 189. — Tubular carcinoma in cystic tumor of the breast ; natural size (Surgical Clinic, St. Joseph's 
 Hospital, Chicago) : a, tumor ; b, pedicle ; c, cavity of cyst ; d, normal gland-tissue ; e, adipose tissue ; f 3 
 pin supporting tumor. 
 
 the morphology of the cells is determined by the part of the gland 
 which the matrix represents. The product of tissue-proliferation rep- 
 resents either the acinous or the duct portion of the gland. 
 
 ■■■>, 
 
 \i 
 
 ^f 
 
 
 ' •* * 
 
 v-- 
 
 
 
 • ■ ■ 
 
 
 ■*>:*? 
 
 Wm 
 
 up 
 
 ■'■■.. ; 
 
 ■•••• 
 
 Fig. 190.— Section from tumor shown in Figure 191 ; X 185 : a, alveolated stroma infiltrated in some places 
 by small cells; b, columnar epithelial cells filling tubular spaces. 
 
 Acinous Variety. — In this variety the cells are packed in the alveoli 
 of the stroma very much in the same manner as in carcinoma of the 
 20 
 
306 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 skin (Fig. 1 8?). If the alveoli are large, we speak of " alveolar carci- 
 noma," although the stroma of all carcinomatous tumors presents an 
 alveolated structure (Fig. 188). If the parenchyma of the tumor pre- 
 dominates greatly over its connective-tissue stroma, the tumor is soft and 
 very vascular, corresponding with what was formerly called "enceph- 
 aloid " or " medullary " cancer. If the tumor is hard and nodulated, 
 it answers to what is still being described as "scirrhus." If the cellular 
 elements or the stroma, or both, undergo such extensive colloid degen- 
 eration that the tumor is largely composed of colloid material, it has 
 been customary to call such a tumor a " colloid cancer." In acinous 
 carcinoma of the mammary gland the cells infiltrate the connective- 
 tissue spaces around the primary growth, and the tumor increases in 
 size (Fig. 186). 
 
 Tubular Variety. — Tubular carcinoma frequently takes its starting- 
 point in a pre-existing cystic disease of the ducts of the gland. The 
 cells are either columnar or resemble columnar cells which line duct- 
 spaces or infiltrate the connective-tissue stroma (see Plate 5). Tubular 
 carcinoma is less malignant than the acinous variety. In one case the 
 writer found in the breast of a woman thirty-five years old a tubular 
 carcinoma which had existed for six months, and during this time it 
 had reached the size of a walnut. The skin over the tumor remained 
 unaffected, and the nipple was not retracted. Distinct fluctuation was 
 felt. The cyst was excised. On laying it open a small quantity of 
 
 mucoid material escaped. The 
 interior of the cyst was occupied 
 by a pedunculated papillary tu- 
 mor (Fig. 189). Dr. Mellish, 
 who examined the tumor and 
 made the drawings, traced its 
 pedicle to the orifice of a duct- 
 like tract in the gland-tissue. 
 This blind tract could be fol- 
 lowed to the depth of about a 
 quarter of an inch into the 
 substance of the gland. There 
 is no doubt that the tumor 
 developed from the wall of a 
 pre-existing duct, and that it 
 caused by its presence in- 
 creased secretion and retention of the secretions which produced the 
 cyst. Sections of the tumor showed a well-marked alveolated struc- 
 ture of its stroma, its spaces filled with columnar epithelial cells. 
 
 Fig. 191. — Tubular form of carcinoma of the breast : infil 
 tration of the stroma by small round cells (after Konig). 
 
CARCINOMA. 307 
 
 In typical tubular carcinoma the tubular arrangement is preserved 
 in the new portions of the tumor. The membrana propria, however, is 
 defective in many places and permits the infiltration of the stroma by 
 new cells (Fig. 191). 
 
 Etiology. — Very little is known concerning the exciting causes of car- 
 cinoma of the breast. It occurs most frequently in women past thirty- 
 five years of age ; the soft variety is more frequent in young persons, and 
 the hard variety in persons advanced in years. The rarity of the occur- 
 rence of carcinoma in men points to the frequently-recurring hyperemia 
 of the mammary gland in females during pregnancy, lactation, and 
 menstruation as an important etiological factor. That pregnancy and 
 lactation are important causes is shown from the fact that in carcinoma 
 of the breast in the female the proportion of the unmarried to the mar- 
 ried, according to Bryant, is 1 : 3 \ ; according to Baker, of 260 cases, 
 23 per cent, occurred in single and 72 per cent, in married women, and 
 4 per cent, in widows. In a small percentage of cases the disease had 
 evidently a traumatic origin. Antecedent lesions of the breast, abscess, 
 fissure of the nipple, and eczema appear to have acted as exciting 
 causes or to have furnished besides the essential tumor-matrix. Occa- 
 sionally an adenoma undergoes malignant transformation. The etio- 
 logical relation between eczema of the nipple and carcinoma of the 
 breast is now generally recognized. In a case that came under the 
 writer's observation the eczema preceded the carcinoma by over five 
 years, and during this time no evidences of the carcinomatous nature 
 of the primary skin affection could be detected by the most careful 
 and frequently-repeated examinations. 
 
 In 1874, Sir James Paget read a paper in which he discussed for the 
 first time the connection of eczema of the areola of the breast with 
 carcinoma, basing his remarks on fifteen cases which had up to that 
 time come under his personal notice. Some of his remarks on this 
 subject are quoted: "The patients were all women various in age, 
 from forty to sixty or more years, having in common nothing remark- 
 able but their disease. In all of them the disease began as an eruption 
 on the nipple and areola. In the majority it had the appearance of a 
 florid, intensely red, raw surface, very finely granular, as if nearly the 
 whole thickness of the epidermis were removed — like the surface of 
 very acute diffuse eczema or like that of an acute balanitis. From such 
 a surface, on the whole or greater part of the nipple and areola, there 
 was always a copious, clear, yellowish, viscid exudation. The sensa- 
 tions were commonly tinglings, itching, and burning, but the malady 
 was never attended by disturbance of the general health. I have not 
 seen this form of eruption extend beyond the areola, and only once 
 
308 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 have seen it pass into a deeper ulceration of the skin after the manner 
 of a rodent ulcer. In some of the cases the eruption has presented the 
 characteristics of an ordinary chronic eczema, with minute vesications, 
 succeeded by soft, moist, yellowish scabs or scales and constant viscid 
 exudation. In some it has been like psoriasis, dry, with a few white 
 scales desquamating, and in both these forms, especially the psoriasis, 
 I have seen the eruption spreading far beyond the areola in widening 
 circles, or with scattered blotches of redness covering nearly the whole 
 
 breast But it has happened that in every case which I have been 
 
 able to watch cancer of the mammary gland has followed within at the 
 most two years, and usually within one year. The formation of cancer 
 has not in any case taken place first in the diseased part of the skin. 
 It has always been in the substance of the mammary gland, beneath or 
 not far from the diseased skin, and always with a clear interval of appar- 
 ently healthy tissue." 
 
 In view of the fact that eczema of the nipple is so constantly fol- 
 lowed by carcinoma, and as the disease appears to resist all kinds of 
 local treatment, Paget is in favor of early operative removal of the dis- 
 eased breast as the only known prophylactic measure against carcinoma 
 from this source. 
 
 Thin, who studied Paget's disease of the nipple from a histological 
 standpoint, found first the skin of the nipple eczematous. The inflam- 
 matory process creeps then along the mucous membrane of the milk- 
 ducts. Bryant estimates that carcinoma of the breast is hereditary in 
 10 per cent, of all cases. Sprengel traced a hereditary influence in 
 thirteen out of 109 cases. 
 
 Symptoms and Diagnosis. — The acinous variety of carcinoma, by far 
 the most frequent, commences as a hard nodule in the substance of the 
 breast, most frequently near the periphery of the organ. If the tumor 
 starts in an accessory mammary gland, it usually occupies primarily 
 the base of the axillary space. The tumor is nodulated, and a certain 
 degree of fixity can be detected almost from the beginning. 
 
 Tubular carcinoma starts more commonly nearer the nipple. As the 
 tumor increases in size it approaches the surface : the skin is drawn 
 inward, and soon becomes discolored in the centre — a condition which 
 precedes ulceration. In soft tumors nodulation is less marked than in 
 the hard variety, and the tumor closely resembles a sarcoma. Exten- 
 sive fatty degeneration of the centre of the tumor and contraction of 
 the stroma at this point leads to a depression which is often noticeable 
 on the surface of the skin. Retraction of the nipple accompanies a 
 similar condition, and is therefore most constant and well marked in 
 hard carcinoma. It is the result of cicatricial contraction of the stroma, 
 
CARCINOMA. 
 
 309 
 
 A serous or sanguineous 
 
 which exerts traction upon the milk-ducts 
 fluid can sometimes be pressed from the nipple, especially in cases oi 
 soft tumors. Soft tumors grow rapidly, being most malignant; the 
 local infection spreads rapidly, the stroma being scanty, and the cells 
 undergo early degenerative changes, especially of a colloid charac- 
 ter. The tumor is soft, fluctuating, and resembles closely a subacute 
 abseess or a rapid-growing sarcoma. Mr. Heath reports such a case : 
 A few months before the examination the* patient, a married woman 
 twenty-four years of age, noticed in the left breast a swelling the size 
 
 Fig. 192. — The lymphatics from the nipple to the axilla, placed upon the axillary vein, whence they 
 mount to the under part of the clavicle, passing through an opening to terminate in the angle of the conjoined 
 jugular and subclavian veins of the right side, at the lower part of the neck (after Astley Cooper) : a, the 
 nipple, with two absorbents from it passing upon the fourth rib, and then dividing into numerous branches 
 which cover the intercostal spaces up to the third and down to the fifth rib ; they then mount to the third rib, 
 to the axillary vein ib), and pass on the inner side of that vein under the clavicle (e), where they are con- 
 tinued, through the opening, into the angle of the jugular and subclavian veins ; d, the subclavian artery ; 
 e, e, axillary plexus of nerves. 
 
 of a hen's egg. The tumor developed rapidly without pain, and occa- 
 sionally blood flowed from the nipple. A little later, in consequence 
 of the large size of the breast and the copious discharge of blood from 
 the nipple, she consulted Mr. Heath, who evacuated about a pint of a 
 thin bloody fluid and injected tincture of iodine. This treatment was 
 repeated on two other occasions. A few months later the breast was 
 
3io 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 removed. At this time there was at the site of puncture a fungous 
 growth through which bloody, offensive fluid was escaping. 
 
 Simmonds has shown that colloid degeneration cannot occur inde- 
 pendently of epithelial cells. When the cells undergo this process the 
 stroma can take part, and in this manner greater or lesser portions of 
 rapid-growing carcinoma are transformed into colloid material. In 
 the atrophic form of carcinoma the stroma is very abundant, and the 
 tumor in the central part shrinks because of the partial or total disap- 
 pearance of the epithelial cells by fatty degeneration and because of 
 the shrinkage of the massive stroma, which in itself favors fatty degen- 
 eration by causing pressure and by diminishing the blood-supply. In 
 nearly all cases which come under the notice of the surgeon glandular 
 infectioii has already occurred. It may be impossible to detect the 
 
 enlarged glands through the intact skin, 
 especially in obese women, but their ex- 
 istence can generally be demonstrated at 
 the operation. 
 
 The relation of the lymphatics to the 
 mammary gland and their location and 
 distribution are well shown in Figures 
 192, 193. 
 
 Careful anatomical researches made by 
 Heidenhain have shown the existence of 
 a dense network of lymphatics underneath 
 the mammary gland in the adipose tissue, 
 between it and the fascia of the pectoralis 
 major muscle. He attributes the fre- 
 quency with which local recurrence has 
 followed the removal of the carcinoma- 
 tous mammary gland to incomplete re- 
 moval of the pectoralis fascia. In all 
 cases this fascia should be removed thor- 
 oughly, which can only be done by taking 
 away the superficial fibres of the muscle. 
 In cases in which the diseased breast is 
 attached to the muscle, the muscle should 
 be removed completely. Stiles fully con- 
 firms the views expressed by Heidenhain 
 by his own investigations. The latter 
 author has also traced a connection be- 
 tween the submammary lymphatics and the lymphatics accompanying 
 the internal mammary artery. 
 
 Fig. 193. — Shows the lymphatics (a) 
 of Figure 192 passing under the blood- 
 vessels (b), the axillary vein (c), the artery, 
 across four of the upper ribs, joining with 
 the anterior, entering the angle of the 
 jugular and subclavian of the right side 
 at d (after Astley Cooper). 
 
CARCINOMA. 
 
 311 
 
 The lymphatic glands nearest the mammary gland usually become 
 affected first, when the regional infection extends in the direction of 
 the apex of the axillary space. The glandular tumors are often more 
 numerous than the normal glands, and some of them are tumors which 
 have developed in the lymphatic vessels. The enlargement of the 
 lymphatic glands belonging to the brachial lymphatics produces 
 oedema of the arm — a condition which becomes aggravated by press- 
 ure of the tumors upon the axillary vein. Lymphatic enlargement 
 usually takes place along the greater pectoral muscle, but, as pointed 
 out by Astley Cooper, if the tumor is situated on the sternal side of 
 the nipple the supraclavicular glands become involved by way of 
 the internal mammary lymphatics. Metastasis takes place most fre- 
 quently in the liver; next in frequency come the lungs, the pleura, 
 and the brain. Torok and Wittelshofer have found metastasis in the 
 bones of the skull. Metastatic tumors of the long bones frequently 
 result in pathological fracture. Carcinoma of the vertebrae resembles 
 clinically spondylitis. Billroth and Konig have observed metastasis 
 most frequently in connection with slow-growing hard carcinoma, 
 which corresponds with the results of the writer's observations. 
 
 In the hard variety the ulcer is at first superficial, and extends 
 primarily more toward its periphery than in the direction of the tumor. 
 
 Fig. 194. — Carcinoma of the breast. 
 
 In soft carcinoma the superficial ulceration often gives rise to central 
 sloughing of a considerable portion of the tumor ; this sloughing, upon 
 separation of the gangrenous part, leaves a crater-like excavation. 
 Infection with pus-microbes hastens the destructive process, and the 
 presence of putrefactive bacilli in the dead tissues causes putrefaction, 
 
312 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 which is the source of the offensive odor which characterizes the dis- 
 charge from soft carcinoma of the breast. Patients who have remained 
 in good health until ulceration begins soon become cachectic from 
 the absorption of septic material from the surface of the tumor and 
 from the inflamed tissues. Pain may be almost entirely absent in 
 soft carcinoma of the breast, the disease resembling in this respect 
 sarcoma. In the hard variety the pain, of a shooting or lancinat- 
 ing character, is always present after the tumor has attained a cer- 
 tain size, but is variable in its intensity ; it is always intermittent, 
 and is apt to be aggravated during the night and after active 
 exercise. 
 
 A rapid-growing tumor of the breast is a malignant tumor. To 
 determine whether the enlargement of the breast is caused by an infec- 
 
 d 
 
 in 
 
 %ff 
 
 %%&: 
 
 ,:>>' 
 
 ^ 
 
 <S^ 
 
 Fig. 195. — Adenoma of the breast ; X 75 (Surgical Clinic, Rush Medical College, Chicagol : a, massive 
 connective-tissue stroma ; b, gland-ducts cut transversely ; c, gland-ducts cut obliquely; d, cystic dilatation 
 of duct. 
 
 tive swelling or by a tumor requires often a very careful examination. 
 A subacute suppurative mastitis often resembles in its signs and symp- 
 toms a malignant tumor. The clinical history must be investigated 
 carefully and all possible sources of infection be ascertained. If any 
 
CARCINOMA. 
 
 3 J 3 
 
 -, ... -v 
 
 ■z -a 
 .r o 
 
 « • s 
 
 U 
 
 SS^- 
 
 * a 
 J" ° 
 
 <U T3 
 
314 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 doubt remain, an opinion should not be given until after an exploratory 
 puncture has been made. 
 
 Tuberculosis of the breast often presents itself as a multiple affec- 
 tion, which is not the case in carcinoma. An adenoma without cystic 
 degeneration hardly ever exceeds in size a walnut. Cystoma forms 
 very slowly, fluctuates on palpation, and upon deep pressure offers a 
 sense of elastic resistance. It is important to distinguish between sar- 
 coma and carcinoma before an operation is undertaken, as the operative 
 procedure will depend to a certain extent on the diagnosis. Sarcoma, 
 as a rule, grows more rapidly than the hard variety of carcinoma. It 
 appears as a smooth tumor, and it is seldom complicated by infection 
 of the axillary glands. It occurs in persons of all ages, while carci- 
 noma is seldom met with in women less than thirty years of age. 
 
 The examination of a section taken from the tumor under the 
 microscope will enable the surgeon to make a differential diagnosis 
 between adenoma (Fig. 195), carcinoma, and sarcoma. In adenoma 
 the stroma is massive and the epithelial cells are limited to the space 
 inside the membrana propria. A glance at Figure 196 will be sufficient 
 to distinguish carcinoma from an adenoma. The epithelial cells here 
 are limited to no one particular place, but are found everywhere and 
 in direct contact with the vascula7 r connective tissue. 
 
 Round-celled sarcoma of the breast, so far as the appearances of the 
 tumor are concerned, very closely simulates the soft form of carcinoma. 
 Under the microscope it is distinguished from the latter by the absence 
 of a well-marked alveolar stroma, by the more uniform distribution of 
 the cells, and by the sarcoma-tissue forming a part of the wall of the 
 new blood-vessels (Fig. 197). The displacement of the gland-tissue by 
 traction and by projecting parts of the tumor in carcinoma distinguishes 
 this tumor from all other pathological products. Paget aptly says : 
 " Moreover, mere indurations do not involve the skin, do not invade or 
 infiltrate it, or produce in it any puckering or dimpling, as by drawing 
 a part of it toward their own mass. In this, indeed, I think there may 
 be an almost unfailing diagnostic sign." 
 
 Another important diagnostic feature of carcinoma that distin- 
 guishes it from all other tumors is its peculiar dissemination through 
 the lymphatics of the skin after the tumor has reached the surface. 
 Billroth has likened this to the manner of dissemination of papular 
 exanthemata. Nodules appear in the skin in the vicinity of a carci- 
 nomatous ulcer, and feel like shot under the epidermis. They rapidly 
 increase in number in all directions. The lymphatic channels are impli- 
 cated, and the whole surface, if the disease spreads rapidly, presents 
 an erysipelatous appearance. So long as the nodules remain isolated, 
 
CARCINOMA, 315 
 
 Yelpeau called this condition squirrhe disseminee ou pustideux, and 
 when the nodules become united into a board-like mass, squirrhe en 
 masse. 
 
 Cicatricial contraction is a prominent feature of this form of sec- 
 ondary carcinoma of the skin. The lymphatic vessels play here a 
 more important part in the dissemination of the carcinoma than do the 
 lymphatic glands. Carcinoma of the superficial lymphatics appears to 
 be, if the expression be allowed, a carcinomatous lymphangitis. In 
 some cases the deep carcinoma becomes adherent to the chest-wall and 
 continues to contract, but at the same time continues to extend after 
 reaching the gland in the opposite side. The chest-wall becomes fixed 
 and respiration becomes difficult. The whole wall of thorax on the 
 affected side is rendered immovable, board-like ; this condition was called 
 by Velpeau cancer en cuirasse. Cancer en cuirasse is not a distinct 
 anatomico-pathological or clinical form of carcinoma, as was formerly 
 asserted, but is always the residt of the extension of a glandidar carci- 
 noma to the lymphatics of the skin. The writer has never observed it as 
 a primary affection. It is a rather frequent complication of neglected 
 carcinoma or of recurrent carcinoma of the breast, and is another form 
 of regional infection, occurring later than regional infection through the 
 deep lymphatic glands. When the tumor has reached this stage it is 
 usually inoperable. Recurrence is almost sure to follow most exten- 
 sive operations. Infection of the superficial lymphatics of the skin 
 appears often in such an acute form that the temperature rises several 
 degrees above normal, and in a few weeks the whole side of the chest 
 becomes involved. New nodules appear every day, and the skin during 
 the acute stage presents an erysipelatous blush. 
 
 In the rudimentary mammary gland in men occur nearly all the 
 tumors that have been observed in the female, especially carcinoma. 
 Schuchhardt recently collected 277 cases of carcinoma of the breast in 
 males. When carcinoma develops in the male breast, it follows the 
 same clinical course as in the female. Regional and general infection 
 occur with equal frequency, and the disease proves fatal in about the 
 same length of time as in the female. 
 
 Prognosis. — Birkett estimated the average duration of life of patients 
 suffering from carcinoma of the breast, and upon whom no operation 
 is performed, as being three and a half years. The duration of the 
 disease is affected very much by the age and the constitution of the 
 patient, the course being slower in the older and less plethoric patients. 
 Astley Cooper's estimate is a fair one — namely, two years for the full 
 development of the disease, and from six months to two years longer 
 for a fatal termination. In some instances, particularly in the aged. 
 
316 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the disease pursues a very slow course, extending over a period of 
 from six to fifteen years. In a case of pathological fracture of the 
 upper part of the femur in a woman seventy-five years of age the writer 
 accidentally discovered a small firm tumor in the left breast. On com- 
 municating this information to the patient she stated that she had first 
 discovered a small lump in the breast twenty years previously. In this 
 case, as in many other cases which finally terminate in metastasis, the 
 tumor remained in a latent condition for twenty years. 
 
 The malignancy of carcinoma of the breast appears to diminish with 
 advancing age. Soft carcinoma, observed most frequently in the young, 
 leads to a fatal termination much more rapidly than the hard variety. 
 The local infection progresses more rapidly, and the tumor attains a 
 larger size, in the soft than^in the hard variety. Patients suffering from 
 the soft form of carcinoma of the breast are frequently carried off by 
 some acute chest complication, and the autopsy reveals secondary 
 tumors in the lung and the pleura. Tumors which have undergone 
 colloid degeneration do not result in early regional infection : they 
 pursue a comparatively benign course. 
 
 It is interesting to know what has been gained in the duration of 
 life by operative treatment. Birkett estimates that patients who have 
 been subjected to operative treatment live, on an average, four years, 
 while the duration of life in those not operated on is three and a half 
 years. Sibley, in 78 cases not operated on and in 63 operated on, 
 ascertained that the latter lived one year and nine months longer 
 than the former. Patients operated upon by Paget and Volkmann 
 lived one year and two and a half months longer than those treated 
 upon an expectant plan. According to Winiwarter, patients not ope- 
 rated on live 32.9 months, and those operated on 39.3 months. A 
 certain percentage of those patients subjected to operative treatment 
 remain free from a recurrence. Winiwarter ascertained that most of 
 the relapses — that is, 82.4 per cent. — occur within three months after 
 the operation. Relapses, however, may occur as late as ten years after 
 operation. The extensive statistics of Winiwarter, Billroth, Oldekop, 
 Esmarch, Henry, Breslau, Fischer, and Dennis show conclusively that 
 operations undertaken before axillary infection has taken place yield 
 the best results. Since surgeons have made it a rule to clear out the 
 axilla in every case of carcinoma of the breast the results are becoming 
 better. Dennis secured a permanent result in 25 per cent, of his cases. 
 The average percentage of cases in which no recurrence takes place in 
 the hands of other operators is, however, much less. The mortality 
 of the operation under the influence of antiseptic measures has been 
 reduced to from 5 to 7 per cent. The writer is confident that when the 
 
CARCINOMA. 317 
 
 public has become educated in reference to the necessity of early 
 operations, and the profession recognizes the importance of carrying 
 the incisions far beyond the palpable tumor and the infected glands, 
 the percentage of permanent recoveries will be increased greatly, and 
 the mortality of the operation, by a strict adherence to aseptic meas- 
 ures, will become reduced to I or 2 per cent 
 
 Treatment. — The palliative measures in inoperable cases of carci- 
 noma consist of such measures and palliative operations as have been 
 described under the head of Palliative Treatment of Carcinoma. The 
 contraindications to a radical operation are : Extreme old age ; meta- 
 static tumors ; local or regional extension of the disease beyond the 
 limits of a justifiable radical operation ; the coexistence of other dis- 
 eases which would in themselves tend to destroy life in a short time. 
 It is useless to emphasize what is now insisted upon by all practical 
 surgeons — that a radical operation should be performed before regional 
 infection has taken place. A radical operation should be performed as 
 soon as a diagnosis has been made. The diagnosis should be made 
 positive either before or at the time of operation. Upon the differential 
 diagnosis between adenoma and carcinoma depends the thoroughness of 
 the operation. An adenoma is removed by enucleation ; a carcinoma 
 demands the removal of the entire breast. The removal of the entire 
 mammary gland for adenoma is unwarranted ; the removal of a carci- 
 noma of the breast without removing the entire organ is almost sure 
 to be followed by an early recurrence. If an unequivocal diagnosis of 
 carcinoma is made, it is not only necessary to remove the entire breast, 
 but all the connective and adipose tissue and lymphatic glands from 
 the margin of the breast to the very apex of the axilla should be 
 removed with the breast. The extent of a radical operation is reached 
 by removing at the same time such parts of the pectoral muscles and 
 the latissimus dorsi as may be deemed necessary. The removal of the 
 entire upper extremity, as suggested by McGraw, and the resection of 
 numerous ribs when the tumor has invaded the chest-wall, are beyond 
 the limits of prudent surgery. 
 
 The field of operation should be prepared the evening before the 
 operation by scrubbing with warm water and potash soap, shaving, and 
 the energetic use of a 1 : 1000 solution of corrosive sublimate. The 
 use of alcohol or of ether is useful in removing infectious material 
 from the appendages of the skin. A compress of aseptic gauze wrung 
 out of the sublimate solution should be applied, the moisture being- 
 retained by applying over the compress an impermeable fabric like 
 gutta-percha paper, mackintosh, or oiled silk. The hands of the 
 operator and his assistants are carefully disinfected, and the instru- 
 
3i8 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 ments, ligatures, and sutures are sterilized by boiling for ten minutes 
 in a I per cent, solution of carbonate of soda. No antiseptics are to 
 be brought in contact with the wound. Gauze sponges should take 
 the place of marine sponges. The chest of the patient should be 
 raised slightly during the operation, and the body should be inclined 
 toward the opposite side. 
 
 Unless the position of the tumor furnishes a contraindication, the 
 incision should be made in such a manner as to include with the nipple 
 an elliptical piece of skin, and should be carried along the border of 
 the pectoralis major to the apex of the axilla (Fig. 198). The necessity 
 of removal of an extensive area of skin was strongly emphasized by S. 
 W. Gross. He made a circular incision around the breast and made 
 no attempt to close the wound. This course should be pursued if the 
 overlying skin is extensively involved, but if sufficient healthy skin 
 remains, it is better to preserve enough to cover the wound. The 
 hemorrhage which freely follows immediately the incision is made 
 should be controlled by pressure — a duty incumbent upon the assist- 
 
 — Incision for carcinoma of the breast (after Esmarch). 
 
 ant. The spurting arteries are then secured with compression-forceps, 
 which must be relied upon as a hemostatic until the tumor and the 
 axillary contents are removed, when every bleeding point is carefully 
 tied with aseptic catgut. The breast with the pectoral fascia should 
 be dissected out first, but should be allowed to remain in connection 
 with the axillary glands. The large wound-surface is now covered 
 with a compress of gauze during the dissection of the axillary space. 
 If the carcinoma has extended beyond the capsule of the gland at its 
 base, parts of the pectoralis major and minor and the serratus magnus 
 and latissimus dorsi muscles may require removal ; but such extensive 
 
CARCINOMA. 
 
 3 J 9 
 
 
 excision of muscular tissue as has recently been advocated by Halsted 
 appears superfluous to the writer. 
 
 The guide to the axilla is the border of the pectoralis major in front 
 and the latissimus dorsi behind. It is advisable to approach the axilla 
 from the front. The skin, the superficial fascia, and the panniculus 
 adiposus are reflected on each side sufficiently to expose the border 
 of both these muscles. After clearing the border of the pectoralis 
 major the space between this muscle and the pectoralis minor is 
 inspected carefully, as a chain of enlarged lymphatics is frequently 
 found in this locality. If the entire chain of glands can be removed 
 by retracting the great pectoral muscle, this part of the operation is 
 completed. If this cannot be done, the pectoral muscle is divided 
 transversely as far as necessary, and after clearing out the axilla it is 
 sutured with a row of buried catgut stitches. 
 
 Fig. 199. — Dissection of the axillary space in operation for carcinoma of the breast (after Esmarch). 
 
 The next thing to be done is to clear the border of the lesser pec- 
 toralis muscle, which at the same time serves as a guide to the axillary 
 vessels, which are the next landmarks to be sought for. The axillary 
 vein can usually be found without any particular difficulty by making 
 a blunt dissection with the finger, with Kocher's director, or with blunt- 
 pointed scissors. Before anything is done in the apex of the axillary 
 space the large vessels must be well exposed to avoid unintentional injury, 
 which is unlikely to occur if the vessels are exposed and are followed 
 
320 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 with tlie requisite care. The space in front of the axillary vessels is 
 next cleared out; and it is here that the chain of glands must often be 
 followed and removed as far as the upper border of the first rib. This 
 part of the operation must be done slowly and carefully. Rupture of 
 glands by pressure or by traction must be avoided. The dissection 
 here must be made with the aid of blunt instruments. A number 
 of small veins emptying into the axillary vein from below should 
 be tied close to the axillary before being cut. Glands are often 
 found attached to the vein, and their separation without injury to the 
 vein requires patience and careful work (Fig. 199). If the vein is 
 incorporated in a mass of carcinomatous glands and cannot be isolated, 
 the part connected with the tumor should be removed between two 
 catgut ligatures. This alternative, fortunately, does not present itself 
 frequently, and resection of the vein must be avoided whenever 
 possible. Small wounds of the axillary veins can safely be closed by 
 lateral ligatures or by suturing, thus preserving the lumen of the 
 vessel. 
 
 The space behind the axillary vessels, which next claims the atten- 
 tion of the surgeon, is cleared out in the same careful manner as the 
 anterior space. When this has been done the dissection is continued 
 in a downward direction. All spurting points are secured by hemo- 
 static forceps. The preservation of the coraco-brachialis and of other 
 smaller nerves traversing the axillary space, as recommended by 
 Kuster, is practised only when the regional infection is slight. In the 
 majority of cases it is better to excise them with the axillary contents 
 than to run the risk of making an incomplete operation by preserving 
 them. 
 
 The removal of the string of glands in the direction of the sub- 
 scapular artery often necessitates ligation of this vessel and its accom- 
 panying vein. If the disease is at all extensive, a considerable portion 
 of the serratus magnus muscle must be removed. The tumor, the adja- 
 cent tissues, and the axillary contents are to be removed in one continuous 
 mass. All attempts at enucleation of infected glands will surely be fol- 
 lowed by a speedy recurrence. Crushing or teasing of carcijiomatous 
 glands will be followed by traumatic dissemination of the carcinoma. 
 As soon as the tumor and the axillary contents have been removed all 
 bleeding points must be ligated. Careful hemostasis is an essential pre- 
 requisite to an ideal wound-healing. 
 
 The wound inflicted by an operation of this extent is a very large 
 one, and considerable parenchymatous oozing will occur after the patient 
 rallies from the immediate effects of the operation and the anesthetic. 
 If the wound is sutured throughout, accumulation of a considerable 
 
CARCINOMA. 
 
 Plate 7. 
 
CARCINOMA. 321 
 
 quantity of blood and serum is almost sure to follow, often giving 
 rise to painful tension, necessitating an early change of the dressing, 
 the removal of one or more sutures, and the insertion of secondary 
 sutures. 
 
 Ordinary tubular drainage is very unsatisfactory in preventing the 
 accumulation of blood in the wound. The lumen of the tube becomes 
 blocked by a blood-clot, and the fluid that escapes is at the sides, and 
 not through the tube. Bergmann overcame these difficulties by pack- 
 ing the wound with iodoform gauze, which he removes on the second 
 or third day, then closing the wound by secondary sutures. He and 
 others have obtained excellent results by this treatment. The sutures 
 can be inserted at the completion of the operation, but they are not 
 tied until the gauze tampon is removed. In hospital practice this 
 method of wound-treatment yields excellent results and is not attended 
 by any additional risks of infection, but in general practice it is better 
 to suture the wound and to drain with iodoform gauze. A strip of 
 gauze folded upon itself several times should extend from the apex of 
 the axilla to the most dependent part of the wound, where it is brought 
 out through a separate incision about two inches in length. The wound 
 is then sutured throughout. On the second or the third day the gauze 
 drain is removed. In closing the wound the deep sutures of silk or of 
 silkworm-gut are placed about an inch apart, and over them the skin is 
 united accurately with a continued suture of fine catgut (PL 7, Fig. 1). 
 After washing the surface with a solution of corrosive sublimate or of 
 carbolic acid and drying it carefully, a copious antiseptic hygroscopic 
 dressing should be applied. The line of suturing is dusted with a 
 powder of iodoform and boric acid (1:5) until the sutures are buried 
 under the powder. Eight layers of iodoform gauze are applied next to 
 the wound, and over the iodoform gauze a large thick compress of 
 sterilized gauze. Absorbent cotton is used as a filter over and around 
 the gauze, including also the shoulder. The dressing is retained by 
 a wide roller composed of several layers of gauze, and the arm is 
 confined to the side of the chest with the same roller bandage (PL 7, 
 Fig. 2). 
 
 The first dressing should not be changed for two or three days, 
 when the gauze drain is to be removed, unless copious oozing saturates 
 the dressing. When the outer dressing becomes simply stained at the 
 end of the first twelve or twenty-four hours, the part stained should be 
 dusted with iodoform and be covered with a thick compress of absorb- 
 ent cotton retained by an additional bandage. 
 
 The deep sutures are removed at the end of eight or ten days. At 
 
 this time only the superficial part of the catgut suture remains. If, not- 
 21 
 
322 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 withstanding the strictest antiseptic precautions, infection has occurred, 
 as will be indicated by a rise in the temperature on the second or the 
 third day, no time should be lost in removing the dressing and some if 
 not all of the sutures, and in establishing additional points of drainage. 
 Antiseptic irrigation frequently repeated, and a compress kept moist 
 with a saturated solution of acetate of aluminum, will then constitute 
 the most important measures in the after-treatment. 
 
 If after the completion of the operation the wound cannot be su- 
 tured, the margins should be brought as close together as possible 
 with tension-sutures, and the remaining surface should be paved with 
 Thiersch's grafts. The results of skin-grafting performed under such 
 circumstances are very encouraging. Skin-grafting enables the surgeon 
 to secure primary healing of the wound under one or two dressings — a 
 great gain in the management of such cases. 
 
 In a case recently under his care the writer resorted successfully 
 to a plastic operation to remedy the resulting defect. The breast 
 and skin on the opposite side were undermined, and with a flap 
 (Fig. 200) taken from the abdomen the wound was readily closed. 
 
 Fig. 200. Fig. 201. 
 
 Figs. 200, 201. — Plastic operation after excision of carcinoma of the breast. 
 
 The opposite breast was mobilized so that it occupied a position 
 near the sternum (Fig. 201). With the exception of a slight mar- 
 ginal necrosis the flap survived, and the wound healed by primary 
 intention. 
 
 After every operation for carcinoma of the breast it is important that 
 the surgeon or the family physician should examine the patient every 
 
CARCINOMA. 3 2 3 
 
 two or three months to determine whether or not a local recurrence 
 has taken place. It is not a good policy to leave this matter to the 
 patient or to her friends. The patient should know as little as pos- 
 sible about the object of these examinations. The first nodule that is 
 discovered should be removed at once. This removal can usually be 
 done with the aid of a local anesthetic. Every local recurrence should 
 be met promptly by a thorough removal. The writer has repeatedly 
 performed three and four operations for slight recurrence in the same 
 patient, and has been able in this way to postpone the fatal termination, 
 and in a few instances has gained complete control over the disease. 
 
 CEsophagns. — Carcinoma of the alimentary canal below the soft 
 palate is composed of tissue derived from the hypoblast. The prevail- 
 ing type of the epithelial cells of the tumor is the columnar. The 
 pharynx is very seldom affected by carcinoma. The oesophagus, on 
 the contrary, is quite frequently the seat of carcinoma. About half 
 of the cases occur in the lower third, about one-third in the middle 
 third, and the balance higher up. Mackenzie's observations led him 
 to formulate different conclusions in reference to the part of the oesoph- 
 agus most frequently affected. He based his statistics on ioo cases. 
 Of these, 44 involved the upper third, 28 the middle third, and 22 the 
 lower third. As Mackenzie was a throat specialist, it is to be expected 
 that he was consulted more frequently by patients who suffered from 
 carcinoma of the upper part of the oesophagus, which would explain 
 the discrepancy existing between the statistics gathered by the general 
 surgeon and those quoted by specialists in reference to the favorite seat 
 of carcinoma of the oesophagus. All surgeons agree in the statement 
 that cicatricial stenosis affects more frequently the upper, and carcinoma 
 the lower, part of the oesophagus. 
 
 Carcinoma of the oesophagus appears in two different pathological 
 forms : (1) the soft variety, which leads to early ulceration and perfora- 
 tion ; (2) the hard form, which results in the formation of a circular strict- 
 ure. The circular stricture seldom involves more than an inch of the 
 oesophageal tube. Not infrequently perforation into the trachea, the pos- 
 terior mediastinum, or the pleura takes place. The writer saw in Von 
 Ziemssen's clinic a case which was frequently presented before the class 
 to demonstrate the existence of a communication between the oesoph- 
 agus and the trachea. A few moments after the patient drank a few 
 tablespoonfuls of milk he was attacked by a violent fit of coughing 
 which did not cease until the milk he had swallowed was expectorated. 
 The post-mortem showed a carcinoma of the oesophagus that had per- 
 forated into the trachea. In some instances a fatal termination takes 
 place from hemorrhage by perforation of the carcinoma into one of 
 
324 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the large blood-vessels. In some cases the disease results in death 
 without having produced any symptoms of obstruction. In the major- 
 ity of cases, however, the first thing that attracts the patient's attention 
 is that he is not able to swallow solid food. This difficulty gradually 
 increases until only liquids can be swallowed, and finally the obstruction 
 becomes complete. The food that is swallowed is not ejected imme- 
 diately, a variable interval elapsing until the food is regurgitated. One 
 of the results of the obstruction is a dilatation of the oesophagus above 
 the stricture ; in cases of long-standing circular stricture the oesophagus 
 becomes dilated into a large pouch holding a teacupful or more. The 
 food is not vomited, but is regurgitated, and is ejected unchanged. As 
 soon as the tumor interferes with deglutition marasmus very rapidly 
 sets in, and death follows in a few weeks. Pain in the region of the 
 tumor is slight or is entirely absent. 
 
 In the differential diagnosis between cicatricial stenosis and carci- 
 noma of the oesophagus it is necessary in the first place to inquire care- 
 fully into the history of the case. Cicatricial stenosis usually develops 
 after destruction of the mucous membrane by the swallowing of lye or 
 of other caustic — an accident which occurs more frequently in children 
 than in adults. Cicatricial stenosis occurs most frequently in children 
 and young adults ; carcinoma of the oesophagus is seldom met with in 
 persons less than fifty years of age. A gradually increasing stenosis 
 of the oesophagus in persons advanced in life, in whom the clinical history 
 does not reveal the existence of the usual causes of cicatricial stricture, is 
 with very few exceptions indeed caused by a carcinoma. The existence 
 of the obstruction must be demonstrated by the use of the olive-pointed 
 oesophageal bougie. The largest size is to be used first to determine the 
 seat, and then the smaller points to ascertain the extent, of the stricture. 
 No force must be used in passing the instrument through the stricture. 
 Disregard of this advice has repeatedly resulted in perforation of the 
 oesophagus and death from immediate and remote complications caused 
 by this accident. The writer has personal knowledge of two such cases : 
 in one the perforation was followed by fatal hemorrhage, in the other 
 by septic peritonitis. Dilatation of a carcinomatous stricture is contra- 
 indicated, as it not only aggravates the local conditions, but is also 
 attended by the risk of perforation. The use of elastic tubes is not 
 attended by the danger of perforation, and if the stricture is permeable 
 they are used to introduce into the stomach liquids and finely-divided 
 food suspended in liquids. A small rubber tube inserted into the 
 stomach from one of the nostrils can be retained and used for stomach- 
 feeding. As soon as stomach-feeding is impossible even with the aid 
 of elastic oesophageal tubes, a gastrostomy should be performed. This 
 
CARCINOMA. 
 
 Plate 8. 
 
 Witzel's method of performing gastrostomy. 2. Witzel's operation, showing tube buried by sutures. 
 
CARCINOMA. 325 
 
 operation should not be postponed too long. As a rule, patients are 
 loath to accept this the last alternative to prolong their lives, and con- 
 sequently frequently postpone the operation until it is too late. 
 
 Gastrostomy. — Fenger's incision has been rendered obsolete by the 
 many recent improved methods of establishing an external gastric fistula 
 in cases of oesophageal obstruction. The operation that has found more 
 favor with the profession than any other is Witzel's (PI. 8, Figs. 1, 2). 
 One of the great difficulties to overcome in gastric feeding through an 
 external fistula was the escape of food through the fistula after its intro- 
 duction into the stomach. Witzel devised an operation that appears to 
 answer all requirements better than any other. The abdomen is opened, 
 under strict antiseptic precautions, through the left rectus muscle, a 
 little to the left of the median line and a little below the tip of the 
 xiphoid cartilage. The stomach is identified, and its anterior wall is 
 brought well forward into the wound. A compress of gauze is packed 
 around the projecting part of the stomach, and in its anterior wall there 
 is made an opening large enough to insert a rubber tube a little larger 
 than an ordinary lead pencil. The tube, about 6 inches in length, is 
 then so inserted that its end projects well beyond the mucous surface 
 of the stomach. There is then made in the anterior wall of the stomach 
 a vertical groove deep enough to receive the rubber tube, when the 
 serous surfaces are stitched together over and below the tube, so as 
 to prevent the escape of fluid from the opening in the stomach into the 
 peritoneal cavity. The tube is buried in this manner to the extent of 
 two inches, when the stomach is fastened by stitches in the upper angle 
 of the incision, and the balance of the wound is closed by suturing. 
 
 Mikulicz modified Witzel's operation by stitching the anterior wall 
 of the stomach around the sutures over the tube to each side of the 
 external incision before closing the wound up to the fistulous opening. 
 This should invariably be done, as it affords an additional safeguard 
 against the escape of stomach-contents into the peritoneal cavity. 
 
 If the patient is very much debilitated, stimulants and liquid food 
 may be introduced at once into the stomach through the rubber tube. 
 The distal end of the tube after feeding is either tied or compressed by 
 a suitable clamp. The fistula established in this manner is oblique, and 
 the internal opening is closed by a valve-like action of the upper part, 
 which, even when the tube is removed, effectually prevents the escape 
 of stomach-contents. Witzel recommends that after a few weeks the 
 rubber tube be removed, and be inserted only when the patient feeds 
 himself. The patient should masticate and insalivate the solid food 
 before he pours or injects it into the stomach. The great mortality 
 which has attended this operation so far is due to the fact that in the 
 
326 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 majority of cases in which death resulted from the operation the patients 
 had postponed it too long. If this operation is to prolong life, it must 
 be performed in time, before the patient's strength has been reduced to 
 the lowest ebb. 
 
 Stomach. — Carcinoma of the stomach, which is by no means a 
 rare affection, occurs most frequently in persons from thirty to sixty 
 years of age. Sutton refers to a case in which the patient, a girl, was 
 only thirteen years old. The youngest patient that has come under 
 the writer's observation suffering from this disease was a man twenty- 
 five years old. The pylorus is the part of the stomach most frequently 
 implicated. Lebert found the disease here in 5 1 per cent, of the cases 
 he examined, and Brinton, Gussenbauer, and Winiwarter have shown 
 that the proportion of cases in which the pylorus is affected is still 
 greater : they estimate it at 60 per cent. As all parts of the mucous 
 membrane of the stomach are freely supplied with tubular glands, the 
 histological structure of carcinoma of the stomach mimics tubular 
 glands. Sections from new parts of the tumor show under the micro- 
 scope a tubular structure (see Fig. 140). 
 
 The character of the structure of the tumor is determined by the 
 relative amount of epithelial cells to the stroma. If the parenchyma 
 of the tumor largely preponderates over the stroma, the tumor grows 
 rapidly, ulcerates early, and soon implicates the entire thickness of the 
 wall of the stomach. These are the cases in which hemorrhage or per- 
 foration frequently terminates life at an early stage. In the hard variety 
 of carcinoma of the stomach, found most frequently at the pyloric end, 
 the tissues become infiltrated slowly and to a limited extent. The 
 circumference of the entire pylorus becomes implicated in the form of 
 a ring-like, circular induration. The connective-tissue stroma contracts, 
 and the lumen of the pylorus is progressively narrowed until finally it 
 becomes impermeable to the passage of food from the stomach into 
 the duodenum. In other cases the disease infiltrates the wall of the 
 stomach very extensively, but no contraction of the stroma takes place. 
 These are the cases in which during life, although the pylorus may 
 show extensive disease, symptoms of obstruction do not occur. In 
 carcinoma of the cardiac end of the stomach a circular carcinomatous 
 stricture presents the same clinical evidences as carcinoma of the 
 oesophagus, and requires the same treatment. In carcinoma of the 
 stomach located between the cardiac and pyloric ends the symptoms 
 are often very vague. Vomiting at irregular periods after meals, 
 hematemesis, indigestion, progressive marasmus, and in some cases 
 a palpable tumor, suggest the existence of a malignant tumor in this 
 part of the stomach. Circular constricting carcinoma of the stomach 
 
CARCINOMA. 3V 
 
 gives rise to a clinical picture that is almost typical. Vomiting of 
 unchanged or partly-digested food in from two to four hours after 
 meals, attended by a sense of relief, gradual dilatation of the stomach, 
 in advanced cases reaching as far as the pubes, and progressive emacia- 
 tion, characterize the case. If the carcinoma appears in the form of 
 a narrow constricting ring, it is often impossible to recognize the tumor 
 by external palpation. If the tumor attains larger dimensions, it can 
 be felt usually a little below the level of the normal pylorus, espe- 
 cially after the stomach has been emptied of its contents by the use of 
 the elastic stomach-tube. Hemorrhage is sometimes profuse, and even 
 fatal if a large vessel, such as the pyloric branch of the hepatic artery, 
 has been eroded by the carcinoma. In pyloric obstruction the retention 
 of food leads to fermentation, which aggravates existing indigestion and 
 ends in causing dilatation of the organ. 
 
 The only disease which is likely to be mistaken for pyloric carci- 
 noma is cicatricial stenosis of the pylorus. Cicatricial stenosis is the 
 result of the healing of an antecedent ulcer in this locality, and the 
 condition occurs, as a rule, in younger persons than does carcinoma. 
 This form of obstruction is found more frequently in the female than 
 in the male. The absence of a palpable tumor should not influence 
 us in deciding in favor of the existence of a cicatricial stenosis, as fre- 
 quently no tumor can be detected externally in cases of circular con- 
 stricting carcinoma of the pylorus. Free muriatic acid is frequently 
 absent in carcinoma of the stomach, but this circumstance is no unfail- 
 ing test for malignant disease, as this acid may be absent in obstruction 
 caused by non-malignant disease, and may be present during the early 
 stage of carcinoma. The occurrence of vomiting in from one to three 
 hours after meals in persons more than fifty years of age should excite 
 suspicion of carcinoma. If the vomited material is mixed with 
 grumous blood, presenting the appearance of coffee-grounds, if the 
 vomiting is followed by a sense of great relief, and if the symptoms 
 do not yield within a short time to the usual treatment, it is very proba- 
 ble that the patient is suffering from carcinoma of the stomach, although 
 no palpable tumor may be present. 
 
 Inflation of the stomach after evacuating the organ by the use of 
 the stomach-tube is the most reliable and safest way by which to deter- 
 mine the presence and extent of dilatation. The area of tympanites 
 will at least approximately correspond with the size of the stomach. 
 If the large curvature of the stomach reaches the umbilicus, the organ 
 has become dilated. During the examination for a tumor of the 
 stomach the patient should be placed in the dorsal recumbent position 
 with the chest elevated and the legs and thighs flexed. Succussion 
 
328 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 after the introduction of a small quantity of fluid into the stomach 
 suggests very strongly the existence of dilatation (Bouchard). 
 
 Carcinoma of the stomach, with few exceptions, proves fatal within 
 a year. Perforation into adjacent viscera, duodenum, and transverse 
 colon may prolong life by creating a new outlet for the stomach-con- 
 tents into the intestinal canal. If perforation into the free peritoneal 
 cavity takes place, death from peritonitis usually ensues. Death from 
 recurring hemorrhages follows the erosion of an artery of considerable 
 size. In most instances of carcinoma of the pylorus the immediate 
 cause of death is inanition resulting from the suspension of digestion 
 caused by mechanical obstruction. 
 
 Metastasis occurs in connection with carcinoma of the stomach. 
 When the carcinoma reaches and involves the peritoneal coat of the 
 stomach, regional dissemination often takes place by the dispersion of 
 carcinoma-cells or fragments of tissue over the adjacent serous surfaces. 
 In this way the great omentum often becomes extensively infected. 
 The lymphatic glands in the gastro-hepatic omentum are infected in 
 more than two-thirds of the cases. The lumbar, cervical, and medias- 
 tinal lymphatic glands are occasionally the seat of regional infection. 
 
 Treatment. — Careful attention to the diet and the use of the siphon 
 stomach-tube in the cases in which dilatation from pyloric obstruction 
 has taken place are to be relied upon in the conservative treatment of 
 carcinoma of the stomach. The internal administration of salol and 
 bismuth affords relief when the obstruction has given rise to catarrhal 
 inflammation of the gastric mucous membrane. The observation that 
 carcinoma of the pyloric orifice of the stomach is frequently very limited 
 in extent, and that patients succumb not so much to the malignant dis- 
 ease as to the effects caused by the mechanical obstruction, has induced 
 surgeons to desist from operations for the removal of the carcinomatous 
 pylorus. 
 
 Pylorectomy. — The first experimental pylorectomies on dogs were 
 made in 1810 by Merem. Parts of the stomach were removed for 
 other indications than carcinoma by Torelli and Esmarch. Accurate 
 experimental investigations concerning the feasibility of pylorectomy 
 for carcinoma were made by Gussenbauer, Winiwarter, and Kaiser. 
 The pylorus was removed for the first time for disease by Pean. 
 Billroth made the first successful pylorectomy. The success of the 
 operation has not been what was expected from it. In 66 cases death 
 occurred soon after the operation in 50. Only in a few cases was life 
 prolonged for any considerable length of time. One of Wolfler's cases 
 lived three and a half years after the operation. That the operation has 
 not yielded better results is due to the fact that the local extension of 
 
CARCINOMA. 
 
 329 
 
 the tumor and the regional infection were such as to require very exten- 
 sive operations, to the immediate effects of which many of the patients 
 succumbed ; and for the same reasons, in those that survived the imme- 
 diate effects of the operation the disease returned soon afterward. In 
 the fifteen cases of abdominal section made by the writer for carcinoma 
 of the stomach the disease was found too extensive and regional infec- 
 tion too diffuse to warrant pylorectomy in all the cases but one, and in 
 this one the circular carcinomatous stricture of the pylorus had resulted 
 in such great impairment of the strength of the patient as to preclude 
 the advisability of resorting to a pylorectomy. 
 
 Surgeons have gone too far in the radical treatment of carcinoma 
 of the pylorus. In the writer's estimation the operation is warranted 
 only if the disease remains limited to the organ primarily affected, and 
 if the patient is strong enough to resist the immediate effects of the 
 operation. The stomach is washed out immediately before the opera- 
 tion. If the organ is thoroughly emptied before the operation, there is 
 hardly any need for the different mechanical devices (Fig. 202, A, b, c, d) 
 
 Fig. 202. — Intestinal and stomach clamps : a, after Rydygier ; b, after Billroth ; c, after Hahn 
 
 Heineke. 
 
 after 
 
 which have been employed for the purpose of preventing the escape 
 of duodenal and stomach-contents. Catch-forceps of special construc- 
 tion (Figs. 203, 204) have also been employed for the same purpose. 
 For the prevention of the escape of intestinal contents nothing equals 
 in efficiency and ease of application the elastic constrictor. A small 
 rubber tube about a foot in length is drawn through a buttonhole made 
 
33° 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 with a pair of hemostatic forceps in the mesentery near its attachment 
 to the bowel. This tube is tied with sufficient firmness to prevent the 
 escape of intestinal contents. It is not in the way of the operator, and 
 it is less likely to inflict unintentional injury to the bowel or the adjacent 
 
 Fig. 
 
 -Intestinal forceps (after Gussenbauer). 
 
 Fig. 204.— Intestinal forceps (after Kiister). 
 
 parts than the different kinds of clamps or forceps. Sterilized gauze 
 should be packed around and on the sides of the part to be resected, 
 to absorb any fluid that might escape during the operation. 
 
 Fig. 205. — Resection of the pylorus after Billroth-Wolner : 1, location and direction of visceral incisions; 
 2, suturing: a, occlusion-sutures ; b, circular sutures. 
 
 The abdomen is usually opened in the median line, below the tip 
 of the xiphoid cartilage, far enough to secure free access to the pylorus. 
 Billroth prefers an oblique incision below and parallel to the right 
 costal arch. The mesenteric attachment of the part to be resected 
 
CARCINOMA. 
 
 33* 
 
 should be tied in small sections with fine braided silk. The lumen of 
 the stomach is made to correspond with the oblique section of the 
 duodenum by closing a part by Czerny-Lembert sutures before it is 
 joined with the duodenum. The junction between duodenum and 
 stomach is made with the same kind of sutures. The suturing is done 
 in steps as the excision wound is enlarged. This method affords a 
 better opportunity to coaptate the parts properly, and is attended by 
 less hemorrhage, than if the excision were made at once. 
 
 Rydygier diminishes the size of the opening in the stomach from 
 the larger instead of from the smaller curvature of the stomach (Fig. 
 
 Fig. 206. — Resection of the pylorus (after Rydygier) : a, location and direction of incisions ; b, sutures. 
 
 206, b). Canalization difficulties are less likely to follow the operation 
 if the duodenum is united with the greater curvature of the stomach 
 according to the Billroth-Wolfler op- 
 eration than when it is attached to 
 the lesser curvature, as recommended 
 by Rydygier. The difficulties expe- 
 rienced in uniting the duodenum with 
 the stomach when a large part of this 
 organ has to be removed have led 
 Billroth to combine pylorectomy with 
 gastro-enterostomy in the operative 
 removal of large carcinomatous tu- 
 mors of the pyloric portion of the 
 stomach (Fig. 207). The resected 
 ends of the stomach and duodenum 
 are closed by a double row of su- 
 tures, and a communication is established between the anterior wall 
 of the stomach and the lower part of the duodenum or the upper part 
 of the jejunum by making in each of these organs a longitudinal slit 
 at least two inches in length and uniting them by Czerny-Lembert 
 sutures. Tuholsky of St. Louis is an ardent advocate of this operation, 
 but he advises that it should be done a deux temps. 
 
 Fig. 207. — Resection of the pylorus with gastro- 
 enterostomy (after Billroth). 
 
332 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Gastroenterostomy . — The limited success of pylorectomy induced 
 Wolfler to devise an operation for the relief of patients suffering from 
 pyloric carcinoma too far advanced for a radical operation. This opera- 
 tion is called gastro-enterostomy, and consists in establishing between 
 the stomach and the upper part of the intestinal canal a communica- 
 tion, thus excluding permanently from the gastro-intestinal canal the 
 affected part. The stomach is prepared for the operation in the same 
 manner as for pylorectomy. It is advisable to wash out the stomach 
 daily at least for two days before the operation, and to nourish the 
 patient during this time exclusively by rectal feeding. The intestinal 
 canal should be cleared of its contents by a mild laxative or a high 
 rectal enema. In one instance the writer performed this operation 
 without an anesthetic. The only pain which the patient complained of 
 was produced by making the external incision. The handling of the 
 stomach and the intestines, the visceral incisions, and the suturing 
 appeared to cause little or no pain. 
 
 If no contraindications exist, chloroform should be used in perform- 
 ing this as well as other operations on the gastro-intestinal canal, in 
 preference to ether, as the use of chloroform is attended and followed 
 by less retching and vomiting than is the case when ether is used. 
 The abdomen is opened by a straight incision in the median line ex- 
 tending from the xiphoid cartilage to the umbilicus. The upper part 
 of the intestinal tract, at a point about twelve inches below the pyloric 
 orifice of the stomach, is brought forward into the wound with the 
 anterior wall of the stomach. 
 
 Fig. 208.— Formation of valve to prevent entrance of Fig. 209.— Implantation of duodenum into jejunum 
 stomach-contents into duodenum (after Wolfler). and jejunum into stomach (after Wolfler). 
 
 Gastro- enterostomy after Wolfler. — Wolfler intended to prevent the 
 entrance of bile into the stomach, and of stomach-contents into the 
 duodenum, by forming a valve by uniting the right half of the opening 
 in the bowel with the intact stomach-wall, and only the left half with 
 the margin of the opening in the stomach (Fig. 208). The same object 
 
CARCINOMA. 
 
 333 
 
 FiG."2io. — Gastro-enterostomy (after Liicke). 
 
 is attained if the bowel is completely divided at the junction of the 
 duodenum with the jejunum, and the proximal end is implanted into 
 the jejunum and the jejunum into an 
 opening in the anterior wall of the stom- 
 ach, as shown in Figure 209. Liicke 
 reversed the position of the bowel as 
 recommended by Rockwitz, in order to 
 bring the peristaltic action of the intes- 
 tine in accord with the movements of 
 the stomach (Fig. 210). 
 
 In making the communication be- 
 tween the stomach and the intestines 
 large enough, some allowance must be 
 made for cicatricial contraction of the 
 opening. The visceral incision should be at least two inches in length. 
 The stomach and the bowel should be united behind by sero-muscular 
 sutures before the visceral incisions are made, as recommended by 
 Lauenstein. After the incisions have been made the deep sutures are 
 applied all around, when the incision is completed by a row of super- 
 ficial sutures in front and on the sides. 
 
 Gastro-enterostomy after Senn. — The writer has made fifteen gastro- 
 enterostomies by substituting in part for the sutures plates of decal- 
 cified bone with a central perforation at least two inches in length and 
 three-quarters of an inch wide. The intestine is brought into the 
 Rockwitz position and is united with the stomach behind by a row of 
 sero-muscular sutures. An incision two inches 
 in length is made in the stomach and the duo- 
 denum ; the plates are then inserted, and are 
 brought into proper position by making trac- 
 tion on the fixation-sutures ; the lateral sutures, 
 armed with needles, are now passed through 
 all the tissues except the peritoneum, and 
 the terminal sutures are brought out at the 
 angles of the visceral wounds. An assistant 
 coaptates the wounds, and the lower fixation- 
 suture is tied with sufficient firmness to bring 
 the parts in apposition without endangering 
 their blood-supply by strangulation ; next the terminal sutures are tied, 
 and finally the superficial fixation-sutures. Before tying the last suture 
 the margins of the wound must be carefully brought well between the 
 plates to prevent eversion. All the sutures are cut close to the knot. 
 The union is completed by stitching the serous surfaces over the 
 
 FiG.21 
 
 . — Moist perforated decal- 
 cified bone-plate. 
 
334 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 anterior margins of the plates, thus completing the ring of superficial 
 sutures (Fig. 212). 
 
 The results following the use of the bone plates in performing 
 gastro-enterostomy for carcinoma have been most encouraging. The 
 
 Ensiform process 
 
 riculus. 
 
 Ascending- colon. X 
 
 'icus._$BFjf . 
 
 Ileum 
 
 Ws Jejunum. 
 
 k 
 
 FlG. 212. — Method of performing gastro-enterostomy (illustration after Von Baracz). 
 
 union between the parts interposed between the plates can be hastened 
 by free scarification. Since using plates with a perforation at least two 
 inches in length the writer has seen no ill results from cicatricial con- 
 traction. In one case of pyloric carcinoma in a man thirty years of 
 age, the patient, who was brought to the hospital on a stretcher, ema- 
 ciated to a skeleton, gained sixty-five pounds in weight after operation, 
 resumed his occupation, that of a butcher, worked for a year and 
 a half, and then gradually sunk from the effects of the carcinoma. In 
 another case, that of a man seventy years of age, emaciated to an 
 extreme degree, the patient recovered sufficient strength to conduct 
 his business for over a year after the operation. In a number of 
 
CARCINOMA. 
 
 335 
 
 instances the patients lived for three, four, and eight months in comfort 
 and ease — a sufficient recompense for the risk assumed in subjecting 
 themselves to a gastroenterostomy. In the majority of cases of 
 pyloric carcinoma the surgeon will have to content himself with making 
 a gastroenterostomy until by improved diagnostic resources we will 
 be able to recognize carcinoma of the stomach early enough to warrant 
 a more frequent recourse to a radical operation by pylorectomy or by 
 partial gastrectomy. 
 
 Intestines. — Carcinoma is more frequent in the lower than in the 
 upper part of the intestines. Of every ioo cases, 75 occur in the rec- 
 tum ; of the remainder, 23 would be localized in the large bowel and 
 2 in the small intestine, including the ilio-cecal valve, and would prob- 
 ably be distributed in the following manner : Small intestine and ilio- 
 cecal valve, 2 ; cecum, 2 ; hepatic flexure of colon, 3 ; splenic flexure 
 of colon, 4; sigmoid flexure, 10; intermediate segments of colon, 4 
 (Sutton). Carcinoma of the intestines represents in its minute struct- 
 ure the glandular appendages of the mucous membrane lining the 
 intestinal canal (Fig. 213). The irregular tubules are lined with cylin- 
 
 
 Fig. 213.— Cylindrical-celled carcinoma of the intestine; X 128 (after Hauser) : above, elongated and 
 distended granular spaces; below, without a sharp border, these tubules terminate in irregular carcinoma- 
 alveoli. The black points indicate cells undergoing karyokinesis. 
 
 drical cells. In the periphery of the tumor the cells which have parted 
 from the parent soil and have escaped through the imperfect membrana 
 
336 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 propria infiltrate the surrounding connective-tissue spaces, and the new 
 cells which they produce arrange themselves again in tubular shape, 
 the pre-existing connective tissue becoming the stroma of that part 
 
 . *■*" ', <**: ' <"-* %~< Hi ' 
 
 
 .,1,;' ■•*& 
 
 '■'■■' .VA ■ 
 
 
 I 
 
 Fig. 214. — Periphery of cylindrical-celled carcinoma of the cecum; X no (Surgical Clinic, Rush 
 Medical College, Chicago): a, rows of carcinoma-cells in connective-tissue spaces; b, intervening con- 
 nective tissue. 
 
 of the tumor. The section represented in Figure 214 was taken from 
 the periphery of a circular constricting carcinoma of the cecum. The 
 tumor had produced intestinal obstruction. 
 
 The parenchyma and the stroma of intestinal carcinoma are very 
 apt to undergo colloid degeneration. Regional and metastatic infection 
 occurs earlier and more constantly than in squamous-celled carcinoma. 
 Carcinoma of the intestines is seldom recognized, or even suspected, 
 before the tumor has produced symptoms of obstruction. Chronic 
 obstruction from this cause is frequently attended by diarrhea, a symp- 
 tom which frequently leads patient and physician into errors in diag- 
 nosis. 
 
 Acute obstruction is caused either by the affected segment of the 
 intestine becoming invaginated or by a suddenly-developed paretic con- 
 dition of the bowel above the seat of obstruction. Great hypertrophy 
 of the muscular coat of the bowel above the obstruction is usually 
 associated with chronic obstruction, and an acute attack is initiated 
 when compensatory hypertrophy no longer keeps pace with the increas- 
 ing mechanical impediment or when the narrowed part of the bowel 
 becomes impermeable by impaction of some foreign substance or of a 
 hardened fecal mass. In cases of acute intestinal obstruction in per- 
 sons advanced in years the existence of a malignant intestinal tumor 
 should be borne in mind. As in the pylorus, carcinoma of the intestine 
 occurs either as a diffuse tumor attaining considerable size or as a cir- 
 cular constriction. The former variety is more liable to ulceration and 
 
CARCINOMA. 337 
 
 perforation ; the latter gives rise to intestinal obstruction. In the con- 
 stricting variety the tumor involves the entire circumference of the 
 bowel, and by constriction of its stroma the lumen of the bowel is 
 gradually reduced in size. The bowel on the distal side becomes 
 much smaller in size, while on the opposite side of the constriction it 
 becomes distended and all its coats are hypertrophied to some distance 
 from the seat of obstruction. The catarrhal inflammation caused by 
 the accumulation of feces and the greatly increased peristaltic action 
 cause the frequent liquid discharges, which are taken only too often by 
 the superficial observer as an indication of the absence of a mechanical 
 obstruction. Chronic intestinal obstruction caused by a carcinoma is 
 attended by intermittent paroxysmal pain which is referred to the region 
 of the umbilicus, irrespective of the anatomical location of the tumor. 
 
 Operative Treatment. — Unless the tumor has given rise to a palpable 
 swelling, the surgeon has seldom an opportunity to perform a radical 
 operation until symptoms of chronic or acute intestinal obstruction 
 set in. In making a laparotomy for intestinal obstruction the surgeon 
 must be prepared to meet with such a condition. A radical operation 
 is indicated if the carcinoma has not passed beyond the limits of the 
 bowel and the patient's strength is adequate to resist the immediate 
 effects of an enterectomy. If the patient has become prostrated from 
 the effects of the intestinal obstruction, it is advisable to resort to the 
 formation of an artificial anus above the obstruction, and to postpone 
 the operation until his strength has been recuperated sufficiently. 
 
 Enterostomy. — If the tumor occupies the ilio-cecal region, a tem- 
 porary artificial anus is established in the right inguinal region by 
 bringing into the wound the first distended knuckle of the small intes- 
 tine that presents itself. The intestine is united with the peritoneum 
 of the external incision, and the bowel is opened by a transverse 
 incision about an inch in length. If the carcinoma is located below 
 the sigmoid flexure, a sigmoidostomy in the left groin is made. These 
 operations are indicated in cases in which £he obstruction is acute and 
 the patient's general condition does not permit of an operation requiring 
 more time. 
 
 Enterectomy. — The removal of a malignant tumor of the intestine 
 requires an enterectomy. The removal of a limited segment of the 
 bowel for malignant disease, if the patient's strength has not been too 
 much exhausted and no regional infection has occurred, is a legitimate 
 procedure, and is often followed by a permanent cure. The operation 
 should not be undertaken if extensive malignant adhesions have formed 
 or if the lymphatic glands have become extensively infected. The 
 bowel on each side of the tumor should be constricted with a piece of 
 22 
 
33% 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 rubber tubing passed through an opening made in the mesentery near 
 its attachment to the bowel (Fig. 215). Before the incisions through 
 
 Fig. 
 
 215. — Separation of mesentery from bowel (after 
 Kocher). 
 
 Fig. 216. — Circular suture and folding of mesen- 
 tery after enterectomy (after Kocher). 
 
 the bowel are made the mesentery should be tied in small sections with 
 fine silk. The bowel sections are made somewhat obliquely at the 
 expense of the convex side, and the ends are at once united with a 
 double row of sutures. The mesentery corresponding with the section 
 of bowel removed should not be excised, but be folded upon itself, and 
 the ligatured margin should be sutured as shown in Figure 216. If 
 the lumina of the bowel-ends do not correspond in size, the smaller end 
 
 - 
 
 Fig. 217. 
 
 -Restoration of the continuity of the bowel after resection of the cecum for carcinoma, with the 
 aid of perforated decalcified bone-plates. 
 
 is cut more obliquely. If the difference in size is too great to be equal- 
 ized by this method, as after excision of the cecum, both ends are 
 closed, and the continuity of the bowel is restored by lateral anasto- 
 mosis, by suturing, or with the aid of perforated decalcified bone-plates. 
 The use of decalcified perforated bone-plates to restore the continuity 
 of the bowel has been resorted to by the writer in three cases of resec- 
 
CARCINOMA. 
 
 339 
 
 tion of the cecum for carcinoma, and in every instance this method 
 of approximation proved eminently successful (Fig. 217). 
 
 Intestinal Anastomosis. — If the carcinoma, by the promotion of car- 
 cinomatous adhesions with neighboring organs or by extensive regional 
 infection through the lymphatic channels, has advanced beyond the 
 limits of a radical operation, an intestinal anastomosis should be made. 
 This operation consists in establishing a fistula between the bowel 
 above and below the tumor. 
 
 A B 
 
 The operation can be done 
 by making in the respective 
 parts of the bowel an incis- 
 ion four inches in length, 
 as advised by Abbe, and 
 the union is effected by a 
 double row of silk sutures. 
 A single row of sutures 
 might prove all-sufficient, 
 but as a matter of safety a 
 double row is preferable. 
 The same object can be 
 accomplished in a shorter 
 time and with a greater de- 
 gree of security by substi- 
 tuting for the inner row of sutures perforated decalcified bone-plates 
 (Fig. 218). The anastomotic opening should correspond in size with 
 the lumen of the bowel. 
 
 The use of the Murphy button would be attended by great danger 
 in such cases, as the button would be just as likely to fall into the blind 
 end of the bowel on the proximal side of the obstruction as into the 
 opposite side. Besides, it has been shown by Keen and others that 
 the opening, small in the beginning, is apt to become contracted beyond 
 the limits of its requirements in a comparatively short time. 
 
 Rectum.. — Carcinoma of the rectum occurs more frequently than 
 carcinoma of the remaining portion of the intestinal canal, its greater 
 frequency here being probably accounted for by the rectum being 
 more often the seat of benign growths, of chronic inflammatory affec- 
 tions, and of prolonged irritations from different sources. The histo- 
 logical structure of most of the rectal carcinomata presents a tubular 
 arrangement of the cells, surrounded and enclosed by a connective-tissue 
 stroma which in the soft variety of tumors is exceedingly scanty, and 
 in the hard, constricting variety is very abundant and compact (Fig. 
 219). In the rapidly infiltrating form the rectal tube becomes indurated 
 
 Fig. 218. — Intestinal anastomosis with the aid of perforated 
 decalcified bone-plates in the operative treatment of inoperable 
 carcinoma of the bowel (after Esmarch) : A, plates in situ ; 
 b, operation completed. 
 
34o 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and the surface ulcerates, but its lumen is not much reduced in size. 
 In the circular constricting form the constricting ring is very dense and 
 the lumen of the bowel is rapidly diminished in size. This is the form 
 
 '^ 
 
 Fig. 219. — Cylindrical-celled carcinoma of the rectum ; X 480 (Surgical Clinic, Rush Medical College, Chicago) : 
 a, connective-tissue stroma ; b, atypical tubules of carcinoma; c, cylindrical epithelial cells. 
 
 of rectal carcinoma that produces obstruction and is most favorable to 
 operative treatment, owing to the limited extent of the tumor and the 
 dilated condition of the bowel above the obstruction, permitting the 
 bowel to be drawn down after removal of the carcinomatous part. 
 
 The writer has already referred to a case that came under his obser- 
 vation of carcinoma of the rectum in a boy eighteen years of age. Car- 
 cinoma of the rectum, however, with few exceptions is a disease of 
 advanced life. According to Hildebrandt's statistics, 16 per cent, of 
 rectal carcinomata occur in persons less than forty years old, 54 per 
 cent, in persons forty to sixty years of age, and 30 per cent, in persons 
 from sixty to eighty years old. The carcinoma is located most fre- 
 quently in the lower third of the rectum. The stagnation of feces 
 aggravates the ulcerative process and produces at the same time a 
 catarrhal proctitis above the tumor. Local extension takes place in 
 the direction of the connective tissue outside of the rectum, in advanced 
 cases rendering the rectum as immovable as though it were held in 
 
CARCINOMA. 341 
 
 a vise. Regional infection takes place in the rapid-growing variety 
 at an early stage, and extends in the direction of the chain of sacral 
 and lumbar lymphatic glands. In advanced cases the regional infec- 
 tion occasionally includes the inguinal glands. Metastasis of different 
 organs hastens the fatal termination. The statement has already been 
 made that cylindrical carcinoma gives rise earlier and more constantly 
 to metastasis than does carcinoma representing epiblastic tissue. 
 
 Symptoms and Diagnosis. — Carcinoma of the rectum is not attended 
 by much suffering until the tumor by its size or by constriction gives 
 rise to obstruction. A sense of weight and an aching feeling in the 
 sacral region, usually attributed to rheumatism or hemorrhoids, is 
 about all the patient complains of during the early stages. The dis- 
 charge of a little blood and mucus, and constipation alternated by 
 diarrhea, are the symptoms which usually induce the patient to seek 
 medical advice under the belief that he is suffering from piles. Patients 
 giving such a clinical history slwuld always be subjected to a thorough 
 rectal examination. Digital exploration is more to be relied upon in 
 conducting this examination than the use of the different kinds of rectal 
 specula. The patient should be brought into the exaggerated lithotomy 
 position. With the right index finger well lubricated the rectum is 
 explored, and unless the carcinoma involves the first part of the rectum 
 the tumor is discovered without any difficulty. In the constricting 
 variety the lower end of the tumor with the constricted lumen feels 
 very much like an enlarged lacerated cervix uteri. The size of the 
 lumen and the mobility of the affected part are now determined, after 
 which careful search should be made for enlarged lymphatic glands in 
 the sacral fossa. If the tumor has infiltrated the rectal wall without 
 having produced contraction, the rectum feels like a firm, unyielding 
 cylinder with points of ulceration of its mucous lining. 
 
 In cicatricial stenosis of the rectum, the only condition liable to be 
 mistaken for carcinoma, the stricture is usually near the anus, infiltra- 
 tion of the rectal wall is less marked, any considerable enlargement of 
 the sacral glands is absent, and the stricture is often multiple, which 
 latter is not the case in carcinoma. Should any doubt exist as to the 
 differential diagnosis between these two rectal affections, a fragment of 
 tumor-tissue should be removed and sections of it be examined under 
 the microscope. 
 
 Indications for a radical operation are absence of paraproctitic infil- 
 tration and of extensive lymphatic infection, and a sufficient accessibility 
 of the tumor to enable the surgeon to remove all the diseased tissue 
 by a radical operation. Opposite conditions must be regarded as posi- 
 tive contraindications to any radical measures. 
 
342 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Palliative Operations. — In inoperable cases of carcinoma of the rec- 
 tum the surgeon can do a great deal to alleviate the suffering of the 
 patient by establishing an artificial anus in the left inguinal region. 
 Removal of the carcinomatous tissue projecting into the lumen of 
 the bowel by scraping, and linear rectotomy, for the purpose of ame- 
 liorating the symptoms due to 
 obstruction, have become, for 
 substantial reasons, obsolete 
 measures. If the carcinoma 
 produces obstruction, an arti- 
 ficial anus will benefit the 
 patient in two ways : it will 
 exclude from the fecal circula- 
 tion the diseased part of the 
 rectum, and at the same time 
 will establish a free outlet for 
 the intestinal contents. If an 
 artificial anus is made under 
 such circumstances, it should 
 be made with a view of com- 
 pletely interrupting the fecal 
 circulation and thus affording 
 absolute rest for the excluded 
 part of the bowel. Maydl's colostomy (Fig. 220) will answer these 
 requirements to perfection. An incision four inches in length is made 
 about two inches above Poupart's ligament, halfway between the symphy- 
 sis pubis and the anterior superior spinous process of the ilium, parallel 
 with the fibres of the external oblique muscle. The muscular layers are 
 separated as far as possible by the use of blunt instruments. The trans- 
 versalis fascia and the peritoneum are incised to the extent of the external 
 wound. Some care is now necessary to recognize, seize, and bring for- 
 ward into the wound in proper position the sigmoid flexure. As soon 
 as the proper loop has been found the mesentery near the bowel is tun- 
 nelled with a hemostatic forceps, and a glass tube four 
 inches in length, the size of an ordinary lead pencil, 
 covered by several layers of gauze, is drawn through 
 this opening with the forceps. The glass tube serves 
 as a bridge for the prolapsed loop of the bowel. 
 The two limbs of the bowel are now sutured together 
 on each side by two sero-muscular sutures under- 
 neath the bridge (Fig. 221). Next, the prolapsed 
 loop is sutured at its base to the parietal peritoneum 
 by at least six points of suture, to prevent the escape of intestinal 
 
 Fig. 220. — Maydl's inguinal colostomy. 
 
 Fig. 221. — Maydl's co- 
 lostomy, showing the posi- 
 tion of the bridge and the 
 sutures underneath it. 
 
CARCINOMA. 343 
 
 loops. If the symptoms are urgent, the base of the loop is surrounded 
 by a ring of absorbent cotton fastened to the bowel and the skin by 
 collodion ; the bowel is then, at the most prominent part, divided trans- 
 versely to the extent of at least two inches. If the symptoms are not 
 urgent, it is much safer to postpone the opening of the bowel for two 
 or three days, until the peritoneal cavity has become shut out by 
 adhesions all around. If this course is adopted, an ordinary antiseptic 
 dressing is applied, taking the precaution that the intestinal loop should 
 not be subjected to harmful pressure. On the second or third day the 
 dressing is removed, the collodion ring is applied, and the bowel is 
 incised as indicated above. It is advisable to keep the bridge in place 
 for at least a week or two, in order to secure at a point opposite to it 
 the formation of an efficient spur. Complete section of the bowel at 
 this time is recommended by some ; but it is not necessary, as the spur, 
 if well developed, will direct all the intestinal contents away from the 
 lower part of the bowel, and the bowel on the distal side can be flushed 
 from time to time as may appear necessary. 
 
 Extirpation of the Rectum for Carcinoma. — Extirpation of the carci- 
 nomatous rectum is now generally made through the sacral route. A 
 long time ago, Kocher recommended removal of the coccyx as a pre- 
 liminary step to the removal of the lower part of the rectum. Encour- 
 aged by the success attending the removal of the rectum from this 
 direction, surgeons have become bolder and have sacrificed parts of 
 the sacrum for the purpose of securing better access to the diseased 
 rectum. The resection, temporary or permanent, of a part of the pos- 
 terior bony wall of the pelvis has 
 enabled surgeons to extend the 
 field of radical operations upon the 
 rectum for malignant disease. 
 
 The different points where the 
 sacrum has been divided in the 
 operation for extirpation of the 
 rectum are shown in Figure 222. 
 
 As is the case with similar ope- 
 rations in other parts of the body, 
 the application of the principle of 
 
 Sacral resection as a preliminary Fig. 222.— Resection of sacrum in extirpation of 
 
 Step tO extirpation Of the rectum -ct"m for carcinoma: .after Kraske; ,-< after 
 r r cardenheuer ; b, after Volkmann, Rose. 
 
 has been carried too far. It ap- 
 pears to the writer unjustifiable to carry the resection of the sacrum as 
 far as has been done by Volkmann and Rose. The simple removal of 
 the coccyx will often suffice in affording ample room for the removal 
 
344 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 « of the lower part of the rectum, and Kraske's operation will usually 
 
 accomplish all that could be desired in the removal of a carcino- 
 matous rectum when the disease is within the limits of a justifiable 
 operation. 
 
 The patient should be prepared for a number of days for the opera- 
 tion by dieting, laxatives, warm baths, and colonic irrigation, so as to 
 secure for the part, as nearly as can be done, an aseptic condition. 
 Immediately before the operation the lower part of the rectum should 
 be flushed thoroughly with Thiersch's solution, and the external sur- 
 face should be scrubbed thoroughly with warm water and potash soap, 
 and later be disinfected with a solution of corrosive sublimate or of 
 carbolic acid. After the patient is under the influence of an anesthetic 
 he is placed face down upon a low table or a cot, the pelvis is elevated 
 by placing under it pillows covered by rubber sheeting, and the thighs 
 and the legs are flexed. This position diminishes the amount of venous 
 hemorrhage, and the abdominal organs gravitate toward the chest, 
 leaving the pelvis comparatively empty. An incision is then made in 
 the median line from the centre of the sacrum to the verge of the anus. 
 The coccyx is enucleated, and the lower two sacral vertebrae are isolated 
 from the soft tissues by the use of the knife and the periosteal elevator. 
 The sacrum is then divided transversely between the last two foramina 
 with a large chisel and a mallet. All hemorrhage is then carefully 
 arrested. After this step of the operation minute details as to the 
 immediate arrest of hemorrhage by the use of hemostatic forceps must 
 be carried out. By careful dissection between tissue-forceps the rectum 
 is reached. As soon as this has been done cutting instruments should 
 be used sparingly. The rectum should be enucleated rather than 
 excised. Connective-tissue bands and muscles are isolated before they 
 are cut. The proximal end of the tumor should be reached first. If 
 the rectum has to be removed high up, the peritoneal cavity is opened 
 carefully, and prolapse of intestines, as well as the entrance of blood 
 into the peritoneal cavity, is prevented by packing the opening with 
 gauze sponges well secured in a hemostatic forceps. When healthy 
 tissue is reached, a strip of gauze is tied around the rectum sufficiently 
 tight to prevent escape of intestinal contents, after which the bowel is 
 divided below transversely. The bowel is then drawn downward, 
 and the diseased segment is separated by a careful dissection. If pos- 
 sible, the external sphincter muscle is preserved. The course to be 
 pursued now depends on how far the rectum has to be removed in a 
 downward direction. If the distal end can be preserved, the surgeon 
 can select one of two procedures. The proximal end can be united 
 with the distal end by circular enterorrhaphy. Owing to the absence 
 
CARCINOMA. 345 
 
 of a peritoneal investment in the lower end, this procedure has not 
 yielded good results. Hochenegg has suggested that the proximal 
 end should be invaginated into the distal end and be sutured to a cir- 
 cular denudation at the anus. The results after this procedure have 
 been more satisfactory than those after the first-named method. If the 
 lower part of the bowel has to be removed, the resected end is drawn 
 downward and is attached to the external skin by sutures. The bowel 
 end must be ruffled so as to diminish its lumen before it is attached : 
 this can be done with a circular purse-string suture of catgut. In 
 either of these procedures the cavity of the wound is packed with 
 iodoform gauze, over which the external wound is sutured except at 
 from one to three places, where the gauze is brought out to the sur- 
 face. The patient should be given a liquid diet for a few days, and 
 small doses of opium to constipate the bowels temporarily. If no con- 
 traindications arise, the gauze should remain for at least a week. At 
 this time the whole wound-surface is covered by a pavement of active 
 granulations that will guard against infection later. The wound pre- 
 senting such a condition heals in a remarkably short time. 
 
 If the rectum is amputated high up and the resected end cannot be 
 brought down, a sacral anus is established by suturing the bowel into 
 the upper angle of the external incision. The writer has pursued this 
 course a number of times, and believes that an artificial anus in this 
 locality has a number of advantages not possessed by an artificial anus 
 devoid of a proper sphincter muscle lower down. Should the wound 
 suppurate, enough sutures are removed to secure free drainage. In 
 this event the dry dressing must give way to frequent antiseptic irriga- 
 tions and to a compress of gauze kept moist with a saturated solution 
 of acetate of aluminum or of boric acid. 
 
 If the carcinoma returns, little is to be expected from another ope- 
 ration, as the local recurrence is usually accompanied by extensive 
 infiltration and lymphatic infection. The formation of an artificial anus 
 in such cases is never indicated, as the recurring carcinoma does not 
 cause constriction of the bowel, but extends to the«pelvic connective 
 tissue. 
 
 Liver. — Primary carcinoma of the liver is extremely rare. Riesen- 
 feld, Klebs, and von Bergmann do not believe in the primary origin of 
 carcinoma of the liver. In 1885, Harris of London collected 19 cases 
 of primary carcinoma of this organ. In 6000 postmortems made by 
 Virchow the liver was found to be the seat of carcinoma in 95 of 
 these; the disease was secondary in 90, and primary in 5. Two cases 
 of carcinoma of the liver have been subjected to operative treatment. 
 In von Bergmann's case the tumor was located in a pedunculated lobe 
 
346 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 of the liver, which was excised with the tumor. The patient recovered 
 and remained in good health a year after the operation. Luecke 
 operated successfully in two stages on a similar case, and the patient 
 was free from recurrence at the expiration of two years. It is only 
 in such isolated and favorable cases that operative treatment is indi- 
 cated. 
 
 Testicle. — Carcinoma as compared with sarcoma of the testicle is 
 an exceedingly rare affection. Sometimes it engrafts itself upon the 
 basis of an antecedent benign tumor or an inflammatory affection. The 
 
 d .^& 
 
 m 
 
 -*» a 
 
 Fig. 223.— Carcinoma and tuberculosis of the testicle ; X 85 (Surgical Clinic, Rush Medical College, 
 Chicago) : a, stroma of carcinoma ; b, alveolus packed with carcinoma-cells ; c, focus of caseous degenera- 
 tion; d, miliary tubercles in carcinoma-tissue. 
 
 section from which the illustration (Fig. 223) was taken was derived 
 from a testicle that had been tubercular for a long time and had only 
 recently commenced to increase rapidly in size. This specimen refutes 
 the assertion made by Rokitansky, that tuberculosis and carcinoma 
 exclude each other. There can be no doubt in this case that the tuber- 
 cular epididymitis was the primary and carcinoma the secondary affec- 
 tion. Sutton has never seen a tubular carcinoma of the testicle. That 
 
CARCINOMA. 
 
 347 
 
 such a carcinoma occasionally, although rarely, occurs is shown by 
 Figure 224. Langhans never saw hard, but always soft, carcinomata 
 of this organ. He believes that the tumor starts from the epithelial 
 cells lining the seminiferous tubules. He also calls attention to the 
 transformation of an adenoma of the testicle into a carcinoma. 
 
 From a diagnostic point of view it is important to remember that 
 tuberculosis almost always begins in the epididymis, and carcinoma in 
 
 
 
 
 i ■ 
 
 >'■■ 
 Jgk 
 
 • ■■' :v# 
 
 ; ■■■■ ' . : ■ 
 
 --49 
 
 
 Fig. 224. — Tubular carcinoma of the testicle; X 270 (after Karg and Schmorl). The tumor is composed 
 of long, solid streaks of large epithelial cells (a). The nuclear structures cannot be seen, as the chromatin 
 has been affected by the hardening solution, Miiller's fluid. The stroma (i) is scanty and is rich in cells. 
 
 the testicle proper. As carcinoma of this organ is always soft, it is 
 liable to undergo cystic degeneration — an occurrence which still further 
 complicates the diagnosis. The regional infection extends along the 
 lymphatics of the cord and from the cord to the iliac fossa. The tumor 
 may attain the size of an adult's head. 
 
 Early removal of the testicle with its envelopes and the cord as far 
 as it can be followed is the only operation that promises a permanent 
 result. Kocher has observed cases in which the disease did not recur 
 for four and a half, eight and a half, and ten and a half years after 
 operation. 
 
 Penis. — Carcinoma of the prepuce and of the glans penis is observed 
 in men past fifty years of age. Kaufmann estimates that one-third of all 
 
348 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the cases occur during the sixth decennium. Occasionally the tumor 
 originates in Tyson's glands. Such a case is referred to by Tyson. 
 Usually the tumor commences in the epithelial layer of the skin and 
 of the glans penis, and presents itself as a cauliflower tumor with great 
 induration at its base. The surface ulcerates early, and is usually the 
 seat of a very offensive discharge. 
 
 The histological structure of carcinoma of the penis (Figs. 225, 226) 
 resembles essentially squamous-celled carcinoma of the skin in other 
 localities. Paget saw in a number of cases carcinoma of the penis pre- 
 ceded by balanitis. In other cases the disease starts in a pre-existing 
 
 Fig. 225. — Squamous-celled carcinoma of the penis ; X 150 (after Perls) : to the right, normal skin ; to the 
 left, proliferating epithelial projections with numerous cancer-nests. 
 
 inflammatory lesion of a more circumscribed nature. Injuries sustained 
 during coitus, during masturbation, and by friction of the clothing may 
 furnish the exciting causes in other cases. 
 
 It was formerly doubted that carcinoma of the penis could give rise 
 to regional infection. Kaufmann and Gussenbauer have shown that 
 carcinoma of this organ pursues the same course as carcinoma of the 
 skin in other localities — namely, that regional infection occurs, as a rule, 
 late, but that it is sure to ensue if the disease is allowed to pursue its 
 own course. The writer has seen regional infection much more fre- 
 quently in carcinoma of the penis than in carcinoma of the lip. The 
 inguinal glands on both sides eventually become involved — a fact which 
 has led to the conviction that it is necessary in most cases to resort at 
 once to clearing out of the inguinal glands in all cases of carcinoma 
 of the penis in which a radical operation is performed. 
 
CARCINOMA. 349 
 
 Amputation of the Penis for Carcinoma. — If the carcinoma is limited 
 to the prepuce, and no evidences of lymphatic affection are present, the 
 organ should be amputated behind the corona glandis. The penis is 
 constricted at its base with a rubber cord or tube to render the opera- 
 tion bloodless. The section through the penis should be made with 
 the knife in such a manner as to secure for the stump a cutaneous 
 covering. The writer generally makes an oval anterior flap with which 
 
 *0m 
 
 
 Fig. 226. — Papillary carcinoma of penis ; X 10 (after Karg and Schmorl). Between the enlarged papillae, 
 covered by thickened layers of epithelial cells, are found infiltrations of epithelial cells which in the vascular 
 connective' tissue show distinct cancer-nests. 
 
 to cover the corpora cavernosa. The mucous membrane of the ure- 
 thra is stitched to this flap and to the adjacent skin. The dorsalis penis 
 artery is ligated. The hemorrhage from the corpora cavernosa, at first 
 profuse, yields to compression, hot water, and the sutures. A small 
 dressing held in place with a number of strips of adhesive plaster fin- 
 ishes the operation. Rest for a few days in bed must be enforced. 
 The suturing of the flap and the urethra should be done with fine cat- 
 gut sutures, so as to obviate the necessity of removing them. 
 
350 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 If the body of the penis is affected by extension of the primary 
 tumor of the prepuce or the glans penis, the organ should be amputated 
 close to the pubes, and at the same time the inguinal glands on both 
 sides should be removed. The amputation is made with the knife and 
 in the manner just described, but an outlet for the urethra is established 
 in the perineum, as first recommended by Thiersch. The urethra is 
 isolated, is brought out through a small buttonhole behind the 
 scrotum, and is firmly anchored to the skin with a few sutures. In a 
 case that recently came under the writer's observation the disease had 
 extended along the penis and had involved the mons veneris as well as 
 the glands in both inguinal regions. In this case the entire penis, part 
 of the mons veneris, and both testicles were removed, and the posterior 
 part of the scrotum was utilized as a covering for the enormous wound. 
 The incision was extended on both sides the whole length of Poupart's 
 ligament, and was joined over the large femoral vessels by a vertical 
 incision reaching to the apex of Scarpa's triangle. The whole chain 
 of glands on each side was removed with the penis in one continuous 
 piece. The urethra was stitched to the margins of a small opening in 
 the perineum. The shock from the operation required active treatment 
 by stimulants. The patient rallied in the course of six hours and made 
 an excellent recovery. Three months after the operation he returned 
 to the hospital greatly improved in general health, but with a recurrence 
 in the left groin. A second operation was performed, and a section of 
 the internal saphenous vein was removed with the carcinomatous tissue 
 by which it was surrounded. Six months after since the second opera- 
 tion there were no signs of further recurrence. 
 
 Ovary. — Carcinoma of the ovary occurs after the period of puberty 
 as a comparatively rare affection as a primary tumor, in cystic tumors, 
 and as the result of extension by contiguity of a carcinoma of an 
 adjacent organ. Olshausen describes papillary carcinoma of the ovary 
 as a primary tumor. The same author makes the statement that Klebs 
 and Spencer Wells first called attention to this form of carcinoma of 
 the ovary. The carcinoma appears as a malignant form of papillary 
 or proliferating cystoma. Marchand has shown that this form of cystic 
 tumor of the ovary gives rise to metastasis. In one case of papillary 
 cyst of the ovary in a woman thirty-five years of age the writer found 
 the tumor extensively adherent to the anterior abdominal wall. The 
 tumor was, however, completely removed, and the patient made a good 
 recovery. Six months later she again entered the hospital, and upon 
 examination quite an extensive carcinoma was found in the scar just 
 below the umbilicus. A considerable portion of the entire thickness 
 of the abdominal wall, and including the whole scar, was resected. She 
 
CARCINOMA. 351 
 
 recovered without any untoward symptoms, but died a few months 
 later from diffuse carcinosis of the peritoneum. Pfannenstiel and 
 Olshausen have seen carcinoma develop in the scar following lapa- 
 rotomy for the removal of non-malignant ovarian tumors, and attribute 
 its origin to implantation of epithelial cells from the tumor upon the 
 wound-surfaces. In one of the cases reported by Pfannenstiel several 
 years after the removal of a small simple cystic tumor of the ovary a 
 typical adenocarcinoma developed in the abdominal scar. He came to 
 the same conclusion as Olshausen, that the development of the carci- 
 
 
 n % 
 
 Fig. 227.— Carcinoma of the ovary; X 75 (Surgical Clinic, Rush Medical College): a, scanty connective- 
 tissue stroma; b, nests of epithelial cells; c, small colloid cysts; d, blood-vessel. 
 
 noma was referable to the cystic tumor ; that epithelial cells from the 
 benign cystoma became detached and implanted either in the abdom- 
 inal cavity or in the wound, and eventually developed into a carcinoma. 
 He is of the opinion that the last process did not follow immediately 
 upon the epithelial deposit, but that first an adenoma developed, and 
 from that a carcinoma sprang. 
 
 Rokitansky described a case of carcinoma of the ovary that started 
 in a corpus luteum. 
 
 The occurrence of carcinoma in cysts, and the resemblance anatom- 
 
352 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 ically of the carcinomatous and adenomatous proliferating cysts of the 
 ovary, make it very difficult to distinguish, from the naked-eye appear- 
 ances of certain cysts of the ovary, between malignant and non-malig- 
 nant tumors. From a histological standpoint this difficulty is increased 
 because endothelial tumors of a malignant character are included by 
 some authors under the head of carcinoma. Endothelioma, which was 
 first described by Birch-Hirschfeld as carcinoma of the lymphatics, con- 
 stitutes a tumor composed of tissue derived from the mesoblast, and it 
 will again be referred to in the section on Sarcoma. Carcinoma as a 
 primary tumor of the ovary undoubtedly originates, as does adenoma, 
 in a remnant of the fetal ducts (Fig. 227). The stroma is alveolated 
 and is usually scanty ; the cells are numerous, filling the alveoli and 
 infiltrating the stroma. The tumor is soft and grows rapidly. Colloid 
 degeneration affecting both the parenchyma and the stroma of the 
 tumor results in the formation of cysts. Diffuse carcinosis of the peri- 
 toneum takes place when the tumor perforates the capsule of the ovary. 
 Tumor-cells and fragments of tumor-tissue are disseminated over the 
 peritoneal surfaces by the peristaltic action of the intestines ; these 
 cells and fragments of tissue become implanted at different places, 
 and establish in this manner independent centres of tumor-growth 
 everywhere. 
 
 Ascites is often the first symptom which induces the patient to seek 
 medical advice. Ascites in the female occurring independently of the 
 existence of organic disease of the liver, heart, or kidneys indicates the 
 existence of either peritoneal tuberculosis, malignant disease of the 
 ovary, or a movable solid tumor of the uterus or the ovaries. If the 
 patient is advanced in years, the possibility of the primary affection 
 being of a malignant character is greatly increased. Carcinoma of the 
 uterus is exceedingly prone to extend to the ovaries. Winckel records 
 a case in which, a year and a half after amputation of the cervix for 
 carcinoma, the disease made its appearance in one of the ovaries, while 
 no local recurrence had taken place. 
 
 Many gynecologists are opposed to radical measures in the treat- 
 ment of carcinoma of the ovary. This sense of helplessness on the 
 part of the surgeon when confronted by such a case has been created 
 largely by the unfavorable experience of late operations. Usually, 
 before a laparotomy is made, the disease has extended from the ovary 
 to the adjacent organs. The broad ligament is often extensively impli- 
 cated. The adherent omentum frequently shows evidences of extensive 
 involvement, and sometimes diffuse miliary carcinosis is present. If the 
 general condition of the patient is such as to warrant an exploratory 
 incision, this should always be done, if for no other purpose than to 
 
CARCINOMA. 353 
 
 make a positive diagnosis. It is just possible that the ascites and the 
 other conditions which have induced the surgeon to make a diagnosis 
 of carcinoma may have been produced by other pathological conditions 
 which are within reach of successful treatment by direct measures. 
 The patient should therefore be given the benefit of the doubt by a 
 resort to an exploratory incision. It appears that temporary relief and 
 prolongation of life have been obtained in cases in which the disease 
 returned later. The writer can recall at least three instances in which, 
 by the removal of a carcinomatous tumor of the ovary with extensive 
 adhesions, great relief was afforded and life was prolonged for from six 
 months to a year. If the disease is limited in extent, the success of an 
 operation should be the same as in operations for carcinoma of other 
 organs similarly situated. If the attachments are such that the removal 
 of the tumor would place the life of the patient in imminent danger, 
 the operator should go no further, and should close the wound after 
 having made a positive diagnosis. 
 
 Uterus. — Carcinoma of the uterus was known to the ancient 
 authors, and has been described elaborately by Hippocrates, Celsus, 
 Galen, ^Etius, and others. In more recent times animated discussions 
 have been carried on in regard to its starting-point. Cancroid, papil- 
 lomatous carcinoma, scirrhus, and medullary carcinoma of the uterus 
 have been regarded as distinct varieties of carcinoma. The histo- 
 genetic origin of carcinoma of the uterus, like that of carcinoma of 
 other mucous surfaces, can be traced either to a matrix of embryonic 
 cells in the epithelial lining or to a matrix representing the glandular 
 appendages of the uterus. 
 
 Histogenesis and Histology. — The cauliflower excrescences of the 
 cervix uteri, or the papillomatous variety of carcinoma, have been recog- 
 nized for a long time as one of the most common malignant tumors 
 of the uterus. How much confusion has existed in separating the 
 malignant from the benign papillary tumors is evidenced from a de- 
 scription of them by Virchow in 1851 : 
 
 " One must distinguish three different papillary tumors of the os 
 uteri : the simple, such as Frerichs and Lebert have seen ; the cancroid ; 
 and the cancerous : the first two forms together constitute the cauli- 
 flower growth. This begins as a simple papillary tumor, and at a later 
 period passes into cancroid. At first one sees only on the surface 
 papillary or villous growths, which consist of very thick layers of 
 peripheral, flat, and deeper cylindrical epithelial cells, and a very fine 
 interior cylinder formed of a scanty stroma of connective tissue with 
 large vessels. The outer layer contains cells of all sizes and stages 
 of development, some of them forming great parent structures with 
 
 23 
 
354 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 endogenous corpuscles. The vessels are for the most part colossal, 
 very thin-walled capillaries, which form either simple loops at the apices 
 of the villi, between the epithelial layers, or toward the surface develop 
 new loops in constantly increasing number, or, lastly, present a retic- 
 ulate branching. At the beginning of the disease the villi are simple 
 and close pressed, so that the surface appears only granulated, as 
 Clarke describes it: it becomes cauliflower-like by the branching of 
 the papillae, which at last grow out to fringes an inch long, and may 
 present almost the appearance of a hydatid mole. After the process 
 has existed for some time on the surface, the cancroid alveoli begin to 
 form deep strings between the layers of the muscular and the con- 
 nective tissue of the organ. In the early cases I saw only cavities 
 simply filled with epithelial structures ; but in Kiwisch's case there 
 were alveoli on whose walls new papillary branching growths were 
 growing — a kind of proliferous arborescent formation." 
 
 It will be seen from this description that the cauliflower excrescences 
 in the two conditions distinguished by Virchow illustrate the usual 
 clinical course of the most malignant growths of the cervix uteri. 
 The growths which he calls " simple papillary tumors " represent the 
 same form of carcinoma of the skin. The outgrowth of the papillary 
 excrescences is always attended by infiltration of the deeper structures 
 (Fig. 228). The tumor is composed of enlarged papillae covered by 
 
 Fig. 228. — Papillary cancer of the cervix: pavement epithelium of the external os ; section, natural size 
 
 (after Pozzi). 
 
 squamous epithelial cells in greatly thickened layers. The enlarged 
 papillae form the branching projections. The tumor begins in that part 
 of the cervix that is below the vaginal insertion, after it starts from 
 cylindrical epithelium which has invaded the surface. It remains for 
 
CARCINOMA. 
 
 355 
 
 a long time local, but later local and regional infection is sure to take 
 place, extending to the vagina, the body of the uterus, the pelvic con- 
 nective tissue, and the lymphatic glands. 
 
 J- 
 
 
 
 <m 
 
 '%0¥m 
 
 ■■-■--. 
 
 <&r 
 
 HPI* 
 
 $&* 
 
 :^*# 
 
 
 2& 
 
 ifi* 
 
 
 ^ 
 
 
 k: ^§jb 
 
 Fig. 229. — Carcinoma of the cervix uteri ; X 12 (after Karg and Schmorl): vertical section through the 
 carcinomatous anterior lip of the cervix. The carcinoma commenced in the vaginal portion of the cervix. 
 The mucous membrane of the cervical canal is completely destroyed. The tumor projects from the cervical 
 canal, in the form of cauliflower excrescences (a), beyond the level of the squamous cells (c) of the anterior 
 lip; at other points it infiltrates, in the form of solid strings of cells and nests of cells, the vascular mus- 
 cularis {d) ; <?, remnants of uterine glands lined with cylindrical cells. 
 
 In other cases the carcinoma appears as an induration without any 
 papilliform projections. Ulceration in the centre of the growth takes 
 place at an early stage, and continues to spread toward the periphery 
 as well as in the direction of the base of the ulcer. These are the cases 
 which correspond with the flat, squamous-celled carcinoma of the skin. 
 
 Carcinomata originating in the mucous membrane of the cervical 
 
356 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 
 Fig. 230. — Uterine gland, showing very early malignant overgrowth of the columnar epithelium at a and b 
 (after Boyce). (Obj. 1 inch, with eye-piece.) 
 
 
 —b 
 
 5 =?- " 
 
 Fig. 231. — Cylindrical-celled carcinoma from the upper part of the cervix, invading the fundus ; X 150 
 (after Cornil) : m, e, hypertrophied glands of the body of the uterus, like those of chronic metritis ; t, en- 
 larged glandular cavity, the walls showing many layers of epithelium ; b, adjacent gland-wall in a similar 
 state ; v, vessels : c, connective tissue. 
 
 
 
 
 Fig. 232. — Cylindrical-celled carcinoma of the body of the uterus, extending from the cervix ; X 150 
 (after Cornil) : c, c, connective tissue; a, cavity full of cells, the external layer being cylindrical: these cells 
 have a tendency to become detached from the wall, well seen at o ; f, cavity with mucous cells, and larger 
 cells in mucous degeneration. 
 
CARCINOMA. 
 
 357 
 
 canal begin in the glands, and are composed of cylindrical cells 
 arranged in tubular form in a stroma very variable in its relative 
 proportions to the parenchyma of the tumor (Fig. 229). Primary car- 
 cinomata of the mucous membrane of the cervical canal and of the 
 uterine cavity histologically resemble each other almost perfectly. 
 The structure is in imitation of the mucous glands. The starting-point 
 of the tumor is in a matrix of embryonic cylindrical epithelial cells that 
 pre-exists in one of the glands or in their immediate vicinity, or that is 
 formed later in these localities by post-natal causes. Boyce had an 
 opportunity to study the incipient stage of a tumor with such an origin 
 (Fig. 230). The illustration represents a complete uterine gland, the 
 mouth of which (a) is stopped by an epithelial overgrowth of the 
 columnar lining, and on whose wall (at b) a plaque of proliferated epi- 
 thelium has formed in the midst of typically columnar cells. It is 
 the beginning of a cancerous change which elsewhere in the uterus 
 has advanced to completeness. Where the change is complete the 
 glands have been converted into solid epithelial cylinders ; these, 
 together with the prolife'rating epithelium on the surface, have branched 
 deeply into the stroma (Fig. 231). 
 
 Fig. 233. — Carcinoma of the uterine mucous mem- 
 brane, circumscribed form (after Pozzi). 
 
 Fig. 234. — Carcinoma of the uterine mucous mem- 
 brane, diffuse form (after Pozzi). 
 
 Cylindrical-celled carcinoma is much more malignant than the squa- 
 mous-celled variety. Carcinoma of the cervical canal creeps along the 
 
358 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 mucous membrane into the cavity of the uterus. The intra-uterine 
 
 
 
 Fig. 235. — Primary carcinoma of the uterus; X 120 (after Pozzi) : b, b, lobules of the tumor; m, lobules 
 showing empty spaces, which are either transverse sections of vessels or cavities filled with cells in mucous 
 degeneration ; n, smaller alveoli of the tumor. Nearly all these epithelial cells have a tendency toward 
 isolation by the walls of the vessels that enclose them. 
 
 part of the tumor presents under the microscope a structure similar to 
 that of the primary tumor (Fig. 232). 
 
 'mm 
 
 Fig. 236. — Primary carcinoma of the uterine body ; X 300 (after Cornil) : a, numerous layers of stratified 
 epithelium, the deepest being cylindrical ; e, e, cells with karyokinesis ; t, muscular tissue of the uterus, on 
 which the cylindrical cells are directly implanted. 
 
 Primary carcinoma of the body of the uterus is a much rarer affec- 
 tion than carcinoma of the cervix. Clinically, carcinoma of the uterine 
 cavity presents itself in two forms, the circumscribed (Fig. 233) and the 
 
CARCINOMA. 359 
 
 diffuse (Fig. 234). In the circumscribed form the tumor often attains 
 considerable size before it breaks down, and frequently it assumes a 
 polypoid shape. In the diffuse variety the mucous membrane is ex- 
 tensively involved from the beginning, and the disease infiltrates the 
 muscular tissues in all directions, resulting in a uniform pear-shaped 
 enlargement of the body of the uterus. 
 
 The structure of a primary carcinoma of the uterine mucous mem- 
 brane, like that of a carcinoma of the cervical canal, is usually in imita- 
 tion of the uterine glands. Cylindrical cells are arranged in a tubular 
 form in an alveolated stroma (Fig. 235). The cylindrical cells are 
 arranged in the tubules in one or more layers. If the layers are 
 numerous, the cells most distant from the matrix become flattened and 
 resemble squamous or pavement epithelium (Fig. 236). Mucous and 
 colloid degeneration leads to dilatation of the tubules and the formation 
 of cysts of small size. The stroma often undergoes similar changes. 
 The infiltration of the cervix and body of the uterus imparts to the 
 affected organ that characteristic hardness with which the surgeon 
 becomes so familiar as an important point in differential diagnosis. 
 The formation of large tumors is rendered impossible by the destruc- 
 tive ulceration which sets in at an early stage and continues in a pro- 
 gressive manner. In the papillary form the copious vegetations slough 
 off, leaving large ulcerating defects. 
 
 Etiology. — Schroeder ascertained that 33 per cent, of all women who 
 die of carcinoma succumb to carcinoma of the uterus. The only organs 
 more frequently affected by carcinoma are the stomach and the mam- 
 mary gland. Wagner estimated that of all persons who die of carci- 
 noma, in one-fourth of them the uterus is the seat of the disease. 
 From these statistics it is evident that the uterus is one of the organs 
 which presents, next to the stomach, conditions, congenital or other- 
 wise, most favorable to the development of carcinoma. The fifth 
 decennium is the time of life most predisposed to the affection. A 
 closer study of the statistics shows that the first five years after the 
 cessation of menstruation furnish the largest contingent of cases. An 
 hereditary predisposition was traced, according to different authors, in 
 from 7.6 to 1 3 per cent. Winckel called special attention to the frequent 
 occurrence of carcinoma of the uterus in tubercular families — another 
 proof of the fallacy of Rokitansky's assertion that tuberculosis and 
 carcinoma do not occur in the same person at the same time. Carci- 
 noma occurs more frequently in married than in single women, and 
 more frequently in sterile women than in those who have given birth to 
 children. Of the women who have borne children, those who have 
 passed most frequently through childbed are most disposed to card- 
 
360 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 noma of the uterus. Difficult or instrumental deliveries and abortions 
 appear to exert an etiological influence. These different etiological 
 influences have been studied by Winckel on the hand of an extensive 
 clinical material that came under his own observation. There can be 
 no question that trauma, inflammatory affections, and benign tumors, 
 which are so frequently found in the cervix, constitute an important 
 element in the production of carcinoma. The most important cause, 
 however, to explain the frequency with which carcinoma selects this 
 locality, is the fact that in the embryo the squamous epithelium of the 
 sinus urogenitalis blends with the cylindrical epithelium of Miiller's 
 ducts at the external os of the cervix. It is at the point of junction of 
 the epithelial cells of different embryonal origin and of different shape 
 and function that carcinoma most frequently takes its starting-point. 
 Embryonal cells are here in excess or they are displaced, and become 
 later the essential tumor-matrix. 
 
 The reasons why carcinoma of the cervix appears in preference after 
 the menopause are the same as Thiersch has advanced for carcinoma 
 of the lip. The shrinking submucous connective tissue loses at this 
 time its physiological resistance, thus opening pathways for invasion by 
 epithelial cells. Emmet has called attention to laceration of the cervix 
 as a cause of carcinoma. The writer is strongly inclined to believe 
 that a laceration of the cervix may not only act as an exciting cause, 
 but that, in addition, it may furnish the essential matrix of embry- 
 onic epithelial cells. It is not difficult to understand that during the 
 healing of a laceration of the cervix new embryonal cells may become 
 buried in the scar-tissue in an immature state, and remain in this con- 
 dition, constituting a tumor-matrix of post-natal origin. E. Martin 
 believes that acute infectious lesions of the vagina and the uterus, like 
 gonorrhea, have an influence in the causation of uterine carcinoma — an 
 opinion which receives the support of Winckel and others. 
 
 Symptoms and Diagnosis. — The symptoms which point to the exist- 
 ence of carcinoma of the uterus are (1) hemorrhage, (2) profuse and 
 often very fetid vaginal discharge, (3) pain, (4) dysuria, and (5) rectal 
 tenesmus. 
 
 If the patient has not ceased to menstruate, menstruation is profuse 
 and prolonged. Greater significance attaches, however, to the occur- 
 rence of hemorrhage between the menses. Bleeding during the interval, 
 occurring spontaneously or provoked by active exercise, by the use of 
 the vaginal syringe, or by coitus, in a woman past thirty-five years of 
 age is very suggestive of the existence of a carcinoma of the uterus, 
 and should induce the medical attendant to make a thorough examina- 
 
CARCINOMA. 361 
 
 tion. The occurrence of hemorrhage after the menopause has a similar 
 diagnostic significance. 
 
 A profuse watery discharge, stained at times with blood, is one of 
 the earliest external evidences of papillary carcinoma of the cervix. 
 The discharge is often very irritating, producing excoriation of the 
 external genital organs, and often a catarrhal vaginitis. When the dis- 
 ease has advanced to extensive ulceration, or the papillary excrescences 
 have become gangrenous, the discharge is always exceedingly fetid and 
 profuse ; at this time it also frequently contains fragments of cast-off 
 tumor-tissue. 
 
 The pain, of a dull, aching, burning, or lancinating character, is 
 referred most frequently to the back, the lower part of the abdomen, 
 the hips, the iliac regions, and the thighs. 
 
 The retention of secretions in the uterine cavity by the blocking of 
 the cervical canal by the tumor-tissue causes expulsive pains. If the 
 carcinoma presses upon the bladder or has reached this organ by 
 extension, urinary disturbances set in, varying in intensity from a desire 
 to pass the urine more frequently than usual to the involuntary escape 
 of urine through a fistula produced by destruction of the posterior 
 bladder-wall by the tumor. The function of the rectum is disturbed 
 by pressure or by the extension of the disease from the uterus to the 
 rectum. 
 
 Constipation, tenesmus, and the escape with the feces of mucus or 
 of mucus stained with blood are some of the indications showing the 
 existence and extent of uterine carcinoma. If the disease has extended 
 to the pelvic connective tissue or the peritoneum, it presents many 
 symptoms and signs of parametritis and pelvic peritonitis — affections 
 which must be excluded carefully in the differential diagnosis. Exten- 
 sive local and regional infection is indicated further by great oedema of 
 one or both lower extremities, caused by compression or thrombosis 
 of one or more of the large veins in the pelvis, by ascites, by tympan- 
 ites, and by carcinoma of the external genitals. Metastatic tumors in 
 distant parts of the body would indicate that general infection has taken 
 place. 
 
 It is unfortunate that the onset of the disease is so insidious, as 
 patients, as a rule, consult the physician only after the disease has 
 manifested itself by symptoms which belong to its advanced stages. 
 Unless discovered accidentally in the examination for obscure pelvic 
 affections, carcinoma of the uterus presents itself to the surgeon in the 
 majority of cases in its advanced stages. As most if not all of the 
 symptoms that have been detailed may be simulated by benign tumors 
 of the uterus and by inflammatory affections involving this organ and 
 
3& 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 its appendages, a reliable diagnosis must rest upon a thorough exam- 
 ination. 
 
 In advanced cases, when the lower segment of the uterus is the seat 
 of fungous masses or of a deep excavation with an infiltration of stony 
 hardness at its base extending from the uterus to the parauterine con- 
 nective tissue on both sides, completely immobilizing the organ, a 
 positive diagnosis can be made by the mere touch of the finger. It is 
 different in cases in which the disease is limited to perhaps one lip of 
 the cervix, or where the disease originated primarily in the mucous 
 membrane of the uterine cavity. In such cases it is sometimes exceed- 
 ingly difficult to differentiate between chronic inflammatory affections, 
 benign tumors, and carcinoma. 
 
 Laceration of the cervix with hypertrophy of one or more of its 
 lips, and ectropion of the cervical mucous membrane with erosion, have 
 frequently been mistaken for carcinoma. A hypertrophic lip of the 
 cervix covered by papillary erosions presents to the palpating finger on 
 passing it lightly over the surface a velvety softness, while on deeper 
 pressure the hypertrophied tissues feel uniformly dense, but lack the 
 stony hardness of carcinoma 
 (Fig. 237). The carcinomatous 
 cervix feels not only hard but '■'■) 
 
 nodulated, and if ulceration has ^H 
 
 taken place the surface of the t*l£ 
 
 A 
 
 Fig. 237. — Broad erosions of both lips of 
 cervix, with numerous glandular openings 
 (after Winckel). 
 
 Fig. 238. — Papillary carcinoma of cervix limited almost 
 entirely to the anterior lip (after Winckel). 
 
 ulcer is uneven and hard (Fig. 238). If the disease involves both lips 
 at the same time and is limited in extent, the opening of the cervical 
 canal is then surrounded by a ring-like induration of great firmness 
 that does not yield on attempting to insert the tip of the index finger 
 
 ( Fi g- 239)- 
 
 Retention-cysts of the external os of the cervical canal might be 
 
CARCINOMA, 
 
 363 
 
 mistaken for carcinoma, as on palpation they feel quite firm, but lack 
 the induration so characteristic of carcinoma, and on deep pressure a 
 
 '-&< 
 
 Fig. 239.— Papillary carcinoma of both lips of the 
 cervix (after Winckel). 
 
 Fig. 240. — Large retention-cysts of both lips of 
 the cervix (after Winckel). 
 
 sense of elastic resistance is produced. These cysts are also usually 
 multiple, while carcinoma extends from one centre (Figs. 241, 242). 
 
 Fig. 241. — Beginning cancer of the cervix, ulcer- 
 ative form (after Pozzi). 
 
 Fig. 242. — Cancer of the cervix, nodular form 
 (after Pozzi) : fi, zone of intact pavement epithe- 
 lium ;/, cancerous nodule ; a, external os ; c, cervix. 
 
 In doubtful cases a diagnosis must be made by the use of the micro- 
 scope. A small fragment of tissue near the margin of the supposed 
 tumor is removed, and from it sections are made. In carcinoma the 
 section will show atypical proliferation of epithelial cells in the form of 
 solid cylinders and epithelial nests in the vascular stroma. In papillary 
 erosions the section will show an increase of glandular structure, but 
 the epithelium is separated from the submucous vascular connective 
 tissue by the membrana propria. No epithelial cells are found in direct 
 contact with vascidar connective tissue. 
 
 Primary carcinoma of the body of the uterus is very rare, and espe- 
 cially so in women less than fifty years of age. It is attended by 
 enlargement of the uterus, profuse and often fetid vaginal discharge, 
 and fitful attacks of hemorrhage. As some of these symptoms attend 
 adenomatous disease of the mucous membrane, it is often necessary to 
 
364 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 remove with the sharp curette fragments of tissue for examination 
 under the microscope. In adenoma the epithelial cells will be found to 
 occupy their normal relative position to the basement membrane, while 
 in carcinoma the epithelial cells, almost always of the cylindrical variety, 
 will be found in and among the vascular structures and arranged in a 
 tubular form (Fig. 243). Retained placental tissue and myoma of the 
 uterus undergoing sloughing are conditions which might lead to errors 
 
 Fig. 243. — Atypical columnar epithelioma derived from uterine glands (after Boyce) : a, the cancer-cylinder. 
 
 (Obj. \ inch, without eye-piece.) 
 
 in diagnosis, and they must be considered carefully in making a differ- 
 ential diagnosis between primary carcinoma of the body of the uterus 
 and other intra-uterine affections. 
 
 Supravaginal Amputation of the Cervix Uteri for Carcinoma. — The 
 first supravaginal excision of the cervix uteri for carcinoma was made 
 by Osiander. The operation was later perfected by C. J. M. Langen- 
 beck and by Schroeder. This operation should be restricted to cases 
 of carcinoma beginning upon the vaginal portion of the cervix and in 
 which the disease has not extended to the body of the uterus. Sur- 
 geons are not agreed as to the value of this operation in the treatment 
 of uterine carcinoma. The combined statistics representing cases from 
 the practice of a number of able surgeons show a mortality of about 
 1 1.5 per cent. Some of the ardent advocates of this operation claim 
 that in nearly half of the cases the carcinoma did not return after 
 operation. Such a statement, however, must be accepted with a good 
 
CARCINOMA. 
 
 365 
 
 Fig. 244.— Schroeder's supravaginal ampu- 
 tation of the cervix for carcinoma, showing the 
 extent of the excision and the ligature of the 
 lower branch of the uterine artery (after Pozzi). 
 
 deal of allowance. On the contrary, the champions of hysterectomy 
 underrate the value of this operation. Common sense would dictate 
 that in a limited carcinoma of the ex- 
 ternal os it is no more necessary to 
 remove the entire uterus than it would 
 be to extirpate the whole of the lower 
 lip in a beginning carcinoma of the 
 lip. Here as elsewhere the surgeon 
 must show good sense and judg- 
 ment in selecting the cases for par- 
 tial and those for complete removal 
 of the uterus for carcinoma. Schroe- 
 der's operation is the one that prom- 
 ises the best results in well-selected 
 cases. 
 
 The uterus is drawn down to the 
 vulva by a pair of vulsellum forceps, 
 and a strong loop of thread is passed 
 through and above each of the lateral 
 culs-de-sac (Fig. 244). These loops 
 serve to draw the parts down and 
 to compress the uterine artery. The cervix is then isolated, through 
 a circular incision made at the vaginal insertion, as far as the internal os. 
 Spirting vessels are at once tied. The dissection is made as far as 
 possible by the use of blunt instruments, to guard against wounding 
 the bladder or the rectum or opening unintentionally the peritoneal 
 cavity. The anterior portion of the cervix is removed first, when the 
 vaginal mucous membrane is stitched to the mucous membrane of the 
 cervical canal. The same is done after the amputation of the posterior 
 half of the cervix. Schroeder has excised with the cervix the upper part 
 of the vagina when the disease had extended in that direction. Some 
 surgeons employ no sutures after amputation of the cervix, but follow 
 the use of the knife by that of the cautery (Koeberle) or of chloride of 
 zinc (Van de Warker). If all the diseased tissue can be removed — 
 and these are the cases which are adapted for supravaginal amputa- 
 tion — it is advisable to suture the vaginal mucous membrane to the 
 mucosa of the cervical stump, as otherwise a stenosis or a complete 
 obliteration of the cervical canal may become a source of trouble and 
 an indication for more operating in the future. The writer has seen at 
 least two cases of supravaginal amputation of the cervix for carcinoma 
 in which the suturing was omitted, and in which complete obstruction 
 by cicatricial contraction gave rise to great pain during the menstrual 
 
3 66 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 period, as all the menstrual discharge escaped into the peritoneal cavity, 
 causing repeated attacks of pelvic peritonitis. In on€ of these cases 
 removal of the uterine appendages disclosed both of the tubes greatly 
 distended, the lumen at the fimbriated extremity having become greatly 
 narrowed by firm adhesions, the remnants of repeated attacks of cir- 
 cumscribed peritonitis. 
 
 Vaginal Hysterectomy for Carcinoma of the Uterus. — C. J. M. Langen- 
 beck in 1813 made the first complete vaginal hysterectomy for carci- 
 noma. Sauter and Dubourg appear next in the list of surgeons who 
 undertook this operation. Vaginal hysterectomy was revived and per- 
 fected in 1878 by Czerny. A radical operation for carcinoma of the 
 uterus involving more than the cervix and limited to the uterus can be 
 performed with less difficulty and greater safety by the vaginal than 
 by the abdominal route. Freund's abdominal hysterectomy for carci- 
 
 FiG. 245. — Vessels of the uterus: uterine and utero-ovarian arteries (after Pozzi). 
 
 noma has been replaced almost entirely by vaginal hysterectomy. Strict 
 antiseptic precautions are necessary when the abdominal cavity is to be 
 opened in the removal of a carcinomatous uterus. The vagina and the 
 external genitals should be disinfected in the usual manner, and if the 
 carcinoma has ulcerated extensively, a preliminary scraping is neces- 
 sary for the purpose of removing necrosed infected tissue that would 
 escape the ordinary means of disinfection. The patient should undergo 
 
CARCINOMA. 
 
 3^7 
 
 Fig. 246.— Vaginal hysterectomy : first step, opening the posterior cul-de-sac and suture of the peritoneum 
 to the vaginal mucous membrane (after Martin). 
 
 Fig. 247.— Vaginal hysterectomy : second step, ligation of the uterine artery (after Martin). 
 
368 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 preparatory treatment as for laparotomy for a number of days. Bladder 
 and rectum should be emptied before the operation is commenced. 
 
 The patient must be placed in the lithotomy position, the thighs being 
 well separated and properly immobilized. Hegar's speculum and re- 
 tractors, made for this special purpose, are best adapted for securing 
 access to the uterus. The modern improved technique of vaginal 
 hysterectomy has special reference to the prevention and arrest of 
 hemorrhage. The principal vessels concerned in this operation are 
 well shown in Figure 245. The uterus is secured and drawn down to 
 the vulva in the same manner as in supravaginal amputation of the 
 cervix. The operation is commenced by opening the cul-de-sac of 
 Douglas by a curved incision behind the cervix at its junction with 
 the vagina, when the vaginal mucous membrane is sutured to the 
 peritoneum (Fig. 246). The suturing arrests the parenchymatous and 
 venous hemorrhage completely. The next step (Fig. 247) consists in 
 ligating the uterine artery on both sides en masse. The left index 
 finger is inserted through the wound, and the exact location of the 
 artery is ascertained by the pulsations ; then, with a large curved needle 
 armed with strong silk, the artery is included in a mass of tissue at 
 each angle of the wound and is secured by drawing the ligature tightly. 
 The cervix is then drawn backward and downward, and, by an incis- 
 ion at a safe distance from the palpable margin of the tumor, the circular 
 incision is completed, the point of the knife being directed against the 
 cervix to avoid wounding the bladder. The dissection between the 
 bladder and the cervix is made chiefly by the use of the finger and 
 of blunt instruments. Hemorrhage is arrested by points of suture 
 on the cut surface of the tissues. The uterus is now retroverted suf- 
 ficiently to bring the broad ligaments within easy reach, when they are 
 tied in three parts. The uterus is now, by means of scissors, severed 
 from all attachments, including the peritoneal reflection between it 
 and the bladder, which attachment so far has been reserved to guard 
 against infection. Prolapse of the intestines is prevented by elevating 
 the pelvis or by means of a large sponge well secured in long hemo- 
 static forceps. 
 
 The wound should be closed on each side by one or two sutures, 
 leaving an opening in the centre for an iodoform-gauze drain. If 
 ovaries or tubes present conditions requiring operative treatment, they 
 should be removed ; otherwise it is better to limit the operation to the 
 removal of the uterus. If the bladder or the rectum should be injured 
 during the operation, the visceral wound must be sutured. After com- 
 pletion of the operation the vagina is lightly packed with iodoform 
 gauze. The packing and dressing should not be removed for from 
 
CARCINOMA. 
 
 369 
 
 three to five days unless hemorrhage or infection demands earlier 
 interference. Ligation of the broad ligaments and blood-vessels is the 
 
 Fig. 248. — Bowed forceps for compression of the broad ligaments in vaginal hysterectomy (after Doyen). 
 
 correct surgical way in which to prevent and arrest hemorrhage in 
 vaginal extirpation of the uterus. 
 
 Pean has substituted for the ligature long compression-forceps 
 (Fig. 248). After detaching the cervix much in the same way as has 
 been described, the broad ligament near the uterus is grasped with 
 long, slightly curved catch-forceps, as shown in Figure 249. The for- 
 ceps are prevented from un- 
 locking by tying the handles 
 together with a strip of gauze. 
 After removal of the uterus 
 the vagina is packed with gauze 
 and the forceps are incorpo- 
 rated in the external antiseptic 
 dressing. The forceps are re- 
 moved at the end of the second 
 day. 
 
 Many surgeons have adopt- 
 ed Pean's method of control- 
 ling hemorrhage in vaginal 
 hysterectomy by permanent 
 forceps pressure, but the pro- 
 cedure is open to a number 
 of serious objections which do 
 not apply to the use of the 
 ligature, the most important 
 being insecurity against second- 
 ary hemorrhage from slipping of the forceps and inability to carry out 
 aseptic precautions to the required extent. The writer has always relied 
 on the ligature, and has had no reason to change his views concerning 
 its superiority over the forceps in the permanent arrest of hemorrhage 
 in vaginal hysterectomy. 
 
 Extirpation of the carcinomatous uterus through the sacral route 
 
 24 
 
 Fig. 249. — Vaginal hysterectomy : application of- for- 
 ceps and section of the base of the broad ligament (after 
 Pean). 
 
37° 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 was first practised by Hochenegg and is strongly endorsed by Czerny. 
 The sacral resection is made in the same way as advised by Kraske for 
 extirpation of carcinoma of the rectum. The sacral operation would 
 certainly appear to present great advantages when the lymphatic glands 
 and the connective tissue behind the uterus have become infected, as it 
 secures better access to the retro-uterine tissues than does the vaginal 
 operation. 
 
 Extraperitoneal enucleation, first practised by the older Langenbeck, 
 and recently revived by Frank and Lane, has no future in the operative 
 treatment of carcinoma of the uterus. 
 
 In inoperable cases of carcinoma of the cervix and uterus — and as 
 such should be considered all cases in which, from the extent of the 
 disease, complete removal of all infected tissues cannot be effected by 
 either vaginal or sacral hysterectomy — the removal of fungous masses 
 with a sharp spoon, followed by thorough cauterization with the 
 Pacquelin cautery, constitutes an important palliative measure. 
 
 External Female Genital Organs. — Carcinoma of the external gen- 
 ital organs of the female is a comparatively rare affection. Its primary 
 
 starting-point may be either the 
 labium majus, the labium minus, 
 or the clitoris. Among 7479 
 women suffering from carci- 
 noma, Winckel found that the 
 vulva was the primary seat of the 
 disease in 72, or about 10 per 
 cent, of all the cases. The tu- 
 mor begins as a firm nodule in 
 the skin, with an indurated base. 
 The tumor is covered at first 
 by thickened layers of epithelial 
 cells, which in the centre of the 
 growth soon disappear by ulcera- 
 tion. Carcinoma of the vulva, 
 according to Klob and Winckel, 
 is always composed of squamous 
 epithelial cells. As soon as ul- 
 ceration has occurred, the oppo- 
 site surface with which the tumor 
 may come in contact is often 
 similarly affected. The tumor 
 does not attain any considerable 
 size, as the older portions are destroyed by ulceration. The tumor 
 
 Fig. 250. — Carcinoma of the labium majus (after 
 Winckel). The tumor is incised vertically, showing the 
 appearance of its interior. The surface is nodulated, 
 and on one side is a fringe of hair derived from the 
 lesser labium. 
 
CARCINOMA. 
 
 371 
 
 represented in Figure 250 was removed by Winckel. In another case 
 the same authority satisfied himself that the carcinoma had originated 
 in a congenital wart of the clitoris. The transformation of a wart of 
 the lesser labium into a carcinoma is well shown in Figure 251. 
 
 Lymphatic infection is an early occurrence in carcinoma of the 
 clitoris and vulva. A case of primary carcinoma of the clitoris in a 
 woman sixty years of age came under the writer's observation six 
 months from the time the tumor was discovered. Both greater labia 
 were involved, and very extensive regional infection had taken place in 
 both groins. In this case an oval flap was made by carrying a curved 
 incision the whole length of Poupart's ligament on both sides, and then 
 across the lower border of the mons veneris. This flap was reflected 
 in an upward direction to a point where the femoral vessels pass under- 
 neath Poupart's ligament. An incision was then made downward to 
 the apex of Scarpa's triangle on both sides. After reflection of the 
 triangular flaps the whole chain of lymphatics was dissected out, being 
 later removed with the mass containing the primary tumor and both 
 
 Fig. 251. — Cancerous transformation of the epithelium of the labium majus (after Boyce) : a, normal epithe- 
 lium ; b, warty condition; c, malignant change. (Obj. \ inch, without eye-piece.) 
 
 the greater labia in one piece. The hemorrhage was controlled by 
 compression and by hemostatic forceps during the operation. The 
 excision had to be carried to the margin of the meatus and to the lesser 
 labia on the sides. The oval flap was then drawn downward and 
 stitched to the upper margin of the meatus, and the wounds caused by 
 
372 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 excision of the labia were closed by stitching the lesser labia to the 
 skin. The remaining parts of the wounds were closed in the usual 
 manner. Primary healing of all the wounds on the right side took 
 place ; a slight suppuration interfered with the healing of the wound 
 below Poupart's ligament on the opposite side. The patient left the 
 hospital three weeks after the operation, and three months later was 
 reported as being free from recurrence. 
 
 The only effective treatment of carcinoma of the external genital 
 organs of the female is free excision. Large defects can be covered by 
 sliding of the skin, and very large wounds heal in the most satisfactory 
 manner. If the disease has resulted in infection of the inguinal glands, 
 all the glands should be removed with the primary tumor in one con- 
 tinuous mass. This removal can be effected by extending the incision 
 just below Poupart's ligament as far as the anterior superior spinous 
 process, and joining it by a vertical incision extending from the femoral 
 canal to the apex of Scarpa's triangle. 
 
 Bye. — Malignant tumors in the interior of the eye are sarcomata. 
 The conjunctiva in rare instances is the seat of carcinoma. The tumor 
 ulcerates early, and generally comes under the observation of the sur- 
 geon before extensive local or regional infection has occurred. Perfor- 
 ation of the eyeball takes place at the junction of the cornea and the 
 sclerotic, as resistance to cell-invasion here is less than in the sclerotic 
 or the cornea. Regional infection takes place through the pre-auricular 
 and submaxillary lymphatics. The diagnosis should always be con- 
 firmed by examination of sections of the tumor under the microscope, 
 as a positive diagnosis justifies the only radical treatment in such cases 
 — enucleation, with clearing out of all the orbital contents. 
 
 Bladder. — Primary carcinoma of the bladder is a rare affection. It 
 is more common in men than in women. It occurs as a sessile, indu- 
 rated, ulcerating tumor or as a papillary growth. The latter form 
 occurs often as a transformation of a benign papilloma into a car- 
 cinoma. 
 
 Villous carcinoma (Zottenkrebs) was first described by Rokitansky. 
 It appears clinically as a projecting growth from mucous or other free 
 surfaces. The villous growth consists, in its stem, of a fibrous struct- 
 ure, on which villous tufts are borne, as buddings or sproutings of the 
 stem or its branches. The same kind of tumors are found in the 
 interior of proliferous cysts. In some tumors the main stem is short 
 and thick, and the buds aggregated in a cluster and nearly round ; in 
 others the stem is delicate and long, branching into secondary and 
 tertiaiy tubes or offshoots. The blood-vessels are large, with thin and 
 imperfect walls, resembling colossal capillaries. 
 
CARCINOMA. 373 
 
 Occasionally the urethra is the starting-point (Fig. 252). If in the 
 female the urethra is primarily affected, the radical operation should be 
 preceded by the formation of a suprapubic fistula. After this has been 
 
 
 Fig. 252. — Primary carcinoma of the urethra in the female (after Winckel) : a, urethra; b, fundus of the 
 
 bladder. 
 
 established the entire urethra and the base of the bladder should be 
 excised and the opening in the bladder be closed permanently. This 
 operation has been performed successfully by Pawlik and Oviatt. 
 
 Carcinoma of the bladder frequently selects that part of the bladder- 
 wall corresponding to the insertion of the ureters. Secondary carci- 
 noma of the bladder from extension of the tumor from the prostate 
 invades the base of the bladder; after the growth has reached the 
 vesical mucous membrane it becomes diffuse, often blocking the orifice 
 of the urethra with masses of tumor-tissue. After ulceration has set in 
 shreds of carcinomatous tissue are often voided with the urine. The 
 ulceration usually extends in the course of time over the entire surface 
 of the tumor (Fig. 253). 
 
 The most prominent symptoms of carcinoma of the bladder are 
 hemorrhage, frequent desire to urinate, and great pain after evacuation 
 
374 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 of the bladder. Microscopical examination of fragments of tissue 
 voided with the urine or removed in the eye of the catheter will often 
 prove of great value in making a positive diagnosis. In women an 
 incision through the vesico-vaginal septum, and in men a suprapubic 
 cystotomy, will enable the surgeon to make a positive diagnosis, and 
 will also afford relief by establishing a permanent fistula. If the car- 
 cinoma is superficial, removal after opening the bladder should be 
 attempted. If the tumor involves the anterior wall or fundus of the 
 bladder, the indication is for a radical operation by excision of the entire 
 thickness of the bladder-wall beyond the limits of the tumor through 
 an abdominal incision. If the carcinoma is so situated that the bladder 
 end of one ureter has to be removed, the resected end should be 
 implanted into a slit of the bladder, as advised by Van Hook, before 
 the opening in the bladder is closed by suturing. 
 
 Fig. 253. — Papillary carcinoma of the anterior wall of the hladder in the female (after Winckel) : a, papillary 
 carcinoma ; b, orifices of ureters ; c, urethra. 
 
 In all these operations the bladder should be drained either by 
 the use of a retaining catheter or through a separate opening. Scraping 
 out of a carcinoma through either a suprapubic or a vaginal incision 
 should not be considered even in the light of a palliative operation. 
 All that can be done in a case of inoperable carcinoma of the bladder 
 is to establish a permanent fistula to relieve the vesical tenesmus and to 
 prevent retention of urine by closure of the urethral opening by the 
 tumor or by blood-clots. 
 
 Kidney. — The kidney is more frequently the seat of sarcoma than 
 of carcinoma. Carcinoma of the kidney is of the tubular variety. 
 In a delicate, very vascular stroma the columnar epithelial cells are 
 
 
CARCINOMA. 375 
 
 arranged in the form of tubules. According to the degree of develop- 
 
 
 
 
 * - • » ~ \ © •, >' • &>♦ 
 
 ■*r*& 
 
 
 -** 
 
 '•.->-' 
 
 Fig. 254. — Displaced tissue from the suprarenal capsule in the kidneys ; X 500 (after Karg and Schmorl). 
 The lower part of the picture is occupied by normal kidney-tissue (a), in which a glomerulus and transversely 
 cut uriniferous tubules can be seen ; the upper part is occupied by typical tissue from the suprarenal capsule 
 (b), which is imbedded in the kidney- tissue. 
 
 ment of the stroma the tumor is either hard or soft, of slow or of rapid 
 growth. In exceptional cases the tumor, instead of springing from a 
 matrix of embryonic cells representing kidney-tissue, originates from a 
 displaced matrix of epithelial cells derived from the suprarenal capsule. 
 Such displaced groups of epithelial cells (Fig. 254) are found in the 
 vicinity of the kidney, in the capsule, or in the parenchyma of the 
 kidney itself (Klebs). Grawitz has shown that tumors originating from 
 such a matrix represent to perfection, histologically as well as clinically, 
 similar tumors of the suprarenal capsule. The tumor gradually dis- 
 places the parenchyma of the kidney, and when the pelvis and the 
 ureter are reached it produces obstruction to the flow of urine secreted 
 by the intact part of the kidney. Eventually the tumor may perforate 
 the capsule of the kidney and extend to the adjacent organs. Lymphatic 
 infection takes place at a comparatively late stage. If the tumor is 
 large, it may produce intestinal obstruction by extending to the colon 
 or by pressure. Hematuria is a frequent symptom after the tumor has 
 invaded the pelvis of the kidney. 
 
 During life it would be, of course, impossible to distinguish a carci- 
 
376 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 noma from a sarcoma. Advanced age and a nodular tumor would lead 
 us to suspect carcinoma. James Israel discovered by palpation a car- 
 cinoma of the kidney not larger than a cherry, removed the kidney, 
 and the specimen confirmed the diagnosis. The average surgeon would 
 
 Fig. 255. — Topography of the renal region (after Esmarch) : Mc, trapezius muscle ; Mid, latissimus 
 dorsi ; SJ>, sacro-lumbalis ; Ql, quadratus lumborum ; Oe, external oblique ; Oi, internal oblique ; Tr, trans- 
 versalis ; Fid, lumbo-dorsal fascia ; R, kidney; C, descending colon. 
 
 have difficulty in detecting a tumor the size of a walnut, and conse- 
 quently it is not very probable that another such early diagnosis will 
 soon be recorded. If a diagnosis of the probable existence of a malig- 
 nant tumor of the kidney can be made, it is the duty of the surgeon to 
 make careful search concerning the condition of the opposite organ, 
 and if this is satisfactory a radical operation is indicated if the disease 
 has not extended beyond the capsule of the kidney. Partial removal 
 of the kidney for malignant disease is not permissible. 
 
 Nephrectomy for Carcinoma of the Kidney. — The location of the 
 kidney and its relations to the parts concerned in lumbar nephrectomy 
 are shown in Figure 255. An accurate knowledge of the topographical 
 anatomy of the renal region is an essential prerequisite in the perform- 
 ance of lumbar nephrectomy. A carcinomatous tumor of the kidney 
 too large for the lumbar operation has in all probability reached the 
 inoperable stage. The lumbar operation is therefore the one that will 
 usually be selected to remove a carcinomatous kidney. The operation 
 of nephrectomy was devised and performed in 1871 by Simon. The 
 incision named after him was in reality planned by his pupil, Dr. Hotz, 
 now of Chicago. One of two incisions is usually selected for the removal 
 of the kidney through the lumbar region. Simon's incision, which gives 
 the best access to the hilus of the kidney, is commenced over the eleventh 
 
 
CARCINOMA. 377 
 
 rib, at the outer margin of the sacro-lumbalis muscle, and is extended 
 in a downward direction to a point halfway between the last rib and 
 the crest of the ilium. If more room is needed, the incision can be 
 extended farther down. Konig's incision, which affords the most room, 
 extends from the twelfth rib, at the margin of the sacro-lumbalis muscle, 
 directly down to near the crest of the ilium ; it is then carried in a 
 curve in the direction of the umbilicus to the outer margin of the rectus 
 muscle. To enlarge the space between the last rib and the crest of the 
 
 Fig. 256. — Position of patient and location of incision for lumbar nephrectomy according to Simon's 
 
 method. 
 
 ilium a firm round cushion should be placed between the chest and 
 the pelvis on the opposite side, and the patient is placed on that side 
 (Fig. 256). The different muscular layers are divided separately, and all 
 hemorrhage is carefully arrested before the fatty capsule of the kidney 
 is opened. When the kidney has been reached the upper half is first 
 separated with the index finger ; then the kidney is seized with three 
 fingers, drawn forward, and carefully isolated all around ; when the 
 hilus is reached the ureter and vessels are exposed by blunt dissection ; 
 all these structures are ligated en masse, and the kidney is separated by 
 a cut at a safe distance from the ligature, after which ureter and vessels 
 are ligated separately. Iodoform-gauze drainage and suturing of the 
 balance of the wound complete the operation. 
 
 We have every reason to believe that if a diagnosis of renal carci- 
 noma could be made at a time before the tumor has extended beyond 
 the capsule and before it has given rise to regional infection, a nephrec- 
 tomy would yield better results than most of the operations for carci- 
 noma in other localities. Under such circumstances the removal of all 
 carcinomatous tissue by a nephrectomy would be assured. 
 
XVII. FIBROMA. 
 
 Fibroma is a representative mesoblastic tumor. Connective tissue, 
 which is found in all parts and organs of the body, is its prototype. 
 We shall include in this class of tumors also the benign endothelial 
 tumors, which have been described as endothelioma because the con- 
 nective tissue and endothelial cells have a common embryonic origin. 
 Histological investigations have shown that in the connective tissue 
 may be formed, independently of pre-existing blood-vessels, vascular 
 spaces lined with endothelial cells derived from connective tissue ; and 
 it is well known that during the cicatrization of blood-vessels after 
 ligature and during plastic inflammation of serous surfaces endothelial 
 cells are converted into permanent connective tissue. Fibroma imitates 
 the normal connective tissue in the arrangement of its fibres. If the 
 tumor is soft, the elastic fibres and connective-tissue corpuscles are 
 arranged loosely and the cells are separated from one another by an 
 abundance of intercellular substance (Fig. ., 
 
 257). In hard fibromata the areolar struc- fill 
 
 ture is lost, and the tumor presents to the 
 
 Fig. 257. — Subcutaneous areolar tissue (after Piersol) : c, c, 
 some of the connective-tissue corpuscles ; w, migratory cells ; 
 v, plasma-cells ; e, elastic fibres. 
 
 Fig. 258. — White fibrous tissue; one 
 end of the bundle has been teased to 
 display the component fibrillae (after 
 Piersol). 
 
 eye and to touch the appearance of firm white fibrous tissue in which 
 the fibrillae form bundles that run parallel, but more frequently inter- 
 lace, forming coarser or finer meshworks (Fig. 258). 
 
 Fibromata occur in every part of the body supplied with connective 
 tissue and blood-vessels. 
 
 378 
 
FIBROMA. 379 
 
 Definition. — A fibroma is a tumor composed of mature fibrous 
 tissue derived from a matrix of fibroblasts. This definition excludes 
 from this class of tumors all swellings of infective origin and all benign 
 tumors in which the predominating histological elements are not con- 
 nective-tissue fibres, but epithelial cells. Virchow included elephantiasis 
 and molluscum fibrosum among the fibrous tumors. We exclude these 
 affections because their infective origin has been demonstrated satisfac- 
 torily. A great deal of confusion has been caused by some pathologists 
 who continue to describe a papilloma as a fibroma. In papilloma the 
 epithelial cells compose the essential part of the tumor, the tumor develops 
 from a matrix of epithelial cells, and the fibrous central part is fur- 
 nished by pre-existing connective tissue which, under the stimulus fur- 
 nished by the proliferating epithelial cells, undergoes hypertrophic changes. 
 We shall exclude from fibroma those tumors of the skin and the 
 mucous membranes that have an epithelial origin and in which the epi- 
 thelial cells take an active part in the growth of the tumor. These 
 tumors have been described in a previous section of this work as 
 papillomata. The connective tissue is the tissue chiefly predisposed to 
 inflammation, and the frequency with which infections of all kinds occur 
 in the connective tissue makes it often exceedingly difficult to distin- 
 guish practically between an infective swelling and a fibroma. It is for 
 this reason that the adjective mature has been used in this definition. 
 Connective-tissue corpuscles in inflammatory products do not reach 
 the same degree of maturity as in fibroma, even if the inflammatory 
 process is ever so chronic. Fibro-sarcomata, which by Paget and others 
 have been described as fibroid tumors with a tendency to recurrence, 
 are composed of connective tissue which has nearly, but not quite, 
 reached maturity. 
 
 " Fibroid," " desmoid," " corps fibreux," are synonyms which even 
 at the present time are occasionally used in place of fibroma. 
 
 Histogenesis and Histology. — The matrix of a fibroma is a group 
 of congenital fibroblasts which in the embryo were set aside, failed to 
 reach maturity, and remained in the connective tissue in a latent condition 
 until, under the influence of local or general causes, they were placed in 
 a condition to assert their intrinsic capacity to proliferate. If we imagine 
 a number of embryonic connective-tissue cells arrested in their develop- 
 ment and unutilized in the embryo, remaining in their primitive condition 
 awaiting favorable conditions for their growth and reproduction, we can 
 readily understand how in later life they would result in the production 
 of tissue of a character differing from, although similar in structure to, 
 the surrounding tissues (see Fig. 2, p. 28). Arrest of differentiation 
 would affect the intercellular substance as well as the cells. From 
 
3 8o 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 an embryological standpoint a fibroma is never a heterologous or a 
 heterotopic tumor, as connective tissue is found in all parts and 
 organs of the body. A matrix of fibroblasts undoubtedly forms 
 frequently in scars following wounds and injuries of all kinds and in 
 the healing process after the subsidence of inflammatory affections. 
 Keloid and other fibroid tumors of scars must have such an origin. 
 A fibroma is always encapsulated, and can readily be enucleated. 
 If it is located underneath a mucous membrane, the tumor-tissue fre- 
 quently becomes oedematous. On section the surface shows a number 
 of bands and bundles of connective tissue interlacing in all directions 
 
 without any definite arrangement. The cut 
 surface often shows concentric arrangement 
 of the connective tissue in different parts of 
 the tumor, as though the tumor had been 
 growing from different centres. Billroth has 
 shown that the centre of these concentric 
 masses corresponds with the location of a 
 blood-vessel. The firmness of the tumor 
 depends on the amount of intercellular sub- 
 stance and the degree of compactness of the 
 tumor-tissue. In the hard variety the tumor is almost as firm to the 
 
 Fig. 259. — Hard fibroma from fascia 
 of rib (after Liicke). 
 
 Fig. 260.— Fibrous tumor from the antrum of Highmore; X 450 (after D. J. Hamilton) : a, fusiform nucleus; 
 b, younger nucleus of an oval shape ; c, isolated fibroblast. 
 
 touch as cartilage, the intercellular substance is very scanty, and the 
 fibrillae are compactly arranged in wavy bundles or the fibres have a 
 
FIBROMA. 381 
 
 concentric arrangement as shown in Figure 259. Sections under the 
 microscope show that the wavy bundles of white fibrous tissue interlace 
 and surround blood-vessels. On each bundle lies an oval or fusiform 
 connective-tissue nucleus, as on any other fibrous tissue (Fig. 260). 
 The younger parts of the tumor show young connective-tissue cells 
 of round or oval shape. 
 
 The firmness and the histological structure of the tumor are not 
 affected by the amount or the character of the connective tissue in 
 which the tumor is developed, A fibroma in firm fascia may be soft, 
 while a tumor in a soft vascular organ may be very dense. Fibroma 
 in the soft parenchyma of the kidney may be very firm and be scantily 
 
 
 
 Fig. 261. — Fibroma of the kidney; X 38 (after Karg and Schmorl). The renal tissue (a), which contains 
 intact uriniferous tubules and glomeruli, is sharply separated from the tumor (b), which is composed exclu- 
 sively of vascular fibrillated tissue. The bundles of fibrous tissue interlace in all possible directions, and 
 include moderately numerous nuclei, which, according to the direction of the section, appear round or spindle- 
 shaped. 
 
 supplied with blood-vessels, although surrounded on all sides by an 
 exceedingly vascular tissue (Fig. 261). In typical fibroma the vessels 
 are small and scanty. In a special form of fibroma — vascular spaces, 
 containing venous blood, that appear anatomically as a transition form 
 between angioma and fibroma — the atypical vascularization of the 
 tumor reaches the highest degree. Rindfleisch classifies this rare form 
 of cavernous fibroma with the fibromata. Nothing- is known regarding 
 the existence of lymphatics in fibroma, but it is probable that they are 
 present in the soft variety. Nerves are probably not present in fibroma, 
 
382 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 but if present, they are pre-existing nerves from the sheath of which 
 the tumor has developed. In fibroma of the uterus muscle-fibres are 
 so constantly found that Virchow classified fibrous tumors of the uterus 
 with the myomata. 
 
 Retrograde Metamorphoses. — One of the frequent retrograde 
 changes found in fibroma is myxomatous degeneration, due, in part at 
 
 FlG. 262. — Myxomatous fibrous tumor of the deep fascia of the neck; X 45° (after D. J. Hamilton). 
 
 least, to oedema of the intercellular spaces (Fig. 262). The tumor 
 undergoing this change becomes softer, and in the course of time there 
 
 may form cysts with mucous or serous con- 
 tents. This form of degeneration is observed 
 very frequently in submucous fibroma. In 
 cystic myofibroma of the uterus there form 
 cysts, often of enormous size, which it is im- 
 possible sometimes to distinguish from ovarian 
 cysts. 
 
 Calcareous degeneration occurs in one of 
 two ways : the tumor is either coated with 
 a thin, rough, nodulated layer of a chalky 
 substance, or a similar substance is deposited 
 more abundantly throughout the tumor (Fig. 
 263). Calcification is preceded by coagulation- 
 necrosis, and the place occupied by the tumor- 
 tissue is taken by the earthy salts. Further 
 growth of the tumor in parts which have 
 undergone calcification is arrested. 
 
 Fig. 263. — Calcareous deposit 
 in a fibrous uterine tumor (after 
 Dusseau). 
 
 Colloid degeneration does not occur in 
 
 fibroma, as Mr. Symmonds has shown that it 
 never takes place in the absence of epithelial cells. Fatty degeneration 
 
FIBROMA. 
 
 383 
 
 is not as constantly found in fibroma as in epithelial tumors, but occa- 
 sionally it not only takes place, but it may destroy large portions of 
 the tumor. 
 
 The tumor when exposed to external irritation is subject to ulcer- 
 ation. Infection and suppuration may occur without exposure of the 
 tissue of the tumor to direct 
 infection by ulceration or in- 
 jury. Gangrene may occur if 
 in a pedunculated tumor the 
 pedicle is twisted or the prin- 
 cipal artery becomes blocked 
 by a thrombus. Transforma- 
 tion of the tumor-tissue into a 
 higher type is occasionally ob- 
 served in fibroma. Ossification 
 has been seen most frequently 
 in fibrous tumors attached to 
 bone (Fig. 264). It is difficult 
 to decide in such cases whether 
 the new bone is produced by 
 transformation of fibrous tissue, 
 or whether — what seems more 
 probable — it is produced by 
 displaced osteoblasts. 
 
 Etiology. — Fibroma alone or in combination with other tumors — 
 lipoma, angioma, adenoma — appears sometimes as a congenital tumor. 
 Old age predisposes to epithelial tumors, while the aptitude for fibroma 
 is lessened after the age of from thirty-five to forty years. The production 
 of fibroma of the lobe of the ear by the wearing of ear-rings, of keloids 
 in scars, and of desmoids in the abdominal wall of childbearing women, 
 would indicate that trauma and irritation are potent factors in the etiology 
 of fibroma. Virchow describes and recognizes an hereditary fibromatous 
 disposition, and he alludes to an instance of the occurrence of multiple 
 subcutaneous fibromata in members of the same family in three con- 
 secutive generations. 
 
 Symptoms and Diagnosis. — The growth of a fibroma is always 
 slow. A simple, uncomplicated fibroma attains a certain limited size 
 and then remains stationary. The large cystic fibroids described in 
 some of the older text-books were sarcomata, as it is often stated that 
 the tumor reached the size of a child's head in a year or less. Fibroma 
 never pursues such a rapid course. Uterine myofibromata grow more 
 rapidly than simple fibroids, are more vascular, and the muscular fibres 
 
 Fig. 264. 
 
 Ossification in a periosteal fibroma of the 
 lower jaw (after Lucke). 
 
384 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 constitute the most important part of the tumor-tissue. The tumor is 
 smooth and is always well encapsulated, hence movable unless restrained 
 by adj oining firm resisting tissues. A fibroma of the breast can be moved 
 among the tissues between two fingers without moving the gland — an 
 important point in the differential diagnosis between fibroma and carci- 
 noma. The tumor displaces, but does not infiltrate, the adjoining tissues. 
 The pressure of a periosteal fibroma frequently results in great displace- 
 ment of the bone by bending and by pressure-atrophy. If the tumor 
 occupies a cavity, it may interfere with important functions. A fibroma 
 of the nasal cavity interferes with respiration, and, when it reaches the 
 pharynx, with speech and deglutition. A fibroma of the uterus, if 
 submucous, causes hemorrhage ; if subserous, it may by its size affect 
 important functions. Pain and tenderness are absent unless the tumor 
 is intimately connected with a sensitive nerve or unless it has become 
 complicated by infection and inflammation. In fibroma ulceration is 
 less likely to take place than in papilloma, because the tumor is covered 
 at least by skin or by mucous membrane. If the skin or the mucous 
 membrane becomes atrophied from pressure, ulceration is likely to 
 ensue, commencing in that part of the surface in which nutrition has 
 become most impaired. 
 
 In differentiating a fibroma from a papilloma it is important to trace 
 the tumor by the aid of its clinical history and by a careful examina- 
 tion as to its origin in the mesoblastic tissues. A papilloma of the 
 skin commences on the surface as an increase in the thickness of the 
 epithelial layer of the skin ; the papillary projections develop in conse- 
 quence of an accompanying hyperplasia of the underlying pre-existing 
 connective tissue. In fibroma of the skin the tumor starts in the con- 
 nective tissue underneath the layer of epithelial cells, and pushes this 
 layer before it. A fibroma of the skin is therefore less liable to become 
 pedunculated than is a papilloma. A fibroma only becomes peduncu- 
 lated if the skin over it is yielding, and after the tumor has attained at 
 least the size of a pea or a cherry. In pedunculated fibroma the skin 
 which covers the tumor becomes atrophic, smooth, and glassy, while in 
 papilloma the epithelial structures increase with the size of the tumor. 
 In deep-seated fibroma the diagnosis between it and sarcoma is deter- 
 mined by the clinical history and, if need be, by the removal of a frag- 
 ment of tissue with a harpoon for microscopical examination. In cystic 
 fibroma the use of the exploratory needle will often determine the cha- 
 racter of the tumor. 
 
 Prognosis. — Fibroma may at any time undergo transition into a 
 sarcoma. As Virchow says, " A fibroma only needs an increase in the 
 size of its cells and a diminution of the cement-substance to change it 
 
FIBROMA. 385 
 
 into a sarcoma." The hard variety is less apt to undergo this change 
 than the soft, and particularly the pigmented, form. That irritation and 
 incomplete removal should hasten, if not determine, the transforma- 
 tion of a fibroma into a sarcoma no one would dispute. The young 
 connective-tissue cells in the periphery of the tumor require only the 
 addition of conditions which enable them to leave the parent-tumor 
 and to migrate into the surrounding connective tissue to become 
 sarcoma-cells. A pure fibroma does not attain large size ; hence the 
 prognosis, aside from the possibility of the tumor undergoing transfor- 
 mation into sarcoma, must rest on the importance of the location it 
 occupies. If it involve passages essential for important functions, the 
 obstruction it produces may prove a source of danger. Fibroma of 
 the respiratory and urinary passages affords an illustration in point. A 
 submucous fibroma of the uterus may become the cause of debilitating 
 and even fatal hemorrhages. A large interstitial fibroma of the uterus 
 may destroy life by the size of the tumor interfering with important 
 functions of the abdominal organs. 
 
 Treatment. — Operative treatment is indicated in fibroma in all cases 
 in which the tumor is accessible, as by the removal of the tumor the 
 patient is protected against a frequent cause of sarcoma. In uterine 
 fibroma an exception must be made to this rule, as the danger attending 
 the operation outweighs the risk of a possible transition of the tumor 
 into a sarcoma. In fibroma of the uterus other indications must 
 decide the necessity of operation. Fibromata should be removed by 
 enucleation. Excision is necessary if the tumor has ulcerated on the 
 surface or if the interior of the tumor has become infected and the 
 resulting inflammation has produced adhesions between its capsule 
 and the adjacent tissues. 
 
 Topography. 
 Skin. — Fibroma of the skin occurs most frequently about the face, 
 neck, shoulders, chest, and abdomen. It is of very slow growth, and 
 seldom exceeds in size a pecan-nut. It appears first as a swelling in 
 the connective tissue of the skin, which swelling projects toward the 
 surface, becoming more and more prominent until the skin at its base 
 becomes contracted and by the weight of the tumor elongated, resulting 
 in the formation of a pedicle. In the course of time this pedicle 
 becomes elongated and very slender. It contains in its centre the 
 principal artery of the tumor, which artery sometimes, in consequence 
 of an injury or of textural changes, becomes thrombosed — an accident 
 which results in gangrene of the tumor and a spontaneous cure. The 
 skin over the tumor atrophies, is thin and shining, and is usually thrown 
 
 25 
 
386 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 into longitudinal folds. The tumor is soft, and under the microscope 
 shows interlacing fibres with an abundance of intercellular cement- 
 substance. 
 
 The diagnosis can be made without difficulty, as in papilloma, which 
 is most frequently confounded with fibroma, the epiblastic part of the 
 tumor predominates, and instead of a smooth surface presents a warty 
 appearance. If the tumor has become pedunculated, it is connected 
 with the body only by a cylinder of skin, which can be clipped with 
 scissors on a level with the skin, and the resulting wound can be sealed 
 with a cotton-collodion crust. If the tumor is sessile, the skin over it 
 or at its base is incised sufficiently to permit the removal of the tumor 
 by enucleation. 
 
 Mole. — A mole is a flat congenital fibroma of the skin. It is caused 
 by fibroblasts in excess in the connective-tissue portion of the skin. 
 Moles are usually pigmented, and giant growth is manifested by exces- 
 sive growth of the appendages of the affected part of the skin, the 
 hair, and the glands. Moles vary in size from that of a pin's head 
 to that of the palm of the hand or even larger. The increase in size 
 after birth reaches its maximum during childhood and up to the age 
 of puberty, when the tumor generally becomes stationary. A mole 
 is exceedingly prone to undergo transition into a carcinoma or a sar- 
 coma, and for this reason should be removed if the area involved is not 
 too extensive. A carcinoma or a sarcoma starting in a mole is usually 
 pigmented ; the resulting malignant tumor is either a melano-carcinoma 
 or a melano-sarcoma — both of them exceedingly malignant growths, and 
 very prone to early diffuse regional infection and general dissemination. 
 
 Spontaneous Keloid. — Under the term keloid Alibert described in 
 1 8 14 an affection of the skin characterized by hyperplasia of the sub- 
 epidermal connective tissue, with a strong inherent tendency to return 
 after extirpation. He classified keloid into germinal and scar keloid. 
 This affection was later described by Schwimmer, Kaposi, Deneriaz, 
 and Warren. For some time doubt existed as to the occurrence of 
 spontaneous keloid, owing probably to the rarity of the affection. A 
 sufficient number of cases have, however, been recorded by reliable 
 observers in which the clinical history revealed no antecedent scar. 
 Warren divided keloid into (1) true keloid, (2) scar keloid, (3) hyper- 
 trophic scar. Warren claimed that the new connective tissue is pro- 
 duced by proliferation of the tissues of the adventitia of blood-vessels, 
 as he found numerous round cells around blood-vessels, which he 
 claimed were later transformed into connective tissue. From an ana- 
 tomical standpoint he distinguished a scar keloid from a true keloid by 
 the absence of papillae in the former. According to Kaposi, the true 
 
FIBROMA. 
 
 387 
 
 keloid occurs about once in every 2000 cases of skin affections of all 
 kinds. It is found most frequently upon the sternum and upon the 
 trunk, although occasionally the limbs, and especially the fingers and 
 toes, are the seat of the disease. Nasse and Volkmann saw each a 
 
 i 
 
 Fig. 265. — Spontaneous keloid (after Thorn). 
 
 case of multiple keloid of the fingers and toes. In Nasse's case 
 repeated excisions of the tumors of the toes finally made removal of 
 two toes by exarticulation necessary. The compact connective-tissue 
 bundles of which a keloid is composed are found in the deeper 
 layers of the corium. The* fibers are arranged, as a rule, parallel to 
 
 
 Fig. 266. — Blood-vessels and tumor-tissue as seen in spontaneous keloid (after Thorn). 
 
 the surface, and contain spindle-shaped nuclei ; some of the fibers 
 take an opposite course — this is especially the case near the sur- 
 face of the tumor underneath the epidermis (Fig. 265). Thorn never 
 saw in any of his specimens any indications that the fibers are derived 
 
388 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 from the vessel walls. The round cells which are found interspersed 
 between the keloid tissue Thorn is inclined to believe are the product 
 of an inflammatory process near the surface of the tumor. The new 
 tissue is unquestionably derived from the pre-existing connective tissue 
 of the corium under the influence of an as yet unknown cause. The 
 appearance of blood-vessels and the arrangement of fibers around 
 them are well shown in Fig. 266. While keloid is an obstinate affection 
 to all kinds of local treatment, it differs from sarcoma in that it remains 
 limited to the tissues primarily affected and never gives rise to metas- 
 tasis. After having attained a certain size it often remains stationary 
 for an indefinite time. That such a tumor should occasionally undergo 
 transformation into a sarcoma is not surprising considering the imper- 
 fect development of the tissues of which it is composed. 
 
 Scar Keloid. — Another variety of fibroma in the skin is the fibrous 
 tumor which starts in scar-tissue following a wound, the healing of a 
 
 &■■■ 
 
 Fig. 267.— Large keloid of the neck. 
 
 burn, or other surface lesions, particularly tubercular ulcers. Alibert in 
 18 14 was the first to describe this fibrous tumor, and from its resemblance 
 to carcinoma he called it " keloid." Keloid resembles clinically some of 
 the granulomata, and under the microscope it is a compromise between 
 a fibroma and a sarcoma. Its frequent occurrence in tubercular scars and 
 
FIBROMA. 
 
 389 
 
 in minute scars resulting from small punctured wounds has led the 
 writer to suspect that it might represent a particular form of tuber- 
 cular inflammation. We are, however, not in a position to prove its 
 tubercular origin and nature, and its clinical behavior would certainly 
 tend to negative the idea that it is a form of sarcoma. For the present 
 we must include it among the fibromata, although strongly inclined to 
 believe that before long it will have to be classified with the infective 
 swellings. The colored race is peculiarly predisposed to keloid. The 
 sting of an insect, the prick of a needle, or a small abrasion frequently 
 acts as the exciting cause. The wearing of ear-rings is also a frequent 
 cause. 
 
 The patient whose photograph is shown in Fig. 267 was the sub- 
 ject at the same time of numerous keloids of the skin of the chest and 
 of the back. 
 
 Keloid sometimes affects different parts of the body at the same 
 time, but always develops in a scar, which may be so small as to elude 
 detection (Fig. 268). The tumor slowly 
 increases in size up to a certain point, and 
 after having remained stationary for from 
 ten to twenty years may slowly disappear 
 — one of the strongest proofs that it is not 
 a true tumor. The keloid tissue is charac- 
 terized by its great vascularity as compared 
 with other fibromatous tumors and by the 
 existence of numerous connective-tissue 
 spaces lined with endothelial cells. The 
 inflammatory part of a keloid is shown by 
 the numerous leucocytes in the perivascular 
 spaces. From the structure of a keloid it 
 would be reasonable to assume that occa- 
 sionally it is transformed into a sarcoma. 
 The benign clinical aspects of a keloid 
 render it easy to distinguish between it and 
 a malignant tumor of the scar-tissue. 
 
 The treatment of keloid is extremely unsatisfactory. External appli- 
 cations and compression are useless. Recurrence even after thorough 
 extirpation is common. The only treatment is by thorough excision. 
 The incisions should include a zone of apparently healthy tissue at least 
 a few lines in width. The scar following the operation should be pro- 
 tected carefully for a long time. 
 
 Mucous Surfaces. — Fibroma of the mucous surfaces resembles 
 that of the skin in every respect except that the surface of the tumor 
 
 Fig. 268. — Multiple keloid in a colored 
 woman (after Taylor). 
 
 
39° PATHOLOGY AND TREATMENT OF TUMORS. 
 
 is covered by mucous membrane instead of by skin, and that the tumor 
 in this locality is more prone to oedema. Many of the polypoid growths 
 in mucous channels are cedematous fibromata. If pendulous, they 
 should be removed with the wire ecraseur; if sessile, by excision or 
 by enucleation. 
 
 Subcutaneous Connective Tissue. — Two kinds of fibroma, clinically 
 distinct, are met with in the subcutaneous connective tissue — the pain- 
 ful tubercle and the soft multiple fibroma of Recklinghausen. 
 
 Painftil Subcutaneous Tubercle. — This is a little hard tumor, not 
 larger than a pea, noted for its painfulness, in the subcutaneous tissue. 
 This tumor was first described by A. Petit, Cheselden, and Camper. 
 The best description was given in 1812 by Mr. Wm. Wood. These 
 tubercles are most frequent in the extremities, especially the lower. 
 They are more frequent in women than in men, they rarely occur 
 before adult life, and they are seldom multiple. Examined under the 
 microscope, they are seen to be composed of dense fibrous tissue, with 
 filaments laid inseparably close together in the fasciculi and compactly 
 interwoven. The young cells in the periphery of the tumor contain 
 large nuclei. The pain and tenderness appear either contemporane- 
 ously with the tumor or after the tumor has reached a certain size. 
 The pain, which is usually paroxysmal, but which can always be pro- 
 voked by pressure, is sometimes attended by muscular spasms. Vel- 
 peau regarded these tumors as neuromata. Dupuytren, who made 
 several very careful dissections, was never able to trace their connection 
 with nerve-fibres. Other surgeons have succeeded in finding the nerve- 
 filaments with which these tumors are connected. In one case the 
 writer could trace the nerve from the capsule of the tumor on both 
 sides. The nerve was no larger than a fine silk ligature. There can 
 be no doubt that these tumors are connected with sensitive nerve-fila- 
 ments. Their removal by excision is often followed by recurrence. 
 Successful removals of recurrent painful tubercles are reported by Sir 
 James Paget and by Mr. Lawson Tait. 
 
 Multiple Subcutaneous Fibroma. — The true pathology of multiple 
 fibrous tumors of the subcutaneous tissue was pointed out in 1882 by 
 Recklinghausen. He ascertained that these tumors are invariably 
 connected with the sheaths of terminal nerves. They are sometimes 
 congenital, but they usually develop after puberty. In number they 
 vary from a few to more than a thousand. In the case of Michael 
 Lawler, described in Smith's monograph, they were estimated at least 
 at two thousand. This affection was formerly known as " molluscum 
 fibrosum " (PL 8, Fig. 2). In size these tumors vary from that of a 
 hemp-seed to that of a filbert. In the course of time some of the 
 
FIBROMA 
 
 Plate 9. 
 
 
 . 1. Keloid of external ear (after Klebs) : «, dense fibrous cutis tissue with wide juice-canals endothelial 
 lining, and hyaline ground substance ; 6, fibrillated connective tissue with abundance of cells w 1 ' laS el 
 
 perivascular proliferation, and at different^places wide juice-canals ; c, attenuated epiderm ' 
 
 in part disappeared. (Obj. 5, oc. 3.) 2. Multiple subcutaneous fibromat? 
 
 pap 
 
 mg 
 
FIBROMA. 
 
 Plate io. 
 
 
 Multiple neuro-fibroma, early stage (after Klebs) : a, outer, *, inner nerve-sheath with endothelial hollow 
 spaces ; c, nerve-substance. (Zeiss, E. 2.) 
 
FIBROMA. 391 
 
 tumors become pendulous. Histologically, these tumors are composed 
 largely of fibrous tissue around and between bundles of nerve-fibres. 
 On Plate 10 a number of nerve-bundles can be seen cut transversely. 
 The connective tissue between the nerve-bundles has been changed 
 but little ; perhaps the connective-tissue spaces are somewhat dilated. 
 Small round groups of nuclei stained blue with hematoxylin show 
 the transverse cuts of blood-vessels. The connective tissue is greatly 
 increased in the nerve-sheaths. The nuclei of the cells are oblong, 
 oval, crowded closely together in the larger bundle (3), while the sheath 
 of the smaller bundle contains fewer nuclei. The nerve-sheath can in 
 many places be distinguished into an outer and an inner (a and b), as 
 there can be seen between the fibres of the sheaths, arranged trans- 
 versely, spaces which do not occupy in a continuous manner the entire 
 periphery ; there can also be seen, on the inner surfaces of the sheath, 
 spaces which at some points are quite wide, and which (at 3) show oval 
 nuclei in their walls. These spaces are in contact with the nerve-fibres 
 and are traversed by delicate connective-tissue threads. In the longi- 
 tudinal section (at 2) they can be seen in the same form. During the 
 growth of the tumor the interstitial connective tissue proliferates and 
 the nerve-bundles are separated more widely. Clinically these tumors 
 form a contrast with the painful subcutaneous tubercle by the absence 
 of pain and tenderness and by their multiplicity. Owing to the multi- 
 plicity of the tumors operative treatment is contraindicated. Should 
 any of the tumors manifest malignant qualities, early and thorough 
 excision is urgently indicated. 
 
 Abdominal Wall. — A peculiar form of deep-seated fibroma of the 
 abdominal wall was first described by Nelaton. In his cases the tumors 
 either occupied the iliac fossa or were located near the crest of the 
 ilium. These places are the favorite localities, but the sheath of the 
 rectus muscle is also not infrequently the starting-point of fibroma 
 of the abdominal wall. The primary starting-point is most frequently 
 near the peritoneum, so that the tumor projects at the same time 
 into the peritoneal cavity, pushing the peritoneum before it while it 
 becomes prominent on the surface. More than sixteen years ago 
 Gratzer advanced the theory that these tumors originate at a point 
 where the mesoblast divides into the peritoneum and the fibro-mus- 
 cular layer. It is most frequently met with in women after delivery. 
 W. Kramer reports a case in which the tumor was congenital. The 
 patient was a girl four and a half years of age. Examination of the 
 tumor after its removal showed that the congenital dermoid had 
 recently been transformed into a sarcoma. Among 42 cases col- 
 lected by Guerrien there were 39 women and only 3 men. Of the 
 
392 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 4 cases which have come under the writer's observation, all were 
 women, and in each of them the tumor appeared soon after child- 
 bed. As compared with other tumors of the abdominal wall, fibroma 
 occurs most frequently. Of 70 cases collected by Sanger, 60 were 
 fibromata. More recently Dannhauer has collected 183 cases. The 
 most important determining cause appears to be trauma. The great- 
 est confusion has existed in regard to the proper classification of these 
 
 2**As*t 
 
 & 
 
 w &li&r*^&--a*j **/ />./ /■■£;.# *\'yi 
 
 
 00. *. 
 
 
 Fig. 269. — Desmoid fibroma of the abdominal wall; X 330, reduced one-third (Surgical Clinic, Rush 
 Medical College, Chicago) : a, tumor-tissue ; b, striated muscle-fibres in cross-section : the striae have disap- 
 peared, and the muscle is degenerating and is infiltrated with young connective-tissue cells. 
 
 tumors. Some authors are inclined to regard them as a variety of 
 fascial sarcoma. Their clinical course and histological structure do not 
 justify their classification with the sarcomata. They seldom recur after 
 thorough extirpation, and their histological structure bears a closer 
 
 
 
 Fig. 270. — Vessel in a desmoid fibroma of the abdominal wall; X 330 (Surgical Clinic, Rush Medical 
 College, Chicago) : a, vessel-wall. 
 
 resemblance to fibroma and keloid than to sarcoma. To distinguish 
 them from ordinary fibroma it is well to retain the name desmoid, 
 

 FIBROMA. 393 
 
 a term applied by Miiller to benign connective-tissue tumors (Fig. 
 269). The tumor-tissue is composed of young connective-tissue cells 
 with a scanty intercellular substance. The cells infiltrate the adjacent 
 tissues besides displacing them, in this respect differing materially from 
 ordinary fibroma. The walls of the new blood-vessels in the tumor 
 display an intimate relation with the tumor-tissue (Fig. 270). The 
 endothelial cells lining the new blood-vessels are large, and the tumor- 
 tissue forms the greater part of the vessel-wall. 
 
 3* 
 
 L 
 
 - ~~ '"-^:-^"~ '-~^' 
 
 Fig. 271. — Relations between vessel-wall and tumor-tissue in a desmoid fibroma of the abdominal wall; 
 X 330, reduced one-third (Surgical Clinic, Rush Medical College, Chicago) : a, junction of vessel-wall and 
 tumor-tissue. 
 
 From the histological description of a desmoid tumor as given 
 above it is evident that the encapsulation of the tumor is imperfect — 
 an important point to be remembered in the operative treatment of such 
 tumors. Desmoid tumors increase quite rapidly in size, sometimes 
 reaching from the umbilicus to the pubes and from the anterior superior 
 spinous process of the ilium to the median line. In three of the writer's 
 cases the peritoneum was firmly attached and had to be excised with 
 the tumor. 
 
 Enucleation of the tumor is liable to be followed by recurrence. In 
 two of the writer's cases the tumor started in the iliac region, and in 
 two in the sheath of the rectus muscle. All these cases recovered. 
 In one of them a recurrence made necessary a second operation, after 
 which complete recovery ensued. 
 
 The diagnosis is not always easy. If the tumor projects as much 
 in the direction of the abdominal cavity as externally, it might easily 
 be mistaken for an intra-abdominal tumor. The tumor moves with the 
 abdominal wall, but this is also the case if an abdominal tumor has 
 become attached to the parietal peritoneum anteriorly. The tumor is 
 
394 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 firm and can generally be outlined accurately. In the excision of a 
 desmoid tumor of the abdominal wall the surgeon must be prepared 
 to resect the peritoneum, and must therefore make all the preparations 
 required for abdominal section. The removal of such a tumor results 
 in great defect of the abdominal wall, which defect must be corrected 
 by suturing the peritoneum and the muscular layer separately with 
 buried catgut sutures, including at the same time all the tissues in the 
 deep sutures in order to approximate the surfaces of the wound accu- 
 rately, so as to prevent the subsequent formation of a ventral hernia. 
 As an additional safeguard it is necessary to instruct the patient to wear 
 a well-fitting abdominal bandage for from six months to a year after the 
 operation. 
 
 Nose. — Robert has shown that many of the naso-pharyngeal fibrous 
 tumors start from the anterior lacerated foramen, the basilar process of 
 the occipital bone, and even from the upper cervical vertebrae. The 
 fibrous polypus of the nose grows slowly, and after it has reached a 
 certain size protrudes in the direction of the nasal outlet or projects 
 into the pharynx. From pressure the nose often becomes flattened and 
 the mouth prominent, or the roof of the mouth is displaced downward. 
 Digital exploration of the naso-pharynx is important to determine the 
 exact location, size, and attachment of the tumor. If the tumor is not 
 pedunculated sufficiently to enable its removal by torsion, its operative 
 removal requires a bloody and often a dangerous preliminary operation 
 to reach its base. If the tumor is attached in front of the naso-pharynx, 
 the nostril is incised from within outward on the side of the septum as 
 far as the nasal process, as advised by Dieffenbach and Konig ; if this 
 incision does not afford sufficient room, the nasal process is temporarily 
 resected ; and if still more room is required, the upper lip is divided in 
 the median line and is dissected backward. If the base of the tumor 
 can be reached in this manner, the tumor is drawn forward with vulsel- 
 lum forceps and its attachment is severed with a narrow periosteal 
 elevator or with blunt-pointed scissors. All operations for the removal 
 of naso-pharyngeal growths requiring a preliminary bone operation 
 should be performed under partial anesthesia, or, as the writer has been 
 in the habit of calling it, " a talking narcosis." 
 
 Fibrous tumors of the nose and the naso-pharynx are exceedingly 
 vascular, and their removal is attended by profuse and even fatal hem- 
 orrhage, notwithstanding the employment of prompt and efficient 
 hemostatic precautions. In a case operated upon before the class in 
 Rush Medical College, Chicago, in 1893, the writer took the precaution 
 to make a preliminary tracheotomy. Two weeks later the operation 
 was commenced by ligating the common carotid. Kocher's temporary 
 
FIBROMA. 
 
 395 
 
 resection of the upper maxilla was then performed. The hemorrhage, 
 notwithstanding compression and the use of hemostatic forceps, was 
 alarming, and the patient nearly died upon the table from loss of blood. 
 
 Fig. 272. — Resection of nasal process of the superior maxilla (after Langenbeck) : a, external incision ; b, 
 line of section through nasal process. 
 
 Instead of slitting open the nostril, Langenbeck makes a curved 
 
 lateral incision through which he 
 resects the nasal process of the 
 superior maxilla (Fig. 272). If the 
 tumor obstructs both nasal passages, 
 temporary detachment of the nose 
 according to Rouge (Fig. 273) or 
 Oilier (Fig. 274) will afford better 
 access to the base of the tumor 
 than will the unilateral incision. 
 
 Fig. 
 
 273- 
 
 -Temporary detachment of the nose ac- 
 cording to Rouge. 
 
 Fig. 274. — Temporary resection of the nose accord- 
 ing to Oilier. 
 
 The bone-sections in making temporary resection of the nose 
 should be made with a sharp chisel instead of with a saw. After the 
 removal of the tumor the nose is replaced and the wounds are sutured 
 accurately with fine silk or with silkworm gut. Bruns makes tempo- 
 rary resection of the nose by displacing it laterally. The removal of 
 naso-pharyngeal tumors through the hard or the soft palate has 
 been practised by Manne (171 1), Dieffenbach, Hueter, and Nelaton. 
 Demarquay and Trelat resected through an external incision the nasal 
 process of the superior maxilla and the anterior wall of the antrum of 
 
39^ 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Highmore. The great deformity which followed this operation led 
 Langenbeck in 1861 to devise temporary resection of the upper maxilla. 
 Kocher has recently modified Langenbeck's operation. Temporary 
 resection of the upper maxilla after Langenbeck and Kocher is a diffi- 
 cult and an exceedingly bloody operation, and should never be lightly 
 undertaken. Konig lost a patient on the table from hemorrhage in 
 performing Langenbeck's operation, and the patient mentioned on page 
 394 barely escaped the same fate, and later succumbed to the effects 
 of the excessive loss of blood, although the common carotid artery 
 had been tied as a prophylactic hemostatic precaution. 
 
 In naso-pharyngeal fibrous growths every attempt should be made 
 to remove the tumor by less heroic measures than extirpation through 
 the hard palate or after temporary resection of the upper maxilla, by 
 the use of the wire ecraseur or the galvano-caustic sling, the formal 
 operation being reserved for the most desperate cases. 
 
 Tumors of the base of the skull which are behind the maxilla and 
 grow into the temporal fossa can be removed only after a temporary 
 resection of the maxilla. 
 
 Mammary Gland. — Most of the tumors that have been described 
 as fibroma have been cases of adenoma. If the tumor contains any 
 adenomatous tissue, it is an adenoma and not a fibroma, no matter 
 how much fibrous tissue it may contain. Pure fibromata of the mam- 
 
 Fig. 275. — Fibroma of the mammary gland ; X 250 (after Perls). The fibrous tissue is swollen ; the spaces 
 with the nuclei appear as connective-tissue corpuscles ; a, a, remnants of gland-ducts. 
 
 mary gland are exceedingly rare. They start in the interacinous or 
 intertubular connective tissue, grow very slowly, and never attain large 
 size. Pain and tenderness are either entire-ly absent or, when present, 
 are not well marked. The fibrous tissue may surround and include 
 pre-existing gland-ducts, in which event the cells become destroyed by 
 pressure-atrophy, and the ducts in the course of time may become com- 
 pletely obliterated (Fig. 275). 
 
FIBROMA. 
 
 397 
 
 Differential diagnosis between fibroma of the breast and adenoma 
 is impossible without the use of the microscope. Fibroma is distin- 
 guished from sarcoma and carcinoma by its slow growth and by the 
 mobility of the tumor in the tissues of the gland. Fibroma of the 
 breast should be removed by enucleation. The recurrent fibroid tumor 
 of the breast described by Paget is a spindle-celled sarcoma. 
 
 Uterus. — Fibroma of the uterus as a purely fibroid growth is ex- 
 ceedingly rare. With few exceptions the tumor contains muscle-cells, 
 and has been described in the section on Myoma. 
 
 Fig. 276. — Fibroma of both ovaries ; the right is as large as a kidney, the left larger than a child's 
 head (after Winckel) : a, surface of tumor on left side, with numerous nodules ; b, fundus of uterus ; c, sur- 
 face of tumor on right side ; d, section of right ovary ; e, os uteri ; f, surface of left ovary ; g, cut surface 
 of tumor on left side. 
 
 Ovary. — Fibromata of the ovary are so rare that Sutton regards 
 them as pathological curiosities. The writer has met with two such 
 cases. In one of them the tumor was recognized ten years before the 
 
398 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 operation. The operation was postponed until the patient was driven 
 to it by a very extensive ascites. The pedicle of the tumor was slender 
 and there were no adhesions. The tumor weighed twenty pounds, was 
 very firm, and was nodulated on the surface. Sections under the micro- 
 scope showed nothing but wavy bundles of fibrous tissue interlaced 
 in all directions. The blood-vessels were few and small. In the sec- 
 ond case the tumor was about half as large and presented a similar 
 structure. The enlargement of the abdomen due to ascites in this 
 instance also induced the patient to submit to an operation. Both 
 patients recovered from the operation and remain well up to the present 
 time, the first twenty and the second two years after operation. In 
 both cases the peritoneum was exceedingly vascular — a condition 
 caused by its being thrashed, as it were, by the tumor, for a number, 
 of years. The writer has come to regard ascites as an important 
 diagnostic evidence of movable solid tumors of the ovary. Neither of 
 the tumors showed on section evidences of cystic degeneration. Occa- 
 sionally both ovaries are affected at the same time (Fig. 276). 
 
 Ascites is usually the first thing noticed by the patient, and it is 
 for this condition, and not for its cause, that the patient seeks relief. 
 Ascites in the absence of malignant disease of the pelvic or abdominal 
 viscera should remind us of fibroma of the ovary as the possible cause. 
 Fibroma of the ovary occurs most frequently in women between twenty 
 
 and forty years of age. Leopold 
 mentions 1 3 cases at from five to 
 thirty years of age, and only 4 
 at thirty to forty years. Ferrier 
 removed a fibroma of the ovary 
 from a woman seventy-six years 
 old. 
 
 The differential diagnosis be- 
 tween a fibroma of the ovary and 
 a desmoid cyst is difficult, and be- 
 tween a fibroma and a peduncu- 
 lated myofibroma of the uterus is 
 impossible, without an explora- 
 tory laparotomy. Removal by 
 laparotomy is a safe operation, 
 and if the tumor is completely 
 removed recurrence never takes 
 place. 
 
 Vulva. — Tumors are rare as compared with chronic infective swell- 
 ings of the vulva. Fibroma occurs less frequently than papilloma, 
 
 mm 
 
 Fig. 277. — Papilloma of the vulva; X 25 (Surgical 
 Clinic, St Joseph's Hospital, Chicago): a, stroma of 
 loose connective tissue ; b, blood-vessels ; c, epithelium ; 
 d, horny layer. 
 
FIBROMA. 399 
 
 is found more often upon the labium majus than upon the nymphae, and 
 appears first as a soft swelling with a broad base. It is of slow growth, 
 does not attain large size, and may become pendulous by elongation of 
 the skin covering it. Fibroma, which can be distinguished from papil- 
 loma by the smoothness and thinness of the overlying skin, is not as 
 often multiple as is papilloma. Sections of a papilloma show that the 
 greater part of the tumor is composed of epithelial cells attached to a 
 vascular stroma (Figs. 277, 278). A vertical section of a fibroma would 
 show the skin covering the tumor to be atrophied and the tumor-tissue 
 to be composed exclusively of interlacing fibres or bundles of fibres 
 of connective tissue. 
 
 Fibromata of the vulva may be enucleated, or their pedicles may be 
 cut, without danger of hemorrhage, as the blood-supply is scanty. 
 
 
 fcj 
 
 Fig. 278 — Periphery of tumor shown in Figure 276 (X J 4o) : a, stroma; b, blood-vessels; c, very thick 
 stratum of epithelial cells ; d, horny layer; e, loss of substance probably caused by degeneration. 
 
 Gums. — Formerly all tumors of the gums were included under the 
 name of " epulis." Microscopical examination of different tumors has 
 shown the necessity of differentiating between sarcoma, carcinoma, and 
 fibroma of the gums. Fibroma of the gums appears as a bone-swelling 
 covered by the mucous membrane ; the tumor grows slowly and does 
 not return after thorough removal. The term " epulis " should be 
 restricted to designate a fibroma originating from the gums or from the 
 periodontal membrane. Local irritation caused by a decayed tooth or 
 by incrustation upon the teeth is the most frequent exciting cause of 
 fibroma of the gums. The tumor is seldom larger than a walnut, and 
 its base is often constricted into a short pedicle. Mr. Hawkins made 
 the assertion that fibroma of the gums, the fibrous epulis, grows, like 
 
4-00 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 most of the other fibrous tumors, from the bone and periosteum and 
 continuous with them. 
 
 The radical removal of a fibroma of the gums can be effected only 
 by excision of the alveolar border of the jaw. This excision can be 
 done, after the extraction of one or more teeth, with the chisel or with 
 a narrow metacarpal saw. In benign fibrous tumors of the alveolar 
 border and the gums it is unnecessary to resect the jaw in its entirety, 
 as recommended by Gross and others. 
 
 Periosteum and Bone. — The maxillary bones are the most frequent 
 seat of fibroma. The fibrous tumor of these bones is very hard, has a 
 
 Fig. 279.— Distortion of dental arch caused by the tumor represented on Plate 10. 
 
 smooth surface, and is covered by skin and mucous membrane. Cystic 
 degeneration occasionally takes place. It is difficult to determine 
 whether these tumors start from the periosteum or from the connective 
 tissue of the bone. They do not infiltrate the bone to which they are 
 attached, but cause pressure-atrophy and distortion of the bone. 
 
 The tumor represented on Plate 1 1 (Fig. i) occurred in a man twenty 
 
FIBROMA. 
 
 Plate ii. 
 
 i. Enormous fibroma of the upper maxilla. 2. Showing condition of parts immediately after excision 
 
 of the tumor. 
 
FIBROMA. 401 
 
 years of age, and was first discovered when he was ten years old. In 
 1890 it was only partially removed through a small incision. Two 
 years before the operation the patient consulted a prominent surgeon, 
 who pronounced it a sarcoma and refused to operate. When the patient 
 came under the writer's observation the tumor had become very promi- 
 nent in the cavity of the mouth — so much so that deglutition and speech 
 were greatly affected. The tumor was removed, through the incision 
 shown on Plate 11 (Fig. 2); by enucleation, without any special diffi- 
 culty. The wound healed promptly, leaving a deep depression in the 
 right cheek, where the tumor had been most prominent. No recurrence 
 had taken place two years after the operation. Sections of the tumor 
 examined under the microscope showed the typical structure of a dense 
 fibroma. 
 
 Small fibromata of the jaw can be removed through the mouth, 
 but large tumors must be enucleated through an external incision. 
 
 Serous Surfaces. — Papillomatous and fibrous tumors of the serous 
 surfaces are rare, and their structure is very similar to that of the same 
 kind of tumors of the skin, except that in place of epithelial cells the 
 tumors are covered by endothelial cells — in the former variety by 
 numerous strata, in the latter usually by a single layer. Benign fibrous 
 and endothelial tumors are found most frequently upon the peritoneum 
 and upon the synovial membrane of joints. When such a tumor 
 becomes pedunculated it is often detached and remains in the cavity 
 as a foreign body. 
 
 Cholesteatoma.- — Closely allied to psammoma is cholesteatoma, first 
 described by J. Miiller. It was later described by Cruveilhier as tumeur 
 perlee, or pearl tumor. The tumors do not exceed in size a cherry. 
 They present a pearl-like metallic lustre, and they are found most fre- 
 quently at the base of the brain, imbedded in the tissues of the pia 
 mater. In this locality these tumors are often found so closely aggre- 
 gated as to form nodulated masses an inch or more in diameter. 
 Within a very delicate membrane there is found a fatty substance in 
 concentric leaf-like layers. Microscopical examination of the layers 
 shows that they are composed of large cells between which globules of 
 fat and cholesterin-plates are seen. The pearl-like appearance of the 
 tumor is due not to the cholesterin, but to the compact layers of the 
 cells. The cells are derived from endothelium, and not from epithelium, 
 as was formerly supposed. Recently some doubt has been raised as to 
 the endothelial origin of cholesteatoma. J. Bland Sutton and Ribbert 
 support their epithelial origin. Ribbert has examined a case in which 
 there was nothing to indicate that the three-layered epithelial coat of 
 the inner surface of the tumor had any connection with the endothe- 
 
 26 
 
402 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Hum of the pia. The very sharp line of demarcation between the epi- 
 thelium and the normal pia mater made the idea of the origin of the 
 tumor from separated epithelial cells seem very probable. This idea 
 has a strong support in the case described by Bonorden, in which the 
 tumor contained glands and hair-follicles, structures belonging only to 
 the external skin. Beneke has shown that the meningeal steatomata 
 are produced by proliferation of the endothelial cells of the pia. He 
 bases his opinion upon the fact that silver staining yields the outlines 
 of endothelial cells, which would not be the case with epithelial cells. 
 
 Fig. 280. — Fibroma of upper jaw. 
 
 Cholesteatoma is found, besides, in the meninges and the ventricles 
 of the brain, in bones, especially the petrous portion of the temporal 
 bone, and in the mastoid process, in the testicle, and in the ovary. 
 In the meninges of the brain cholesteatoma probably starts in the 
 perivascular lymph-spaces. Rindfleisch very strongly maintains that 
 these tumors in the meninges of the brain are of endothelial origin. 
 Wendt believes that in the petrous portion of the temporal bone chole- 
 steatoma is produced by inflammation of the middle ear resulting in 
 desquamation and accumulation of epithelial cells, but he has described 
 also genuine cholesteatoma of endothelial origin in the drum of the 
 
FIBROMA. 4°3 
 
 ear. In tumors of the pia mater belonging to this category this mem- 
 brane surrounds the tumor mass, but the space is not lined by endo- 
 thelial cells. Ziegler found hair in some of these tumors, in which 
 case we must assume for some of them an epithelial origin from a 
 displaced tumor-matrix ; but these cases must be exceedingly rare. 
 Eberth found that in cholesteatoma of the pia mater the first change 
 that is seen in the formation of the tumor is the appearance of proto- 
 plasmic masses which surround the vessels like a sheath. In. the 
 sheath irregular nuclei are seen, besides giant-cells. Virchow and 
 Eberth claimed that these cells were epithelial cells produced by hetero- 
 plastic proliferation of the connective tissue. This view is, of course, 
 no longer tenable, as we have shown repeatedly that epithelial cells 
 are never produced from connective tissue. Cholesteatoma never gives 
 rise to metastasis, and it manifests no tendency to invade surrounding 
 tissues to any extent, resembling in these respects psammoma, with 
 which it is histologically and clinically so closely allied. 
 
XVIII. LIPOMA. 
 
 Definition. — A lipoma is a circumscribed or diffuse tumor composed 
 of fatty tissue produced from a matrix of lipoblasts. The subcutaneous 
 fatty tissue is the favorite seat of lipoma. Toldt ascertained that in 
 the embryo the panniculus adiposus is formed by cell-islets, the so- 
 called " fat-organs," each of which has a separate and independent 
 blood-supply. These islets are separated from one another by connec- 
 tive tissue. Young fat-cells are called " lipoblasts." Their number and 
 activity, as well as the assimilation of fat from the blood or the food, 
 determine the amount of fat. Each fat-lobule has its own artery and 
 capillary circulation, terminating in a common vein. The lobule there- 
 fore represents an organized unity, like an acinus in the liver. Accord- 
 ing to Virchow, the lipoblasts develop from fetal myxomatous tissue 
 into which the mature fat-cells can revert. If the cells of any of 
 these fat-forming centres should become arrested in their develop- 
 ment and remain in a quiescent state, it is easy to see how at any time, 
 by their resuming active tissue-proliferation, they could give rise to a 
 fatty tumor. Having become emancipated, as it were, from the organ- 
 
 Fig. 281.— Fat-cells imbedded in subcutaneous areolar tissue (after Schiefferdecker) : /, fat-cells; n t 
 nucleus; c, connective-tissue corpuscles; w, migratory cells; e, elastic fibres; b, capillary blood-vessels. 
 
 ism, their growth, development, and reproduction would no longer be 
 controlled by the laws which regulate normal nutrition. It would be 
 difficult to explain localized hyperproduction of fatty tissue in any 
 other way. 
 
 Histology. — The fat-cells in a lipoma, as in normal adipose tissue, 
 represent connective-tissue cells with oily contents. The cells are 
 
 404 
 
LIPOMA. 4°5 
 
 round or oval sacs ; the transparent contents are limited by a delicate 
 envelope composed of cell-membrane and of an extremely thin layer 
 of protoplasm. The nucleus is located on one side of the sac (Fig. 
 281). 
 
 There is nothing to distinguish a fat-cell in a lipoma from a fat-cell 
 in normal adipose tissue. The cells occur in groups supported and 
 held together by areolar tissue through which ramifies a rich vas- 
 cular network. The amount of stroma varies : in the soft lipomata it 
 is very scanty, so that under the microscope it is difficult to recognize 
 it, it being almost completely overshadowed by the fat-cells. In the 
 hard lipoma the fibrous structure of the tumor is well developed and 
 the fat-cells are crowded into the large areolae of the stroma. Some 
 lipomata are exceedingly vascular, and we then speak of a lipoma 
 telangiectodes. In other instances the stroma contains venous channels 
 of large size, when the tumor is called lipoma cavernosum. The writer 
 has met with such vascular lipomata most frequently in congenital 
 lipoma. 
 
 Regressive Metamorphoses. — The stroma of a lipoma is more 
 prone to undergo retrogressive metamorphosis than is the parenchyma 
 of the tumor. The most frequent degenerative change observed is 
 myxomatous degeneration of the stroma. The connective-tissue fibres 
 are separated by the myxomatous material, and the stroma presents 
 the appearance of juvenile connective tissue. The tumor or part of a 
 tumor undergoing this process becomes softer. Calcification of the 
 stroma arrests the growth of the tumor affected by this change, the 
 parenchyma-cells degenerate, and the tumor becomes eventually com- 
 pletely petrified. Burow found cholesterin in a large lipoma of the 
 axilla. The lime-salts found in a calcified lipoma are carbonate and 
 phosphate of lime. Furstenberg found in the fat-cells lime-salts in 
 combination with fatty acids. Ossification of parts of the stroma occurs 
 in rare cases. Oil-cysts have been found in the interior of fatty tumors, 
 and are supposed to have been formed by atrophy of the cell-envelopes 
 and accumulation of their contents in the stroma. 
 
 Anatomical Varieties. — All lipomata are encapsulated. The cap- 
 sule is perfect in the circumscribed variety ; in the diffuse form the 
 tumor sends out into the surrounding loose connective tissue pro- 
 longations which sometimes are not discovered in the removal of the 
 tumor, and lead to a recurrence of the growth. The diffuse form fre- 
 quently occupies a large territory, as, for instance, the anterior surface 
 of the neck. The lipoma arborescens or raccmositm described by 
 J. Muller is a branching fatty tumor (Fig. 282). It is found most 
 frequently in the knee-joint, where it starts beneath the synovial mem- 
 
406 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 brane, and, pushing this before it, sends branching lobes into the joint. 
 Lipoma arborescens is also found quite frequently as a diffuse tumor 
 under the peritoneum and the pleura. 
 
 Symptoms and Diagnosis. — Lipoma frequently occurs as a con- 
 genital tumor. Sometimes it is found as a symmetrical affection — for 
 instance, the simultaneous occurrence of a lipoma in each axillary 
 space. The writer has observed such a case in a woman fifty years of 
 
 Fig. 282. — Lipoma arborescens (after Liicke). 
 
 age. Billroth, in a paper published shortly before his death, called 
 attention to the occurrence of symmetrical lipoma. As a post-natal 
 tumor it commences most frequently after puberty. Its growth is 
 always slow. Sometimes it remains stationary for a certain length of 
 time, when, without any apparent provocation, it resumes its growth. 
 It attains occasionally an immense size. Rhodius recorded a case in 
 which the tumor weighed sixty pounds. Tumors weighing more than 
 ten pounds, however, are very rare. If the tumor is subcutaneous, the 
 skin over it, from tension, atrophies, and ulceration from impaired nutri- 
 
LIPOMA. 407 
 
 tion may take place. In other instances ulceration is caused by a 
 trauma or in consequence of irritating applications. Infection of a fatty 
 tumor through a break in the surface is frequently followed by intense 
 phlegmonous inflammation of the stroma of the tumor, extensive gan- 
 grene, and profuse suppuration. 
 
 Examination of a tumor complicated by acute inflammation might 
 lead the surgeon to suspect a malignant growth. Under such circum- 
 stances a careful consideration of the clinical history will prevent a 
 mistake in diagnosis. A soft lipoma imparts to the palpating finger 
 a sense of fluctuation. Pseudo-fluctuation of soft tumors has led to 
 many mistakes in diagnosis. Chelius compares the sensation felt on 
 palpating a lipoma to that felt on compressing a bag filled with cotton. 
 If the tumor is hard, the resistance to pressure is of a firm, elastic 
 kind. A subcutaneous lipoma is a lobulated, movable tumor. Its slow 
 growth differentiates it from sarcoma. A lipoma, however, may attain 
 considerable size before being discovered by the patient, and surgeons 
 have often been misled by dating the origin of the growth to its acci- 
 dental discovery by the patient. In doubtful cases the negative result 
 of an exploratory puncture will prove of great value in differentiating 
 between a lipoma and an infective or cystic swelling. The recognition 
 of a cavernous or telangiectatic lipoma is often impossible. This com- 
 bination tumor should be suspected if under pressure the tumor is 
 diminished in size, but the effect of pressure is less marked than in 
 cases of deep-seated angioma. 
 
 Prognosis. — The prognosis in lipoma is favorable. Transition into 
 sarcoma is less frequently observed than in any other kind of benign 
 mesoblastic tumors. Myxomatous degeneration of the stroma often 
 initiates the transition of a lipoma into a sarcoma. This transition occurs 
 most frequently in intermuscular lipomata. The first case of this kind 
 was described by Forster. Virchow examined three fatty tumors which 
 had undergone this degeneration, and made the statement that their 
 malignancy depended upon the extent of the degeneration. The fat- 
 cells are not affected by this change. Waldeyer showed that myxo- 
 lipoma can give rise to metastasis. In a mesenteric tumor of this kind 
 he found metastatic deposits in the liver and lungs. The pressure- 
 effects are also less marked, owing to the location of the tumor being 
 usually in places where the surrounding tissues are yielding. Even the 
 large subserous lipomata seldom give rise to any serious functional 
 disturbances. Patients with fatty tumors seek surgical advice more 
 frequently for cosmetic reasons or for inconveniences attending the 
 presence of the tumor than for the relief of suffering or the functional 
 disturbances. 
 
4-08 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Treatment. — The only proper surgical treatment of lipoma is 
 removal by excision. Lipoma of the abdominal cavity is rarely or 
 ever recognized before the abdomen is opened. The removal of a sub- 
 cutaneous lipoma must be done under strictest aseptic precautions, because 
 the bed of the tumor presents the most favorable conditions for progres- 
 sive infection. The numerous large connective-tissue spaces which are 
 exposed by the removal of the tumor and the abundance of connective 
 tissue forming its bed are admirably adapted for a diffuse infection. 
 Before antiseptic surgery came in use numerous instances of progres- 
 sive phlegmonous inflammation, sepsis, and pyemia occurred after the 
 removal of small lipomata. The surgeon must not be lulled into a 
 sense of ease and security offered by an easily-removable lipoma in 
 undertaking its removal by enucleation. He must make as careful 
 preparations to procure asepsis as though he were to operate upon the 
 abdominal cavity. Owing to the attenuated skin overlying tumors 
 immediately under the surface, the incision, as a rule, should be made, 
 not over the centre of the tumor, but at its base. A semilunar incision 
 in this location will secure more room than a straight one. After reflec- 
 tion of the flap the capsule of the tumor must be found, and in the 
 enucleation which follows it is taken as a guide. Bands of connective 
 tissue which convey the blood-vessels to the tumor should not be torn, 
 but should be cut with scissors or with a knife. Tearing must be 
 avoided. After the enucleation all bleeding points are tied. As few 
 blood-vessels are cut in the operation, the wound can be sutured 
 throughout. Drainage is unnecessary. The dressing must be applied 
 with care in order to bring and to hold the wound-surfaces in uninter- 
 rupted apposition. If the wound is sealed with cotton and iodoform 
 collodion, an elastic dressing is applied over it to aid the sutures in 
 securing and maintaining accurate coaptation of the wound-surfaces. 
 In the majority of cases general anesthesia is superfluous in the removal 
 of a lipoma. 
 
 Topography. 
 
 Subcutaneous Adipose Tissue. — By far the greatest number of 
 fatty tumors originate in the panniculus adiposus and present them- 
 selves as lobulated movable subcutaneous tumors. In this locality the 
 tumor is occasionally multiple, from two to ten or more appearing 
 simultaneously or in succession. Lipoma is found most frequently 
 upon the neck (Fig. 283), shoulders, chest, abdomen, arms, and thighs. 
 Grosch collected 716 cases of solitary lipoma, and found their regional 
 distribution, in the order of frequency, as follows : Neck, back, thigh, 
 forearm, volar side of hand and foot; the scalp only in exceptional cases. 
 It appears, then, that lipoma occurs most frequently in localities where 
 
LIPOMA. 
 
 409 
 
 the skin is scantily supplied with glands. Symmetrical lipomata Grosch 
 regards as of neuropathic origin. Lipoma of the scalp is very rare. In 
 this locality the tumor is flattened and never becomes pendulous. 
 Lipomata in localities where the skin is loose often become peduncu- 
 lated. 
 
 A neuropathic cause of symmetrical lipomata has been assumed 
 by some. Madelung observed the growth of fatty tumors at the 
 insertion of the deltoid muscle following neuralgia and tremors which 
 occurred in consequence of contusions. In one of the two cases which 
 
 Fig. 283.— Diffuse lipoma of the neck (after Baker) 
 
 he reported the neuralgia disappeared after extirpation of the tumor. 
 Mathieu in 1890 described a case in which sciatic neuralgia attended 
 two pairs of lipomata, one on the trochanter major, of the size of the 
 head of a new-born child, and two smaller ones, of the size of a fist, 
 on the inner side of the knee. Other tropho-neurotic affections com- 
 plicated the case. Targlowa recorded a case where symmetrical 
 lipomata, seven pairs, had developed in a man affected with general 
 paralysis. The tumors occupied the neck, the zygomatic and mastoid 
 processes, the subclavicular, the deltoid, and the sacral region of both 
 sides. Cases of the same nature are reported by Oldham, MacCormac, 
 Hutchinson, C. Beck, and others. In Beck's case the tumors occupied 
 the neck, the parotid, and the mastoid regions on both sides. The 
 
4io 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 writer has seen only one case of diffuse lipoma of the neck, and in this 
 instance the swelling extended diffusely around the whole neck and 
 came up well in front of both ears. Diffuse lipoma is not encapsulated. 
 
 
 
 Fig. 284. — Symmetrical lipoma of the axillae. 
 
 The fat bears a coarsely granular appearance, due to being bound up 
 in small lobules, which causes it to resemble omentum in its structure. 
 Operative treatment in diffuse lipoma is not indicated, as a rule, as 
 the tumor usually becomes stationary. 
 
LIPOMA. 411 
 
 The palm of the hand is occasionally the seat of a lipoma. The 
 tumor in this locality might be mistaken for tuberculosis of the tendon- 
 sheaths or for a plexiform neuroma. The very slow growth and the 
 absence of pain are important factors in differentiating lipoma from 
 neuroma and inflammatory swellings. 
 
 Eyelids. — The "fibroma lipomatodes " of Virchow, the "xanthoma " 
 which is usually found upon the eyelids, appears as yellowish or brown 
 spots, and consists of large fat-cells with a reticulated protoplasm. 
 The tumor is sometimes quite diffuse and large. Some authors have 
 described xanthoma as a variety of endothelioma, but the cells of 
 endotheliomata contain no fat except as a product of degeneration. 
 The coloring-material is lipoxanthin, belonging to the class of blood- 
 pigments. Klebs proposes for these tumors the name of lipoxan- 
 tJwma. Xanthoma may occur as a primary lesion in other parts 
 of the body, more especially where the skin is exposed to repeated 
 injuries. 
 
 Subserous Lipoma. — The peritoneum, like the skin, rests upon 
 a bed of fat, the thickness of which varies considerably. This layer 
 of fat is sometimes the seat of very large fatty tumors. In Carlsberg's 
 case the tumor weighed thirty-five pounds and was in part petrified. 
 Terillon removed a subperitoneal lipoma weighing fifty-seven pounds. 
 Homans of Boston removed two large retroperitoneal fatty tumors. 
 Josephson and Vestberg have collected 30 cases of multiple, retroperi- 
 toneal lipomata, of which 3 have been seen personally. The point of 
 origin of these tumors is always retroperitoneal, and never mesenteric, 
 although they may encroach upon the mesentery secondarily. In the 
 diagnosis it is stated that an abdominal tumor which presents none of 
 the evidences of malignancy, but which increases rapidly in size, 
 which displaces the large intestine to one side, which presents pseudo 
 fluctuation, and which is hard in some places, is surely a retroperitoneal 
 lipoma. If the tumor is perceptible beneath the abdominal wall, in 
 the lumbar region, and if it tends to return to its former position by a 
 kind of spring, due to its elasticity, when one tries to pull it away from 
 the abdominal wall, its retroperitoneal location can be assumed with a 
 great deal of certainty. The authors advise surgical intervention, call- 
 ing attention to the fact that in certain cases resection of a portion 
 of the large intestine will be made necessary for the removal of a 
 tumor which has involved the entire thickness of the mesentery, if one 
 wishes to avoid gangrene of the intestine. The removal of large lipo- 
 mata by laparotomy is a very dangerous operation : of 10 cases, only 
 3 recovered. Smaller lipomata cause no serious symptoms, and when 
 incidentally discovered can be safely removed by enucleation. They 
 
412 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 are frequently found in connection with femoral and inguinal herniae. 
 Roser believed that lipoma in subperitoneal spaces usually occupied 
 by herniae is a frequent cause of hernia. A subperitoneal tumor of 
 the anterior abdominal wall sometimes, by displacing the abdominal 
 muscles, becomes subcutaneous, especially near the umbilicus. If the 
 tumor is situated between the folds of the broad ligament, it simulates 
 very closely an ovarian tumor. The removal of omental lipoma has 
 proved more successful than the removal of tumors from behind the 
 
 peritoneum of the posterior ab- 
 dominal wall. Meredith removed 
 <s ^' W^k successfully an omental lipoma 
 
 weighing fifteen and a half pounds. 
 j uJ/t Forster saw one that weighed fifty- 
 
 ^=^' -M three pounds. Waldeyer described 
 
 IJW^X^^^M" \ a lipo-myxoma of the mesentery 
 
 that weighed sixty-three pounds. 
 
 Subserous lipoma of the colon 
 is met with occasionally. The 
 appendices epiploicae are often the 
 seat of polypoid lipomata. Lipoma 
 of the abdominal organs and of the 
 subperitoneal layer of fat are not 
 recognized before the abdomen is 
 opened. If abdominal section re- 
 veals the existence of a lipoma in 
 the retroperitoneal space, its removal 
 should not be attempted if, as is so 
 often the case, it dips down deeply 
 on the side of the vertebral column, 
 unless the tumor interferes with an 
 important function or is the cause 
 
 Fig. 285.— Meningeal lipoma simulating a spina Q f p a i n< If the tumor is more 
 bifida in a child eight months old (after Temoin). 111 11 
 
 favorably located, the peritoneum 
 covering it should be incised over the most prominent part of the 
 tumor, and the tumor should be removed by enucleation. After the 
 tumor is removed the peritoneal incision should be sutured. 
 
 Submucous Lipoma. — Submucous lipoma of the gastro-intestinal 
 canal is rare. Virchow examined a submucous lipoma of the stomach 
 as large as a walnut. Turner has seen a fatty tumor, the size of a large 
 walnut, growing in the submucous tissue of the large intestine and pro- 
 jecting into the lumen of the bowel near the ileo-cecal valve. Sub- 
 mucous intestinal lipomata may cause intussusception, and thus become 
 
LIPOMA. 413 
 
 a source of danger to life. A few instances of submucous lipoma of 
 the larynx have also been reported. 
 
 Meninges of the Brain and Spinal Cord. — Lipoma of the menin- 
 ges of the brain and spinal cord is a heterotopic tumor which develops 
 from a displaced matrix of lipoblasts. Tauber records a case where 
 the tumor was located in the tubercula quadrigemina on the right side, 
 and had given rise to destruction of brain-tissue from pressure. Roki- 
 tansky has seen cases of lipoma upon the internal surface of the dura 
 mater and in the lateral ventricle. Polypoid masses of fat are occa- 
 sionally associated with protrusions of the spinal or cerebral meninges, 
 and fatty tumors may be found as a pathological curiosity in the central 
 nervous system. Chiari found two lipomata the size of a pea under the 
 arachnoid, and Weichselbaum found one in the posterior lobe of the 
 hypophysis in a soldier twenty-two years old. Lipomata are frequently 
 observed at the seat of a spina bifida occulta, which may even penetrate 
 inside the theca (Fig. 285). 
 
 In the cases of meningeal tumors examined by Recklinghausen 
 and Obre the tumors contained striped muscular fibres, showing 
 that the matrices were composed of displaced fetal tissue. A lipoma 
 complicating a spina bifida greatly complicates the diagnosis. The 
 presence of a solid tumor over the spine in children should induce the 
 surgeon to look for, and to be prepared to treat, a spina bifida at its 
 base. 
 
 Intermuscular Lipoma. — Fatty tumors in rare instances have been 
 found between nearly all the great muscles, and have given rise to 
 great difficulty in diagnosis. Myxo-lipoma, according to Liicke, 
 occurs most frequently below the gluteal fold, between the muscles 
 of the thigh, and frequently penetrates the ischiatic foramen. 
 
 Intermuscular lipoma being more liable than superficial tumors to 
 undergo transition into sarcoma, their operative removal is rendered so 
 much more imperative. 
 
 Periosteum. — As a heterotopic tumor lipoma of the periosteum 
 must be mentioned. Sutton collected nine such cases representing so 
 many different bones. The heterotopic nature of periosteal lipomata 
 has been established by microscopical examination, which in each 
 specimen showed traces of striated muscle-fibre. Without an explora- 
 tory incision or an examination of tissue removed it would be next to 
 impossible to make a positive diagnosis. 
 
 Joints. — Subserous lipoma of joints, from the location of the tumor, 
 appears as a diffuse growth. The lobes of the branching tumor present 
 a racemose or arborescent appearance ; hence these tumors are known 
 and described as lipoma arborescens. So far, 16 cases of lipoma of the 
 
 
414 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 knee-joint have been recorded. In this joint Schmolk describes two 
 varieties : (i) the diffuse and (2) the circumscribed. The diffuse variety 
 is not a tumor, but an inflammatory swelling of a tubercular nature 
 with fatty degeneration of the synovial villi. The circumscribed form 
 has, according to Konig, its starting-point in the retrosynovial fat-tissue 
 in the same manner as the retroperitoneal lipoma. The tumor projects 
 into the joint through a rent in the synovial membrane caused by an 
 injury or otherwise. Subsynovial lipoma is found most frequently in 
 the knee-joint, but has also been seen in the shoulder-joint. The 
 fringes of the tumor are covered by the synovial membrane. If the 
 tumor disturbs the function of the knee-joint, its removal by arthrec- 
 tomy is indicated. Thorough removal under strict aseptic precautions 
 is not followed by recurrence and yields a satisfactory functional result. 
 
 Tendon-sheaths. — Lipoma outside the tendon-sheaths has been 
 described by Ranke and Trelat. It is found most frequently along 
 the tendon-sheaths of the flexor tendons of the hand. Lipoma inside 
 the tendon-sheaths springs from the adipose tissue of the mesotendon. 
 It develops usually as a multiple tumor which presents an arborescent 
 appearance, and it is easily mistaken for tuberculosis of the tendon- 
 sheaths and for plexiform neuroma. According to Hammann, Sprengel, 
 and Haeckel, it can be treated successfully by excision. 
 
 Eye. — Subconjunctival lipoma is a rare affection of the eye. It 
 occurs most frequently near the point where the conjunctiva is reflected 
 from the lower lid to the eyeball, and it is almost confined to children. 
 As a rare retrobulbar benign tumor a lipoma is found in the cushion 
 of fat behind the eyeball, producing, according to its size, more or less 
 displacement of the eyeball. 
 
 Broad Ligament. — Lipoma of the broad ligament as a subserous 
 tumor is very rare. Pozzi saw a case of this kind in which the tumor 
 was mistaken for an ovarian tumor because of the misleading sense of 
 fluctuation. The patient suddenly died of embolism three days after 
 an exploratory incision. 
 
 Vulva. — Lipoma of the vulva arises in the fatty tissue of the mons 
 veneris, and often reaches large dimensions. Stiegele operated on one 
 which weighed ten pounds. In one of Bruntzel's cases the tumor 
 increased greatly in size during pregnancy. 
 
 Scrotum. — Lipoma of the scrotum occurs rarely as a subcutaneous 
 tumor. Fatty tumors of the cord often reach considerable size. Park 
 successfully removed a large lipoma of the cord, and he refers to a 
 number of similar cases. Sarazin has collected from different sources 
 26 cases of lipoma of the spermatic cord. 
 
XIX. MYXOMA. 
 
 The frequent occurrence of myxomatous degeneration of the stroma 
 of benign and malignant tumors and the rarity with which pure myx- 
 omatous tumors are found have induced some authors to abandon 
 myxoma as a separate class of tumors and to include it among the 
 fibromata. Myxoma is a tumor which presents so many characteristic 
 peculiarities that it is well to give it a separate place in the classification 
 of tumors, and not to regard it as a variety of cedematous degeneration 
 of other connective-tissue type of tumors. 
 
 Definition. — A myxoma is a tumor composed of mucous tissue resem- 
 bling Wharton's jelly in the umbilical cord. Virchow selected Wharton's 
 jelly of the umbilical cord as a prototype 
 of the tissue of which a myxoma is com- 
 posed (Fig. 286)- 
 
 In the embryo the connective tissue is 
 identical in structure with Wharton's jelly. 
 The meshes of the cellular network are 
 occupied by a semi-gelatinous, indifferent, 
 and but slightly differentiated intercellular 
 substance containing few fibres and occa- 
 sional wandering cells. During the devel- 
 opment of myxomatous into connective 
 tissue the fibrous tissue in the meshes 
 
 becomes more abundant, while the intercellular substance is diminished 
 in quantity. If a group of cells should become arrested in their devel- 
 opment at an early stage and be set aside, it is to be expected that 
 tissue-proliferation from them would result in a connective-tissue tumor 
 of lowly-organized tissue — a myxoma. On the contrary, arrest of 
 development at a later stage would result in a tumor-matrix which would 
 produce a connective-tissue tumor of a higher type — a fibroma. The 
 stage at which development of the mucous cells in the embryo is arrested 
 determines whether the tumor from such a matrix is to be a myxoma or 
 a fibroma. The intrinsic capacity of mature connective tissue to revert to 
 its original embryonic state accounts for the frequency with which the 
 stroma of all tumors undergoes myxomatous degeneration. A post-natal 
 
 415 
 
 Fig. 286. — Connective-tissue cells from 
 young umbilical cord : processes of cells 
 unite to form protoplasmic network ; 
 fibrous elements slightly developed (after 
 Piersol). 
 
416 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 matrix of myxoma is created if the pre-existing connective-tissue cells 
 revert to their original embryonic state and remain unspecialized. 
 
 Histology. — The histological structure of a myxoma is subject to 
 many variations. The variable structure depends on the amount and 
 character of the intercellular gelatinous substance and the abundance 
 and vascularity of its stroma. Mucin is a substance which in the living 
 body is rapidly destroyed and eliminated. In a myxoma the retention 
 of this substance gives rise to hydropic conditions, and this reten- 
 tion occurs in myxomatous tumors if the production and absorption of 
 mucin are arrested. 
 
 Myxoma may occur as a clear, colorless, gelatinous mass which 
 differs from fluid only in its greater consistence. The delicate stroma 
 of such a jelly-like mass contains small blood-vessels which nourish 
 the lowly-organized tumor-tissue. Such tumors are found in the 
 antrum of Highmore. In the firmer variety the translucency is lessened 
 by a more copious stroma and by larger blood-vessels. The prognosis 
 in the latter form is less favorable than in the former, on account of 
 the more active cell-proliferation. The capsule of a myxoma is com- 
 posed of connective tissue which has become condensed by pressure 
 on the part of the tumor-tissue. 
 
 The typical myxoma is composed of a network of branching cells, 
 the intercellular substance in its meshes being composed of a gelatinous 
 homogeneous substance which contains mucin. The nuclei of the cells 
 are large. If the cells of the tumor are few and the stroma is in an 
 
 extremely hydropic condition, the 
 tumor is called a hyaline myxoma 
 (Fig. 287, a). If the cells are more 
 abundant and less stellate, it is 
 called a medullary myxoma (Fig. 
 287, b). If the tumor is very 
 vascular, we speak of a myxo- 
 angioma. Klebs found that 
 myxomatous degeneration takes 
 place in cells which are in close 
 proximity to blood-vessels, and 
 that it appears first as a vacuole 
 in the protoplasm of the cell. 
 As a component part of other 
 tumors, benign as well as malignant, myxomatous tissue is very com- 
 mon, in which case the nomenclature of the tumor is modified by 
 substituting a compound word for the single word and retaining the 
 name of the primary tumor, as adeno-myxoma, chondro-myxoma, 
 
 Fig. 287. — Myxoma : transition of (a) hyaline form into 
 (b) medullary form; X 2 5° (after Perls). 
 
MYXOMA. 417 
 
 myxo-carcinoma, myxo-sarcoma, etc. The most frequent combination 
 is myxoma with lipoma, lipoma myxomatodes. 
 
 Etiology. — Congenital myxomata have been reported by C. O. 
 Weber, Schuh, and others. No age is exempt, but they are met with 
 most frequently in young adults. The most potent exciting causes 
 are chronic irritation and inflammation. The formation of nasal 
 myxomata is frequently preceded by chronic catarrhal inflammation. 
 Myxomatous polypi of the external auditory meatus are most always 
 associated with chronic inflammation of the external ear. 
 
 Symptoms and Diagnosis. — A myxoma is a soft, gelatinous, trans- 
 lucent, interstitial, sessile or pedunculated growth. It is of slow growth, 
 and as a surface tumor it does not attain large size. Its growth is 
 unlimited if it receives its blood-supply from the entire periphery, as is 
 the case in interstitial myxoma. The diagnosis is not attended by any 
 difficulties if the tumor is accessible to sight and touch. Its color and 
 consistence distinguish it from fibroma, adenoma, and the malignant 
 tumors. Fluctuation is a constant sign, owing to the softness of the 
 tumor-tissue. The transition of a myxoma into a sarcoma should be 
 suspected when the tumor without any obvious cause begins to grow 
 rapidly. In such cases an examination of the tumor-tissue under the 
 microscope should be made before an operation is undertaken, as a 
 correct diagnosis is of paramount importance in planning and executing 
 an operation of sufficient thoroughness to remove all the infected tissues 
 in case the tumor has become malignant. If the microscope is to be 
 relied upon in ascertaining whether or not malignant transition has taken 
 place, tissue from the new part of the tumor must be obtained for exam- 
 ination. Serious blunders in practice have arisen from the examination 
 of old portions of the tumor, in which portions no traces of malignant 
 transition could be seen. Wherever possible, tissue from the base of 
 the tumor should be taken for microscopic examination, as it is here 
 that malignant transition is most frequently initiated. 
 
 Prognosis. — A pure myxoma is a benign, local, encapsulated tumor. 
 Myxoma has received an unenviable reputation from a prognostic 
 standpoint from the fact that it has been so often confounded with 
 malignant tumors that had undergone myxomatous degeneration, and 
 from the frequency with which it undergoes transformation into sar- 
 coma. A pure myxoma does not give rise to local, regional, or general 
 infection. The implication of adjacent tissues, regional infection, and 
 general dissemination are positive proofs either that the primary tumor 
 was malignant and had undergone myxomatous degeneration or that 
 the tumor is no longer a myxoma, but is a sarcoma produced in con- 
 sequence of transformation of a benign into a malignant tumor. In 
 27 
 
418 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 rendering a prognosis in cases of myxoma the aptitude of such a tumor 
 to undergo malignant transition must be remembered. The greater 
 liability of myxoma than of fibroma to become transformed into a 
 sarcoma is due to the more lowly organized cells of which its matrix 
 is composed. 
 
 Treatment. — Remembering the liability of myxoma to transition 
 from a benign tumor into a sarcoma, it is necessary to emphasize the 
 importance of early and thorough removal. Imperfect removal by 
 operation or incomplete destruction by caustics has frequently been 
 followed by a sarcomatous recurrence. The irritation incident to such 
 imperfect treatment has proved sufficient to bring about a transition of 
 the remnant of the tumor into sarcoma. The writer has more than once 
 seen such a transformation follow incomplete removal of nasal polypi 
 with the snare. It is especially necessary to remove the base of the 
 tumor ; complete removal is seldom accomplished with the snare or by 
 torsion. A hyaline myxoma of a mucous surface is so friable that its 
 complete removal cannot be effected by avulsion. If the tumor is so 
 located that its base cannot be reached for its removal by the snare or 
 by avulsion, these procedures should be followed by cauterization with 
 the Pacquelin cautery, in order to destroy every remaining vestige of 
 the tumor. The removal of an intermuscular myxoma must be done 
 with the utmost care, as the tumor usually has prolongations into the 
 loose connective tissue surrounding it ; these prolongations might be 
 overlooked, and if not removed would become the source of a certain 
 and early recurrence. 
 
 Topography. 
 
 Skin. — Myxoma of the skin occurs as a sessile or pedunculated 
 tumor, but is rare as compared with fibroma or with papilloma. Myx- 
 omatous tumors of the skin are most frequent in the neighborhood 
 of the perineum and the labia in women. In young persons these 
 tumors possess a regular, usually oval, outline. Later in life they 
 shrink, and the surface of the tumor assumes a lobulated appearance. 
 These tumors ordinarily occur in the labium majus, although they 
 may be found in the nymphae or in the perineum. 
 
 Sessile myxomata are very prone to recur after removal, unless espe- 
 cial care is taken to carry the incisions beyond the limits of the capsule. 
 Enucleation is often attended by rupture of the capsule ; consequently 
 this method of operating cannot be relied upon for complete removal 
 of the tumor unless its capsule is unusually firm. 
 
 Intermuscular Spaces. — Myxoma, like lipoma, is sometimes found 
 to occupy the intermuscular spaces, and in this locality frequently 
 
MYXOMA. 419 
 
 exists in combination with lipoma. The favorite locality, as has been 
 pointed out by Lucke, is the space between the external and internal 
 hamstring muscles, below the gluteal fold. These tumors are of slow 
 growth and may reach great size. The writer has seen a myxoma the 
 size of an adult's head between the adductor muscles of the thigh. In 
 the excision of deep-seated myxoma it is often necessary to excise 
 some of the connective tissue around it in order to remove all the 
 myxomatous tissue. 
 
 Nose. — Unmixed myxoma occurs more frequently in the sub- 
 mucous tissue of the nasal cavities than in any other locality. It starts 
 usually in the mucous membrane overlying the turbinated bones, and 
 only in exceptional cases in the frontal sinus or in the antrum of 
 Highmore. The tumor is usually multiple, often from three to six 
 being found in one nasal cavity. Frequently both nasal cavities are 
 simultaneously affected. The growths may project anteriorly or in the 
 direction of the pharynx. During moist weather the tumors absorb 
 moisture, swell, and produce more obstruction than during dry weather. 
 If numerous and large, they distend the nose; and when located in the 
 frontal sinus bulging at the inner angle of the orbit takes place, like 
 that produced by hydrops or by empyema of this cavity. 
 
 Fig. 288.— Myxoma of nose (Surgical Clinic, Rush Medical College, Chicago) : a, delicate connective-tissue 
 stroma; b, granular amorphous myxomatous material, non-staining; c, nuclei ; d, blood-vessels. 
 
 A nasal myxoma appears as a jelly-like, translucent mass which 
 moulds itself to the cavity of the nose. It is covered by mucous 
 membrane paved with columnar or stratified epithelium. Under the 
 microscope the tumor-tissue appears like very cedematous connective 
 tissue. The great mass of the tumor is composed of myxomatous 
 tissue in the meshes of the reticulum of connective tissue and paren- 
 chyma-cells (Fig. 288). The blood-vessels traversing the connective- 
 
420 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tissue stroma are usually quite large with very thin vessel-walls. Nasal 
 myxoma occurs most frequently in persons from the age of puberty to 
 that of fifty years. 
 
 The removal of nasal myxomata is by no means an easy operation. 
 Avulsion with the different kinds of forceps devised for this purpose is 
 usually followed by recurrence owing to incomplete removal of the 
 tumor; the use of the snare gives better results, but recurrence is by 
 no means infrequent. In cases in which a permanent cure followed 
 these procedures, usually a part of the turbinated bone to which the 
 tumor was attached was removed with the tumor. Konig's operation 
 should be resorted to if snaring and avulsion have not resulted satis- 
 factorily. This operation consists in cutting through the ala of the 
 nose on the side of the septum from within outward as far as the bony 
 framework, thus rendering the base of the tumor more accessible. 
 After locating the attachment of the tumor the index finger should be 
 inserted into the nasal passage from the pharynx, and with it the tumor 
 is pushed forward, when it may be removed with the snare or, what is 
 perhaps better, the sharp spoon. If the tumor is attached far back, a 
 temporary resection of the nose may become necessary to effect 
 complete removal. This preliminary operation becomes absolutely 
 necessary in the removal of polypoid tumors of the nose that have 
 undergone malignant transformation. 
 
 Middle Ear. — Myxomatous tumors in the external meatus are fre- 
 quently preceded by chronic or acute inflammation of the middle ear 
 and by perforation of the drum. These tumors usually spring from 
 the mucous lining of the tympanum, filling this cavity and projecting 
 into the external meatus through a perforation in the drum, causing 
 deafness. Jacobson suggests that myxoma of the middle ear may in 
 some instances arise from vestiges of connective tissue in this locality — 
 an opinion which will be sustained by all who adhere to Cohnheim's 
 theory regarding the origin of tumors. 
 
 The operative treatment of aural myxomata should be consigned to 
 skilled aural surgeons, as the reckless use of instruments and of caustics 
 in the middle ear is calculated not only to destroy hearing, but may 
 even be followed by fatal cerebral complications. 
 
 Nerve-sheaths. — Myxomatous tumors are not infrequently found 
 in the central nervous system, the brain and the spinal cord. Myxoma 
 of the sheaths of peripheral nerves is called neuroma myxomatosum. The 
 tumors often occur multiple, and they have been found in connection 
 with diffused nerves (Fig. 289). They often produce serious functional 
 disturbances in the form of neuralgia or paralysis. The most frequent 
 seat of myxomatous tumors of the nerve-sheaths is the optic nerve. 
 
MYXOMA. 
 
 421 
 
 Glands. — In the mammary and salivary glands, the ovary, and the 
 testicle myxomatous tumors occur frequently, but usually in combi- 
 
 Fig. 289. — Myxoma of the sheath of the ulnar nerve (after Huter). 
 
 nation with other benign tumors or as the result of regressive meta- 
 morphosis of benign or malignant tumors. 
 
XX. CHONDROMA. 
 
 Chondroma is a tumor which, according to its structure, is a close 
 imitation of hyaline, reticulated, or fibrous cartilage. It occurs in parts 
 of the body in which cartilage exists in the fetus, as in the epiphyseal 
 extremities of the long bones, or it springs from an island of displaced 
 cartilage-cells, as in the connective tissue, the parotid gland, the testicle, 
 and the ovary. 
 
 Definition. — A chondroma is a tumor composed of cartilage which is 
 the product of tissue-proliferation from a matrix of chondroblasts. This 
 definition refers all cartilaginous tumors to a matrix composed of 
 embryonal cartilage-cells. 
 
 Origin. — It has been customary to attribute to the connective tissue 
 under certain conditions a chondrogenetic function. It is not more 
 likely that connective tissue can produce cartilage than that it can pro- 
 duce epithelial cells. In the study of the origin of tumors we must 
 adhere closely to the teachings of Remak and Thiersch, that tissue 
 begets tissue of its own kind. We have traced adenomata to localities 
 where, in a normal condition, neither glands nor epithelial tissue exists, 
 and we have to account for the presence of the tumor-matrix by the 
 displacement of islets of adenoid tissue during the development of the 
 embryo. We have to assign to heterotopic chondroma a similar origin 
 by assuming as its starting-point the presence of a matrix composed 
 of embryonic cartilage-cells or chondroblasts. Chondroma is some- 
 times produced by a simple outgrowth from pre-existing cartilage, that, 
 as a rule, attains no great size. Virchow names these growths ecchon- 
 droses, and cites as their best examples outgrowths from the cartilages 
 of the ribs, the cartilages of the amphiarthrodial joints, the cartilages 
 of the trachea and the bronchial tubes, and from the cartilage between 
 the basi-sphenoid and occipital bones in the young cranium. In such 
 
 422 
 
CHONDROMA. 4^3 
 
 cases we must assume the existence of a superabundance of chondro- 
 blasts which produce the localized hyperplasia, but which do not 
 result in the formation of large tumors, owing to the inhibitory 
 influence exerted upon the growth by the surrounding normal 
 cartilage. 
 
 In the majority of cases cartilaginous tumors are found connected 
 with the bones and the joints. Virchow, in his classical article on 
 " Chondroma," places great stress on the frequency with which such 
 tumors spring from the epiphyseal cartilage. He found frequently in 
 this locality, in adults, remnants of unossified cartilage a centimeter 
 and more in diameter. Such islands of cartilage-tissue are frequently 
 seen in the epiphyseal extremities of the long bones in rickety sub- 
 jects. 
 
 It is well known that rickety persons are exceedingly prone to car- 
 tilaginous tumors. Virchow believes that a deficient blood-supply is 
 often the cause of arrested ossification in such cases. The influences 
 that excite proliferation in such embryonal remnants of cartilage are 
 rickets and an hereditary predisposition. In glands and in other parts 
 of the body in which normally no cartilage is found the tumor springs 
 from a displaced matrix of chondroblasts. Forster describes two car- 
 tilaginous tumors of the lung, as large as a bean, that had undergone 
 partial ossification. In these cases the matrix was derived from the 
 cartilage-rings of the bronchial tubes. 
 
 Heterotopic chondroma occurs most frequently in the parotid gland 
 and about the external ear, from tumor-cells which are derived from 
 the cartilage of the external ear. In the vicinity of the external ear and 
 the neGk they occur as remnants of the first branchial cleft. Wartmann 
 made a careful study of eight cases of chondroma in which the tumor 
 developed independently of bone or cartilage. He is of the opinion that 
 the tumor-elements start from ordinary fibrillary connective tissue, 
 some of the fibres of which undergo hyaline degeneration ; the con- 
 nective-tissue fibres proliferate actively, and form groups of cells which 
 become surrounded by a capsule and are transformed into cartilage- 
 cells. Other cells assume a stellate form ; the projections form free 
 anastomoses with similar structures which constitute a network, the 
 intercellular hyaline substance becoming softer, forming myxomatous 
 spaces. Both forms of cells, prior to encapsulation, present glycogen 
 reaction, which with the perfection of the capsule disappears. 
 
 It is of course difficult to trace a tumor to its primary histogenetic 
 origin, but it is no more difficult to explain the occurrence of chon- 
 droma in connective tissue from a displaced matrix of chondroblasts 
 
424 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 than to explain its presence in other tissues normally devoid of carti- 
 lage-tissue, for which such an origin is generally conceded. 
 
 Histology. — The structure of a chondroma depends on the kind 
 of cartilage it represents. 
 
 Hyaline chondroma is composed of a uniform, dense, cartilaginous 
 mass in which islands of cartilage can be seen surrounded by ground 
 substance. The islands of cartilage-cells are not larger than a line or 
 a line and a half in diameter (Fig. 290). The stroma of the tumor is 
 
 
 % > 
 
 
 
 
 
 % ^ *. m 
 
 "■■■.■p.v .;."■•■■ w 
 
 S£5*T>*I 
 
 iF^gha** 
 
 
 
 ?« >*.-. <§ i 
 
 :■-■-••<=• «^. ;; i- 
 
 «»•■ 
 
 »/i *■... 
 
 .,/;§. 
 
 j^L 
 
 FiG. 290. — Hyaline chondroma of ilium; X !30 (Surgical Clinic, Rush Medical College, Chicago): a, amor- 
 phous and granular stroma; b, cartilage-cells and capsule; c, cells in course of segmentation. 
 
 supplied with blood-vessels, but the cartilage-masses are devoid of ves- 
 sels of any kind. The spaces in which the cartilage-cells are enclosed 
 are called " lacunae." The interior of these spaces is lined by a mem- 
 branous structure from which the cells, after death, separate by shrink- 
 age. The spaces are sometimes branched, and they have been described 
 as " branched cells." 
 
 Fibro-chondroma. — These tumors occur most frequently in the cap- 
 sule of joints and in the fibrous structures adjacent to the parotid 
 gland. In the latter location the tumor often reaches the size of a 
 hen's egg. The tumor resembling fibro-cartilage is not so sharply cir- 
 cumscribed as is the hyaline variety. The tumor-tissue consists of a 
 uniform mass composed of fibrous tissue in the meshes of which car- 
 tilage-cells are uniformly distributed throughout (Fig. 291). The cells 
 frequently contain oil-globules. 
 
 Reticidated Chondroma. — In this variety of chondroma the fibrous 
 
CHONDROMA. 
 
 425 
 
 tissue is arranged in a reticulate manner and the spaces are occupied 
 by groups of cartilage-cells (Fig. 292). The vascular system of chon- 
 droma is imperfect. Lymphatics and nerves have not been found. 
 
 Fig. 291. — Fibro-chondroma from a cartilaginous Fig. 292. — Reticulated chondroma from index finger 
 tumor of the parotid gland (after Liicke). (after Liicke). 
 
 Retrogressive Metamorphoses. — Calcification is the most common 
 regressive metamorphosis ; it begins at circumscribed points of the 
 
 Fig. 293.— Chondroma of index finger, showing central ossification and lobulated structure of the tumor 
 
 (after Liicke). 
 
 tumor, and often terminates in the formation of large plates which are 
 exceedingly hard and which have often been mistaken for bone. The 
 
426 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 granules of chalk form first in the capsules and later in the cells, and 
 deposition in the intercellular substance, takes place later. 
 
 Cystic degeneration is often found in the interior of chondroma. 
 Sometimes the tumor presents a honeycombed appearance from the 
 presence of numerous small cysts. Coalescence of many cysts results 
 in the formation of large irregular cavities. The softening which results 
 in the formation of cysts is preceded by fatty degeneration of the carti- 
 lage-cells. Fat-granules appear at different points in the protoplasm 
 of the cells, and the fatty degeneration finally terminates in the dis- 
 solution of the cells. At the same time the intercellular substance 
 undergoes mucoid liquefaction. Hemorrhage into the cysts results 
 in discoloration and pigmentation of the cyst-contents. If a cyst by 
 ulceration on the surface is opened, there forms a fistulous tract which 
 resists all treatment short of extirpation of the tumor. 
 
 Development of cartilage-cells into bone is observed in chondromata 
 of bone and periosteum as well as in those of soft parts. Complete 
 ossification of the tumor has never been observed. The new bone 
 appears in the form of spiculae representing cancellated bone (Fig. 293). 
 The spiculae of bone form septa between the cartilage-masses. Very 
 frequently small islets of bone are found disseminated throughout the 
 tumor. 
 
 Myxomatous degeneration is frequently observed in glandular 
 chondroma. 
 
 Cartilaginous tumors have always been looked upon with suspicion, 
 as they are liable to undergo transformation into sarcoma. Wartmann 
 asserts that embolism may occur in the centre as well as in the periphery 
 of a chondroma, and that from the emboli secondary tumors develop 
 with the assistance of the endothelial cells of the blood-vessels, the 
 seat of the embolic process. It is more than probable that in all cases 
 in which a chondroma invaded adjacent tissues, and in all instances in 
 which metastasis occurred, the tumor had undergone transition into 
 sarcoma. 
 
 Etiology. — We have reason to assert that a chondroma cannot occur 
 independently of the existence of a congenital matrix of chondroblasts 
 or a post-natal matrix of embryonal cartilage-cells derived from the 
 periosteum or the bone. O. Weber describes a case of multiple chon- 
 droma of fifteen years' duration in a man twenty-five years of age. 
 Regarding the heredity, it has been ascertained that the grandfather, 
 the father, the brother, and one sister were also affected with the same 
 disease. He alludes to similar cases proving the heredity of chon- 
 droma. 
 
 Chondroma of bone occurs usually before or at the age of puberty, 
 
CHONDROMA. \2J 
 
 *■. 
 while in other tissues it frequently appears later in life. Trauma 
 
 appears to exert a powerful influence in stimulating a latent matrix of 
 
 embryonal cartilage-cells to active tissue-proliferation. O. Weber 
 
 proved by statistics that in one-half of all cases of chondroma the 
 
 origin of the tumor could be traced to a trauma. 
 
 Rachitis is a frequent exciting cause of chondroma of bones. We 
 can readily understand that the serious changes which occur in this 
 disease in the bone surrounding a matrix of chondroblasts would excite 
 tumor-growth by diminishing the physiological resistance of the adja- 
 cent tissues. 
 
 Symptoms and Diagnosis. — A chondroma, from the unequal 
 growth of its different parts, always appears as a lobulated tumor. 
 Lobulation increases with the size of the tumor. In central chondroma 
 of the long bones the tumor is surrounded by a shell of bone that 
 becomes thinner as the tumor increases in size ; this shell eventually 
 disappears entirely by absorption. Periosteal and glandular chondro- 
 mata are never surrounded by a complete shell of bone. Occasionally 
 an attempt at the formation of such a shell can be seen, but it is always 
 imperfect. 
 
 A chondroma displaces, but does not infiltrate, the adjacent tissues, 
 So long as it remains as a benign tumor it is surrounded by a capsule 
 which completely separates it from the adjacent tissues. The tumor is 
 hard except at points where cysts may have reached the surface of the 
 tumor, which upon palpation would impart a sense of fluctuation. A 
 chondroma may attain the size of an adult's head, but it may become 
 stationary at any time, especially at the age of puberty. Ossification 
 arrests tumor-growth in that part of the tumor which is the seat of 
 such a transition. Tumor-growth is also arrested by calcification. 
 Epiphyseal chondroma often appears in many of the long bones at the 
 same time, and is commonest in rickety subjects. Chondroma always 
 grows slowly. Its growth is not attended by pain or by tenderness. 
 A tumor in the vicinity of a joint may by its presence interfere with 
 full motion. The slow growth and the frequency with which it occurs 
 as a multiple affection distinguish chondroma from osteo-sarcoma. 
 
 The differential diagnosis between chondroma and osteoma can often 
 only be made by resorting to akidopeirasty. If the tumor is an 
 osteoma, the advance of the steel needle will be arrested when the 
 surface of the tumor is reached ; if the tumor is a chondroma, the 
 needle can be forced into the substance of the tumor. 
 
 Prognosis. — Aside from the aptitude of a chondroma to undergo 
 transformation into a sarcoma, the prognosis is favorable. Epiphyseal 
 chondromata may impair the range of motion of adjacent joints, but 
 
428 PA THOLOG Y AND . TREA TMENT OF TUMORS. 
 
 otherwise functional disturbances do not occur. Glandular chondro- 
 mata usually become stationary after they have reached a certain, and 
 usually a very moderate, size. A chondroma upon the inner surface 
 of the pelvis in females may complicate labor and necessitate Cesarean 
 section. A chondroma of the shaft of the long bones may cause such 
 a degree of atrophy of the bone by pressure that fracture will occur 
 upon application of slight force. Chondromata of the bones usually 
 become stationary after the completion of ossification of the skeleton. 
 
 Treatment. — The removal of a chondroma is indicated only in 
 exceptional cases. The removal of an epiphyseal chondroma should 
 not be attempted unless the tumor interferes materially with the func- 
 tion of an important joint or unless by pressure upon a nerve it causes 
 pain. The removal of such a tumor should not be undertaken lightly, 
 as during the operation recesses of the joint may be opened or bursae 
 overlying the chondroma may communicate with the joint. If the 
 chondroma completely surrounds a long bone, its extirpation is out of 
 the question, and amputation is only justifiable if the tumor is very 
 large or its interior has become infected through a suppurating super- 
 ficial cyst. Chondroma of the fingers, if pedunculated, can readily be 
 extirpated. The same treatment will suffice in similar tumors of the 
 shafts of the larger bones. Large encircling tumors of the phalanges 
 may require amputation. 
 
 In the removal of a chondroma of the long bones it must be 
 remembered that the tumor usually has a central origin, and that 
 removal on a level with the bone is generally followed by recurrence. 
 The central part of the tumor must be removed with gouge and 
 hammer to guard against a recurrence. The removal of chondromata 
 of the soft tissues should be done by enucleation. If a chondroma 
 manifests malignant properties, no time should be lost in making a 
 correct diagnosis by the microscopical examination of sections of the 
 tumor taken from the parts which are most suspicious ; in case the 
 microscope reveals evidences of a malignant transition, the most 
 radical measures must be resorted to, in removing not only the 
 tumor, but also the adjacent infected tissues. 
 
 Topography. 
 
 Chondroma occurs most frequently in connection with bone and in 
 organs situated in a locality where displacement of chondroblasts is 
 most likely to occur. A post-natal matrix can occur only in bone- 
 producing tissues, in bone, and in periosteum. 
 
 Cartilage. — The overgrowth of cartilage Virchow calls " ecchondro- 
 sis." Localized ecchondroses occur in four favorite localities — namely, 
 
CHONDROMA. 
 
 429 
 
 along the edges of articular cartilages, of the laryngeal cartilages, of 
 the cartilages of the ribs, and of the triangular cartilage of the nose. 
 The tumors never attain large size, and they resemble in many respects 
 the osteomata. Ecchondrosis of the articular cartilage is found most 
 frequently in persons past middle life, in connection with the condition 
 known as " rheumatoid arthritis." Bruns collected 14 cases of laryngeal 
 
 Fig. 294.— Lad twenty years of age with multiple chondromata (after Steudel). 
 
 4 with 
 Small 
 They 
 
 chondromata; of these, 8 were connected with the cricoid, 
 the thyroid, 1 with the arytenoid, and 1 with the epiglottis, 
 chondromata of the triangular nasal cartilage are quite common, 
 are sessile, and they hardly ever exceed in size a pea. 
 
 Bone and Periosteum. — The existence of islands of cartilage 
 the interior of the long bones near the epiphyseal cartilages has been 
 demonstrated by Virchow and others. A chondroma of bone always 
 
 in 
 
43Q 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 springs from such a matrix or from a matrix of post-natal origin pro- 
 duced by the bone-forming cells of the marrow or the periosteum. 
 Periosteal chondroma is rare, and springs from a matrix of displaced 
 chondroblasts or from a post-natal matrix produced by the cambium. 
 The greater frequency of chondromata in rickety subjects is due, as 
 Virchow pointed out, to the existence of islands of cartilage that have 
 failed to undergo ossification, and which serve the purpose of a tumor- 
 matrix. 
 
 Epiphyseal chondromata often appear simultaneously in different 
 parts of the skeleton, notably in the epiphyseal extremities of the long 
 bones. The phalanges of the fingers and toes are favorite localities 
 (Fig. 294). The tumors are always lobulated, and in the central variety, 
 
 when the tumor is covered by a thin 
 shell of bone, a crackling sensation 
 is produced on pressure. In the super- 
 ficial form enucleation can be effected 
 without difficulty, while in the central 
 variety it may become necessary to 
 remove the remnants of the tumor 
 with chisel and hammer. Unless the 
 tumor interferes seriously with the 
 function of a joint or causes pain by 
 pressure upon a nerve (Fig. 295), ope- 
 rative treatment is not indicated, as 
 m the majority of cases limitation of 
 the growth takes place at the age of 
 puberty. If the tumor causes great 
 inconvenience from its weight or 
 becomes the seat of ulceration, ampu- 
 tation may become necessary. A 
 resort to a mutilating operation may 
 become necessary if a fracture occurs 
 at the place where the bone has become 
 partially destroyed by the tumor. 
 Joints. — Floating or loose cartilages are found most frequently in 
 the knee- and elbow-joints. They are in the majority of cases sub- 
 synovial chondromata which are formed at the margin of the articular 
 cartilage, project into the joint, become pedunculated, and finally are 
 detached, changing their position in the joint with the movements of 
 the joint. A less frequent source of such loose fragments of cartilage 
 in joints is the detachment of fragments of the articular cartilage by 
 a trauma. The ecchondroses of the articular cartilage exhibit under the 
 
 Fig. 295. — Chondroma of humerus, show- 
 ing relations of tumor to vessels and nerves 
 (after Liston). 
 
CHONDROMA. 431 
 
 microscope a cartilaginous structure which has undergone partial cal- 
 cification. They vary in size from a pea to double the size of the 
 patella. In many instances the articular ecchondroses are multiple. 
 Bentlif removed 1532 loose cartilages from the shoulder-joint of a girl. 
 The presence of the foreign movable body usually produces hydrops 
 of the joint. Impaction of the cartilage between the articular surfaces 
 is attended by sudden pain and fixation of the joint — symptoms which 
 continue until the cartilage becomes displaced to a part of the joint 
 where its presence is less harmful. 
 
 The most characteristic symptoms of a loose cartilage in a joint are 
 attacks of sudden pain and arrest of function of the joint when the 
 cartilage gets between the opposed surfaces of the joint, followed, as a 
 rule, by more or less serous effusion into the joint. 
 
 The removal of such cartilages from joints calls for special anti- 
 septic precautions. Before the incision is made the cartilage should be 
 immobilized in a sacculus of the joint by transfixing it with a stout 
 aseptic needle. After the removal of the cartilage the capsule of the 
 joint should be sutured separately with one or two catgut sutures 
 before closing the external wound. The joint should be immobilized 
 for at least a week or two. 
 
 Salivary Glands. — Chondroma is found much more frequently in 
 connection with the parotid than with the submaxillary gland. Of 12 
 cases of chondroma in the soft tissues observed by Bryant, 9 occurred 
 in the parotid, 2 in the submaxillary, and 1 in the leg. Chondroma is 
 found in connection with the salivary glands more frequently than any 
 other benign tumor. Lucke and Konig have shown that the tumor 
 springs from the capsule of the glands or from the surrounding con- 
 nective tissue, and as it enlarges it grows into the glands and becomes 
 bound up with the gland-substance. The growth of such tumors is 
 always very slow. They seldom exceed in size a walnut. They are 
 movable and lobulated, and displace the surrounding tissues. 
 
 The proper treatment is enucleation. This operation requires special 
 care in the removal of benign tumors of the parotid gland, in order 
 to prevent injury to the facial nerve and to Stensen's duct. The ex- 
 ternal incision must be made with special reference to these structures, 
 and the deep dissection must be made between two dissecting-forceps, 
 dividing the tissues only after they have been identified. Incomplete 
 removal of cartilaginous tumors is very often followed by transforma- 
 tion of the remnant of the tumor into a sarcoma. A case of this kind 
 has recently come under the writer's observation. A chondroma in 
 the parotid gland in a woman thirty-five years of age had existed for 
 twenty years. It was removed partially by a timid surgeon. Two 
 
432 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 years later, when the case came under the care of the writer, there was 
 found in the scar and involving the entire gland a sarcoma larger than 
 a hen's egg. This case and many similar cases must impress the sur- 
 geon with the importance of a careful and complete removal of all 
 cartilaginous tumors when a radical operation is deemed advisable. 
 
 Testicle. — In rare cases the testicle is the seat of pure and of mixed 
 chondromata. Kocher recorded eight cases of pure chondroma. 
 O. Weber saw a case of congenital chondroma of the testicle. The 
 cartilage is usually hyaline, seldom fibrous. The great liability of chon- 
 droma of the testicle to undergo malignant transformation is shown by 
 the fact that in half the cases regional and general infection were 
 noted. Paget reports a number of such cases in detail. The tumors 
 are very hard and lobulated, with softer portions between the nodules. 
 Unless the tumor is very small enucleation should give way to castra- 
 tion. 
 
 Ovary. — Chondroma of the ovary occurs very rarely as an isolated 
 separate tumor. Kiwisch reported two cases of cartilaginous tumors 
 of the ovary, but only in one case was the diagnosis corroborated under 
 
 the microscope. Klob has shown 
 that the cartilage in such tumors 
 appears in the form of large fen- 
 estrated plates in the periphery 
 of the tumor, or forms granular 
 prominences, or, finally, is dis- 
 seminated through the fibrous 
 stroma in groups of cartilage- 
 cells the size of a pea. 
 
 Connective Tissue. — In ex- 
 ceptional cases chondromata 
 occur in the subcutaneous and 
 deep connective tissue in different 
 parts of the body. Their origin 
 in such unusual localities must 
 be sought in displaced matrices 
 of chondroblasts. The tumors 
 are met with most frequently in situations where such displacements are 
 most liable to occur — that is, in localities in close proximity to parts 
 containing cartilage in the embryo. 
 
 Chondroma Branchiogenes. — Chondromata in line with the first 
 branchial tract spring from displaced islands of cartilage derived from 
 the external ear. Some of the cartilaginous tumors in the vicinity of 
 the hyoid bone may derive their matrix from the hyoid bone and larynx, 
 
 Fig. 296.— Accessory auricles of neck (after C. Beck). 
 
CHONDROMA. 
 
 433 
 
 as suggested by Callender. A number of writers have described acces- 
 sory auricles in lines of the branchial tracts. Beck of Chicago recently 
 described such a case. Some of these isolated islands of cartilage have 
 become the matrix of cartilaginous tumors the size of a hen's egg and 
 larger. Heusing describes the case of a large cystic chondroma of 
 the neck. In Schaffer's case the tumor was of the size of an egg, 
 beneath the skin on the side of the neck. Beck described a case of 
 accessory auricles of the neck in a man forty-eight years old (Fig. 296). 
 
 
 
 VfL® 
 
 Fig. 297. — Cartilage from accessory auricles of neck (after C. Beck) : a, perichondrium ; b, new cartilage-cells 
 under perichondrium ; c, reticulum ; d, islands of cartilage-cells surrounded by stroma of fibrous tissue. 
 
 He removed a particle of one of the cartilaginous masses and subjected 
 sections of it to microscopical examination. The sections showed the 
 typical structure of cartilage (Fig. 297). 
 
 In the majority of cases of branchiogenous chondroma the matrix 
 remains latent until after the age of puberty, as in most of the fourteen 
 cases so far reported the tumors did not develop until some time after 
 puberty. 
 
 28 
 
XXI. OSTEOMA. 
 
 Definition. — An osteoma is a tumor which possesses a structure 
 resembling that of cancellous or compact bone, produced from a con- 
 genital or post-natal matrix of osteoblasts. Osteomata occur usually in 
 connection with some part of the skeleton, but they are also found in 
 parts and organs that have no genetic relations with the skeleton, as in 
 the pia mater and the brain. It is doubtful if the tumors which are not 
 in connection with bone present the structure of bone so perfectly as do 
 osseous tumors of the skeleton. Fleischer described an osteoma of the 
 tendon of the ilio-psoas muscle in which he found the Haversian canals 
 and the medullary tissue arranged in the same typical manner as in 
 normal bone. In another heterotopic osteoma described by the same 
 author the tumor was situated upon the inner surface of the dura mater. 
 In both instances bone-production was traced to the connective tissue 
 and independently of the presence of osteoblasts. According to 
 Fleischer's interpretation, the connective tissue at the seat of tumor- 
 formation became more vascular and presented active tissue-prolifera- 
 tion, and was transformed into hyaline masses in the interior of which 
 the bone-cells appeared. The hyaline lumps become coalescent and 
 undergo calcification. Osteoblasts were active in the further develop- 
 ment of bone. The capacity of connective tissue to produce bone 
 has been recognized for a long time, and this view of the bone-pro- 
 ducing power of connective tissue is accepted by most of the modern 
 pathologists. 
 
 A distinction must be made between calcification and ossification of 
 connective tissue. The production of bone is carried on in the embryo 
 by a distinct and specific part of the mesoblast, resulting in the forma- 
 tion of the skeleton and the growth of bone, and the production of 
 new bone can take place only from a matrix of cells derived from the 
 osseous system. The displacement of osteogenetic matrices into the sur- 
 rounding tissues is as liable to occur as the displacement of matrices of 
 epiblastic and hypoblastic tissue. Heterotopic osteomata are usually 
 found in close proximity to a bone. Heterotopic matrices of osteoblasts 
 usually result in imperfect development of the tissue of the ttimor. 
 Virchow found in the apex of the lung an osteoma in which Haversian 
 
 434 
 
OSTEOMA. 435 
 
 canals and medullary spaces were absent. Steudener found a number 
 of small osteomata near the trachea, but entirely distinct from its rings. 
 Lesser found in the lung an osteoma which presented under the micro- 
 scope all the histological elements and the typical structure of bone. 
 
 The metaplastic theory concerning the origin of bone is no longer 
 tenable. A careful etiological distinction must also be made between 
 a true osteoma and an exostosis. The origin of the former must be 
 restricted within the limits of the definition to a growth of bone from 
 a matrix of osteoblasts either in the bone or by displacement from a 
 bone, while the latter is the result of a localized or diffuse hypertrophy 
 usually following a reparative process. 
 
 Histogenesis. — The osteomata representing compact bone are usu- 
 ally found upon the surface of bone, and they appear to be produced 
 from the periosteal osteoblasts, as in the case of bony tumors of the 
 flat bones of the skull and of the shafts of long bones ; or they 
 begin as chondromata, and proceed most commonly from the epiphys- 
 eal lines and from the places of origin of ecchondroses. The latter 
 group of tumors, which have therefore a mode of origin distinct from 
 the preceding, are usually pedunculated, are covered with cartilage, 
 and possess a cancellous structure continuous with that of the bone 
 from which they arise. Osteomata from a displaced matrix of osteo- 
 blasts are found most frequently at the insertion of tendons. Ossifica- 
 tion of the deltoid from the shouldering of arms in the soldier, ossi- 
 fication of the adductors of the thighs in cavalrymen, and the more 
 diffuse bone-formation in myositis ossificans do not belong to osteoma t 
 but occur as one form of muscular degeneration. 
 
 Histology. — In spongy osteoma (Figs. 298, 299) the cancellated 
 structure of the bone is well shown in decalcified stained sections. If 
 the tumor starts in the bone, it is surrounded by a zone of connective 
 tissue which separates it from the surrounding tissues. In the ivory- 
 like tumors upon the surface of the cranial bones and the shaft of the 
 long bones the lamellae are so compact that the medullary spaces and 
 the blood-vessels cannot be identified. The section of such a tumor 
 resembles ivory in compactness. In periosteal osteoma the tumor is 
 at first not connected with the underlying bone, and at this stage can 
 readily be detached. Later the surface of the tumor becomes attached 
 to the bone and receives from it a part of its vascular supply. After 
 the union has become complete a section through the tumor does not 
 show the line where the union was effected. 
 
 In the development of an osteoid chondroma into an osteoma the 
 different phases of transition of cartilage into bone-tissue can be 
 observed. Osteoma is almost immune to the different regressive meta- 
 
43^ 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Fig. 298. — Spongy osteoma of cranium ; X 250 (after Perls) : a, old bone-tissue with thick cancelli parallel 
 with the surface ; b, young spongy bone-tissue with irregularly-arranged cancelli. 
 
 —6 
 
 
 
 
 
 w 
 
 ■**' 
 
 >"/, 
 
 
 ^^ 
 
 Fig. 299. — Osteoma of finger ; X 3° (after Karg and Schmorlj. The tumor (a), separated by a narrow- 
 zone of connective tissue (b) from the epithelium of the surface (c), consists of cancellous tissue. The nar- 
 row cancelli with delicate contour include the bone-cells, which appear as minute black dots and are covered 
 on the surface with cells arranged like epithelium. Between the cancelli is a substance like myeloid tissue, 
 which toward the periphery of the growth shows many nuclei. 
 
OSTEOMA. 437 
 
 morphoses which have been described in connection with the other 
 benign mesoblastic tumors. 
 
 Transformation of an osteoma into a sarcoma has never, to the 
 writer's knowledge, been observed. 
 
 Anatomical Varieties. — Osteoma durum or eburneum resembles 
 ivory by its hardness ; it is found most frequently upon the outside 
 of the skull. Osteoma spongiosum resembles the cancellated structure 
 of bone, and usually takes its origin from the epiphyses of the long 
 bones. As the tumor is usually covered with a thin crust of cartilage, 
 Virchow used the term exostosis cartilaginea. Enostosis is a term 
 applied to a bony tumor which originates in the interior of a bone. 
 Exostosis apophytica is a term introduced by Virchow to denote the 
 origin of a bony tumor in a tendon independently of the bone to which 
 it is attached. A tuberous osteoma is an osseous tumor with a con- 
 tracted, pedunculated base, as is the case in osteomata of the frontal 
 sinus, the antrum of Highmore, and the orbit. Callus luxurians is a 
 term used to designate an osteoma produced at the seat of a fracture 
 (Van Heekeven). 
 
 Symptoms and Diagnosis. — An osteoma always grows very 
 slowly, and becomes stationary after it has reached a certain limited 
 size. It is not attended by pain or by tenderness. The slow growth 
 and the absence of pain and tenderness distinguish it from inflamma- 
 tory swellings of bone. Sarcoma of bone is usually a painless affection, 
 but it increases in size more rapidly than osteoma, and its growth is 
 progressive. Osteoma is frequently a multiple affection like chondroma, 
 while sarcoma as a primary disease of bone seldom if ever appears 
 except as an isolated tumor. The differential diagnosis between an 
 osteoma and a chondroma can often be made only by resorting to 
 akidopeirasty. 
 
 Prognosis. — The prognosis in osteoma is always favorable. Trans- 
 formation into sarcoma does not take place, and regressive metamor- 
 phosis of any kind is almost unknown. In the female, pelvic osteomata 
 may become a source of danger to life by interfering with the passage 
 of the child through the pelvis. As the osteoma rarely attains great 
 size, ulceration of the skin is seldom observed. Osteomata in mucous 
 cavities occasionally necrose and give rise to a continuance of sup- 
 puration until they are removed by operation. Osteoma of the orbit 
 by displacing the eyeball may cause impairment of vision and expose 
 the eye to destructive inflammation from exposure. 
 
 Treatment. — The indications for surgical interference in the treat- 
 ment of osteoma are the same as in chondroma. This statement 
 should be modified in so far that operative removal is less urgently 
 
438 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 demanded in osteoma than in chondroma, because in chondroma there 
 is some liability of the tumor undergoing malignant transformation, 
 which is not the case in osteoma. The removal of an osteoma of bone 
 should be done either with a fine saw or with a sharp, thin chisel. 
 
 Topography. 
 Cranial Bones. — The cranial bones are the most frequent seat of 
 osteoma durum, or ivory exostosis. The tumors, which are occasion- 
 ally multiple, are found most frequently upon the frontal bone, 
 especially at or near the superciliary arch. The tumors are smooth 
 with a wide base, and the overlying skin is usually intact. In con- 
 sequence of a trauma or of the application of irritating salves or 
 lotions ulceration of the skin will occasionally ensue. 
 
 Osteomata of the cranial bones must be distinguished from syphilitic 
 exostosis by a careful inquiry into the history of the case and by the 
 
 exclusion of all signs and symp- 
 toms suggestive of an inflam- 
 matory origin. The removal 
 of such tumors, in the absence 
 of complications such as shown 
 in Figure 300, is usually done 
 only for cosmetic considerations. 
 If an operation is decided upon, 
 it should be performed under 
 strictest antiseptic precautions, 
 with a view of obtaining primary 
 healing of the wound and of 
 preventing necrosis, and pos- 
 sibly also pyemic complications, 
 which might result from sup- 
 purative infection. The tumor 
 should be well exposed by a 
 semilunar incision following its 
 
 Fig. 300.— Osteoma durum of the frontal bone with baSC After reflecting all the 
 superficial ulceration (after Textor). Tumor removed by cQff tissues with the skin-flaD 
 Textor. . 
 
 the tumor should with a very 
 fine saw be sawed off even with the surrounding bone. For this pur- 
 pose the writer prefers a scroll saw to the metacarpal or butcher's saw. 
 By using the scroll saw the cut surface can be made to correspond 
 with the outlines of the surface occupied by the tumor. After all 
 hemorrhage has been arrested the soft parts are replaced carefully and 
 are sutured with fine catgut or with horse-hair. The wound should be 
 
OSTEOMA. 
 
 439 
 
 
 Fig. 301. — Osteoma of the skull, transverse section (Bruns). 
 
 sealed with cotton and iodoform collodion, over which an elastic com- 
 press is to be applied for the purpose of keeping the flap in uninter- 
 rupted contact with the sawn surface of the bone. In Guy's Hospital 
 Reports for 1864 four cases of ivory exostosis of the skull are described. 
 In all of them the tumors were removed with a fine saw, as they were 
 too hard to chisel. 
 
 The internal surface of the skull is occasionally the seat of an 
 osteoma. The small conical exostoses which Virchow describes as occa- 
 sionally growing from the upper surface of the basilar process into the 
 
 Fig. 302. — Osteoma of the frontal sinus (after Paget). 
 
 cranial cavity are ossifications of outgrowths of cartilage connected with 
 the basicranial synchondrosis, and a thin layer of cartilage often remains 
 on the surface of the tumor. Osteomata have been found upon the 
 inner surface of nearly all the cranial bones, but more especially upon 
 the frontal. Endocranial osseous tumors, when they reach consider- 
 
44° PATHOLOGY AND TREATMENT OF TUMORS. 
 
 able size, disturb the function of the brain by causing irritation and 
 pressure-atrophy, which are frequently manifested by well-defined focal 
 symptoms. 
 
 Frontal Sinus. — Osteomata of the frontal sinus belong to the 
 tuberous variety. Their origin from islands of persistent cartilage has 
 been described fully by J. Arnold. A very interesting specimen rep- 
 resenting an osteoma in this locality has been preserved in the 
 museum of the Royal College of Surgeons, London. Many of these 
 tumors extend into the orbit, and others sometimes enter the cranial 
 cavity through the orbital roof. The tumor in this locality sometimes 
 attains a very large size, growing externally and in the direction of 
 the cranial cavity. One of the largest specimens of this kind is in 
 the Museum of the University of Cambridge, England. Clark, who 
 examined this tumor, found in the hardest parts neither Haversian 
 canals nor lacunae ; in the less hard parts the canals were very large 
 and the lacunae were not arranged in circles around them ; and every- 
 where the lacunae were of irregular or distorted forms. In a case 
 examined by Turner the bony growth from the inner table and orbital 
 plate of the 'left frontal bone, which had a knotted, irregular, cerebral 
 surface, caused a considerable indentation in the anterior part of the 
 left frontal lobe of the cerebrum. In the absence of suppurative in- 
 flammation of the frontal sinus the presence of the tumor is indicated 
 by an expansion of the anterior wall of the sinus and by displacement 
 of the eye if the tumor has extended in the direction of the orbit. 
 Headache and focal symptoms would point to the extension of the 
 tumor toward the cranial cavity. 
 
 Suppurative inflammation often results in detachment of the pedicle 
 of the tumor, when the osteoma becomes a sequestrum in the suppu- 
 rating cavity. Cases of this kind have been described by Dolbeau, 
 Volkmann, Badal, Fenger, Socin, and Konig. 
 
 An osteoma large enough to expand the frontal sinus should be 
 removed by operation. The operation is not a difficult one if the 
 osteoma has necrosed. In such cases the anterior wall of the sinus is 
 resected with the chisel and the loose sequestrum is extracted, after 
 which the cavity is carefully disinfected, drainage into the nasal cavity 
 is established, and the wound is sutured with the exception of the 
 lower angle, which is used as an additional point for drainage. If the 
 osteoma remains attached, its removal is attended by more difficulty 
 and requires a larger opening. In such cases it would be advisable to 
 make a temporary resection of the anterior wall of the frontal sinus, 
 in order to prevent the unsightly deformity which follows the loss of 
 so much bone. The pedicle of the tumor should be traced carefully 
 
OSTEOMA. 
 
 441 
 
 to its point of attachment to the bony wall of the sinus, when it is 
 severed with a chisel. 
 
 External Meatus. — Osteomata of the external meatus, which are 
 not uncommon, are of importance, as they are apt to obstruct the 
 meatus and cause deafness. The tumors always spring from an island 
 of cartilage-tissue ; these islands are present in great numbers during 
 the development of the external ear. Seligmann has given a very 
 accurate description of osteoma of 
 the external meatus. If the tumor 
 encroaches sufficiently upon the 
 meatus to threaten deafness, it 
 should be removed with a small 
 chisel and a hammer after detach- 
 ing from it freely the surrounding 
 soft tissues. 
 
 Jaws. — Osteoma of the jaws is 
 of very rare occurrence, and some 
 of the tumors described as such 
 have been cases of odontoma. The 
 tumor may appear as an enostosis 
 or an exostosis, and usually belongs 
 to the hard variety. Removal is 
 necessary only if the tumor inter- 
 feres with speech or with mastica- 
 tion or if it causes an unsightly deformity. In the case of symmetrical 
 osteomata of the upper maxillae described by Hutchinson the tumors 
 had taken their starting-point from the nasal processes (Fig. 303). 
 Paget describes a specimen of an osseous tumor of the lower jaw. The 
 tumor appeared as a nodulated mass nearly three inches in diameter, 
 invested the right angle of the jaw, and was in its whole substance as 
 hard and as heavy as ivory. He refers to another specimen in which 
 ivory-like osseous tumors were formed in connection with the outer 
 and inner surfaces, especially the latter, close to the alveolar border. 
 Osseous tumors of the jaws are more frequent in the lower animals 
 than in man. The antrum of Highmore and the nasal processes of the 
 superior maxillae are sometimes the seat of large and disfiguring osseous 
 tumors. 
 
 Brain. — Heterotopic osteomata are occasionally found in the brain. 
 Some of these tumors are connected with the meninges ; others have 
 their origin in the brain independently of its envelopes. These tumors 
 spring from a displaced matrix of cartilage-tissue or of osteoblasts. 
 Maschede describes an osteoma which was attached to the pia and 
 
 Fig. 
 
 Symmetrical osteomata of nasal processes 
 of maxillae (after Hutchinson). 
 
442 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 which produced epilepsy and idiocy. Bidder found an irregular 
 denticulated osteoma four centimeters in diameter in the left corpus 
 
 striatum. The patient was the subject of 
 contracture of the left arm and leg since 
 infancy, the left leg being shortened two 
 centimeters. In the case reported by 
 Ebstein the tumor was located in the 
 cerebellum and produced no symptoms. 
 In operations upon the brain for epilepsy 
 or other focal or cerebral symptoms 
 osteoma as a possible cause should be 
 remembered. 
 
 Epiphyses of the Long- Bones. — By 
 far the greatest number of osteomata 
 occur in the epiphyses of the long bones. 
 Their origin is similar to that of chon- 
 dromata in the same locality, only that in 
 this instance the chondroblasts undergo a 
 higher degree of development and the 
 chondroma is transformed into an osteo- 
 ma. Syme met with cases of epiphyseal 
 osteoma in which the tumor was sur- 
 rounded by a sort of synovial capsule ; in 
 other cases the tumor projects into the joint. 
 Epiphyseal osteomata are often multiple like the chondromata, and 
 are nearly always covered by a thin crust of cartilage, resembling in 
 this respect the articular extremities. The tumors, which are composed 
 of cancellous bone-tissue, are often supplied on their surface with a 
 bursa interposed between the tumor and the fascia, tendons, or muscles 
 overlying it. Occasionally an osteoma is pedunculated, and frequently 
 it has a broad base. The tumors are painless, but they often produce 
 pain by pressing on adjacent nerves. 
 
 A favorite locality for osteoma is above the inner condyle of the 
 femur (Fig. 304), close to the insertion of the adductor magnus. In this 
 locality the tumor is peculiarly apt to acquire a narrow, pedunculated 
 base. The pedicle of such a tumor may occasionally fracture, as hap- 
 pened in the cases reported by Paget and Lawrence. Epiphyseal 
 osteomata, unless of great size, seldom interfere with the functions of 
 adjacent parts, and unless this is the case operative treatment is contra- 
 indicated. 
 
 Muscles and Tendons. — Osteomata are occasionally found in soft 
 parts as distinct and discontinuous tumors invested with capsules of 
 
 Fig. 304. — Exostosis of the femur 
 (after Orlow) : its surface was clad with 
 cartilage and surmounted by a bursa. 
 
OSTEOMA. 443 
 
 connective tissue. Paget refers to a tumor of soft cancellous tissue 
 occupying the dorsal surface of the trapezial and scaphoid bones, com- 
 pletely isolated from them and from all the adjacent bones. In the 
 museum of St. George's Hospital, London, is a tumor formed of com- 
 pact bony tissue that lay over the palmar aspect of the first metacarpal 
 bone, loosely imbedded in the connective tissue, and easily separated 
 from the flexor tendons of the fingers. 
 
 Exostoses tendineae have frequently been observed. The bony 
 growth originated in the tendon, independently of the bone to which 
 the tendon was attached. Folk removed an exostosis apophytica which 
 was attached with a broad base to the sacrum and which terminated 
 in a conical projection several inches in length in the gluteus maximus. 
 
 Seat of Fracture. — Under certain circumstances the callus in the 
 repair of a fracture is so profuse that a large bone-tumor remains after 
 consolidation has been completed. Van Heerkeven applied to this 
 condition the term callus luxuriaiis. A good example of this condition 
 is furnished by the bony hyperplasia which often occurs around a frac- 
 tured rib in a lower animal. Such enormous permanent callus-forma- 
 tion has been observed by Konig and others as one of the remote 
 results of fracture. In some cases it has been impossible to make 
 a differential diagnosis between an osteoma at the seat of fracture and 
 an osteo-sarcoma. The tumor under such circumstances springs from 
 a post-natal matrix of osteoblasts produced by the injury. The differ- 
 ence between a superabundant callus and an osteoma at the seat of 
 a fracture is that in the former case the provisional callus disappears 
 or is at least greatly diminished in size, while an osteoma remains per- 
 manently as a bone-tumor. The operative removal of such an osteoma 
 may become necessary if the tumor implicates important muscles, ves- 
 sels, or nerves. An operation should not be undertaken until by the 
 clinical course the true nature of the tumor has been revealed, by 
 which means only is it possible to make a differential diagnosis between 
 a superabundant provisional callus, an osteo-sarcoma, and an osteoma. 
 
 Orbit. — Osteoma of the orbit occurs either as a primary tumor, 
 when it is attached to the bony wall of the orbit, usually on the nasal 
 side, or the tumor reaches the orbit from the frontal sinus or from the 
 antrum of Highmore. In the latter case the appearance of the tumor in 
 the orbit is usually preceded by signs and symptoms which point to its 
 primary location in either of the adjoining cavities. In a case of orbital 
 osteoma that recently came under the observation of the writer, con- 
 siderable exophthalmus was observed and the eye was displaced out- 
 ward. Beneath the orbital arch a hard tumor could be felt under the 
 upper eyelid, at the inner angle. The tumor, which was exposed by 
 
444 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 an incision along the superciliary arch, was an inch and a half in length, 
 and was attached to the inner wall of the orbit by a contracted, almost 
 pedunculated, base. The tumor was detached from the bony wall with 
 a narrow chisel, and was removed without inflicting any injury upon 
 the more important contents of the orbit. The eye after the operation 
 gradually resumed its normal position. If the tumor is located pri- 
 marily in the frontal sinus or in the antrum of Highmore, its removal 
 must be preceded by a temporary resection of the anterior wall of the 
 cavity in which it is located. 
 
 Eye. — Schiess-Gemuseus collected eight cases of osteoma of the 
 eyeball. In each case the tumor occupied the elastic lamella and the 
 choroid capillaries. 
 
 Subungual Osteoma. — The last phalanx of the great toe is not 
 infrequently the seat of a subungual osteoma. It always grows on the 
 margin, and usually on the inner margin, of this bone. The tumor 
 projects under the edge of the nail, lifting it up, and thinning the skin 
 that covers it until an excoriated surface is presented at the side of 
 the nail. The growth of the tumor is usually veiy slow, and when it 
 has reached a diameter of from one-third to one-half an inch it becomes 
 stationary. The extirpation of subungual osteoma with cutting-forceps 
 must be preceded by partial or complete removal of the nail. 
 
)> from the tooth-follicle. 
 
 XXII. ODONTOMA. 
 
 Definition. — An odontoma is a tumor composed of dental tissue in 
 varying proportions and in different degrees of development, arising from 
 teeth-germs or from teeth still in the process of growth. This definition 
 and the description of the different varieties are gleaned from Sutton's 
 excellent work on Tumors, which contains the most accurate account 
 of tumors of dental origin. 
 
 Sutton's Classification of Dental Tumors. — 
 
 1 . Epithelial odontome, from the enamel-organ. 
 
 2. Follicular odontome, 
 
 3. Fibrous odontome, 
 
 4. Cementome, 
 
 5. Compound follicular odontome, J 
 
 6. Radicular odontome, from the papilla. 
 
 7. Composite odontome, from the whole gum. 
 
 1. Epithelial Odontomes. — These tumors occur, as a rule, in the 
 mandible; but they have been observed in the maxilla (Sutton). They 
 are encapsulated and contain numerous small cysts. In color they 
 resemble myeloid sarcoma, for which they have been mistaken. They 
 consist of branching and anastomosing columns of epithelium, portions 
 of which form alveoli. Although they may occur at any age, they 
 are most frequent at the age of puberty. 
 
 2. Follicular Odontomes. — The follicular odontomes are the den- 
 tigerous cysts. They occur commonly in connection with teeth of the 
 permanent set, and especially with the molars. The tumors often 
 attain large size. The wall of the cyst may be very thin, so that it 
 crepitates under pressure. The cavity contains a viscid fluid and the 
 encysted tooth, which is often imperfectly developed. 
 
 Dentigerous cysts rarely suppurate. Three cases of follicular odon- 
 tome have come under the writer's observation. In one case the cyst 
 was as large as an orange, and contained an imperfectly developed 
 molar tooth and a clear viscid fluid. In the second case a fistulous 
 opening led into the bone above the permanent molars, and necrosis of 
 the maxilla was suspected. The patient had been treated for a long 
 time for suppuration of the antrum. At the bottom of the cyst part 
 of a molar tooth was found. 
 
 445 
 
44 6 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 A follicular odontome invariably occurs in connection with teeth the 
 eruption of which is retarded or prevented owing to their being devel- 
 oped in an abnormal position, whereby they become impacted by the 
 surrounding bone. These tumors appear at a period of life succeeding 
 that at which the alveolar portions of the maxillae are in a state of 
 active development, in which they readily furnish an amount of bone 
 sufficient to perfectly envelop the tooth. The capsule of the tooth, the 
 remains of the enamel-organ, has been shown by Tomes to be, after 
 the calcification of the enamel, quite free and detached from that struc- 
 ture, and therefore, being attached only to its surroundings, will be 
 carried away from the surface of the enamel with them ; there will 
 thus be left a space into which, as a matter of course, serous fluid must 
 under atmospheric pressure be effused, and thus there is formed a 
 cyst, the walls of which will be the dental capsule, including the pro- 
 jecting crown of the tooth (Coleman). 
 
 3. Fibrous Odontomes. — The fibrous capsule of a tooth, composed 
 of an outer firm wall and an inner loose layer of tissue, may become 
 thickened, constituting with the contained tooth a fibrous odontome. 
 Such a tumor is often mistaken for a fibroma, especially if the tooth be 
 small and ill-developed. Under the microscope fibrous odontomes pre- 
 sent a laminated appearance with strata of calcareous matter. Rickets 
 appears to play an important part in the production of fibrous odontomes. 
 
 4. Cementomes. — A cementome is a fibrous odontome which has 
 undergone ossification. The tooth in such cases is encapsuled in a 
 mass of cementome. Cementomes occur most frequently in horses. 
 Tomes describes a tumor of this kind which weighed ten ounces. 
 Sutton refers to one which weighed seventy ounces. 
 
 5. Compound Follicular Odontomes. — " If the thickened capsule 
 ossifies sporadically instead of en masse, a curious condition is brought 
 about, for the tumor will then contain a number of small teeth or den- 
 ticles consisting of cementum or of dentine, or even ill-shaped teeth 
 composed of three dental elements — cementum, dentine, and enamel " 
 (Sutton). As many as four hundred denticles have been found in a 
 single tumor. Tumors of this character have been seen in the human 
 subject. Tellander met with a case in a woman aged twenty-seven. 
 
 6. Radicular Odontomes. — " This term is applied to odontomes 
 which arise after the crown or the root has been completed and while 
 the roots are in the process of formation " (Sutton). In the specimen 
 represented in Figure 305 the outer layer of the tumor is composed of 
 cementum ; within this is a layer of dentine, deficient in the lower part 
 of the tumor; and inside this dentine is a nucleus of calcified pulp. A 
 number of radicular odontomes have been observed in the human 
 subject. Suppuration is a common complication of these tumors. 
 
ODONTOMA. 
 
 447 
 
 7. Composite Odontomes. — These are hard tooth-tumors which 
 bear little or no resemblance in shape to teeth, but which occur in the 
 jaws. The tumors, which consist of a disordered conglomeration of 
 enamel, dentine, and cementum, arise from an abnormal growth of all 
 
 Fig. 305. — Radicular odontome from human subject (after Salter) : a represents the natural size of the 
 
 specimen. 
 
 the elements of a tooth-germ (Fig. 306). In the majority of cases the 
 tumors are composed of two or more tooth-germs indiscriminately 
 fused (Sutton). It is supposed that odon- 
 tomes are more frequent in the lower than 
 in the upper jaw, but there is good ground 
 for the belief that many such tumors have 
 been described as exostoses of the antrum. 
 The diagnosis of dental tumors is very 
 obscure, and in consequence of faulty 
 diagnosis uselessly severe operations have 
 often been performed for the removal of 
 tumors of this kind. It is important to 
 examine solid and cystic tumors of the 
 jaws, especially if they occupy the site of tooth-germs, with special 
 reference to their possible dental origin. A diagnosis once made, a 
 successful operation can be performed with little mutilation. The bone 
 surrounding the tumor is removed by subperiosteal resection, when the 
 tumor can be enucleated or removed with gouge and mallet. The 
 cavity is tamponed for a few days with iodoform gauze. 
 
 Fig. 306. — Composite odontome from 
 a young lady aged eighteen ; natural size 
 (after Heath). 
 
XXIII. ANGIOMA. 
 
 Definition. — -An angioma is a tumor composed of blood-vessels pro- 
 duced from a matrix of angioblasts. Angiomata were formerly 
 described as " teleangiectasia," " angiotelectasia," " angioma pleni- 
 forme," " erectile tumors," and " nsevi." Virchow included all vascular 
 tumors under the head of angioma. Tumors composed of lymphatic 
 vessels are called " lymphangioma," to distinguish them from tumors 
 composed of blood-vessels, and this is what is generally understood 
 by the unqualified term " angioma." The definition excludes from 
 this class of tumors all swellings caused by dilatation of pre-existing 
 blood-vessels, aneurysm, and varicose veins. The angiomatous tumor 
 
 Fig. 3°7-— Angioma of tongue, showing newly-formed blood-spaces not yet in connection with pre- 
 existing vessels; X 33° (Surgical Clinic, Rush Medical College, Chicago): a, angioblast ; b, newly-formed 
 spaces filled with delicate fibrous network and amorphous material. 
 
 is composed of new blood-vessels which are in communication with 
 the adjacent vessels, interstitial tissue composed of the pre-existing 
 tissues in which the tumor develops, and the blood contained in the 
 vascular spaces. The size of the tumor is very variable at different 
 
 448 
 
ANGIOMA. 449 
 
 times and under different circumstances, according to the anatomical 
 structure of the vessels and the amount of blood the vessels contain. 
 
 Histogenesis. — Weil in a study of the growth of angioma came 
 to the conclusion that the origin of new blood-vessels is as variable as 
 is the formation of new embryonal vessels. He found projecting 
 from the wall of old and new capillary blood-vessels streaks of proto- 
 plasm which showed nucleated projections which in the course of time 
 became laminated and were traversed by blood from the pre-existing 
 vessels. In other places he found proliferation of the endothelial cells 
 which formed buds and projected into the surrounding tissues. These 
 masses of endothelial cells form new vessels by the formation of hollow 
 spaces which communicate with the vessels from which they originated. 
 Rokitansky has seen and described the formation in the connective 
 tissue of blood-spaces discontinuous with pre-existing blood-vessels, 
 and which only later entered into communication with them (Fig. 307). 
 In a case of pulsating cavernous tumor of the spleen Langhans noticed 
 an extraordinary proliferation of the endothelium of the venous spaces, 
 and to this proliferation he ascribes the growth of the tumor, in oppo- 
 sition to the theory advanced by Rindfleisch, and the illustrations 
 which accompany his paper appear to justify his conclusions. If the 
 matrix of angioblasts forms a part of the vessel-wall, the new blood- 
 vessels are formed by budding, and are in communication with the pre- 
 existing vessel from the beginning. If the angioblasts have become 
 displaced into the connective tissue, the tumor-tissue becomes vascular 
 after the new blood-spaces have formed a communication with the pre- 
 existing vessels. 
 
 Histology. — Angioma is closely related to endothelioma, as its 
 cellular elements possess the shape and arrangements of their mother- 
 soil. The angioblasts are a modified form of fibroblasts. Their intrin- 
 sic function is to produce new blood-vessels. 
 
 In the growth of normal blood-vessels the angioblasts furnish the 
 essential tissue-elements of blood-vessels ; the blood-vessels reach their 
 requisite normal size, when the process becomes stationary. The angio- 
 blasts from which an angioma develops observe no such limitation of 
 function ; their function is a progressive one, and their product of tissue- 
 proliferation results in the formation of atypical blood-vessels which are 
 not required by the part in which they are produced, and which con- 
 stitute the essential tumor-tissue. The vascular spaces, whether capil- 
 lary, venous, or arterial, are lined with endothelial cells the product of 
 the angioblasts. In a growing angioma new blood-spaces continue to 
 form, and again enter into communication with the older vascular spaces 
 (Fig. 308). As the blood-spaces are formed by the production of an 
 
 29 
 
450 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 intima from the angioblasts, active proliferation takes place in the 
 remaining tissues of the vessel-wall. Connective tissue and muscle- 
 
 . 
 
 
 
 
 
 <lpi 
 
 
 
 
 
 
 
 
 
 
 
 ^■j 
 
 """' : "-:V^-> 
 
 ■: i^gt0' ' 
 
 — b 
 
 Fig. 308. — Angioma of the back ; X no (Surgical Clinic, Rush Medical College, Chicago) : a, wall of blood- 
 spaces ; b, newly-formed blood-spaces. 
 
 fibres derived from the pre-existing blood-vessels are produced, form- 
 ing the outer and middle coats of the new vessels (Fig. 309). The 
 
 Fig. 309.— Angioma of rib, showing new vessel-wall; X no (Surgical Clinic, Rush Medical College, Chi- 
 cago): a, intima; b, adventitia ; c, proliferating cell-areas in the media. 
 
 limits of the tumor, as in all benign growths, are well defined, as will 
 be seen in Figure 310. 
 
 Angioma as a component part of other tumors gives rise to the 
 different combination tumors in which the angiomatous part so often 
 
ANGIOMA. 451 
 
 constitutes what imparts to the tumor its most serious clinical aspects, 
 as in angio-lipoma, angio-fibroma, angio-adenoma, angio-sarcoma, and 
 angio-carcinoma. The communication of all angiomata with blood- 
 vessels is very free. Virchow and Maier have shown that an angioma 
 of the liver can be injected from the hepatic artery and vein and from 
 the portal vein. 
 
 Complications. — According to the number and activity of the 
 angioblasts, the tumor may grow rapidly, may remain stationary, or in 
 exceptional cases may disappear spontaneously. Inflammation occur- 
 
 n 
 
 — b 
 
 Fig. 310. — Cavernous angioma of liver; X 3° (after Karg and Schmorl). The tumor (a), which shows 
 a well-defined border at its junction with the liver-tissue {b), exhibits a structure similar to cavernous tissue. 
 The tumor consists of irregular spaces lined with endothelial cells and separated by their connective-tissue 
 septa. The hollow spaces contain blood ; c, a hepatic vein. 
 
 ring spontaneously or produced by artificial means occasionally results 
 in a permanent cure. This complication may, however, become a 
 source of danger to life from septic thrombo-phlebitis. In venous 
 angioma there sometimes forms a thrombus of a plastic character that 
 may result in the formation of a phlebolith or vein-stone. Extensive 
 thrombosis is one of the ways in which finally all the blood-vessels 
 become obliterated. Transformation of an angioma into the most 
 malignant form of sarcoma is by no means rare. Such a transition 
 is shown in Figure 311. The tumor from which the section repre- 
 sented in Figure 3 1 1 was taken was a superficial capillary angioma of 
 
45 2 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the face that had become stationary during childhood in a man 
 twenty years of age. Without any obvious cause the tumor com- 
 menced to grow very rapidly, and when removed it showed the typical 
 structure of a round-celled sarcoma. The section represented in the 
 illustration was taken from the periphery of the tumor. Calcification 
 of the stroma of the tumor and of the vessel-walls arrests the further 
 growth of the tumor. The angiomata are occasionally the seat of a 
 striking hyaline or colloid change, a cylindromatous appearance often 
 being given to the tumor. 
 
 >< , .-'■'■ 
 
 Fig. 311. — Capillary angioma undergoing transformation into a sarcoma; X 55 (Surgical Clinic, Rush 
 Medical College, Chicago) : a, connective tissue ; b, capillary vessel cut transversely ; c, capillary vessel cut 
 obliquely ; d, group of sarcoma-cells. 
 
 Anatomical Varieties. — The division of angioma into anatomical 
 varieties is based on the kind of vessels the tumor-tissue represents. 
 In superficial angioma the color of the tumor indicates its structure and 
 the kind of blood it contains. An arterial angioma presents the bright- 
 red hue of arterial blood ; the red color of a capillary angioma is of a 
 less bright hue ; and the venous or cavernous angioma presents the 
 dark-blue appearance of venous blood. 
 
 Capillary Angioma — A capillary angioma, known as simple naevus 
 or " mother's mark," is the incipient form of vascular tumor. Its 
 
ANGIOMA. 
 
 453 
 
 favorite sites are the skin of the face and the orbit. The tumors 
 are flattened or slightly pendulous, and they are blue, pink, or purple 
 in color. The difference in color, varying from a pink to a livid tint, 
 depends, according to Billroth, upon whether the vessels be situated 
 superficially or deeply. The most superficial form of capillary angioma 
 is known as a " port-wine stain." If the terminal veins are involved, 
 the tumor is more prominent and of a darker color. The tumor can 
 usually be emptied of its blood by pressure ; sometimes, however, this 
 cannot be done. The dilated capillaries and veins are separated by 
 a variable quantity of connective tissue. If the connective tissue is 
 abundant, the tumor is firm ; if scanty, it offers little resistance to 
 pressure. As a rule, the tumor-tissue does not extend beyond the 
 subcutaneous cellular tissue. The vessels are arranged in small groups 
 from the size of a hemp-seed to that of a pea, consisting of dilated 
 capillaries and venulae arranged around the appendages of the skin 
 (Fig. 312). 
 
 All capillary angiomata are congenital. They may be so small that 
 
 *£s 
 
 Fig. 312. — Capillary angioma of the skin (after Perls). In the upper layer of the skin can be seen capil- 
 laries dilated into cavernous blood-spaces. In the fatty layer only a few capillaries (a), somewhat dilated and 
 with thickened walls, can be seen ; b, a sweat-gland. 
 
 they cannot be detected at the time of birth, but they soon begin to 
 increase in size, whereas the cavernous angiomata are not always con- 
 genital and may develop at any time after birth. Their growth is best 
 studied in the subepithelial fat, where the tumor forms small cellular 
 masses of angioblasts and connective-tissue corpuscles. 
 
 Cavernous Angioma. — The cavernous angiomata form tumors of 
 
454 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 larger size than the capillary variety, and are composed of irregular 
 blood-spaces which communicate freely with one another. The new 
 blood-spaces are formed by angioblasts in the cellular connective tissue. 
 Cavernous angiomata are found in the deep connective tissue, in the 
 bones, the liver, the spleen, and the kidney, and are composed of a 
 tissue almost identical with that of the corpus cavernosum penis — that 
 is, of irregular blood-spaces communicating freely with one another and 
 separated by fibrous septa of variable thickness (Fig. 313). The walls 
 
 
 Fig. 313.— Cavernous angioma of the liver; X 350 (after D. J. Hamilton) : a, liver-cells at margin of the 
 tumor ; b, blood contained in the cavernous spaces ; c, walls of the cavernous spaces. 
 
 of the blood-spaces are lined by endothelium. The formation of new 
 blood-spaces takes place in the fibrous septa and in the periphery of 
 the tumor. Cavernous angioma is a much more formidable tumor than 
 a superficial naevus, as its tendency to progressive growth is much 
 greater and from its deeper location it involves more important struc- 
 tures. A simple naevus may, however, later in life become converted 
 into a cavernous angioma. 
 
 Plexiform Aiigioma. — Plexiform angioma, which is a true angioma- 
 tous tumor, and not an aneurysm, has been known as " aneurysm by 
 anastomosis " or " cirsoid aneurysm " — terms that should no longer be 
 employed to designate an arterial angioma. Plexiform angioma con- 
 
ANGIOMA. 
 
 455 
 
 sists of a number of tortuous blood-vessels of moderate size arranged 
 parallel with one another. These tumors, which are composed of 
 arteries alone, of veins, or of arteries and veins in equal proportions, 
 are found most frequently about the forehead, the temporal regions, the 
 fingers, the anus, and the legs. The largest angioma that came under 
 the writer's observation was in the axilla of a boy seventeen years old. 
 The tumor had existed for many years and had undergone active 
 growth for two years. It had reached the size of a child's head. 
 
 Fig. 314.— Dissection of a plexiform angioma of the forehead (after H. Miiller). 
 
 Some of the veins were as large as the thumb, and the arteries, several 
 in number, were about the size of an ordinary lead-pencil. Pulsations 
 and bruit were well marked and extended along the subclavian vessels. 
 Preliminary to excision, on two different occasions two of the largest 
 arteries that fed the tumor were ligated. The operation of excision, 
 despite the preliminary deligation, was an exceedingly bloody one. At 
 least fifty compression-forceps were required, and nearly as many points 
 were ligated after the excision of the growth. The boy made a good 
 recovery, notwithstanding the excessive loss of blood. 
 
 The tumors are found most frequently in young adults, and they 
 almost always, sooner or later, manifest progressive tendencies. Plex- 
 iform angioma in many instances develops in pre-existing blood-vessels, 
 
456 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 being then caused by an excessive quantity of angioblasts in the vessel- 
 wall. During the growth of the tumor there are produced new blood- 
 vessels which remain in communication with the lumen of the vessel 
 similarly affected. Bruit and pulsation are usually frequent, and the 
 size of the tumor is greatly diminished by pressure. In cases of 
 epicranial plexiform angioma the bone beneath the tumor undergoes 
 pressure-atrophy, so that deep depressions occur, and even perforation 
 of the skull may take place. 
 
 Symptoms and Diagnosis. — The diagnosis of a surface angioma 
 can be made from the color of the tumor alone. The color depends 
 on the kind of blood the tumor contains, and is also modified, accord- 
 ing to Billroth, by the amount of tissue over the tumor. In most 
 instances the color of the tumor disappears under pressure, and returns 
 with the entrance of blood into the tumor-tissue. In plexiform angioma 
 pulsation and bruit are frequently present, and the tumor almost dis- 
 appears under pressure. Any and all of the causes which increase 
 intravascular pressure, as coughing, laughing, straining, and active 
 exercise of all kinds, increase the size of plexiform and cavernous 
 angiomata. In plexiform angioma, if the tumor is subcutaneous, the 
 tortuous vessels can be outlined distinctly. 
 
 The differential diagnosis between intracranial angioma and angioma 
 of other internal organs and aneuiysm is impossible. A positive dif- 
 ferential diagnosis between pulsating inflammatory swellings and 
 angioma can be made by resorting to an exploratory puncture. 
 
 Prognosis. — Surface angioma in exceptional cases becomes con- 
 verted into a plexiform angioma, and not infrequently it serves as a 
 starting-point for sarcoma. With the exception of these possible termi- 
 nations it is a benign affection. In some cases a spontaneous cure is 
 effected ; in other cases a cure follows inflammation occurring acci- 
 dentally or produced intentionally. In cavernous and plexiform 
 angiomata the prognosis is more grave. Inflammation of such tumors 
 may result in septic thrombo-phlebitis, pyemia, and death. Wounds 
 of angiomata may give rise to serious and even fatal hemorrhage. The 
 progressive growth of a plexiform angioma may interfere by pressure 
 with the function of important adjacent organs. Ulceration may result 
 in serious hemorrhage or may give rise to dangerous inflammatory 
 complications. 
 
 Treatment. — The probability of the occurrence of a spontaneous 
 cure in angioma is so small that operative treatment should be instituted 
 in appropriate cases as soon as the tumor is discovered. In the super- 
 ficial variety, the so-called " port-wine mark," operative treatment is 
 contraindicated if the tumor is diffuse — that is, if it occupies an area 
 
ANGIOMA. 457 
 
 larger than a silver dollar. If the tumor is limited, excellent results 
 are obtained by electrolysis. Only a small part of the surface should 
 be treated at each sitting, and the operation should be repeated every 
 few days. Among the other surgical resources which have been em- 
 ployed in the treatment of ordinary naevus may be mentioned ignipunc- 
 ture, coagulating injections, ligature, and the application of caustics. 
 Ignipuncture with the needle-point of a Pacquelin cautery is an excel- 
 lent method of treating superficial angiomata in localities not easily 
 accessible to excision, as the soft palate and the mucous membrane of 
 the mouth and the pharynx. The method can also be employed in 
 the removal of surface angiomata in parts of the body not exposed, as 
 the chest, abdomen, arms, and legs. The scarring following ignipunc- 
 ture is much greater than after excision. The needle should be heated 
 to a dull-red heat, as puncturing with a needle heated to a white heat 
 is likely to give rise to hemorrhage. The punctures should be made 
 a few lines apart and in a circle corresponding with the periphery of the 
 growth. The central portion may be treated in the same manner at 
 the same time, or this part of the tumor may be treated later. If the 
 tumor is larger than a half-dollar, a number of sittings are necessary 
 to complete the treatment. Before puncturing the surface should be 
 made aseptic, and after the puncturing it should be protected carefully 
 against infection. 
 
 Coagulating injections in the treatment of angiomata are mentioned 
 simply for the purpose of condemning them. Their employment has 
 produced instant death from embolism, and has frequently been fol- 
 lowed by suppuration and ulceration. 
 
 The ligature causes pain and sloughing, and the resulting scar is 
 more unsightly than that following excision. The ligature is now 
 seldom used in the treatment of angioma. The same may be said of 
 percutaneous threads saturated with coagulating solutions. Nitric acid 
 has been recommended strongly by Billroth and others in the treat- 
 ment of circumscribed superficial angiomata. All caustics are inferior 
 to the use of the knife. 
 
 The fear of hemorrhage attending the excision of angiomata is 
 unfounded, provided the incisions are not made through, but outside 
 of, the tumor-tissue, or, as Sutton so happily says, " if the naevus 
 is cut out, not cut into." The writer never encountered trouble- 
 some hemorrhage when this advice was followed in the excision of 
 angiomata. 
 
 The ideal treatment of angioma is excision. The incision should be 
 made a few lines away from the visible boundary of the tumor, on the 
 sides as well as at its base. The bleeding vessels can be caught at once 
 
458 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 with hemostatic forceps, the surgeon being enabled to remove the 
 growth quickly before the bleeding points are tied. Circular pressure 
 some distance from the periphery of the tumor is a material aid in 
 diminishing the amount of bleeding. If the wound cannot be closed 
 by suturing, the surface should be covered at once by a Wolfe graft 
 or by Thiersch grafts. 
 
 The surgical treatment of plexiform angioma has so far not yielded 
 very encouraging results. Ligature of the principal artery of the part 
 occupied by the tumor has not proved satisfactory. Ligature of the 
 arteries supplying the tumor has not yielded much better results. In 
 tumors of moderate size and readily accessible on all sides, excision 
 offers the best prospects. If the tumor is large, as in the case men- 
 tioned on page 455, it is well to tie several of the larger vessels prior 
 to the excision. If it is important to make the incision some distance 
 away from the growth in the excision of an ordinary naevus, this advice 
 applies with still greater force to the excision of a plexiform angioma. 
 The principal vessels which nourish the tumor should be exposed and 
 be secured with hemostatic forceps before they are cut. Pressure is 
 an important factor in removing provisional hemostasis in the excision 
 of a plexiform angioma. In such cases the skin over the tumor should 
 be reflected and preserved if it is intact. If the angioma involves the 
 skin, this must be excised with the tumor, and the resulting wound- 
 surface is paved at once with Thiersch grafts. 
 
 Topography. 
 Skin and Mucous Membranes. — The skin and the mucous mem- 
 branes are the seats of capillary angioma. The face and the mouth are 
 the favorite localities. The most superficial form, the " port-wine mark," 
 frequently is very extensive, occupying the larger part of one side of 
 the face, and in some instances even one half of the body. This 
 variety of tumor is occasionally converted into a cavernous or a plex- 
 iform angioma. Breschet relates the case of a girl who was born with 
 a port-wine mark on the external ear. The tumor remained stationary 
 for several years, when it became the seat of pulsation, ulcerated, and 
 bled freely from time to time. In her eighteenth year all the arteries 
 in the temporal region were consistently enlarged, as was also the 
 occipital, which, together with the tumor, made a pulsating swelling of 
 considerable size. At the necropsy it was ascertained that the arteries 
 had such thin walls that they could hardly be distinguished from the 
 accompanying veins. Breschet believed that the arteries communicated 
 directly with the veins. In another case observed by Breschet an 
 insignificant angioma behind the ear was followed by dilatation of the 
 
ANGIOMA. 459 
 
 carotid artery on the same side to three times its natural size ; the aorta 
 and the common iliac artery showed similar changes, while the arteries 
 of the extremities were normal in size and in structure. The disease 
 in this case was progressive, extending from the congenital angioma to 
 the vessels mentioned by an uninterrupted process. 
 
 The most typical structure of angioma of the skin is seen in the 
 growing tumors in young children. The appendages of the skin in 
 the part affected undergo hypertrophy. In port-wine mark the skin is 
 but little thicker than normal ; the epidermis is thinner than normal, 
 the papillae are flattened, and the epithelial depressions between them 
 are more shallow. The arteries and veins can be distinguished with- 
 out difficulty, and the dilated capillaries can be identified readily. A 
 closer study of the process under the microscope reveals the places 
 where the new vessels permeate the fatty tissue. Klebs has seen the 
 angioblasts form solid cylinders of cells which project into and displace 
 the adipose tissue and which mark the beginning of a new blood- 
 vessel. These cell-masses are in immediate connection with open 
 vessels, and within the mass can be seen red corpuscles which push 
 before them the cellular wall. The new vessel is at first composed 
 simply of a tube of endothelial cells. Weil has seen how the angio- 
 blasts in pre-existing vessels proliferate and form cell-masses outside 
 the vessel-wall ; these masses become hollow cylinders and form new 
 vessels. The same process is observed in arteries which supply the 
 fat-tissue. According to Ziegler, this process is characterized by active 
 karyokinetic changes. The new endothelial cells perforate the muscu- 
 lar coat, and outside form cell-masses which are transformed into new 
 blood-vessels. Klebs is inclined to believe that other angioblasts find 
 their way through the muscular coat by ameboid movements. Most 
 of the new vessels are formed from the capillaries in the form of solid 
 buds of new endothelial cells. The process is accomplished exclusively 
 by the angioblasts. 
 
 All the superficial angiomata are congenital. Port-wine marks 
 seldom increase much in size after birth. The deeper variety often 
 appears as small red dots not larger than a pin-head at the time of 
 birth, but later they increase in size. These small tumors should be 
 destroyed by ignipuncture as soon as they are discovered. If the 
 tumors are larger than a split pea and occupy exposed parts of the 
 body, they should be excised. If the wound is too large to be closed 
 by suturing, it should be covered at once by skin-grafts. 
 
 Deep Connective Tissue. — The deep connective tissue is the seat 
 of cavernous or plexiform angiomata. The tumors may have their 
 primary origin in the skin, and reach the deep connective tissue by 
 
460 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 extension, or may originate primarily in the connective tissue. The 
 formation of blood-spaces is not always the result of dilatation by 
 growth of the vessel-wall, but is also produced by confluence. The 
 vessel-walls, at points where they come in contact, undergo absorption 
 by pressure-atrophy and impaired nutrition. In cavernous and plex- 
 iform angioma the skin overlying the tumor is usually intact if the 
 tumor originated primarily in the deep connective tissue. In large 
 pulsating tumors the skin is subjected to pressure, becomes atrophic, 
 and, in consequence of impaired nutrition or of injury, ulceration may 
 ensue, giving rise to recurrent hemorrhages and to infection. Venous 
 cysts, which often result from passive dilatation of veins, are a form of 
 deep varices, and do not belong to tumors. In other cases such cysts 
 occur as a congenital affection, and are discontinuous from pre-existing 
 vessels. These cysts are produced by a displaced matrix of angioblasts. 
 
 The frontal and parietal regions are favorite localities for deep angio- 
 mata. The tumors are usually congenital, but from their deep location 
 they are not discovered until they become larger. W. Koch reports a 
 case where, immediately after birth, an angioma the size of a walnut was 
 discovered above the right clavicle ; the tumor could be seen through 
 the normal intact skin. Uninterrupted slow growth took place until 
 the child was eighteen months old, when it died. The tumor then 
 measured fifteen inches in a horizontal and seven inches in a vertical 
 direction. After the fourth month pressure had no effect in diminish- 
 ing the size of the tumor, but brought on asphyctic symptoms. Post- 
 mortem examination showed that the tumor was made up of three 
 compartments which communicated with one another, of which only 
 one compartment answered to the external swelling. Of the other 
 compartments, one occupied the deep region of the neck, and the third 
 occupied the anterior mediastinum and the right pleural cavity, where 
 it had displaced the lung. The chambers contained spaces variable in 
 size occupied by fluid and coagulated blood. The right subclavian vein 
 was absent, and the tumor was undoubtedly composed of the tissues 
 which were intended for its structure. 
 
 In a case of cavernous angioma of the arm Esmarch removed in 
 a man twenty-eight years old fifty-four tumors, each of which com- 
 municated with veins. The first tumor appeared about the region of 
 the wrist when the patient was six years, old. Esmarch believed that 
 the tumors developed from pre-existing veins. 
 
 The legs and arms, and more especially the fingers, are sometimes 
 the seat of plexiform angioma. Vascular tumors of the fingers should 
 be excised ; if their size renders this procedure impracticable, multiple 
 ligation should be tried before resorting to amputation. Deep plexi- 
 
ANGIOMA. 461 
 
 form angiomata of the leg and the arm are always grave affections. 
 If the extent of the tumor contraindicates excision, multiple ligation 
 should be tried ; in some cases this procedure may be followed by 
 excision. In the gravest cases amputation may become necessary. 
 Plexiform angioma of the frontal, temporal, and occipital regions should 
 be treated by excision with or without preliminary ligation of the prin- 
 cipal vessels supplying the tumor, according to the size of the tumor 
 and the accessibility of the vessels which feed it. 
 
 Bones. — Most difficult to explain is the origin of vascular tumors 
 of bone, called by Virchow myelogenous angiomata. There is good 
 reason to believe that pulsating sarcoma of bone has often been mis- 
 taken for so-called "aneurysm of bone." Only a very few well-authen- 
 ticated cases of myelogenous angioma of bone have been recorded. 
 Dupuytren ligated the femoral artery in a case of pulsating tumor of the 
 tibia, and the tumor disappeared, but returned (sarcoma) after seven 
 years. Virchow in a case of cavernous angioma of the liver found 
 also two similar growths in two separate vertebrae. Klebs saw a case 
 of genuine bone-aneurysm and cavernous angioma in the same patient. 
 The case occurred in Kronlein's practice. The patient was a woman 
 twenty-four years old. The tumor was of one year's standing, and 
 occupied the upper portion of the vertebral column and the lateral 
 aspect of the neck. The tumor was covered by a thin shell of bone, 
 and presented neither bruit nor pulsation. On incising the tumor there 
 was found a blood-cyst from which at one point there was free hemor- 
 rhage. It was ascertained that the hemorrhage was from the vertebral 
 artery. As the vessel could not be ligated, hemorrhage was arrested 
 by grasping the bleeding point with a hemostatic forceps which was 
 incorporated in the dressing. Death occurred from sinus-thrombosis. 
 The necropsy showed that the vertebral artery was bent at an acute 
 angle and terminated in a network of vascular spaces, and that through 
 a small opening these spaces communicated with a large blood-cyst. 
 The third and fourth cervical vertebrae were involved by the tumor. 
 Microscopical examination of sections of the tumor showed giant-celled 
 sarcoma. 
 
 Angioma of bone, as angioma in other localities, is always produced 
 by the formation of new blood-vessels from a matrix of angioblasts. 
 The differential diagnosis between angioma of bone and myeloid sar- 
 coma is impossible. In doubtful cases, in view of the fact that the 
 more benign forms of sarcoma have been treated successfully by a local 
 operation, it is advisable to resort to removal of the diseased tissue with 
 a sharp spoon. Should the subsequent clinical course and microscopical 
 examination of the tissue removed reveal the sarcomatous nature of the 
 
462 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumor, amputation should be performed as soon as evidences of a 
 recurrence show themselves. Angioma of bone is a?i exceedingly rare 
 affection, whereas myeloid sarcoma is common — facts which should not 
 be forgotten in the differential diagnosis between these two affections 
 of bone. 
 
 Intracranial Angiomata. — Demme has described bjood-cysts of the 
 superior longitudinal sinus that perforate the skull and appear exter- 
 nally as pulsating vascular tumors. A positive diagnosis between such 
 cysts and an extracranial plexiform angioma must be made before an 
 operation is decided upon. Akidopeirasty with a fine needle will show 
 whether or not the skull has been perforated. Intracranial angiomata 
 may belong to blood-cysts of bone developed from the vasa nutritia of 
 the parietal bone. As the walls of such cysts are lined by endothelial 
 cells, the cysts are undoubtedly produced by angioblasts, possibly 
 aided by mechanical causes. Other cysts communicating with the 
 longitudinal sinus are multilocular. Bruns cites such a case. The 
 cyst, which was discovered when the patient was fourteen years old, 
 was situated in the parietal region and was composed of veins covered 
 by normal skin. The cystic spaces communicated freely with one 
 another. In a case of large plexiform angioma of the frontal region, the 
 writer, in excising the tumor, found at its base large veins which com- 
 municated with the longitudinal sinus. The hemorrhage from this 
 source could be controlled only by compression. Death resulted from 
 suppurative sinus-phlebitis. 
 
 Angioma in the central nervous system occurs where the vessels 
 are all new, all of them starting from the pia. Brunetti found such a 
 tumor the size of a pea in the fourth ventricle. Klebs found a similar 
 growth upon the surface of the middle lobe. 
 
 Liver. — Cavernous angioma of the liver is of common occurrence. 
 It appears in the form of round or wedge-shaped spaces filled with 
 blood in parts of the organ not occupied by parenchyma. The spaces 
 are nearly uniform in size. New spaces form in the fibrous septa 
 and in the periphery of the tumor. It has been asserted that the 
 cavernous spaces are formed by dilatation of pre-existing vessels accom- 
 panied by pressure-atrophy — an opinion which receives the sanction 
 of Ziegler. Such a view is untenable, as the structure of the tumor 
 does not represent the conditions produced by vascular obstruction. 
 The endothelial cells which line the spaces are attached to and sup- 
 ported by a strong scaffolding of connective tissue. In the neighbor- 
 hood of such angiomata no evidences of inflammation can be found. 
 Johannes Muller found in the lining of such spaces large spindle-shaped 
 cells which are the endothelial cells. The number of these cells is not 
 
ANGIOMA. 463 
 
 the same in all parts of the wall : they are most numerous where the 
 process of cell-proliferation is most active, and less numerous where 
 the growth of the tumor has become stationary. Similar tumors are 
 found less frequently in the spleen and the kidney. 
 
 Mammary Gland. — In rare instances the mammary gland is the 
 seat of an angioma. Sutton relates the case of a boy, seventeen years 
 of age, who as a child had an ordinary nevus of small size in the skin 
 above the left nipple. For many years this nevus gave no trouble ; 
 it then gradually increased in size until the whole breast was converted 
 into a cavernous angioma three inches in diameter. At intervals the 
 surface ulcerated, and profuse hemorrhages were the consequence. 
 Another and larger angiomatous tumor of the breast came under the 
 observation of Smage. 
 
 Tongue. — The tongue is not infrequently the seat of simple and 
 cavernous angioma. In a lad fifteen years old the writer successfully 
 removed a tumor the size of a pullet's egg. The excision was greatly 
 facilitated by elastic constriction of the affected side of the tongue. 
 
 Muscles. — Cavernous angiomata of the voluntary muscles have been 
 observed by a number of surgeons. In the clinic of Rush Medical 
 College, Chicago, such a case came under the care of the writer during 
 the session of 1894. The patient was a boy sixteen years of age. 
 The tumor, which was first discovered five years previously, extended 
 from a point three inches above the patella, over the outer aspect of the 
 thigh, ten inches in an upward direction. The swelling was oblong, 
 very prominent and firm when the patient was standing, but disap- 
 peared almost wholly when he was placed in the recumbent position 
 with elevation of the affected limb. The tumor, which was removed 
 by excision, involved the outer part of the extensor quadratus femoris 
 muscle, and extended on the outer side as far as the intermuscular 
 septum. A strip of the muscle three inches wide and eight inches 
 in length was removed, and on examination it was found to contain 
 numerous vessels the size of a crow's quill. The hemorrhage upon 
 the removal of the elastic constrictor was very profuse, and about fifty 
 vessels had to be ligated before it was controlled. The boy made a 
 good recovery and regained perfect use of the limb. The formation 
 of a muscle-hernia was prevented by careful suturing of the fascia lata 
 with a separate row of buried catgut sutures and rest in bed for six 
 weeks. 
 
 Liston removed a cavernous angioma from the popliteal space 
 in connection with the semimembranosus muscle. Holmes Coote 
 removed a similar tumor from the deltoid, and Campbell de Morgan 
 removed one from the semimembranosus in a girl ten years old. 
 
464 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 In the diagnosis of muscular angiomata the variable size of the 
 tumor in different positions of the body is an important element. 
 
 Larynx. — Except in the tongue and the rectum, angioma of the 
 mucous membranes is very rare. It has been observed in the larynx 
 in a few instances, springing from the vocal cords, the ventricular 
 bands, from the ventricle, and from the sinus pyriformis. Angiomata 
 of the larynx are either sessile or pedunculated. They are rarely 
 larger than a haricot bean, and are red or purple in color. They should 
 be removed with the snare, with the aid of the laryngoscope. 
 
XXIV. LYMPHANGIOMA. 
 
 Definition. — A lymphangioma is a tumor composed of lymphatic 
 vessels produced from a matrix of angioblasts. The lymphatic vessels 
 of the tumor are new structures containing lymph, and they constitute 
 the essential part of the tumor. Their walls are more delicate than 
 those of angioma, but they are composed of the same histological 
 elements. A lymphangioma is a firmer tumor than an angioma, as 
 the connective tissue between the vessels is more abundant. 
 
 Anatomical Varieties. — Wagner divides lymphangioma into — I. 
 Capillary ; 2. Cavernous ; and 3. Cystic. In the capillary variety the 
 tumor is composed of lymph-spaces and lymphatic vessels which con- 
 stitute an anastomosing network. The cavernous variety is composed 
 of a framework of connective tissue with communicating spaces which 
 contain lymph. The cystic form presents to the naked eye an appear- 
 ance of a convolution of large and small vesicles with translucent walls 
 containing lymph. These vesicles are dilated new lymphatic vessels 
 which have lost in part or completely their connection with the 
 lymphatic system. Such cysts can be produced experimentally in 
 rabbits by forcing atmospheric air under considerable pressure into the 
 abdominal cavity. Under such conditions the air is forced into the 
 lymph-spaces, especially those of the pelvis, producing rapid dilatation. 
 
 Histology and Histogenesis. — In capillary lymphangioma the new 
 vessels are formed by angioblasts in the wall of pre-existing lymph- 
 spaces by a process of budding, in the same manner as in capillary 
 angioma. As the vessels are composed of exceedingly delicate walls 
 lined with endothelial cells, they dilate earlier and under less pressure 
 than in angioma, consequently cystic dilatation takes place at an earlier 
 period and to a greater extent. Capillary lymphangioma is always 
 congenital, whereas the cavernous and cystic varieties may develop 
 at any time after birth. The beginning of a capillary lymphangioma 
 manifests more or less swelling before its lymphangiectatic character 
 can be discerned. Microscopically, lymphangioma of the tongue, 
 a comparatively frequent affection, appears in the form of a sym- 
 metrical swelling of the tongue, while the same affection of the skin 
 begins in the subcutaneous connective tissue as a softer swelling with 
 ill-defined borders. The loose connective tissue is cedematous, and 
 
 30 465 
 
466 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 only in cases where large quantities of clear lymphatic fluid escapes 
 can we suspect the existence of dilated vessels. In specimens that are 
 somewhat finer, spaces can be seen traversing the tumor, while the 
 delicate walls of the ectatic lymphatic vessels and cysts collapse so 
 that the openings in the vessels cannot be seen. Microscopical exam- 
 ination, unless carefully conducted, may lead to errors in diagnosis, as 
 the specimens often present more the appearance of hyperplasia of the 
 tongue than that of dilated lymph-channels. In lymphangioma of the 
 
 Y ' ■■ 
 
 Fig. 315.— Lymphangioma of the skin ; X 375 (Surgical Clinic, Rush Medical College, Chicago) : a, connec- 
 tive-tissue reticulum ; b, round cells (lymphoid cells); c, lymph-space : d, blood-vessels. 
 
 tongue young muscle-fibres are met with, which proves that the mus- 
 cular tissue is also increased in quantity. In the subcutaneous tissue 
 the growth of lymphangioma is attended by an increase of connective 
 tissue (Fig. 315). 
 
 The subcutaneous lymphangioma differs from elephantiasis arabum 
 by the tumor being composed of new lymphatic channels instead of 
 dilated diseased pre-existing vessels, as is the case in elephantiasis. 
 Lymphangioma of the tongue (Fig. 316), or, as it is called, macroglossia, 
 is always a congenital tumor. It commences with an enlargement of 
 the blood-vessels ; the veins are thin-walled, but a new tissue-product 
 
L YMPH ANGIOMA. 
 
 467 
 
 cannot be recognized so far. On the contrary, the new lymph-spaces 
 are dilated and are paved with numerous large nuclei. The dilatation 
 of the lymphatic spaces progresses parallel with the new tissue-prolif- 
 eration. The muscular bundles are at some points ensheathed by 
 
 Fig. 316. — Lymphangioma of the tongue; X 50 (after D. J. Hamilton): a, lymphadenoid deposits; b, a 
 cavernous lymphatic space ; c, muscular fibres of tongue, d, a small artery. 
 
 lymphoid tissue. An increase of endothelial cells is apparent, but 
 vessel-dilatation has not as yet occurred. At other points free hyper- 
 plastic lymphatic vessels are seen in the connective tissue. In the 
 further development of macroglossia, angiomata as well as multilocular 
 lymph-cysts appear. If angioma predominates, it is interesting to 
 observe that the blood often circulates through the new dilated lymph- 
 channels. Lucke observed that on puncturing such cysts, at first 
 lymph escaped, and at subsequent repetitions of puncturing blood 
 instead of lymph escaped. In such cases the communication between 
 blood-vessels and lymphatic vessels is not accidental, but is due to an 
 embryonal relationship between the two kinds of vessels. The new 
 lymph-spaces contain at first a colorless fluid. Thrombi are also 
 found, and their occurrence renders a diagnosis less difficult. Wagner 
 found in the lymph ectatic muscular-sheathed hyaline thrombi, and this 
 discovery made it easy to give a correct interpretation of their patho- 
 logical significance. Lewinski described a case of calcification of 
 lymphatic thrombi in a boy twelve years old suffering from lymph- 
 angioma of the scrotum. 
 
 Cavernous lymphangioma (Fig. 3 1 7) presents upon section a honey- 
 combed appearance, the spaces being separated by their septa lined 
 
468 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 - 
 
 r *€^' 
 
 Fig. 317. — Lymphangioma of the lip; X 55 (after Karg and Schmorl). In the connective tissue under 
 the epithelium numerous lymph-spaces of different size, lined by endothelial cells, are seen ; these spaces 
 contain a few finely granular leucocytes in a mass of lymph (coagulated by hardening). 
 
 with endothelium. The septa are perforated, so that all the spaces com- 
 municate with one another. In other cases the interior of the tumor is 
 
 Fig. 318.— Lymphangioma of the orbit ; X 350 (after D. J. Hamilton) : a, stroma of the walls of the cavernous 
 spaces ; b, a cavernous lymphatic space ; c, endothelium lining the space. 
 
 occupied by larger spaces, as though coalescence had taken place by 
 the breaking down of septa (Fig. 318). The spaces not only undergo 
 
L YMPHANGIOMA . 4 6 9 
 
 cystic dilatation, but are enlarged by coalescence. In some cases hyper- 
 plasia of the other tissues also takes place. 
 
 Cystic lymphangioma differs from the cavernous variety only in that 
 the individual separate spaces arising from new and dilated lymph- 
 channels possess forms which correspond with their origin : they are 
 more or less globular in shape, corresponding in this respect with the 
 rosary-like appearance of the lymphatic vessels during the early stages 
 of the growth of the tumor. Cysts of large size are produced by the 
 confluence of numerous smaller spaces. The cystic variety is more 
 prone to progressive growth than the cavernous ; in this respect the 
 distinction between the two varieties is of importance from a prognostic 
 standpoint. This difference in the clinical aspects of these tumors 
 applies only to cases where the cysts are multiple, as when only one 
 cyst is present its increase in size takes place more on account of reten- 
 tion of secretions than by tissue-proliferation. The skin covering the 
 tumor is at first intact. As the tumor increases in size it may become 
 hyperplasic or it is thinned out by pressure from beneath, constituting 
 an important element in the production of ulceration. 
 
 Cystic lymphangioma of the neck has seldom been interpreted 
 correctly, and has been described under the vague terms of " cyst 
 hygroma," " hydrocele of the neck," " cystic tumor of the neck," " serous 
 cyst," etc. Forster first pointed out the correct histogenesis of cystic 
 lymphangioma of the neck. He demonstrated the endothelial nature 
 of the lining of the cysts by silver-staining. He also showed that these 
 cysts communicated with the lymphatic vessels. Luschka asserted 
 that the serous cysts of the neck originate from the glandula carotica 
 or from the glomeruli of the arteria inter carotica, but in two cases at 
 least Arnold was able to show the presence of these organs in a normal 
 condition in connection with the cysts. Klebs, who found in a large 
 cyst of this kind lymphatic glands in the cyst-wall, believes that the 
 glands occasionally take part in the production of the cyst. In none 
 of these cases was a connection found between the cavity of the skull 
 and the cyst, hence meningocele takes no part in their production; 
 neither was there found any connection between the skull and the cyst, 
 hence meningocele can be excluded as a factor in their causation. If 
 located in the neck, the cyst may extend in an upward direction as far 
 as the cavity of the mouth and downward as far as the mediastinum. 
 If very large the cysts become pendulous. Besides the cysts which 
 can be seen with the naked eye, endothelial proliferation and the forma- 
 tion of new lymphatic vessels can be seen under the microscope in the 
 adjacent connective-tissue spaces. In the neck the tumor follows the 
 direction of the lymphatics, along the large blood-vessels and the inter- 
 
47o 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 muscular septa. In cases where proliferation is active the blood-vessels 
 are also enlarged, and many of these tumors attain the structure of a 
 
 Fig. 319. — Haemo-lymphangioma of the groin. Patient a native of the West Indies. Tumor successfully 
 
 removed (Senn). 
 
 mixed tumor — a hcemo-lymphangioma. In such instances the transfor- 
 mation of lymph-cysts into blood-cysts, as first described by Lucke, 
 takes place. 
 
 Multilocular lymphangioma is also found in glandular organs. 
 Weichselberg reported a case of lymphangioma of the mesentery. 
 It was a flat tumor, the size of the palm of the hand, between the 
 layers of the mesentery at a point corresponding with the upper por- 
 tion of the ileum. It contained a fluid which by chemical tests and by 
 microscopical examination was shown to be chyle. In the same cate- 
 gory belong the congenital cysts of the lung described by Virchow. 
 These cysts might be regarded as dilated lymphatics, but the active 
 endothelial proliferation which is always found present in the smallest 
 lymphatic channels speaks in favor of their being true tumors. 
 
 The kidney is another organ in which multilocular lymphangioma 
 is occasionally met with. The histological structure of the cysts in 
 
L YMPHANGIOMA . 471 
 
 this organ is a counterpart of angioma of the liver. The tumor 
 is composed of multiple spaces lined by a single layer of endothelial 
 cells and communicating freely with one another. The multilocular 
 structure of the tumors distinguishes them from retention-cysts of the 
 uriniferous tubules. Klebs describes a specimen of multilocular lymph- 
 angioma of the kidney. 
 
 Varicose lymphangioma must be distinguished from simple dilata- 
 tion of pre-existing lymphatic vessels. It differs from lymphatic vari- 
 cosity by the absence of obstruction and by an abnormal increase in 
 the amount of lymphatic structures. Dr. Busey, in his monograph on 
 Congenital Occlusion and Dilatation of Lymph-channels (1878), describes 
 minutely a case that came under his observation. The disease was 
 congenital and involved one of the lower extremities, and, as the post- 
 mortem showed, extended behind the peritoneum far up into the pelvis. 
 The child lived a little more than a year. He collected in addition 
 8y cases. In some of them the disease was limited to fingers and toes, 
 and resulted in great hypertrophy of all the tissues, including the bones. 
 In Busey's case the surface of the limb was covered with translucent 
 vesicles which contained a serum-colored fluid. The sweat-glands 
 were found enormously hypertrophied. 
 
 A lymphangioma, wherever it occurs, is characterized by the forma- 
 tion of new lymphatic structures, the process extending to places in 
 which, in normal condition, no lymphatics are found. 
 
 Lymphangioma may occur almost in any part of the body if it 
 springs from the perivascular lymph-sheaths. In some cases the pro- 
 liferation is very active and the extension of the disease is progressive. 
 The endothelial cells are large, and the connective-tissue reticulum is 
 infiltrated with lymph-corpuscles (Fig. 318). Langhans, in a child 
 seven years old, saw the disease affect the perivascular lymph-sheaths 
 in almost the entire panniculus adiposus, while the large lymphatic 
 vessels were free. The inguinal lymphatic glands were permeable to 
 injection. Holmes, in a child three years old, saw a case where the 
 disease was limited to the right leg. Extension to the external genital 
 organs and the lymphatics of the groin and the pelvis took place when 
 the child reached its seventh year. A somewhat similar case is the 
 one reported by Busey. In this instance the disease extended very 
 rapidly, and when the child died the corresponding side of the pelvis 
 was found extensively involved. 
 
 Regressive Metamorphoses. — The connective-tissue stroma of 
 lymphangioma is subject to nearly all the retrograde tissue-metamor- 
 phoses found in other tumors. The most frequent forms of degenera- 
 tion met with in such tumors are fatty degeneration and calcification. 
 
472 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Myxomatous degeneration is liable to occur in large tumors in which 
 the connective tissue is abundant. Cystic degeneration by the break- 
 ing down of fibrous septa, caused by pressure-atrophy, is of frequent 
 occurrence, especially in tumors in which the tissue-proliferation is 
 very active and their growth, consequently, rapid. The pathological 
 complication that occurs most frequently is thrombosis. Aseptic throm- 
 bosis renders the affected part of the tumor harder, and frequently 
 results in arrest of growth, as the removal of the thrombi is followed 
 by obliteration of the vessels by granulation and cicatrization. The 
 enlargement of the tumor caused by this accident under such favorable 
 circumstances is followed by progressive shrinkage which attends the 
 obliteration of the vessels. Of more serious import is septic thrombo- 
 lympJiangitis, which occurs most frequently in connection with ulcera- 
 tion of the surface of the tumor. The ingress of pyogenic microbes 
 through such an infection-atrium results in suppurative inflammation 
 of the walls of the infected lymphatic channels and of the interstitial 
 connective tissue. If the suppurative infection is severe, the resulting 
 inflammation assumes a phlegmonous character and may successively 
 involve the entire tumor, attended by all the risks to life incident to 
 septic infection and pyemia. The septic thrombo-lymphangitis is usu- 
 ally accompanied by a septic thrombo-phlebitis. In septic thrombo- 
 lymphangitis the thrombi are not observed, but they undergo puriform 
 softening. 
 
 The transformation of a lymphangioma into a lympho-sarcoma is 
 possible, and there is good reason for believing that in cases in which 
 the disease extended over a large territory in a short time, resulting in 
 death, such a transformation had occurred. 
 
 Symptoms and Diagnosis. — Lymphangioma in the majority of 
 cases presents itself as a congenital affection with an intrinsic tendency 
 to increase in size after birth. In some cases the growth is very rapid, 
 involving different regions successively, and resulting in death by the 
 tumor interfering with important functions. If the tumor is not com- 
 plicated by inflammation, it is pale and the overlying skin is intact. 
 The density of the tumor depends on the amount of connective tissue 
 it contains and on the presence or absence of thrombosis. The effect 
 of pressure is more marked if the tumor is composed of new blood- 
 vessels as well as lymphatic channels — that is, in cases of hemo- 
 lymphangioma. If the skin or the mucous membrane is broken and 
 the surface defect communicates with lymphatic spaces, lymph in 
 varying quantities escapes. The escape of lymph is the most reliable 
 diagnostic element in the differentiation between a lymphangioma and 
 other tumors or inflammatory swellings. The surface of the tumor is 
 
L YMPHANGIOMA . 473 
 
 often undulated from the presence of superficial cysts. Lymphangioma 
 of the tongue and the lips can usually be recognized without much 
 
 Fig. 320. — Author's case of lymphangioma involving the gluteal region and lower extremity. The gluteal 
 tumor was successfully removed ; no recurrence. 
 
 difficulty. In both instances all the tissues implicated by the tumor 
 are in a hypertrophic condition and constitute a part of the swelling. 
 Lymphangioma is ordinarily not limited by a well-defined capsule, as the 
 connective tissue in the periphery of the tumor is progressively invaded 
 by new lymphatic vessels. 
 
 Cystic tumors of the neck, of lymphatic origin, are almost always 
 congenital, are thin-walled, and contain a clear serous fluid ; or, if 
 hemorrhage into the cyst has taken place, the serum is discolored by 
 the admixture of blood. The use of the exploring syringe will fre- 
 quently render material aid in the differential diagnosis between cystic 
 lymphangioma and other cystic tumors and inflammatory swell- 
 ings. If the exploratory puncture yields first lymph, and later 
 lymph and blood or pure blood, the diagnosis of hemo-lymph- 
 angioma is established. In the differentiation between a lympho- 
 sarcoma and lymphangioma the use of the microscope may be re- 
 quired. 
 
 Prognosis. — With few exceptions, lymphangioma is a chronic affec- 
 tion and does not tend to destroy life. Great enlargement of the 
 tongue in macroglossia may interfere with speech and deglutition. A 
 cystic lymphangioma of the neck may become a source of danger by 
 interfering with deglutition and respiration. In rapid-growing tumors 
 the prognosis should be guarded, more especially if cystic degeneration 
 is a permanent feature. The liability to infection, and also to trans- 
 
474 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 formation into sarcoma, should not be forgotten in the prognosis of 
 lymphangioma. 
 
 Treatment. — Complete excision is indicated if the tumor can be 
 removed safely. Partial excision is indicated in lymphangioma of the 
 lip and the tongue if the tumor interferes with deglutition, speech, or 
 respiration, or for cosmetic reasons. In the removal of cystic tumors 
 of the neck, of lymphatic origin, it must be remembered that the cyst- 
 wall is in close relation with the large vessels, and that parts of the 
 tumor often dip deeply into the intermuscular septa. Amputation in 
 uncomplicated lymphangioma of the extremities is not a justifiable pro- 
 cedure. In cystic tumors of the neck not amenable to enucleation or 
 excision a cure may be effected by free excision, cauterization of the 
 interior of the cyst with the Pacquelin cautery, and packing of the 
 cavity with iodoform gauze. In progressive inoperable cases paren- 
 chymatous injection of a 10 per cent, solution of chloride of zinc 
 may be tried with a view of arresting further growth by cicatricial 
 contraction. 
 
 Topography. 
 
 Tongue. — Lymphangioma of the tongue is known as macroglossia 
 (Fig. 321). Clinically, the condition manifests itself as a congenital 
 enlargement of the tongue, implicating mainly its anterior two-thirds. 
 The growth is progressive, and when the organ becomes too large to 
 be accommodated by the cavity of the mouth, its tip protrudes from 
 the mouth. The irritation and repeated injuries of the enlarged organ 
 by the teeth during mastication, and the exposure of the organ to 
 external influences after it protrudes from the mouth, aggravate the 
 condition by producing inflammation of the surface of the tongue or 
 of the tumor-tissue itself. The disease begins in the submucous con- 
 nective tissue, but later implicates the muscular tissue of the tongue. 
 Capillary lymphangioma of the tongue is limited to its surface, and 
 appears in the form of enlarged papillae. 
 
 The proper treatment consists in partial excision of the tongue if 
 the organ has become sufficiently enlarged to interfere with mastication 
 and speech. In some cases the lymphangioma is complicated by 
 angioma, which calls for special prophylactic precautions to control the 
 hemorrhage during the operation. Lymphangiomata of the cavity of 
 the mouth have been described by Sachs. 
 
 Lips. — Lymphangioma of the lips is called macrochilia. Billroth 
 described a case that came under his own observation. The patient, 
 who was fifteen years of age, was born with a diffused tumor of the 
 upper lip, which projected considerably beyond the lower lip. The 
 
L YMPHANGIOMA. 
 
 475 
 
 tumor was painless, firm, pale, and hard, and could not be diminished 
 in size by pressure. It was often the seat of inflammation, and it bled 
 readily on being handled or when injured. The tumor was extirpated. 
 A section through it showed that it was composed of a firm framework 
 of connective tissue, the meshes of which were occupied by coagula 
 
 Fig. 321. — Macroglossia in a girl eleven years old (after Humphrey). 
 
 and a serous fluid. The spaces were lined by endothelial cells, and the 
 connective tissue contained many elastic fibres. The fluid contained 
 lymphoid corpuscles. 
 
 Macrochilia is very rare, and in the cases which have been described 
 it was always congenital. As the disease is sure to become complicated 
 by repeated attacks of inflammation, it should receive attention during 
 infancy or childhood. If the tumor is limited in extent, as in Billroth's 
 case, it should be removed by excision. If it is too extensive for 
 complete removal, the size of the lip should be reduced to the desired 
 extent by wedge-shaped excisions. Under such circumstances Lanne- 
 longue's sclerogenic method of treatment deserves a trial. 
 
 Neck. — Many cases of congenital hydrocele or serous cysts of the 
 neck are of lymphatic origin. Usually, although not always, they are 
 
47^ PATHOLOGY AND TREATMENT OF TUMORS. 
 
 congenital. The development of the capsule is very imperfect as com- 
 pared with true cystomata in the same locality. Arnold divides these 
 tumors into superficial and deep. The former are situated between the 
 skin and the platysma ; the latter, beneath the platysma, usually along 
 the anterior surface of the larger vessels. The deep tumors generally 
 reach the greater size. They may surround the whole neck, and may 
 extend beneath and below the clavicle, in the direction of the axillary 
 space. In an upward direction they may encroach upon the cavity of 
 the mouth. Rokitansky and Gurlt believed that these cysts originated 
 in the connective-tissue spaces during intra-uterine life. The formation 
 of multilocular cysts they explained by assuming that collections of 
 serous fluid formed in different parts of the connective tissue at the 
 same time. It would be impossible to explain why similar hydropic 
 conditions of the connective tissue should not take place in other parts 
 of the body if hydrocele of the neck had such an origin. Luschka 
 maintained that serous cysts of the neck originated in the ganglion 
 caroticum — a theory which does not deserve further consideration, since 
 Arnold found this ganglion intact in two cases of hygroma of the neck. 
 The existence of an endothelial lining of the cyst in all cases and the 
 presence of lymphoid tissue in the cyst-wall leave no doubt that in the 
 majority of cases of serous cysts of the neck, of congenital origin, we 
 have to deal with cystic lymphangioma. The serum contained in these 
 cysts is often stained by the admixture of blood, in which event the cysts 
 lose their translucency. If the diagnosis is not clear, an exploratory 
 puncture will provide the desired information. The tumor either 
 remains stationary after birth or increases very rapidly in size. In the 
 former case no treatment is indicated, as a spontaneous cure not infre- 
 quently takes place ; if this should not be the case, operative treatment 
 is postponed until the child is older. In rapid-growing tumors death 
 often results from pressure of the tumor on the trachea, the oesophagus, 
 and the large vessels and nerves of the neck. In such cases urgent 
 symptoms call for aspiration, which may be repeated as often as the 
 pressure-symptoms demand it. In older children strong enough to 
 withstand the immediate effects of a radical operation, the tumor should 
 be excised, in whole or in part, under strict antiseptic precautions. If 
 complete removal is impracticable, the part of the cyst-wall which 
 remains should be seared with the actual cautery sufficiently deep to 
 destroy its endothelial lining, and the wound should be packed with 
 iodoform gauze. Injections of iodine are too uncertain and dangerous. 
 Injections of carbolic acid after tapping are less objectionable, and 
 should be resorted to if partial or complete excision of the sac is 
 contraindicated. 
 
L YMPHANGIOMA . 
 
 477 
 
 Subcutaneous and Submucous Connective Tissue. — Most of the 
 chronic lymphatic affections of the subcutaneous connective tissue are 
 of an infective origin and nature. They are caused by the filaria san- 
 guinis hominis, and they are prevalent in southern countries, where this 
 parasite has its habitat. Reference has been made to a case of almost 
 general lymphangioma of non-infective origin. True lymphangioma- 
 tous tumors of the submucous and subcutaneous connective tissue are 
 exceedingly rare (Fig. 322). Steudener described a cavernous lymph- 
 
 Fig. 322. — Busey's case of lymphangioma. 
 
 angioma of the conjunctiva. Biesiadecki found a small lymphangioma 
 in the subcutaneous connective tissue. Gjorgewic found a similar tumor, 
 the size of a fist, in the subcutaneous tissue of the thigh in a girl nine- 
 teen years old. In this case large quantities of lymph escaped through 
 two small openings. Reichel described a congenital lymphangioma, 
 the size of a pigeon's egg, which he found in the perineum. More 
 comprehensive statistics of lymphangioma can be found in the mono- 
 graphs on this subject by Busey and Wagner. 
 
 Uterus. — The lymphatic origin of some of the cystic tumors of the 
 uterus has been established by Leopold and Fehling. These cysts 
 contain a fluid which coagulates on exposure to air, and which is often 
 stained by the admixture of blood. The cyst-wall is lined by endo- 
 thelial cells. Many of these cysts are multilocular, the septa being 
 composed of firm fibrous tissue. The new cysts show in their interior, 
 on silver staining, the characteristic reaction of endothelium. In most 
 instances these cysts occur in connection with myofibromata. 
 
XXV. LYMPHOMA 
 
 Upon histogenetic, histological, and physiological grounds tumors 
 of the lymphatic glands should be excluded from tumors of the true 
 glandular organs. The lymphatic glands are mesoblastic structures, 
 and are not secreting organs. They are hematoplastic organs, physio- 
 logically closely allied to the medullary tissue of bone and the spleen. 
 They are composed of lymphoid corpuscles and a delicate reticulum 
 of connective tissue enclosed in a firmer capsule 
 of connective tissue. They contain normally no 
 epithelial cells (Fig. 323). The lining of the lymph- 
 sinuses and the follicles is composed of numerous 
 plate-like connective-tissue cells, in places these 
 elements constituting almost an endothelial cover- 
 ing. The lymphatic vessels and glands are found 
 wherever blood-vessels are present ; besides, lymph- 
 spaces are found in the cornea. In the submucous 
 tissue lining the different hollow viscera lymphoid 
 tissue is found as a diffuse infiltration in the form 
 of follicles (Fig. 324). 
 
 Fig. 323. — Elements of ade- 
 noid tissue from partially 
 brushed section of lymphatic 
 
 As a lymphatic gland is not a true gland, the glandofa child (after Piersol) . 
 tissue composing it is called, from its resemblance «> fibres of reticulum ; t>,\ y m- 
 
 1 1 i . 7 • 7 • 1 phoid cells : c, expanded con- 
 
 to glandular tissue, adenoid tissue ; and as it pro- nective-tissue plate. 
 duces the lymph, it is also called lymphoid tissue. 
 
 Its essential histological element is the lymphoid cell or lymphoid cor- 
 puscle, the product of proliferation of the plate-like connective-tissue cell. 
 Definition. — A lymphoma is a benign tumor formed of lymphatic 
 tissue produced from a matrix of lymplwblasts. In no department of 
 surgical pathology do we meet with more confusion than in the 
 differentiation between benign and malignant tumors and infective 
 swellings of the lymphatic glands. Virchow includes under the term 
 " lymphoma " all tumors and swellings composed of lymphoid tissue. 
 Many authors still continue to speak of a " primary carcinoma " of the 
 lymphatic glands. Some pathologists entirely ignore the existence of 
 non-malignant tumors of the lymphatic glands. This confusion of 
 terms and pathological conditions was increased when Billroth intro- 
 duced the term " malignant lymphoma." At the present time it is 
 
 47S 
 
LYMPHOMA. 
 
 479 
 
 easier to say what a lymphoma is not than what it is : it constitutes in 
 surgical pathology at the present time a veritable lucus a non lucendo. 
 
 Lymphoid tissue is exceedingly susceptible to infection, and is 
 therefore predisposed to acute and chronic inflammation ; it is also 
 frequently the seat of sarcoma, but lymphoma, in the restricted sense 
 
 Fig. 324. — Diffuse lymphoid tissue occupying 
 deeper layers of mucosa of human stomach (after 
 Piersol). The lymphoid cells infiltrate the fibrous 
 tissue between the glands without being definitely 
 limited. 
 
 Fig. 325. — Simple lymph-follicle from the con- 
 junctiva of a dog (after Piersol) : a, lymphoid tissue 
 limited by the fibrous capsule {b) ; c, surrounding 
 connective tissue. 
 
 in which this term will be used here, is exceedingly rare. The resem- 
 blance in the structure of tumors and infective swellings of lymphatic 
 glands is so close that a reliable differentiation must be based on the 
 clinical aspects and the etiology of the different affections of the 
 lymphatic glands. Enlargement of the lymphatic glands may be due 
 (1) to infection, (2) to sarcoma, (3) to carcinoma, or (4) to lymphoma. 
 The acute affections of the lymphatic glands, characterized by rapid 
 enlargement, pain, tenderness, and fever, are produced by the entrance 
 into the lymphatic system of pyogenic microbes, of the bacillus mal- 
 leus, or of pre-formed septic material. If the process is chronic, the 
 immediate cause is usually the virus of either syphilis or tuberculosis. 
 In leukemia and pseudo-leukemia the infection is diffuse and is unat- 
 tended by the usual symptoms which indicate the existence of an acute 
 or a subacute inflammation ; the glandular affection either appears 
 diffusely from the beginning or becomes diffuse during its course. 
 These affections point so strongly to the existence of a microbic origin 
 that no doubt can be entertained as to their infective origin. Sarcoma 
 invades successively the glands of the same chain, and frequently 
 terminates fatally by general metastasis. Carcinoma of the lymphatic 
 glands is always a secondary affection ; it never occurs as a primary 
 disease, as the lymphatic glands do not contain the essential histological 
 elements — epithelial cells. Lymphoma is a tumor of the lymphatic 
 
480 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 glands composed of lymphoid tissue ; the growth remains as a local 
 affection, and appears clinically as an encapsulated tumor which mani- 
 fests no tendency to implicate adjacent glands, and which is never com- 
 plicated by affections of other blood-producing organs. The lymphoblasts 
 of the matrix of the tumor produce lymph-corpuscles which are not 
 transformed into leucocytes, but which remain in the reticulum of the 
 tumor as the essential tumor-elements. Lymphoma is a functionless 
 tumor, in this respect differing from the hyperplastic, highly active glands 
 in leukemia. 
 
 Histology and Histogenesis. — A lymphoma is not produced from 
 pre-existing adenoid tissue, as are the infective swellings. It is the 
 product of tissue-proliferation from an embryonal matrix of lympho- 
 blasts of congenital or post-natal origin. A lymphoma is a tumor which 
 has no more connection with the adjacent lymphatic channels than an 
 adenoma has with the surrounding ducts of a gland. The connective- 
 tissue plates, modified endothelial cells of the matrix, the lymphoblasts, 
 produce the lymph-corpuscles 
 which are the essential histo- 
 logical elements of the tumor 
 (Fig. 326). 
 
 In its structure a lymphoma 
 bears a strong resemblance to 
 myeloma (PL 12, Fig. 1). The 
 lymphoid cells are so numer- 
 ous that often they almost 
 completely obscure the stroma. 
 The capsule of the tumor is 
 firm, being composed of con- 
 centric layers of fibrous tissue. 
 The atypical structure of the tumor is characterized by the absence of 
 well-defined lymph-sinuses, while the follicular structure is well pre- 
 served. The surface of the tumor is smooth, and lacks completely the 
 prolongations into the surrounding connective tissue that are such 
 conspicuous features of lymphangioma. The lymphoid corpuscles, 
 which are only occasionally present in lymphangioma, form the bulk 
 of the tumor in lymphoma. 
 
 Retrograde Metamorphoses. — Permanency of the tumor-tissue as 
 compared with the inflammatory products which constitute the infective 
 swellings is one of the most important elements in the differentiation 
 between a lymphoma and the different forms of inflammatory swellings 
 of the lymphatic glands, both acute and chronic. Suppuration can 
 occur only if the tumor becomes the seat of infection with pyogenic 
 
 Fig. 326. 
 
 Lymphoma, showing lymphoid cells and delicate 
 reticulum (after Paget). 
 
LYMPHOMA. 
 
 Plate 12. 
 
 
 ' ■•:■ "■■£■■' ""- 
 
 
 
 
 1. Myeloma of rib (after Klebs) : myeloid cells with large nuclei in a delicate network of connective tissue. 
 2. Hyaline degeneration of a lymphatic gland (after Kara; and Schmorl). The reticulum of the gland has been 
 transformed into a shining, structureless framework. The hyaline masses are continent in some places; 
 between the masses in the centre of the field are scanty remnants of gland-tissue. The glandular structure is 
 more abundant in the peripheral portions of the picture. 
 
LYMPHOMA. 481 
 
 microbes, and caseation can take place only in the event of the tumor 
 becoming infected with tubercle bacilli. A lymphoma may attain con- 
 siderable size before any degenerative changes occur, in this respect 
 differing greatly from suppurative, tubercular, glandulous, septic, and 
 gonorrheal adenitis. Myxomatous degeneration of the stroma may 
 occur — a change which renders the tumor softer — or the tumor 
 may become harder by an increase of the connective-tissue reticulum. 
 A hyaline degeneration such as that shown on Plate 12 (Fig. 2) some- 
 times inaugurates graver degenerative changes in a lymphoma. Calcare- 
 ous degeneration preceded by fatty degeneration has been observed. 
 Small cysts occasionally form by dilatation of follicles. A lymphoma, 
 after having remained stationary for a long time, may become trans- 
 formed into a sarcoma. 
 
 Symptoms and Diagnosis. — Lymphoma is a rare tumor of the 
 lymphatic glands, if we exclude, as should be done, all infective swell- 
 ings. It is found most frequently in the region of the neck, in the 
 groins, the axillae, the mediastinum, and the retroperitoneal space — that 
 is, in localities in which the lymphatic glands are most numerous. 
 Lymphoma occurs most frequently in young adults. If several tumors 
 appear at the same time, they increase in size at the same rate, and are 
 movable, painless, and not tender on pressure. The skin over the 
 tumor remains intact. The tumor is smooth and is surrounded by 
 a perfect capsule. Extension to other glands never takes place, as is 
 the case in sarcoma and in infective swellings. All signs and symptoms 
 of inflammation are absent. The general health is not impaired. The 
 tumor or tumors, if large, may cause pressure upon important organs, 
 and in this way may become a source of danger. In the differential 
 diagnosis between lymphoma and other tumors and swellings of the 
 lymphatic glands it is important to consider the following affections : 
 lymphangioma, sarcoma, lymphadenitis, tuberculosis, glanders, leu- 
 kemia, pseudo-leukemia, and syphilis. 
 
 Lymphangioma. — Lymphangioma occurs as a more diffuse tumor 
 and is not encapsulated. In many cases lymph escapes from one 
 or more openings in the tumor — an occurrence never observed in 
 lymphoma. 
 
 Sarcoma. — Lympho-sarcoma appears first as a single tumor, which 
 is followed by successive infection of glands in the same region, usually 
 in the direction of the lymph-stream. The tumors grow very rapidly, 
 and general infection not infrequently takes place. 
 
 Lymphadenitis. — Acute suppurative lymphadenitis is attended by 
 fever and all the local signs and symptoms of inflammation, and is 
 always attended by lymphangitis between the infection-atrium and the 
 
 31 
 
482 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 inflamed glands. In the chronic form the symptoms of inflammation 
 are often masked, so that the source of infection is overlooked and the 
 accompanying or preceding lymphangitis is not recognized. The 
 disease may be limited to one or two glands, which renders it still 
 more obscure. Some tenderness is, however, always present, and 
 foci of suppuration can often be detected by palpation or by explor- 
 atory puncture. 
 
 Tuberculosis. — Glandular tuberculosis is a progressive disease. The 
 affection extends from gland to gland in the infected region. Regres- 
 sive metamorphoses, coagulation-necrosis, caseation, and liquefaction 
 of the cheesy product are early and almost constant manifestations. 
 The extension of the disease beyond the capsule of the gland in 
 advanced cases is also an important factor in distinguishing between 
 a lymphoma and swellings of an infective origin. 
 
 Glanders. — Glanders occurs, if it affects the glands, as an acute or 
 a subacute diffuse affection, in this respect differing entirely from 
 lymphoma, which remains as a local tumor. The discovery of the 
 bacillus of glanders in the inflammatory product will render the diag- 
 nosis positive. 
 
 Leukemia. — Leukemia, as was correctly shown by Virchow in 1845, 
 appears as a hyperplasia of all hematoplastic organs — the spleen, the 
 lymphatic glands, and the marrow of bone — and is characterized by a 
 specific pathological change in the blood — an excess of white blood-cor- 
 puscles. The increase in the number of leucocytes that typifies this dis- 
 ease led Bennet to apply to it the term leucocythemia. Neumann added 
 to the splenic and lymphatic forms the myelogenous variety. The 
 lymphatic glands in different parts of the body become enlarged and 
 hard, and, as a rule, this process is attended by enlargement of the 
 spleen and by a simultaneous affection of the marrow of the bone, 
 which affection is often manifested by tenderness over the junction 
 of the xiphoid cartilage with the sternum and over the epiphyseal 
 extremities of the long bones. The excess of leucocytes in the blood 
 is never absent, and from a slight change during the incipiency of the 
 disease may reach such an extent that the red and white corpuscles 
 are present in the same proportion. Neumann traced in the blood of 
 leukemic patients cells intermediate between the red and the white cor- 
 puscles — small nucleated red corpuscles. 
 
 In the commencement of the disease it is often difficult, if not 
 impossible, to differentiate simple leucocytosis and leukemia by micro- 
 scopical examination of the blood. Huss thinks that if the pro- 
 portion of white to red corpuscles is increased to 1 : 20, such blood 
 is leukemic blood ; but this is not always the case. Staining of the 
 
L YMPHOMA. 483 
 
 blood-corpuscles with eosin is an important diagnostic aid. Leukemic 
 blood always contains eosinophilous cells. In doubtful cases micro- 
 scopical examination of the blood will succeed in making a positive 
 differential diagnosis between lymphoma and enlargement of the glands 
 attending leukemia. W. S. Church reports a case of leukemia in which 
 
 *£& g 1 
 
 
 jb. 
 
 ?& J 
 
 W 
 
 Fig. 327. — The blood in leukemia (after Karg and Schmorl). Besides the pale-red blood-corpuscles are 
 leucocytes in various forms, the number of the leucocytes being immensely increased. The smaller leucocytes 
 contain irregular lobulated nuclei ; the larger ones contain large nuclei equally stained throughout; a, nucle- 
 ated red blood-corpuscles. 
 
 only the thoracic and abdominal lymphatic glands were found enlarged 
 at the post-mortem examination. Murchison records the case of a 
 child twelve years old, in whom no enlargement of any subcutaneous 
 lymphatic glands existed, who died with " lymphatic new formations " 
 in the liver and enlargement of the glands in the fissure of the liver. 
 In Church's case the disease was attended by fever, which he regards 
 as of diagnostic importance in the differentiation between leukemia and 
 malignant tumor. 
 
 Pseudo-leukemia . — This affection of the lymphatic glands, known 
 also as " anaemia lymphatica," " Hodgkin's disease," " adenie " (Trous- 
 seau), " malignant lymphoma " (Billroth), and " lympho-sarcoma " (Vir- 
 chow), resembles lymphoma more closely than leukemia. It is unques- 
 tionably an infective disease in which the undiscovered microbe selects 
 the lymphatic tissue as its field of action. The lymphatic glands of 
 one region of the body, most frequently the cervical, become success- 
 ively enlarged, forming hard masses, to be followed by a similar con- 
 dition of the glands in other regions of the body. The disease is 
 attended by progressive anemia, but the blood-changes which have 
 been described as occurring in leukemic blood are absent. In this 
 
484 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 disease the lymph-cells are increased in number in the meshes of the 
 enlarged glands, and the cortical and medullary portions of the glands 
 cannot be distinguished from each other. The disease sometimes 
 remains stationary for a certain length of time. The spleen, the ton- 
 sils, and the marrow of the bones are frequently implicated. Meta- 
 stasis in the liver and kidneys has frequently been observed. The 
 disease terminates fatally in from one to two years. The appearance 
 of enlarged glands in the different regions of the body distinguishes 
 this disease sufficiently from lymphoma, in which such a dissemination 
 is never observed. Lymphoma, being a strictly local disease, is not 
 attended by impairment of the general health. 
 
 Syphilis. — Enlargement of lymphatic glands in syphilis after the 
 disease has become general is not limited to one region : all the glands 
 are more or less implicated. In primary syphilis the extension of the 
 disease to the lymphatic structures is indicated by enlargement (bubo) 
 of the glands which are in connection through lymphatic channels 
 with the primary sore. We must restrict the term " lymphoma " to 
 non-malignant tumors of the lymphatic glands, single or multiple, but 
 their number is limited and usually confined to one region in which 
 an infective origin can be excluded either by a careful study of the 
 clinical aspects or by bacteriological examination. As has previously 
 been stated, lymphoma is quite rare. The writer has seen these tumors 
 in the cervical and axillary regions and in the groins. The tumors are 
 movable, painless, and firm, and may in the course of several years 
 attain the size of a hen's egg. The tumors may occur at any time of 
 life, but they are most frequently met with in young adults. After the 
 tumors have reached a certain size they become stationary throughout 
 life, unless they become the seat of infection or undergo transformation 
 into sarcomata. They do not return after extirpation, and they become 
 dangerous only when from their size they exert harmful pressure upon 
 important adjacent organs. 
 
 Treatment. — The proper treatment of lymphoma is enucleation. 
 The tumors are always well encapsulated, and there is no danger of 
 recurrence after complete removal by this method. 
 
XXVI. MYOMA. 
 
 Myoma was first described as a distinct variety of tumors by Virchow. 
 It has often been mistaken for fibroma, on account of the predominance 
 of fibrous tissue in many of the myomatous tumors. Fibrous tumors 
 which contain muscular fibres should be classified with the myomata, 
 and not with the fibromata, as the muscle-fibres constitute, from a 
 histogenetic standpoint, the essential part of the tumor. In myoma 
 the concentric striated appearance so characteristic of a proper fibroma 
 is frequently less marked, and the substance of the tumor seems to be 
 more homogeneous in its structure. Fibrous tissue is always present 
 in varying proportions, and often is so abundant as almost to obscure 
 the essential tumor-tissue. 
 
 Definition. — A myoma is a tumor composed of muscle-tissue produced 
 from a matrix of myoblasts. Vogel called them " muscular tumors ; " 
 Virchow, " myomata." Zenker made a subdivision of this group of 
 tumors necessary, as he described tumors which were composed of 
 striated muscular fibres, while before his time it was believed that all 
 myomatous tumors were composed of unstriped muscular fibres. 
 A tumor composed of striped muscular fibres is called a " rhabdo- 
 myoma " or " myoma striocellulare," whereas a tumor composed of 
 unstriped muscular fibres is called a " leiomyoma " or " myoma laevi- 
 cellulare." For the sake of brevity we shall describe the two histo- 
 logical varieties as rhabdomyoma and leiomyoma. There are many 
 reasons to believe that a myoma springs from a matrix of myoblasts 
 independently of the pre-existing muscular fibres between which the 
 tumor takes its origin. 
 
 Embryology. — According to Rabl, the muscular tissue in the 
 embryo is derived from a part of the mesoblast enclosed by the 
 three-faced original vertebrae at a point, corresponding with the mesial 
 junction, which is in contact with the nerve-tube, while the ventral- 
 border surface, which adjoins the primitive aorta, becomes the sclero- 
 toma, which forms the axial connective tissue, while the upper wall 
 furnishes the skin with its connective tissue. The embryonal tissue 
 destined to become transformed into muscular tissue develops into a 
 large plate under the connective tissue of the skin, and sends forth, in 
 the form of muscular buds, projections to the extremities. The con- 
 
 4S5 
 
486 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 nective tissue cannot produce muscle-tissue, and when muscular fibres 
 are found in a locality not normally supplied with this tissue, its occur- 
 rence is always due to an erratic deposition of embryonal cells during 
 early life. 
 
 Rhabdomyoma. — Benign tumors composed of striated muscular 
 fibres are exceedingly rare. They were first described by Zenker. 
 Marchand, Eberth, and Cohnheim confirmed Zenker's observation and 
 reported new cases. The tumors usually grow in connection with the 
 kidney, sometimes in the testis, and they are always congenital. Reck- 
 linghausen found in several new-born children myomata the size of a 
 pigeon's egg in the heart-muscle. Fibromatous and myomatous tumors 
 of the heart have been described by Zander, Bostrom, and others. 
 
 mm 
 
 fm 
 
 
 "V * 
 
 H 
 
 Fig 328. — Adeno-rhabdosarcoma of kidney (after Karg and Schmorl) : the tumor (a) is composed of bun- 
 dles of striated muscular fibres arranged in different directions ; the striations can be seen by the aid of a 
 magnifying lens. The interstitial tissue at b is scanty and the nuclei are small ; at c the nuclei are larger and 
 more numerous, and appear as round-celled sarcoma arranged in spaces (d) lined by cylindrical cells. 
 
 Rokitansky found a rhabdomyoma in the scrotum. Neumann observed 
 a similar tumor in the same locality in a boy three and a half years old. 
 It took its origin at the lower pole of the testicle, where the gubernac- 
 ulum Hunteri has its point of attachment. The muscular fibres con- 
 tained no glycogen, and the sarcolemma was imperfectly developed. 
 Prudden found striated muscular fibres in a tumor of the parotid gland 
 in a boy seven years old ; Virchow, in the stroma of ovarian tumors ; 
 Senftleben, in cystoid tumors of the testicle ; and Cattani, in a vesical 
 
MYOMA. 
 
 487 
 
 polypus in a boy twelve years of age. Huber, Bostrom, Marchand, 
 and others have described cases of striated myosarcoma of the kidney 
 in children. Striated muscular fibres are found more frequently as a 
 constituent part of sarcoma of the urogenital organs than as the sole 
 characteristic constituent of benign muscular tumors. The structure 
 of such a complicated tumor is shown in Figure 328. Rhabdomyoma 
 is interesting from an etiological standpoint, but it presents itself to the 
 surgeon only as a pathological curiosity. We shall discuss in this 
 section more in detail leiomyoma, which is of vastly more practical 
 interest to the surgeon. 
 
 Leiomyoma. — Histology and Histogenesis. — Leiomyoma occurs 
 most frequently in the uterus, Fallopian tubes, and gastro-intestinal 
 canal. The tumor seldom pre- 
 sents the same parallel arrange- 
 ment of the muscular fibres which 
 in normal condition is the rule. 
 The muscular fibres cross one 
 another in all possible directions, 
 so that in sections they are cut 
 transversely, obliquely, and longi- 
 tudinally (Fig. 329). Parallel with 
 the bundles of muscular fibres 
 are found the blood-vessels,which 
 would indicate that the irregular 
 
 > ; w v^wy &r 
 
 Fig. 329.— Myofibroma of the broad ligament; X 
 480 (Surgical Clinic, Rush Medical College, Chicago) : 
 a, muscle-fibres in cross-section ; b, muscle-fibres in 
 longitudinal section ; c, interstitial elastic fibres. 
 
 distribution of fibres is determined 
 by the irregular course of the 
 blood-vessels (Fig. 330). 
 
 The irregularity in the arrange- 
 ment of the muscular fibres is 
 unfavorable to functional activity, as muscular contraction would pro- 
 duce a diminution in size of the tumor in all directions, and would thus 
 diminish the lumina of all the vessels. In consequence of this arrange- 
 ment the muscular tissue with the growth of the tumor is diminished, 
 and is replaced largely by fibrous tissue. Even if the muscular tissue 
 almost disappears during the growth of the tumor, its original character 
 as a myoma is preserved from a genetic standpoint, and this tumor 
 should be called a " myoma," and not, as was suggested by Miiller, 
 a " desmoid," or by Rokitansky, a " fibroid." As the connective tissue 
 becomes more abundant, the muscle-fibres are compressed into streaks 
 which are sometimes difficult of recognition. 
 
 The structure of a leiomyoma is influenced by the character of the 
 muscular tissue in which it develops. The muscle-fibres are spindle- 
 
 
PATHOLOGY AND TREATMENT OF TUMORS. 
 
 ■"' .K.? 
 
 HB 
 
 \ 
 
 *^#s 
 
 Fig. 330. — Myofibroma of the uterus ; X 75 (Surgical Clinic, Rush Medical College, Chicago) : a, fibrous 
 tissue ; b, longitudinal section of muscle-fibres ; c, large blood-vessels. 
 
 shaped, tapering into filamentous points, and contain near their centre 
 the typical hammer-shaped nucleus (Fig. 331). In tumor-sections these 
 filamentous ends of the cells are not shown, even if the section happens 
 to fall parallel with the fibres (Fig. 332). 
 
 Fig. 331. — Muscle-cells from myoma of the uterus, isolated by the aid of caustic potash ; X 250 (after Perls). 
 
MYOMA. 489 
 
 In the uterus myofibroma is found as a round, firm-on-the-surface, 
 uneven tumor. On section the surface is not smooth, as the fibres that 
 are cut transversely contract more than those cut longitudinally. The 
 color of the tumor is either a pure white or somewhat translucent, 
 according to the preponderance of the muscular or of fibrous tissue. 
 
 J--.-: 
 
 - 5 . ■-M 
 
 Fig. 332.— Myofibroma of broad ligament ; X 510 (Surgical Clinic, Rush Medical College, Chicago) : 
 a, muscle-cells ; b, intercellular fibrous tissue. 
 
 The section is mapped out into lobes by dense septa of fibrous tissue 
 which traverse the tumor from the surface toward the centre. In these 
 septa are found the larger arteries which supply the tumor with blood. 
 The capillaries are collected mostly on the surface of the tumor, and ter- 
 minate in veins which, if any obstruction exists, which is frequently the 
 case, are often dilated into large channels. The capsule of the tumor 
 forms at a late stage, when from pressure the surrounding tissue disap- 
 pears by atrophy, and from its connective tissue the capsule is formed. 
 The earliest stages of the development of a uterine myoma has not 
 been investigated sufficiently. Runge traces the origin of such tumors 
 to round indifferent cells ; Virchow, to a hyperplasia of existing 
 muscular fibres. Kleinwachter found the smallest myomata supplied 
 with a muscular pedicle which he believes springs from a blood-vessel. 
 As endothelial cells cannot be transformed into muscular fibres, such 
 a mode of origin is not probable. Kleinwachter's observations, how- 
 ever, show that muscular fibres are produced along capillary vessels, 
 and the pedicle which he described may correspond to one of these 
 vessels. The most recent observations of Hauser would indicate that 
 the remains of the Wolffian ducts have something to do with causing 
 the surrounding muscular tissue to develop into myomata. A number 
 of observers have found inside of myomata epithelial collections in the 
 form of cavities, canals, and cysts ; a few containing ciliated epithelium. 
 These structures need not necessarily have come from the Wolffian 
 bodies ; they might, as Hauser suggested, be derivatives from the 
 uterine mucous membrane. Ribbert has a specimen in which a chain 
 of epithelial cells extends seven or eight millimetres into the uterine 
 
49° PATHOLOGY AND TREATMENT OF TUMORS. 
 
 wall, and which in the section appear as isolated epithelial islands. The 
 extreme tip of this chain lies against a small myoma, but does not 
 penetrate into its substance. 
 
 Ricker found frequently in myomatous tumors epithelial structures, 
 channels, etc., which he believed were derived from Miiller's ducts. 
 From such epithelial nests adenomata and cystic tumors may develop 
 within or independently of myomatous growths. In the majority of 
 cases the tumor no doubt springs from a matrix of myoblasts in the 
 uterine tissue, while in exceptional cases the tumor may start from a 
 similar matrix in the walls of blood-vessels. The round cells which 
 have been found within and in the vicinity of recent myomata are 
 fibroblasts, which always take part in the production of a myo- 
 fibroma. 
 
 The shape of a myoma is also subject to influences exerted by the 
 surrounding tissues. Pedunculation of submucous and subserous 
 myofibromata of the uterus is of frequent occurrence. The tumor in 
 
 Fig. 333. — Very vascular uterine myoma seen in section (after Virchow). 
 
 either of these localities grows in the direction offering the least resist- 
 ance, carrying before it the mucous membrane or the peritoneum, which, 
 with the blood-vessels that supply the tumor, forms the pedicle. 
 
MYOMA. 
 
 49 1 
 
 Intestinal myofibroma develops usually not in the submucous mus- 
 cular fibres, but in the middle coat, giving rise to diffuse thickening, and 
 resulting often in the formation of a ring of tumor-tissue including the 
 whole circumference of the tube. 
 
 The vascular supply of a myoma varies greatly. In dense tumors 
 composed principally of fibrous tissue it is often exceedingly scanty. 
 Virchow described an angiomatous myoma of the uterus. In tumors 
 of this kind there are found numerous larger venous channels which 
 communicate freely with one another. Wesener described a telangi- 
 ectatic myoma of the duodenum. 
 
 Regressive Metamorphoses. — One of the most frequent causes of 
 degeneration of the tissues of a myofibroma is oedema. The oedema is 
 produced by venous obstruction resulting from twisting or flexion in 
 the case of pedunculated growths, or from pressure or thrombosis 
 in interstitial tumors. The serum distends the connective-tissue spaces, 
 macerates the fibrous tissues, and crowds apart the muscular fibres, 
 which at the same time become narrower from compression (Fig. 
 
 334)- 
 
 Cystic degeneration is another regressive change quite frequently 
 met with in uterine myofibroma. As recent investigations have shown, 
 the formation of cysts is in all probability in the majority of cases due 
 to distention of lymphatic spaces. 
 
 Hyaline degeneration and dis- 
 appearance of the tumor-tissue 
 by pressure-atrophy accompany 
 the growth of lymphatic cysts. 
 In a case, described by Klebs, 
 of endotheliomatous prolifera- 
 tion in a uterine myofibroma the 
 primary tumor was surrounded 
 by round nodules, and in the 
 kidney myomatous metastatic 
 deposits were found. It is to be 
 taken for granted that metastasis 
 
 of the myoblasts was caused by infiltration of the tumor by endothelial 
 cells. Fatty degeneration and calcification in parts of the tumor are 
 of frequent occurrence. Myxomatous degeneration of the fibrous part 
 of the tumor is another not uncommon form of regressive meta- 
 morphosis. Finally, myofibroma may undergo transformation into 
 sarcoma. 
 
 Symptoms and Diagnosis. — Myofibroma begins insidiously and 
 grows slowly. Frequently its existence is suspected only after the 
 
 Fig. 334. — CEdematous myofibroma of the uterus ; 
 X 590, reduced one-third (Surgical Clinic, Rush Medical 
 College, Chicago) : a, muscle-cells; b, cedematous inter- 
 cellular substance. 
 
492 PATHOLOGY AND TREATMEN7 OF TUMORS. 
 
 tumor has produced symptoms. A circular myofibroma of the oesoph- 
 agus by encroaching upon the lumen of the organ may give rise to 
 difficulty in deglutition and to other symptoms which suggest the 
 presence of a progressive stenosis of the tube. A myoma of the intes- 
 tine gives rise to no symptoms until the tumor produces intestinal ob- 
 struction by stenosis, invagination, volvulus, or flexion. An interstitial 
 or subserous myofibroma of the uterus may attain large size before it 
 produces pathognomonic symptoms. Its presence is discovered either 
 during an examination for the cause of obscure symptoms, or acci- 
 dentally by the patient after the tumor has become palpable above the 
 pubes. A submucous myofibroma of small size may become the cause 
 of severe and repeated hemorrhages. Myoma of the uterus is often 
 multiple, converting the organ into a nodular, shapeless mass. Biman- 
 ual palpation shows that the tumor or tumors are attached to the 
 uterus. In intra-uterine growths the cervix is often considerably 
 dilated, and the tumor can be discovered by inserting the right index 
 finger into the uterine cavity and pressing the organ with the opposite 
 hand well down into the pelvis. 
 
 Prognosis. — The danger which attends myofibroma depends on the 
 organ or part of an organ from which the tumor springs and upon 
 the histological structure of the tumor. A circular myoma of any of 
 the different parts of the digestive tube is more likely to result in 
 obstruction than is a tumor involving only a part of the circumference 
 of the tube. Progressive growth will take place in proportion to the 
 amount of muscular tissue in the tumor. Tumors in which the muscle- 
 fibres predominate grow more rapidly and attain larger size than the 
 hard, fibrous variety. Great vascularity also tends to increase the 
 growth of the tumor. Submucous tumors of the uterus undermine 
 the health and shorten life from hemorrhages. Large interstitial and 
 subserous tumors of the uterus may interfere mechanically with the 
 functions of important abdominal organs. Uterine myomata sometimes 
 give rise to sepsis from infection with pus microbes. Not infrequently 
 a pregnancy results in dangerous, and occasionally in fatal, complica- 
 tions. The possibility of myofibroma undergoing transformation into 
 sarcoma must not be lost sight of in rendering a prognosis. 
 
 Treatment. — Medical treatment in the management of myoma 
 should be restricted to alleviation of the symptoms which a tumor 
 may produce. The administration of ergot as a curative agent has not 
 met the expectations of those who have given this drug a fair and 
 prolonged trial. In bleeding uterine myomata rest and the internal 
 administration or injection of ergot have yielded good results, but 
 have no effect in arresting the growth of the tumor. The treatment 
 
MYOMA. 
 
 493 
 
 of uterine myoma by electricity, so strongly advocated by Apostoli, is 
 still on trial. It has not yielded the results claimed for it, and seems 
 fast giving way to operative measures. In the treatment of uterine 
 myoma demanding operative measures the surgeon either resorts to 
 removal of the tumor through the vaginal route, by abdominal hyster- 
 ectomy or by myomectomy, or he seeks to arrest further growth of 
 the tumor by diminishing its blood-supply by removal of the uterine 
 appendages. 
 
 Myomata of the intestinal canal are not diagnosed before they give 
 rise to intestinal obstruction, in which event a positive diagnosis should 
 be made by opening the abdominal cavity, when the tumor is dealt 
 with according to the indications that present themselves. 
 
 Topography. 
 Uterus. — The uterus is by far the most frequent seat of myomatous 
 tumors. For anatomical, clinical, and pathological reasons it has been 
 
 / 
 
 Fig. 335-— Myoma at the fundus of the uterus, 
 growing outward (after Winckel) : a, anterior lip ; 
 b, posterior lip; c, cavity of the uterus; d, tumor. 
 
 Fig. 336. 
 
 -Myoma from fundus, growing inward 
 (after Winckel). 
 
 customary to describe these tumors, according to their location, as — 
 I. Interstitial; 2. Submucous; 3. Subserous. A tumor that is primarily 
 interstitial may eventually grow in the direction of the mucous or serous 
 surface, and become a submucous or subserous tumor (Figs. 335, 336). 
 
494 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Interstitial — or, as they are also called, intraparietal — tumors may 
 
 Fig. 337. — Two interstitial myomata near cervix 
 (after Winckel). 
 
 Fig. 338. — Two interstitial myomata near fundus 
 (after Winckel) : a, posterior lip ; b, bladder. 
 
 start in any part of the uterine wall. A frequent location is near 
 the cervix (Fig. 337). Another favorite locality is at the fundus 
 
 Fig. 339. — Subserous and submucous myomata (after Winckel) : a, cavity of the uterus ; b, submucous 
 
 tumor ; c, subserous tumor. 
 
 (Fig. 338). Not infrequently subperitoneal and submucous tumors 
 are found in the uterus at the same time (Fig. 339). In multiple 
 
MYOMA. 
 
 495 
 
 myofibromata of the uterus tumors are often found in all three 
 localities, and sometimes also in the broad ligaments. 
 
 Fig. 340.— Multiple myofibromata of the uterus and broad ligament (after Winckel) : a, right ovary ; 
 b, right Fallopian tube; c, interstitial myoma; d t submucous myoma; e, subserous myoma; f, orifice of 
 uterus; g, interstitial myoma; h, intraligamentous myoma. 
 
 Uterine myomata become encapsulated at an early stage and grow 
 in the direction offering the least resistance. If they are located nearer 
 the external than the internal surface, they 
 become prominent on the serous surface, and 
 eventually may become pedunculated. If the 
 reverse is the case, they finally become sub- 
 mucous, and pedunculation in this direction 
 may take place. If the resistance is equal on 
 all sides, they remain as interstitial growths. 
 The vessels in the uterine wall, from which the 
 tumor receives its nourishment, become dilated, 
 forming a system of channels which communi- 
 cate freely with one another and with the vessels 
 of the tumor. The vessels appear like channels, 
 devoid of a proper vessel-wall, but lined by an 
 intima resembling the sinuses of the pregnant 
 uterus (Fig. 341). In some instances myoma 
 of the uterus is associated with other tumors 
 of a benign type, the increased vascularity at- 
 tending the presence of growths of the mucous 
 membrane acting as an exciting cause in the production of the myoma 
 
 Fig. 341. — Cavernous wall of the 
 uterus as found in connection with 
 large myomata (after Winckel). 
 
496 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 (Fig. 342). There is also reason to believe that the engorgement of 
 the uterus which attends the presence of a 
 myoma is favorable to the development of 
 papilloma and adenoma of the uterine mucous 
 membrane. 
 
 Histology and Histogenesis. — The propor- 
 tion between the muscular fibres and fibrous 
 tissue varies greatly. The hardness of the 
 tumor increases with the amount of fibrous 
 tissue it contains. The muscular fibres are 
 larger than in the non-pregnant uterus and con- 
 tain large nuclei. The arrangement of the fibres 
 is very irregular ; they interlace freely with one 
 another and with the stroma of connective tissue. 
 In sections the fibres that have been cut trans- 
 versely retract much more than those divided 
 an uneven surface to the section (Fig. 343). 
 
 J 
 
 Fig. 3 
 
 4-- 
 
 -Myoma and adeno- 
 ma of the uterus (after Winckel) : 
 a, adenoma of mucosa ; b, inter- 
 stitial myoma. 
 
 longitudinally, imparting 
 
 Fig. 343 — Myoma of the uterus; X 85 (Surgical Clinic, Rush Medical College, Chicago): a, longitudinal 
 section of muscle-fibres ; b, transverse section of muscle-fibres. 
 
 Tumors in which the fibrous tissue predominates are firmer, less vas- 
 
MYOMA. 497 
 
 cular, and grow more slowly than those in which muscle-cells pre- 
 dominate. The vessels in the tumor itself are usually not large, and 
 such tumors can be enucleated without difficulty so far as hemorrhage 
 is concerned, provided the uterine tissue is not torn. In rare cases the 
 tumor is very vascular and is permeated in all directions by cavern- 
 ous spaces like those of the uterine wall, when the tumor is called 
 myoma telangiectodes. If the lymphatic vessels between the muscular 
 bundles and in the vicinity of the vessel-sheaths are dilated, we speak 
 of a myoma lymphangiectodes (Leopold). 
 
 Recklinghausen has confirmed the theory of Coblenz, Doran, 
 and Sutton that relics of the Wolffian body are very frequently 
 the starting-point for many cystic and solid tumors in the append- 
 ages and the uterus. He advances the theory, however, very much 
 further than any of the other observers. Following Babes, who in 
 the year 1882 detected true epithelial growths in the interior of 
 uterine myomata, he traces these growths, lined with epithelial 
 cells, to the Wolffian ducts. He first discovered these adenomata 
 in a large myoma, and afterward found similar growths — minute as 
 a rule — in the tubes postmortem, mostly in old women. In cystic 
 myomata of the uterus he makes a distinction between true gland- 
 ular cysts and dilated lymphatic spaces and pseudocysts, developing 
 in consequence of degeneration of the parenchyma of myomatous 
 tumors. 
 
 Great dilatation of the lymphatic spaces in a myofibroma is the 
 most frequent cause of cyst-formation. The muscle-fibres and the 
 connective tissue are arranged in concentric layers around the vessels 
 of the tumor — a condition which has induced some pathologists to 
 assert that myofibroma of the uterus springs from the wall of pre- 
 existing blood-vessels. The blood-vessels in a myofibroma, like those 
 in any other tumor, are new structures formed from pre-existing blood- 
 vessels in the vicinity of the tumor-matrix. Nerves have been found 
 only in a few instances in myomatous tumors of the uterus. Bidder 
 found nerve-fibres in one of these tumors. 
 
 Regressive Metamorphoses. — The degenerative changes that occur 
 in a myoma of the uterus are dependent largely upon the location 
 of the tumor. They occur most frequently, according to Lee, if the 
 tumor is located in the body of the uterus. Originally most of the 
 tumors are interstitial. Pedunculation diminishes the blood-supply of 
 the tumor and brings about regressive metamorphoses. Pedunculated 
 subserous tumors frequently undergo fatty degeneration and calcifica- 
 tion. Calcification occasionally takes place in interstitial tumors, but, 
 
 32 
 
49 8 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 according to Virchow, it has never been observed in polypoid growths 
 projecting into the uterine cavity. 
 
 Subserous myomata frequently form adhesions with the surrounding 
 viscera, and then receive a new blood-supply from this source. Whether 
 pedunculated subserous tumors ever become completely detached is, 
 according to Virchow, questionable. That such an occurrence is pos- 
 sible the writer is satisfied, as in one instance, in making a laparotomy 
 for the removal of multiple myofibromata, there was found in the 
 abdominal cavity a detached tumor as large as a small pear ; the apex 
 of the tumor tapered to a very small point, marking the place where 
 the pedicle became detached. 
 
 The uterus may undergo serious pathological changes from traction 
 on the part of a large pedunculated tumor, resulting in great elongation 
 of the organ — hydrometra ; and instances are on record in which the 
 body of the uterus was severed from the cervix. If the tumor is sur- 
 rounded on all sides equally by uterine tissue, pedunculation does not 
 take place. 
 
 Intramural tumors frequently attain great size. Walter reports a 
 case in which such a tumor weighed seventy pounds. The posterior 
 wall at a point a little below the fundus is the favorite location for intra- 
 mural tumors. The uterine cavity in such cases, if the tumor is large, 
 may reach the size of the cavity of the pregnant uterus at full term. 
 Lateral growth of a uterine myofibroma involves the broad ligaments, 
 and the tumor becomes partly or wholly intraligamentous. 
 
 Intra-uterine growths attached by a broad surface result in enlarge- 
 ment of the uterine cavity in all directions, and the cervix becomes 
 gradually obliterated in the same manner as in pregnancy. Intramural 
 tumors may undergo fatty degeneration in the same manner as the 
 muscular fibres of a pregnant uterus after delivery. Calcification fre- 
 quently follows fatty degeneration. Myxomatous degeneration fre- 
 quently takes place, during which mucin, nucleated round cells, and 
 mucous cells appear, changing the tumor into a myxomyoma. The 
 cysts which form in consequence of this form of degeneration are 
 empty spaces between the bundles of muscle-tissue, and do not possess 
 a proper cyst-wall. CEdema of the tumor-tissue also gives rise to the 
 formation of spaces which resemble cysts. The so-called " fibrocysts " 
 originate in this way or develop in consequence of an interstitial 
 extravasation of blood. The cysts contain a synovia-like fluid often 
 stained by the admixture of blood. In rare cases the tumor becomes 
 exceedingly vascular by the formation of large venous spaces, when 
 the tumor resembles a venous angioma. Such tumors increase in size 
 
MYOMA. 499 
 
 under influences which produce intravascular tension. The venous 
 spaces occasionally, by such influences or by distention, become con- 
 verted into blood-cysts. If in a myxomyoma the intercellular con- 
 nective tissue begins to proliferate actively, the tumor undergoes trans- 
 formation into a sarcoma. 
 
 Suppuration in myofibroma of the uterus has repeatedly been 
 observed. This complication is announced by temperature, rapid pulse, 
 and other symptoms indicative of pyogenic infection, and is attended 
 by a sudden increase in the size of the tumor, by pain, and by tender- 
 ness. If the tumor takes its starting-point near the mucous membrane, 
 it pushes the tissues before it as it projects in the direction of the 
 uterine cavity, and soon it becomes submucous. Pedunculation of 
 submucous myofibromata takes place most rapidly if the growth of the 
 tumor toward the uterine cavity is not retarded by strong layers of 
 muscular fibres. The nearer the tumor is to the mucous membrane,, 
 the more rapidly does pedunculation take place. Spontaneous detach- 
 ment and escape of such tumors has repeatedly been observed. Intra- 
 uterine myofibromata undergoing ulceration and sloughing have often 
 simulated carcinoma of the cavity of the uterus. Transformation of 
 intra-uterine myofibroma into carcinoma has never yet been demon- 
 strated. 
 
 Etiology. — Myoma of the uterus has never been observed as a 
 congenital tumor. The most important cause in exciting tissue-pro- 
 liferation from the essential matrix of myoblasts is the congestion of 
 the organ during menstruation. Winckel found in his cases the tumors 
 subserous in 25 per cent., intramural in 65 per cent., and submucous 
 in 10 per cent. Of 528 cases collected by Chiari, West, Beigel, 
 Schroeder, and Winckel, 18 per cent, occurred in women between 
 twenty and thirty years of age, 3 per cent, between thirty and forty, 
 one-third of the whole number before the age of thirty-five, and one- 
 fourth of the whole number had symptoms before the age of thirty. 
 It is safe to assume that in the majority of cases the tumors appear 
 during the latter part of the third and the beginning of the fourth 
 decennium. The youngest patients suffering from myofibroma have 
 been ten years of age (Beigel). Marriage increases the frequency of 
 myoma of the uterus. In 33 per cent, of the married women the 
 tumors caused sterility. Abortions and injuries to the uterus of all 
 kinds must be regarded as exciting causes. Chronic inflammation 
 of the uterus and its appendages is another fruitful source of tumor- 
 formation. 
 
 Symptoms and Diagnosis. — The degree of suffering caused by 
 
500 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 a uterine myoma does not depend on the size of the tumor : a tumor 
 the size of a pea or a hazel-nut frequently produces graver symptoms 
 than a tumor the size of a child's head. Small myomata often pro- 
 duce a complexus of nervous symptoms frequently mistaken for 
 hysteria. The uterus is exceedingly tender to the touch ; the organ 
 is turgid and occasionally displaced, and rectal and vesical distress 
 often obscures the original difficulty. As soon as the tumor is large 
 enough to escape from the pelvis the subjective symptoms may 
 disappear almost completely, and the patient, who has been, per- 
 haps, a sufferer for years, is suddenly relieved and apparently restored 
 to health. As the tumor increases in size new symptoms arise by 
 its pressure anteriorly upon the bladder or posteriorly upon the rec- 
 tum ; circumscribed peritonitis, rotation of the uterus, or torsion of 
 the pedicle gives rise to new symptoms which often force the patient 
 to seek medical advice. If the tumor ascends into the abdominal 
 cavity and does not become pedunculated, its growth is usually 
 rapid, and the tumor often reaches an enormous size in the course of 
 a few years. The abdominal cavity becomes greatly distended and its 
 contents are subjected to pressure. If the tumor involve the lower 
 segment of the uterus, its ascent into the abdominal cavity is impeded, 
 and its increasing size results in impaction of the tumor in the pelvis, 
 attended by the unavoidable pressure-symptoms which accompany 
 such a condition. 
 
 The pain which attends a uterine myoma is caused by tension of 
 the uterine wall and by pressure upon adjacent organs, and especially 
 upon nerves. Pressure upon the sciatic nerve on one side will often 
 produce sciatica, which, unless its cause is investigated, is often treated 
 uselessly for months. Intra-uterine myoma is often the cause of ex- 
 pulsive pains which occur at irregular intervals. During the begin- 
 ning of menstruation the symptoms are usually aggravated. Profuse 
 menstruation is the most important symptom in submucous tumors. 
 It is less constantly present in the interstitial form, and is entirely 
 absent in subserous tumors. Menstruation is not only more profuse, 
 but the duration of the period is also increased. The loss of blood 
 not only undermines the patient's general health, but may become a 
 source of danger to life. Hemorrhage is frequently aggravated by the 
 coexistence of adenomata and by great vascularization of the tumor. 
 The menorrhagia is variable in its intensity. Sometimes several months 
 will elapse without undue loss of blood, when, without any obvious 
 cause, the hemorrhage returns with menstruation. 
 
 In submucous myoma there is present between the menstrual 
 
MYOMA. 501 
 
 periods a copious catarrhal discharge caused by the great vascularity 
 of the uterine mucosa and the hypertrophic condition of the glandular 
 appendages. The cervix is soft and easily dilatable, and when the 
 tumor has reached the internal os it can readily be discovered by a 
 digital examination. Expulsion of the tumor by uterine contractions 
 and traction upon the tumor not infrequently result in inversion of 
 the uterus. After the tumor has reached the vagina it is exposed to 
 infection ; ulceration and sloughing may occur, and under such cir- 
 cumstances the patient's life is in danger from pyemia and septic 
 peritonitis. 
 
 The growth of uterine myomata is usually arrested with the cessa- 
 tion of menstruation. The tumors at this time, as a rule, not only 
 cease to grow, but are also reduced in size by fatty degeneration and 
 shrinkage. The danger to be apprehended from uterine myomata is 
 greater if the tumors occur at an early age. 
 
 The progressive anemia which inevitably attends the repeated 
 hemorrhages and bleeding myomatous tumors of the uterus, and the 
 profuse offensive discharges caused by ulceration and sloughing, have 
 often given rise to mistakes in diagnosis, prognosis, and treatment. 
 Tumors producing such conditions differ clinically from malignant 
 affections principally in the length of time since the first symptoms 
 appeared. 
 
 The diagnosis of small myomata is always difficult and frequently 
 impossible. An increased localized resistance in some part of the 
 uterine wall is often the only evidence of the existence of a small 
 myoma. As soon as the tumor becomes prominent on the surface of 
 the uterus, its presence can be ascertained by bimanual palpation, as it 
 moves with the uterus, which is not the case if the swelling consists of 
 the remnants of a' hematocele or of pelvic peritonitis. Repeated exam- 
 inations are at times necessary to avoid errors in diagnosis. A careful 
 use of the uterine sound is often invaluable in distinguishing between 
 tumors of the uterine wall, ovarian tumors, and inflammatory swellings. 
 It is understood that the use of the sound should be restricted to cases 
 in which a pregnancy can safely be excluded. Auscultation should 
 never be omitted, as in more than one-half of all cases of large uterine 
 myomata a bruit can be heard. The removal of fragments of tissue 
 by harpooning is a harmless procedure if done under proper antiseptic 
 precautions, and the microscopical examination of sections made from 
 such fragments is of great value in differentiating between a benign and 
 a malignant tumor of the uterus. Digital exploration of the uterine 
 cavity for submucous myomata can be done to greatest advantage 
 
502 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 during menstruation, as at this time the cervix is most dilatable. If the 
 tumor involve one of the lips of the cervix, its presence should be 
 suspected if the lip is enlarged and unusually vascular. If the tumor 
 in this locality is large, it is often difficult, if not impossible, to find the 
 os uteri, which may be displaced above the pubes or against the prom- 
 ontory of the sacrum, according to whether the tumor involves the 
 posterior or the anterior lip. 
 
 The greatest difficulties are often encountered in making a differen- 
 tial diagnosis between myofibroma and pregnancy. Numerous are the 
 instances in which experienced surgeons have opened the abdominal 
 cavity with the expectation of removing a myofibroma or an ovarian 
 tumor, when a direct examination revealed a pregnancy. Such mis- 
 takes have frequently been made, and will continue to be made in the 
 future. The surgeon is often misled by misstatements on the part of 
 the patient. Exploratory laparotomy will occasionally be resorted to 
 in settling the doubt in certain obscure cases : this is as far as the sur- 
 geon should go. After the abdomen has been opened and the uterus 
 exposed to sight and touch, it is not difficult to recognize a pregnant 
 uterus. The thoughtless use of the trocar under such circumstances 
 has brought great reproach upon surgery in many a community. The 
 writer has twice been in the unenviable position of having to close the 
 abdomen over a pregnant uterus : in one instance a double uterus mis- 
 led him, and in the other a pregnancy was overlooked in a woman over 
 fifty years of age who had not borne children for twenty-five years. 
 Fortunately, both patients recovered without any untoward symptoms, 
 and were delivered at full term of healthy children. In myoma the 
 resistance is greater than that of a pregnant uterus, and the swelling is 
 more circumscribed. In pregnancy the lower segment of the uterus 
 presents a characteristic bluish-red color, and both uterine arteries 
 are enlarged — conditions that are not present to the same degree 
 in myoma. Examination of the breasts should never be omitted. 
 Repeated examinations are often necessary to exclude the possibility 
 of a pregnancy. In doubtful cases not calling for prompt active 
 interference it is advisable to postpone operative measures until a 
 sufficient time has elapsed to exclude a pregnancy. If for any reason 
 it is deemed necessary to establish a positive diagnosis, an explora- 
 tory laparotomy is justifiable, but the trocar should not be used until 
 by careful examination the possibility of a pregnancy can safely be 
 excluded. 
 
 The affections that call for special attention in the differential diag- 
 nosis of uterine myoma are retroflexion, endometritis and parenchym- 
 
MYOMA. 503 
 
 atous metritis, hematocele, pelvic peritonitis, ovarian tumors, pyosal- 
 pinx and hydrosalpinx, chronic inversion of the uterus, retroperito- 
 neal tumors, and malignant tumors of the uterus. Myofibromata of 
 the uterus appear more frequently as multiple tumors than as an iso- 
 lated affection, and, unless the uterus has become adherent, if it is the 
 seat of multiple tumors the nodulated mass is movable. Chronic 
 inversion can readily be distinguished, by the use of the sound, from 
 partial or complete inversion produced by a myoma. In affections 
 of the ovaries and tubes the swelling can usually be separated from 
 the uterus, especially if the patient be examined under the influence 
 of an anesthetic, which examination should never be omitted in doubt- 
 ful cases. 
 
 Prognosis. — The prognosis of myofibroma of the uterus is more 
 grave than is generally supposed. Winckel's statistics show that in 
 about 10 per cent, of all cases death ensues after a longer or shorter 
 duration of the affection. Hemorrhage and uremia are the most fre- 
 quent immediate causes of death. The profound anemia which is such 
 a common occurrence in submucous tumors is incompatible with the 
 performance of important functions for any length of time, and, besides, 
 a chronic progressive anemia engenders fatal complications, such as 
 thrombosis, embolism, and pulmonary oedema. In rare cases the 
 patients succumb to the Immediate effects of hemorrhage alone, when 
 death is usually preceded by convulsions and coma. Organic disease of 
 the kidneys is produced by compression of the ureters. If the tumor 
 distends the abdominal cavity, death results in consequence of dyspnea 
 caused by compression of the contents of the thorax. Infection of the 
 tumor has resulted in death from sepsis, pyemia, peritonitis, and ex- 
 haustion from prolonged suppuration. In other cases death is pro- 
 duced by the complications arising from abortion or from delivery at 
 full term. In 119 cases of myomata of the uterus complicated by 
 pregnancy, collected by Soloczinow, in 21 cases the patients aborted, 
 and in 98 they were delivered at full term. 
 
 It has been observed that tumors that remained perhaps stationary 
 for a long time begin to grow rapidly during pregnancy. This is 
 particularly true of the soft variety and of cavernous myoma. Both 
 these forms of uterine myoma are interstitial, and hence become sur- 
 rounded on all sides with large blood-vessels which develop during 
 pregnancy. 
 
 A great deal has been said regarding the spontaneous disappearance 
 of uterine tumors and the curative effects of certain non-operative 
 measures. A myoma seldom if ever diminishes in size during the 
 
504 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 active sexual life of the patient, whereas the menopause, whether nat- 
 ural or brought about by the removal of the uterine appendages, has 
 a decided influence in arresting further tumor-growth, and is usually 
 followed by fatty degeneration of the muscular fibres and shrinkage, 
 if not total disappearance, of the tumor. Virchow thinks it unlikely 
 that complete disappearance by retrograde metamorphoses ever takes 
 place, and it has never, to the writer's knowledge, been proved by dis- 
 section. The muscular fibres under favorable circumstances degenerate 
 and are removed by absorption, but the connective-tissue stroma 
 remains ; hence it is the soft myomata that are diminished in size under 
 conditions which induce fatty degeneration of the parenchyma of the 
 tumor. 
 
 The liability of a myofibroma to undergo transformation into a 
 sarcoma has repeatedly been referred to. Virchow has described 
 a number of such cases. A most interesting case of malignant trans- 
 formation of a myoma of the stomach has been reported by Brodowski. 
 The tumor, after it had undergone this transition, caused myosarcoma- 
 tous metastatic deposits in the liver. The metastasis of muscle-fibre 
 is almost unique, but it has been observed in a case of myosarcoma 
 of the kidney that produced similar metastatic deposits in the dia- 
 phragm (Eberth). 
 
 The prognosis of the operative treatment of myofibroma of the 
 uterus has become vastly better since aseptic surgery has more gen- 
 erally been adopted, and since the technique of the different operative 
 procedures has been so decidedly improved during the last ten years. 
 Only twelve years ago laparo-hysterectomy had a mortality of from 30 
 to 35 per cent, in the hands of expert surgeons; to-day the mortality 
 probably does not exceed 10 per cent., and some operators have 
 reduced it to 5 per cent. The success of the operative treatment will 
 be improved with a better selection of cases and a still more improved 
 technique of the different operative procedures. 
 
 Treatment. — The treatment of uterine myofibroma should not be 
 neglected, as much can be done in retarding the growth of the tumor 
 by rational treatment. All measures that diminish the blood-supply 
 to the uterus are calculated to diminish tissue-proliferation, and thus 
 retard tumor-growth. The patient must be advised to avoid active 
 exercise, such as dancing, skating, horseback riding, or the climbing of 
 heights, and should remain the greater part of the time in the recum- 
 bent position during menstruation. Constipation is a common evil in 
 nearly all patients suffering from uterine myoma. The bowels should 
 be kept in a soluble condition by the administration of saline laxatives, 
 
MYOMA. 505 
 
 enemata, or by the use of glycerin suppositories. If pain is a con- 
 spicuous symptom, it should be controlled by the administration of the 
 milder narcotics, such as potassic bromide, hyoscyamus, and belladonna. 
 Preparations of opium and of chloral hydrate must be used with the 
 greatest caution and restriction, lest patients become habituated to their 
 use. Warm baths are nearly always beneficial and grateful to the 
 patients. The use of pessaries is occasionally indicated if the uterus 
 has become displaced, and can be replaced and held in its normal posi- 
 tion by a proper mechanical support. The internal use of ergot was 
 strongly recommended by the late M. H. Byford. Favorable results 
 were also obtained by its subcutaneous administration in the clinic of 
 Hildebrandt at Konigsberg. The writer believes the general experience 
 in the use of this drug coincides with that of Winckel, who states that 
 he has observed in several instances, under the prolonged use of ergot, 
 decided diminution in the size of the tumor, but in none of them 
 was there a complete disappearance. 
 
 Ergot has little or no effect in the treatment of hard myofibromata. 
 Its therapeutic value as a palliative is limited to the soft myomatas and 
 teleangiectatic varieties. Large and long-continued doses not infre- 
 quently produce ergotism, especially in very anemic patients. The 
 writer has found a combination of ergotin, extract of nux vomica, and 
 sulphate of iron to be of more value in checking hemorrhage than 
 ergot alone. Parenchymatous injections of ergotin, as advised and 
 practised by Delore, have yielded no better results than the internal or 
 subcutaneous use of this drug; besides, the procedure is attended by 
 considerable risk of infection. 
 
 Curetting of the uterine cavity has yielded good results in diminish- 
 ing the hemorrhage. The effect of this treatment is particularly well 
 marked if the mucous membrane is the seat of adenomata, as is so 
 often the case. The insertion of strips of gauze saturated with tincture 
 of the sesquichloride of iron into the uterine cavity has also been found 
 useful in diminishing the hemorrhage. Hot vaginal douches have also 
 proved beneficial. The tincture of digitalis alone or in combination 
 with ergot has a well-earned reputation for diminishing hemorrhage, 
 especially in patients suffering at the same time from a weak heart. 
 During the interval between the menstrual periods the different prepa- 
 rations of iron with strychnia have a salutary effect. In patients greatly 
 reduced from repeated and severe hemorrhages intravenous infusions 
 of a physiological solution of salt will be indicated if stimulation by 
 ordinary means is not sufficient to maintain the requisite degree of 
 intravascular tension. 
 
506 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 i 
 
 Electrolysis has had quite an extended trial, but it has not yielded 
 the anticipated results. Kimbal and Cutter inserted strong needles 
 seven and a half inches in length not far apart into the substance 
 
 of the tumor and passed through 
 them the electrical current. In 
 2 cases death resulted from peri- 
 tonitis ; in 23 the tumor is said 
 to have diminished in size ; in 
 10 no effect whatever was pro- 
 duced. Apostoli and his followers 
 have revived this treatment, and 
 have claimed that in some in- 
 stances the tumor disappeared 
 completely. Apostoli increased 
 the strength of the current from 
 100 milliamperes, used first, to 
 250 milliamperes. One of the 
 poles is applied to the abdomen 
 by means of a moist clay elec- 
 trode, and the other pole is intro- 
 duced into the uterine cavity in 
 the form of an insulated sound. 
 The electrode is pushed into the 
 substance of the organ " after 
 preliminary puncture where we 
 desire to hasten the demolition 
 of the neoplasm, or where the 
 cervix is impermeable or inaccess- 
 ible." 
 
 It is difficult to conceive in 
 what way complete removal of 
 the tumor is accomplished. That electrolysis combined with rest will 
 diminish hemorrhage and in a certain percentage of cases bring about 
 reduction in the size of the tumor no one will deny, but as a curative 
 measure its claims have been, to say the least, over-estimated. In 
 many cases the treatment has produced complications that proved fatal, 
 and in others it has necessitated operative treatment. The. reputation 
 of this method of treatment will diminish with the improved results 
 following operative procedure. 
 
 Operative Treatment. — Myomata of the lower segment of the 
 uterus accessible from the vagina should be removed by enucleation. 
 The use of the ecraseur and of the galvano-caustic wire should be 
 
 Fig. 344. — Apostoli's uterine electrode : a, natural 
 size of the instrument ; a, ordinary hysterometer ; b, 
 trocar for puncture ;f, notch marking average depth of 
 uterus ; b and c, entire instrument, reduced to one- 
 third size, in c, celluloid handle, to protect the vagina ; 
 e, electrode ; d, thumb-screw, to regulate length of 
 exposed sound; d, carbon electrode for galvano-chem- 
 ical cautery, one-third size. 
 
 
MYOMA. 
 
 507 
 
 displaced by this operation. In cases of intra-uterine tumors the 
 adjustment of the wire is attended by the greatest difficulties, and not 
 infrequently there is left a part of the tumor, which is responsible for 
 many recurrences of pedunculated benign tumors. The twisting off 
 of a pedunculated growth if the pedicle is narrow is usually attended 
 by satisfactory results, but the operation of enucleation is applicable 
 in all such cases and is attended by less risk. 
 
 Vaginal Enucleation. — This operation is the ideal one in all cases 
 in which the base of the tumor can be reached. In tumors of the 
 cervix and in pedunculated tumors of the uterine cavity the base of 
 the tumor can be reached without much difficulty. The 
 tumor should be brought down as far as possible by the 
 use of one or more vulsellum forceps, when the mucous 
 membrane covering the pedicle is divided by a circular 
 incision sufficiently far away from the attached part of the 
 pedicle to allow the cuff of mucous membrane to cover 
 the entire wound after the enucleation has been com- 
 pleted. The mucous membrane is then detached with 
 a pair of blunt-pointed scissors or with Pozzi's enucle- 
 ator (Fig. 345). Very little hemorrhage is caused during 
 this part of the operation. By reflection of the cuff of 
 mucous membrane the pedicle, containing the principal 
 blood-vessels of the tumor, is reduced considerably in size, 
 and at the same time the capsule of the tumor is exposed 
 thoroughly at the base of the tumor. The tumor is then 
 enucleated if the pedicle is broad, or if it is narrow the 
 tumor is wrenched from its base by twisting it around its 
 axis. The danger of hemorrhage attending this opera- 
 tion has been over-estimated greatly. If the mucous 
 membrane is divided by a circular incision and reflected, 
 and the tumor is removed by the use of blunt instruments 
 or by torsion, the hemorrhage is very slight. After the 
 removal of the tumor the wound is tamponed with a long 
 strip of iodoform gauze, which is allowed to remain for 
 three or four days. After the removal of the gauze the mucous mem- 
 brane will cover the granulating surface, and healing of the entire 
 wound is effected in a few days. 
 
 The writer has enucleated in this manner tumors the size of a child's 
 head attached by a pedicle to the fundus of the uterus. If the pedicle 
 is short, traction upon the tumor sufficient to partially invert the uterus 
 will facilitate the operation. After the removal of the tumor the in- 
 version usually corrects itself, otherwise the fundus is pushed into its 
 
 Fig. 345-— Pozzi's 
 enucleator. 
 
508 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 normal position. If the tumor occupies either the anterior or posterior 
 lip and is sessile or interstitial, it is exposed by an incision parallel with 
 the long axis of the uterus, and as soon as its capsule has been reached 
 it is grasped with vulsellum forceps and is removed by enucleation. 
 Care must be exercised to make the blunt dissection close to the 
 capsule, as otherwise the laceration of uterine tissue might result in 
 troublesome hemorrhage. 
 
 Vaginal Myomotomy. — If the tumor is too large to be removed 
 through the vagina by enucleation, it often becomes necessary to 
 remove the growth by fragmentation or morcellement. Pean, who 
 practised this operation on a large scale and carried its indications 
 to their utmost limits, successfully removed through the vagina 
 by this method many large myomata which other surgeons would 
 have attacked by an abdominal section. The operation is especially 
 intended for sessile and interstitial myofibromata of the body of the 
 uterus. Pean employs in this operation forceps of special construction 
 
 Fig. 346.— Pean's 
 
 forceps, serrated and with teeth, for morcellation of myofibromata. 
 
 (Fig. 346), with which he performs morcellation of the tumor. It is 
 the object of the operation to remove the tumor piecemeal, and not 
 by enucleation. The tumor is attacked from the centre, and fragments 
 are removed in the direction of the periphery until all tumor-tissue 
 has been removed. 
 
 The first step of the operation consists in rendering the tumor 
 accessible. This is done by detaching the cervix in the same manner 
 as in performing a vaginal hysterectomy, only that opening of the 
 peritoneal cavity is carefully avoided. Hemorrhage during this step 
 of the operation is controlled by the use of hemostatic forceps. After 
 the cervix has been isolated it is incised, and the incision is carried into 
 the uterus as far as the tumor. The tumor is then carefully located 
 with the finger, after which the morcellation is begun in the centre 
 of the growth. The vagina is retracted by elbow retractors, so as to 
 
 
MYOMA. 5°9 
 
 expose the field of operation as thoroughly as possible for the fingers 
 and forceps. When the tumor has been reached it is drawn down 
 with vulsellum forceps and a deep incision is made into it parallel with 
 its long axis. The sides of the tumor are then grasped with forceps, 
 retracted, and fragment after fragment is drawn down with forceps 
 and removed with scissors or with a bistoury (Fig. 347). 
 
 Fig. 347. — Removal of myofibroma by morcellement (after Pean). 
 
 After the removal of the lower part of the tumor by this method 
 the upper portion can often be detached by traction and twisting. 
 Bleeding vessels are caught with forceps and tied. When the tumor 
 is very large, Pean excises the two cervical lips, and after the removal 
 of the tumor sews the lips of the vaginal wound. If the peritoneal 
 cavity is opened, Pean advises that the wound should be closed with 
 sutures. If more than one tumor is present, the operation is repeated 
 until all the tumors are removed. After the removal of the tumor, 
 if the cervical lips have not been amputated — which is necessary only 
 in exceptional cases — the cavity is cleansed thoroughly by mopping, and 
 after hemorrhage has been attended to carefully it is packed with a 
 long strip of iodoform 'gauze. If compression-forceps are used in 
 arresting the hemorrhage, they are removed after thirty-six or forty- 
 eight hours. The cervical as well as the circular incision is closed by 
 
510 PATHOLOGY AND TREATMEN1 OF TUMORS 
 
 suturing. The iodoform-gauze tampon is brought out of the cervix 
 into the vagina. 
 
 There can be but little doubt that Pean and his followers have 
 carried vaginal myomotomy by morcellation too far. The average 
 aseptic surgeon will obtain better results by laparotomy than by piece- 
 meal extraction if the tumors are large, multiple, and subperitoneal. 
 The operation, however, has a legitimate field, and it will undoubtedly 
 find favor with many operators. 
 
 Vaginal Hysterectomy. — Removal of the entire uterus for myofi- 
 broma has been performed by Pean, Sanger, Richelot, Terrier, Leopold, 
 and others. The mortality has been about 13 per cent. Tumors not 
 too large to be removed through the vagina should be removed by 
 enucleation or morcellement — operations that have yielded better 
 results than vaginal hysterectomy, and with less mutilation. 
 
 Laparotomy. — The removal of myofibromata through an abdominal 
 incision or the removal of the uterine appendages to arrest further 
 tumor-growth is indicated in cases of myofibromata in which vaginal 
 operations are inapplicable and the tumors threaten to destroy life, or 
 incapacitate the patient from following her occupation, or cause sufficient 
 suffering to warrant an operation. Contraindications are cessation of 
 growth of the tumor, unimpaired health of the patient, and advanced 
 age. If a tumor at the menopause causes no serious inconvenience, 
 conservative treatment should be pursued. Soft myomata are more 
 frequently subjected to operative treatment than hard tumors, because, 
 as a rule, they grow more rapidly and occur more frequently in the 
 young than in women approaching the menopause. 
 
 Abdominal section for myofibroma should be done under the same 
 strict aseptic precautions as in other operations requiring opening of the 
 abdominal cavity. The patient should be placed on a course of pre- 
 liminary treatment, including a daily warm bath, laxatives, and a 
 restricted diet, for at least three or four days before the operation. 
 
 Salpingo-oophorectomy . — The removal of the uterine appendages is 
 indicated in the operative treatment of myofibroma of the uterus in 
 which enucleation is impossible and the tumor or tumors have not pro- 
 duced serious pressure-symptoms. Arrest of menstruation, effected by 
 the removal of the uterine adnexa, exerts the same effect on uterine 
 myofibroma as the natural menopause. The tumors, as a rule, not only 
 cease to grow, but also are materially reduced in size by fatty degene- 
 ration and shrinkage. Salpingo-oophorectomy yields the best results in 
 soft multiple myomata occurring in women from twenty to thirty-five 
 years of age. The danger attending this operation in well-selected cases 
 is very small. The first operation of this kind for uterine myoma was 
 
MYOMA. 
 
 511 
 
 performed in 1876 by Trenholme. Tait and Hegar prefer it to other 
 operations in the majority of cases. If the uterus is movable and the 
 tumors are not large, the uterine appendages can be removed through 
 
 Fig. 348. — Hegar's forceps for cauterizing the pedicle in castration : a, upper surface ; b, under surface with 
 
 ivory plate. 
 
 a two-inch median incision. If the ovaries are imbedded in inflamma- 
 tory adhesions, it is often exceedingly difficult to find and isolate them. 
 Under such circumstances it is advisable to enlarge the incision to the 
 
 Fig. 349.— Castration (after Pozzi): the tube and the ovary are seized in Hegar's forceps; the ligature is 
 passed around the pedicle by a blunt needle. 
 
 requisite extent, so that the surgeon can not only feel but see what he 
 is doing. The operation will prove of value only if every vestige of 
 ovarian tissue is removed or destroyed. For this reason many opera- 
 
512 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tors advise that the stumps should be cauterized thoroughly after the 
 ovaries and the tubes have been removed. For this purpose a forceps 
 of suitable construction should be employed (Fig. 348). The pedicle 
 below the forceps, consisting of the broad ligament, the Fallopian tube, 
 and the ovarian ligament, should be transfixed with a blunt needle 
 armed with medium-sized Chinese silk ; the silk is then cut in the centre 
 and each part is tied on its respective side, after which one of the liga- 
 tures is made to encircle the whole pedicle. The tying must be done 
 slowly and with jerks, so that the ligatures may cut their way deeply 
 into the tissues to prevent slipping. The ligatures are then cut short 
 to the knot. 
 
 The cauterization of the stump outside the compression-forceps is 
 an additional safeguard against hemorrhage, and frequently destroys 
 ovarian tissue that has escaped the scissors. For the purpose of aiding 
 the mummification of the stump the writer has been in the habit of 
 covering it with a thin film of iodoform before dropping it into the 
 abdominal cavity. 
 
 Wiedow collected 149 cases of castration for myofibroma, and found 
 that in 54 cases the tumors underwent shrinkage and hemorrhages 
 ceased. In 15 cases the result was fatal. The mortality of this opera- 
 tion has been reduced greatly since Wiedow's statistics, and at the 
 present time probably does not exceed 5 per cent. Menstruation is 
 either arrested at once by the operation, and with it the hemorrhages, 
 or it ceases a few months later. The writer has seen tumors the size 
 of a fist shrink to the size of a hen's egg in the course of three or four 
 months after the operation. 
 
 Laparo-myomectomy . — In pedunculated intraperitoneal myofibroma 
 of the uterus the pedicle should be transfixed and securely tied, close 
 to the uterus, with medium-sized Chinese silk. As little of the uterine 
 tissue as possible should be included in the ligatures. The uterine 
 tissue in the vicinity of a tumor is always quite vascular and is easily 
 cut by the ligature — an accident which is invariably followed by trouble- 
 some hemorrhage. In a case where this occurred the writer was forced 
 to suture the margins of the wound to the parietal peritoneum of the 
 margins of the external wound, when he was able to make efficient 
 use of the antiseptic tampon, which was placed over the now extra- 
 peritoneal wound and compressed under the deep sutures which con- 
 trolled the hemorrhage. Two days after the operation the sutures 
 were cut and re-tied after the removal of the tampon. 
 
 Intraperitoneal Enucleation. — This operation is adapted for single 
 tumors of moderate size. The uterus should be brought well forward 
 into the wound and be surrounded by a gauze compress wrung out of 
 
MYOMA. 
 
 513 
 
 warm sterilized water. As a provisional hemostatic precaution the 
 uterus is constricted by an elastic cord above the cervix (Fig. 35°)- 
 The uterine tissue covering the tumor is then incised at a point where 
 
 Fig. 350.— Enucleation of an interstitial myoma ; a, disposition of sutures after enucleation (after Pozzi). 
 
 the large vessels can be avoided, when the tumor can easily be shelled 
 
 out from its bed with the fingers or with the aid of blunt instruments. 
 
 Occasionally strong septa of fibrous tissue passing from the adjacent 
 
 tissues into the tumor have to be cut with 
 
 scissors. Bleeding points are at once ligated 
 
 with catgut. When the cavity is large Martin 
 
 uses a cross-drain passed through the cervix 
 
 into the vagina. The cavity is closed by 
 
 several rows of catgut sutures, as shown in 
 
 Figure 350, a. It has happened in 10 cases 
 
 out of 16 in Martin's practice that the uterine 
 
 cavity was opened. He recommends suturing 
 
 of the mucous membrane with a continuous 
 
 catgut suture. The writer has had excellent 
 
 results from tamponing the cavity with a long 
 
 strip of iodoform gauze which was brought 
 
 into the vagina through the cervix as shown 
 
 in Figure 351. The wound over the gauze tampon is sutured in the 
 
 same manner as after Cesarean section. 
 
 The gauze tampon answers an excellent purpose in arresting the 
 33 
 
 Fig. 351. — Vaginal drainage of 
 cavity after intraperitoneal enucle- 
 ation. 
 
514 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 parenchymatous oozing, and serves also as an efficient capillary drain. 
 It should not be removed before the third or fourth day after operation. 
 In favorable cases several subserous and interstitial myofibromata 
 can be removed successfully by enucleation. Should the hemor- 
 rhage prove troublesome, the wound can be made extraperitoneal 
 by suturing the margins of the visceral wound to the margins of 
 the external wound, after which the hemorrhage can be controlled 
 by the antiseptic tampon placed under the provisional deep su- 
 tures. 
 
 Laparo-hysterectomy. — Laparo-hysterectomy has been performed too 
 frequently in the treatment of myofibromata. It is a mutilating opera- 
 tion, and as such it should be limited to cases not amenable to success- 
 ful treatment by less heroic measures. The operation includes the 
 removal of a part or the whole of the uterus with the tumors in one 
 mass. This operation is undergoing rapid changes in its technique. 
 The methods now being discussed and advocated by different surgeons 
 are — (1) Complete laparo-hysterectomy; (2) Partial hysterectomy with 
 intraperitoneal treatment of the stump ; and (3) Partial hysterectomy 
 with extraperitoneal treatment of the stump. 
 
 Complete Abdominal Hysterectomy. — Bar, Krug, and others have 
 taken advantage of Trendelenburg's position in the complete removal 
 of the uterus for myofibroma. The operation is not a difficult one, as, 
 after tying off the broad ligaments and ligation of the uterine arteries, 
 hemorrhage is under control, and Trendelenburg's position secures 
 ready access to the floor of the pelvis in suturing the pelvic wound. 
 It is well known, however, that myofibromata of the uterus, with few 
 exceptions, involve the upper part of the organ, and that the cervix 
 and the lower part of the uterus are free, and do not require removal 
 on account of pathological indications. The best surgery is always 
 conservative surgery. In operations for benign tumors healthy organs 
 or parts of healthy organs should not be sacrificed unnecessarily. The 
 writer is inclined to believe, notwithstanding the satisfactory results of 
 this operation so far as the mortality is concerned, that its popularity 
 will be of short duration. 
 
 Laparo-hysterectomy with Lntra-abdominal Treatment of the Pedicle. — 
 This operation, which was introduced by Schroder, has been but little 
 modified since his time. The broad ligaments in each side are tied off 
 with two or three separate ligatures of silk or with the chain ligature 
 (Fig. 352) before they are cut between the ligatures and compression- 
 forceps on the uterine side. After the uterus has been brought well 
 forward upon the surface of the abdomen it is constricted above the 
 cervix with a strong rubber cord. The uterus is then surrounded with 
 
MYOMA. 
 
 515 
 
 compresses of guaze, which are also made use of to prevent intestinal 
 prolapse. The incisions through the uterus below the tumors are 
 then made behind and in front in an oblique downward direction, 
 
 Fig. 352.— Chain ligature (after Pozzi) : a, separate ligatures as introduced, showing the method of looping; 
 
 b, the same, tied. 
 
 so that the lower portion of the part removed presents the shape 
 of a wedge. All visible vessels are tied. The mucous membrane 
 below the cone-shaped excision, to the depth of half an inch or 
 
 Fig. 353. — Schroder's intraperitoneal suture of pedicle : S, deep suture, passed at once under the whole 
 bleeding surface; C, continuous suture of catgut in different terraces, bringing together the whole wounded 
 surface, whose lower portion is marked by the heavy line a a, formed by the cauterized uterine cavity ; 
 P, peritoneal investment. 
 
 more, is either cauterized or excised, after which the wound is sewed 
 transversely with several rows of catgut, as shown in Figure 355. 
 
5i6 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Fig. 354. — Vaginal drainage with a cross tube after 
 abdominal hysterectomy (after Martin). 
 
 The last row of sutures brings the serous surfaces over the wound 
 in accurate contact (Fig. 354). After a careful toilet the pedicle 
 
 is dropped and the external in- 
 cision is closed. The two great 
 dangers which attend this opera- 
 tion are hemorrhage and sepsis. 
 Martin aimed to reduce these 
 dangers to a minimum by estab- 
 lishing drainage from the cul-de- 
 sac into the vagina. The danger 
 of infection is always greater when 
 the uterine cavity is opened. 
 Schroder's operation is an ideal 
 one, and it is to be hoped that the 
 technique will become so perfect 
 that it will yield as good results 
 as when the pedicle is treated by 
 the extraperitoneal method. 
 
 Laparo-liysterectomy with Ex- 
 traperitoneal Treatment of the Ped- 
 icle. — The extraperitoneal treatment of the pedicle aims to eliminate 
 or to minimize the danger from hemorrhage and sepsis. G. Kimball 
 first proposed abdominal hysterectomy for interstitial myofibroma, 
 and his patient recovered. He was followed by Koeberle and Pean in 
 rapid succession. The uterus is liberated in the manner described 
 above. Elastic constriction as a prophylactic hemostatic agent is also 
 employed. Koeberle secured the pedicle with an instrument of his 
 own device, the serre noend, which is still quite extensively used. It is 
 a miniature wire ecraseur, with which he constricted the pedicle, tight- 
 ening the wire loop from time to time until it cut its way through the 
 tissues ; this result was generally accomplished in from twenty to 
 twenty-five days. Hegar modified the operation in so far that he 
 excluded the peritoneal cavity from the mortifying stump by suturing 
 the pedicle below the constricting elastic ligature to the parietal perito- 
 neum of the margin of the wound ; this modification marked a decided 
 advance in the extraperitoneal treatment of the pedicle. Koeberle's 
 wire loop and the elastic ligature used by most surgeons in the extra- 
 peritoneal treatment of the pedicle to control hemorrhage and to effect 
 gradual division of the pedicle are objectionable, as they invariably give 
 rise to necrosis or sloughing of the stump — a condition which has been 
 a frequent remote source of infection and of ventral hernia, and which 
 prevents rapid healing of the wound. 
 
MYOMA. 
 
 517 
 
 If the amputation has to be done close to the cervix in cases in 
 which the uterus is not much elongated, harmful and painful tension 
 has been one of the drawbacks of Hegar's operation. The writer 
 aimed to overcome this difficulty by making, below the level of the 
 rectum, through the broad ligaments, a peritoneal cuff long enough to 
 permit the balance of the pedicle to recede, and at the same time to 
 shut out completely the peritoneal cavity. A circular incision is made 
 through the peritoneum, at a point corresponding with that at which the 
 broad ligaments have been divided. The peritoneum is then, with the 
 fingers and by means of blunt instruments, peeled off from the pedicle 
 to the point at which it is desired to apply the elastic constrictor — that 
 is, beyond the limits of the part to be removed. If the incision is not 
 extended into the muscular tissues, this part of the operation is attended 
 by very little hemorrhage. The peritoneal cuff is now sutured with 
 catgut to the parietal peritoneum all around in the lower angle of the 
 incision, and the balance of the incision is closed (Fig. 355). A solid! 
 
 Fig. 355.— Extraperitoneal abdominal hyster- 
 ectomy : elastic constrictor in place; balance of 
 wound sutured. 
 
 Fig. 356. — Extraperitoneal abdominal hysterectomy 
 operation completed. 
 
 rubber cord is now tied firmly around the denuded pedicle, and the 
 uterus is amputated about an inch above it. Thorough cauteriza- 
 tion of the stump and of the uterine cavity as far as the elastic ligature 
 is advisable. Gauze is now packed around the pedicle as far as the 
 bottom of the peritoneal cuff, after which the usual external dressing is 
 applied (Fig. 356). As the pedicle is not fixed with pins or needles, it 
 sinks back and all tension is avoided. The writer made nineteen con- 
 secutive operations by this method, and not only did all the patients 
 recover, but they never complained of a single untoward symptom. 
 
5i8 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The ligature with the stump usually came away about the twenty-fifth 
 day, after which the wound rapidly healed. This peritoneal cuff is 
 transformed into a solid string which makes no traction on the scar, and 
 which so far has not given rise to ventral hernia. 
 
 The only drawback of this method of operating is the inevitable 
 necrosis or sloughing of the stump, something in common with Hegar's 
 and Koeberle's operations. The writer has recently abandoned the 
 elastic ligature, and instead has resorted to ligation of the uterine 
 arteries and suturing of the cut surface ; the results have been very 
 satisfactory. The operation is performed in the manner just described 
 until after the amputation of the uterus. The elastic constrictor may be 
 
 Fig. 357.— Extraperitoneal abdominal hysterectomy without the use of the elastic constrictor or the wire 
 
 loop : operation completed. 
 
 dispensed with if both uterine arteries are tied immediately after they 
 are divided, and parenchymatous oozing is arrested by suturing the cut 
 surface with several rows of catgut sutures. A small strip of mucous 
 membrane is then excised, after which the cut surfaces are brought 
 together with several rows of catgut sutures (Fig. 357). The pedicle 
 is accessible at all times in case of hemorrhage. By abandoning the 
 elastic ligature sloughing of the stump is avoided and the wound heals 
 by primary intention. The space around the sutured pedicle is packed 
 with iodoform gauze. Secondary sutures are in place, and are pro- 
 
MYOMA. 
 
 5 J 9 
 
 visionally tied in a loop over the gauze packing. On the second day 
 the gauze is removed and the sutures are tied. 
 
 A little oozing has been observed in several cases operated upon by 
 this method. In some of the cases the external gauze dressing had 
 to be changed at the end of the first twenty-four hours. All the 
 patients operated upon by this method recovered without any compli- 
 cations whatever. Until the intraperitoneal treatment of the pedicle 
 has been made safer, the writer regards this method of disposing of 
 the pedicle preferable, as it gives the surgeon access to it should any 
 complications set in. 
 
 Broad Ligament. — Myofibroma of the uterus not infrequently 
 extends between the folds of the broad ligaments, and the tumor 
 becomes in part intraligamentous, greatly complicating the operations 
 for its removal. As the connective tissue of the broad ligament con- 
 tains unstriped muscular fibres, it is not surprising that occasionally 
 there is met with in this locality a myoma which has developed inde- 
 pendently of the uterus. Tumors in the broad ligament seldom attain 
 great size and usually give rise to but little disturbance, but occasion- 
 ally they rapidly increase in size and produce pressure-symptoms which 
 may require operative interference. The tumors occurred in women 
 past thirty-five years of age in the eleven cases so far reported. In one 
 instance the tumor weighed sixteen pounds ; usually the tumors did 
 not exceed the size of a fist. 
 
 Fig. 358.— Myofibroma in the broad ligament : decortication and suture of the cavity and drainage by the 
 
 vagina (after Martin). 
 
 It would be next to impossible to diagnosticate a myoma of the 
 broad ligament without an exploratory laparotomy. If such a tumor 
 
-«» * 
 
 520 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 is revealed by an exploratory laparotomy and its removal is deemed 
 necessary, this should be done by enucleation. Large vessels should 
 be avoided so far as possible in cutting down upon the tumor. The 
 enucleation is to be done exclusively with the fingers and with blunt 
 instruments. If the cavity is not large, the wound can be sutured after 
 the hemorrhage has been arrested completely. If parenchymatous 
 oozing is troublesome or if the cavity is large, drainage into the vagina 
 by means of a cross-tube, as advised by Martin and Kaltenbach, should 
 be resorted to (Fig. 358). The wound is sutured throughout with special 
 reference to bringing the serous surfaces in accurate apposition. Infec- 
 tion from the vagina is prevented by iodoform-gauze packing, which 
 should also embrace the distal end of the tube. The drain may be 
 removed as soon as all discharge from it has ceased. 
 
 Fig. 359. — Subserous myofibroma of Fallopian tube (after Winckel). 
 
 Fallopian Tube. — Myofibroma of the Fallopian tube is exceedingly 
 rare. Winckel describes such a specimen (Fig. 359). In this instance 
 
 Fig. 360. — Myofibroma of the round ligament (after Heydemann). 
 
 the tumor was small, oblong, and immediately underneath the peri- 
 toneum. Sutton saw only one specimen, and in this case the myoma 
 was associated with dermoid cyst of one of the ovaries. The tumor, 
 
MYOMA. 521 
 
 which was of the size and shape of a Tangerine orange, involved the 
 whole thickness of the tube. 
 
 Round Ligament. — The first operation for myofibroma of the round 
 ligament was performed by Sir Spencer Wells in 1865. In the year 
 1882 Sanger collected 12 cases, and classified tumors of the round 
 ligament according to their anatomical location into (1) intraperitoneal, 
 (2) intracanalicular, (3) extraperitoneal. In the 12 cases reported by 
 Sanger the tumor was intraperitoneal in only 3, on the left side twice, 
 and on both sides once. If the tumor occupies the inguinal canal, it 
 simulates very closely an irreducible inguinal hernia. Such cases have 
 been reported by Polaillon, Heydemann, and others. The differential 
 diagnosis of intraperitoneal tumors of the round ligament and myo- 
 fibroma of the uterus can only be made by a direct examination through 
 an abdominal incision. 
 
 Alimentary Canal. — Myomatous tumors of the alimentary canal 
 are rare. 
 
 Pharynx. — Myomata of the posterior wall of the pharynx have 
 been described by Middeldorpf. They are either sessile or pedunculated. 
 The sessile tumors cause pressure-symptoms of various kinds accord- 
 ing to their size and location. Polypoid growths, from their mobility, 
 often produce acute attacks of dyspnea, and even death, when they 
 become displaced into the entrance of the pharynx. They should be 
 removed with the galvano-caustic wire, as their point of attachment is 
 usually so low down that arrest of hemorrhage by other measures 
 usually proves inefficient. The tumor is made accessible by exciting 
 vomiting ; the tumor is then seized and drawn out at one angle of the 
 mouth, when the wire loop is pushed over it and adjusted. 
 
 (Esophagus. — Hilton Fagge reports the cure of a myomatous tumor 
 of the oesophagus in a man thirty-eight years of age. The tumor was 
 situated in the anterior wall just below the level of the bifurcation of 
 the trachea. Virchow refers to a specimen which he found at the 
 cardiac end of the oesophagus. In neither of these cases -was the 
 tumor pedunculated. 
 
 Stomach. — Virchow makes the statement that myomata are more 
 frequent in the stomach than in any other part of the digestive tract. 
 We have already referred to a myoma of the stomach that was con- 
 verted into a sarcoma. If the tumor should occupy the pyloric 
 extremity and produce obstruction, a gastro-enterostomy should be 
 performed in preference to making an attempt to remove the tumor 
 by enucleation or by excision. 
 
 Small Intestines. — Myoma of the small intestines has been described 
 by Flenier, Aufrecht, Wesener, and Bottcher. In Flenier's case the 
 
522 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumor produced invagination, and enterectomy was performed success- 
 fully by Czerny. In nearly all cases which have so far been reported 
 the tumors were located in the upper part of the intestinal canal. 
 
 Rectum. — The rectum is more frequently the seat of myoma than 
 any other part of the intestinal canal. On the mucous surface the 
 tumors appear either as sessile tumors or as polypoid growths. 
 Konig removed a pedunculated tumor in the region of the prostate 
 gland in a man ; in a girl eighteen years of age he removed a myoma- 
 tous tumor with a long pedicle. A few years ago the writer removed 
 by laparotomy a subserous myoma from the rectum of a woman 
 forty-five years old. The probable diagnosis was either a peduncu- 
 lated myofibroma of the uterus or a dermoid cyst of the ovary. The 
 tumor, which had been growing for ten years, was movable. From 
 its size it produced distressing pressure-symptoms. On opening the 
 abdominal cavity a smooth, hard, movable tumor was found, covered 
 by peritoneum. In seeking for its attachment a broad pedicle was 
 found behind the uterus and extending in the direction of the pelvis. 
 Uterus, ovaries, and tubes were normal. The peritoneum was incised 
 where the pedicle appeared to be narrowest, and the tumor was enucle- 
 ated. As soon as the tumor was removed gas escaped, and an exam- 
 ination revealed, in the anterior wall of the rectum, an opening large 
 enough to admit two fingers. With a moist compress the intestines 
 were protected, and after cleansing the wound an attempt was made to 
 close the opening by suturing. Owing to the depth of the rectal open- 
 ing the suturing was unsatisfactory. A large drain was placed vis-a-vis 
 with the sutured place and was brought out at the lower angle of the 
 wound. Iodoform gauze was packed around the tube. The remain- 
 ing part of the external incision was sutured. On the second day gas 
 and feces escaped ; otherwise there were no untoward symptoms. The 
 intestinal fistula swelled in the course of a few weeks, after which the 
 patient recovered quickly and perfectly, and remains well at the present 
 time. Microscopical examination of sections of the tumor showed the 
 typical structure of myofibroma. 
 
 Bladder. — According to Virchow, myoma of the bladder can 
 develop only in the prostatic portion of the urethra and the base of the 
 bladder. Belfield's investigations have shown that myomata of the 
 bladder not only occur as tumors projecting into the bladder, but that 
 they also may grow in the direction of the perivesical tissues. Myo- 
 mata of the bladder are comparatively rare. Terrier and Hartmann 
 have recently gathered the particulars of 16 cases from different 
 sources. Of 15 cases in which the clinical history was given with 
 sufficient detail, there were 7 women and 8 men. The age varied from 
 
MYOMA. 523 
 
 twelve to seventy-four years. In structure the tumors are in many 
 respects analogous to uterine myofibromata. The tumor originates in 
 the muscular layers of the bladder. Projection takes place most fre- 
 quently in the direction of the bladder. In the 16 cases reported this 
 was the case in 10 instances; in 4 the growth was external; in 1 
 case, a diffuse infiltration ; in 1 case growth occurred in both direc- 
 tions. The part of the bladder which the tumors occupy is most vari- 
 able : six times they were in the region of the trigone ; three times in 
 the anterior wall ; two were at the summit ; one in the posterior wall 
 and trigone ; one case included nearly the entire bladder-wall except 
 the right side ; one was a multiple tumor, and invaded both the anterior 
 and the posterior walls. In size they varied from a walnut to that of 
 a child's head. They appear either as rounded or lobulated tumors. 
 They are likely to be pedunculated, but may be sessile or even infil- 
 trative ; in the first instance they are easily removed. The presence of 
 the tumor sooner or later causes cystitis, ureteritis, and obstructive 
 lesions of the kidney Pressure-symptoms are frequently present. 
 When the tumor projects into the bladder hematuria is one of the 
 most frequent symptoms. Intravesical exploration does not always give 
 much assistance to reach a correct diagnosis. Hypogastric, vaginal, 
 and rectal palpation, and especially bimanual examination under the 
 influence of an anaesthetic, are much more satisfactory, and in most 
 instances the site and size of the tumor can thus be determined. The 
 treatment necessarily must vary according as the growth is external or 
 internal. In the subperitoneal variety the usual rules of abdominal sur- 
 gery will apply. Removal by enucleation through an abdominal incis- 
 ion and suturing of the visceral wound will usually lead to a satisfactory 
 result. In the intravesical form removal by perineal section, vaginal 
 section, and hypogastric section, or combinations of these, have each 
 their advocates. At the present time, however, the advantages of hypo- 
 gastric section, as shown by Guyon, are especially marked in the re- 
 moval of this form of tumor. Knox and Gussenbauer observed cystic 
 degeneration in vesical myomata, and Volkmann observed partial necro- 
 sis. Konig removed through a perineal incision a tumor the size of a 
 pigeon's egg from the caput gallinaginis in a boy twelve years old. 
 Volkmann removed a similar tumor by suprapubic cystotomy. 
 
XXVII. NEUROMA. 
 
 Definition. — A neuroma is a tumor composed of nerve-tissue pro- 
 duced from a matrix of neuroblasts or fibroblasts, according to the 
 anatomical structure of the tumor. Virchow made a distinction between 
 benign nerve-tumors according as the tumor is composed of medul- 
 lated or of non-medullated nerve-fibres, designating the former neur- 
 oma myelinicum, and the latter neuroma amyelinicum. This anatomical 
 distinction is retained at the present time. By far the greatest number 
 of benign tumors of the nerves belong to the amyelinic variety, as 
 they do not contain a numerical increase of medullated nerve-fibres. 
 Some of these tumors have already been discussed in the section on 
 Fibroma. The nerve-sheaths not infrequently contain matrices of fibro- 
 blasts from which true fibromata develop, the pre-existing nerve-fibres 
 being simply an accidental anatomical constituent of the tumor. In 
 other cases the fibrous tissue is more intimately intermingled with 
 terminal nerve-fibres, as in cases of amputation-neuroma. 
 
 Embryology. — In the embryo the neural canal consists at first of 
 a solid cylinder of epithelial cells developed from the epiblast. During 
 the differentiation of these cells there forms a supporting frame- 
 work of which the neuroblasts constitute the essential element. They 
 are the " germinal cells " of His, and they multiply by karyokinesis. 
 Further differentiation of the neuroblasts results in the formation of 
 ganglion-cells and conducting cells. The conducting cells, which are 
 connected with nerve-fibres and acquire sheaths of greater or lesser 
 thickness, are known as the medullated and the non-medullated fibres. 
 
 In the central nervous system the connective tissue is represented 
 by neuroglia. Ranvier asserts that the processes of the pia mater and 
 the vessels are surrounded by a sheath of neuroglia. It is, however, 
 difficult to determine just where the connective tissue ends and the 
 neuroglia begins. In the brain and the spinal cord the connective- 
 tissue tumors, benign and malignant, develop from the neuroglia. 
 Biirgner and Klebs regard the nuclei and the protoplasm of the sheath 
 of Schwann as neuroblasts. From these neuroblasts new nerve-fibres 
 are produced in the case of myelinic neuroma, and the proliferation 
 from them is concerned in the repair of nerves after injury or disease. 
 
 Histology and Histogenesis. — The structure and origin of a neur- 
 
 524 
 
NEUROMA. 
 
 525 
 
 oma depend upon the nerve-trunk or the part of the central nervous 
 system from which the tumor springs. A tumor produced from nerve- 
 cells or neuroblasts is composed very largely of nerve-tissue, whereas 
 a tumor produced by proliferation of neuroglia or from fibroblasts 
 contained in the nerve-sheath is more akin to a fibroma than to 
 a neuroma. Virchow classifies neuromata as follows : 
 
 1. Hyperplastic fascicular neuroma: 
 
 a. White, containing medullated 
 nerve-fibres ; 
 j b. Gray, containing non-medul- 
 v. lated nerve-fibres. 
 
 2, 
 
 Hyperplastic medullary neuroma, usually occurring in the brain or 
 as a congenital tumor. 
 3. Heteroplastic medullary neuroma, found in the ovary by Virchow 
 and Gray, found in the testicle by Verneuil. 
 
 The majority of neuromata are simply fibrous tumors lying along 
 the course of a nerve or attached to the nerve-terminations in a stump. 
 True nerve-tumors are most common on 
 the ears, the eyelids, and the side of the 
 face. They usually have a plexiform ap- 
 pearance, and these ramifications can be 
 felt under the skin (Fig. 361). The tumor 
 consists of a fibrous framework through 
 which run bundles of nerve-fibres, some 
 of them completely medullated, others 
 only partially so (Fig. 362). Large gan- 
 glion-cells with characteristic nuclei and 
 nucleoli are also sometimes found im- 
 bedded in the tumor-mass. Waldenstrom, 
 who doubts the correctness of Virchow's 
 idea that a neuroma is composed largely 
 of nerve-fibres without medullary sheath, 
 regards them as fibromata originating from 
 the interstitial connective tissue. 
 
 Westphal has traced neuromata of the 
 skin to the endoneurium. The nerve-fibres 
 in neurofibromata undergo a change which 
 is conceded by nearly all observers, in that the medullary sheath under- 
 goes atrophy, and that the nerve-sheaths become the seat of hyaline 
 degeneration, which was first noticed and described by Schuster. The 
 enlargement of a nerve-end in amputation-neuroma is due to an abun- 
 dant formation of small myelinic fibres produced from the neuroblasts 
 
 Fig. 
 
 61. — Portion of a neuroma from 
 the right ear (after Bruns). 
 
526 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 which have been exposed for a long time to irritation caused by cica- 
 tricial tissue. It is well known that an amputation-neuroma will only 
 develop in connection with scar-tissue and the irritation incident to the 
 
 k 
 
 w 
 
 Fig. 362. — Transverse section of a painful subcutaneous tubercle (Surgical Clinic. Rush Medical Col- 
 lege, Chicago) : a, fine connective-tissue reticulum ; b, axis-cylinders ; c, nerve-bundle cut transversely ; 
 d. neurilemma, somewhat thickened. 
 
 conditions producing it. Witzel has recently shown that in many cases 
 the neuroma is found attached to the end of the bone in the stump. 
 The tumor presents itself in the form of a bulbous enlargement of the 
 end of the nerve, which closely resembles a spring onion in outline 
 (Fig. 363). Cross-sections of such tumors show the numerical increase 
 of myelinic nerve-fibres (PL 13, Fig. 1). Under the same influence the 
 fibroblasts proliferate and greatly increase the amount of connective 
 tissue, producing thus a true neurofibroma. In the majority of cases 
 the tumor is limited and forms the bulbous extremity of the nerve ; 
 in some instances, as in the case reported by Hayem and Gilbert, the 
 nerve is at this time enlarged for a very considerable distance, the 
 enlargement being due to an abundant formation of small myelinic 
 fibres and to hyperplasia of the pre-existing interstitial connective 
 tissue. 
 
 Every surgeon of large experience knows that an amputation- 
 
NEUROMA. 
 
 Plate 13. 
 
 OMR. 
 
 . Simple neuroma after amputation (after Boyce) : a and *, nerve-bundles ; c, connective tissue. (Obj. I inch 
 osmic acid.) 2. Neuroma of the fourth ventricle (after Klebs). (Nigrosin and hematoxylin ; Zeiss. &, , ) 
 

NEUROMA. 
 
 527 
 
 neuroma in some cases is exceedingly prone to return after excision, 
 and these cases are undoubtedly those in which the nerve is enlarged 
 far beyond the bulbous extremity. The writer has known instances in 
 
 b—~ 
 
 
 Fig. 363.— Amputation-neuroma (after Karg and Schmorl). Upon the crural nerve (a) is seen the bulbous 
 tumor (b), which has been produced by proliferation of the bundles of nerve-fibres. The tumor is composed 
 of interlacing myelinic nerve-fibres ; at c is seen a bundle of nerve-fibres which is divided into numerous 
 filaments in a downward direction. 
 
 which such neuromata were excised four and five times, and an early 
 recurrence of the pain, with return of the tumor, followed each opera- 
 tion. In one case a cure was finally effected by excising four inches of 
 the sciatic nerve, far beyond the apparent limits of the tumor. 
 
 Klebs is of the opinion that neuromata of the central nervous 
 system are not composed, as is usually asserted, of cells derived exclu- 
 sively from neuroglia, but that the nerve-cells take an active part in 
 their development (PL 13, Fig. 2). He consequently regards them not 
 as histioid but as organoid tumors. He proposes the name " neuro- 
 
528 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 glioma " in place of " glioma." With due deference to the weight of 
 opinion of this author, it must be maintained that in glioma the 
 neuroglia-proliferation furnishes the bulk of the tumor, and that the 
 nerve-cells constitute an accidental product incident to the increased 
 vascularity caused by the tumor-formation. 
 
 The mesenteric nerves are occasionally the seat of diffuse miliary 
 fibromyxomatous neuromata (Fig. 364). 
 
 Fig. 364. — Miliary fibromyxomatous neuromata of the mesenteric nerves; X 50 (after Perls). In the 
 nodule (a) the nerve passes unchanged through the centre of the swelling; in b it is separated by myxomatous 
 degeneration of the perineurium into two bundles ; in c its fibrillar are separated. 
 
 Neurofibroma is occasionally diffuse, following different nerve-trunks, 
 when it is called a " plexiform neurofibroma." The tumors often attain 
 
NEUROMA. 
 
 529 
 
 oreat size, imbedding the nerve-trunks in large masses of fibrous tissue 
 (Fig. 365). Marchand, who reports two cases of this affection, regards 
 the tumor as a cylindrical fibroma of the nerve-sheaths. In one case, 
 
 Fig. 365. — Plexiform neurofibroma of the plexus pudendus and ischiadicus, one-fourth natural size (after O 
 Weber). The whole mass forms a tumor weighing several pounds. 
 
 a boy twelve years old, the tumor involved the upper lid of the left eye 
 and the adjacent part of the temporal region ; at the same time it pene- 
 trated deeply into the orbital cavity. It was first noticed when the child 
 was six months old. The second case was a boy eight years old. The 
 tumor was soft, extended from a point behind the right ear in the direc- 
 tion of the temporal region and beyond the parietal eminence, and 
 projected an inch beyond the surrounding skin. The tumor in each 
 case was composed of convoluted cords which contained remnants of 
 34 
 
530 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 nerve-fibres. Schwann's sheath was intact, consequently the tumor 
 must have developed from the perineurium, with participation of the 
 walls of the blood-vessels. In the only case of plexiform neurofibroma 
 that has come under the writer's observation, the tumor, which occu- 
 pied the palmar side of the hand and extended along the branches of 
 the median nerve which supply the thumb and the index finger, was 
 several inches in length, quite hard, and presented the characteristic 
 convoluted appearance. The tumor was extirpated, and did not return 
 after the operation. 
 
 Regressive Metamorphoses. — With the exception of plexiform 
 neurofibroma, benign tumors of nerves do not attain large size. After 
 they reach the size of a hemp-seed or that of a walnut they remain 
 
 stationary. They are not much disposed to 
 regressive metamorphosis. Besides hyaline 
 and myxomatous degeneration, no other 
 retrograde pathological changes have been 
 observed. The liability of a neuroma to 
 become transformed into a sarcoma is 
 perhaps a little greater than that of a sim- 
 ple fibroma, more especially in cases in 
 which the tumor has undergone myxoma- 
 tous degeneration. 
 
 Etiology. — In many instances neuroma 
 appears as a congenital tumor, particularly 
 the heterotopic variety and plexiform neur- 
 oma. Plexiform neuroma has usually been 
 met with in young persons, and the growth 
 of the tumor was in most instances referred 
 to infancy or early childhood. The heredity of neuroma, like that of 
 many other forms of benign tumors, is unquestionable. The heredity 
 of multiple neurofibromata is particularly well marked. Chronic 
 inflammatory affections of the nerve-sheaths or of tissues in close 
 proximity to nerve-trunks is a potent exciting cause. The trau- 
 matic influence in the etiology of neuroma is well shown in the 
 case of amputation-neuroma. Wounds and contusions may exert a 
 similar influence in exciting a latent tumor-matrix to active tissue- 
 proliferation. 
 
 Symptoms and Diagnosis. — The symptoms produced by a neur- 
 oma consist in varying degrees of functional disturbance of the nerves 
 which are the seat of the tumor. With the exception of amputation- 
 neuroma and the subcutaneous painful tubercle, pain and tenderness 
 are not conspicuous symptoms unless the tumor causes nerve-compres- 
 
 
 Fig. 366. — Fibromyxomatous tis- 
 sue from specimen shown in Figure 
 372 ; X 250. 
 
NEUROMA. 531 
 
 sion, as when the tumor is located in a bony channel through which 
 the nerve passes. In multiple neurofibromata of the skin pain and ten- 
 derness are usually absent. In some cases in which pain is absent it 
 can be produced by pressure. With the exception of plexiform neur- 
 oma, the tumor is circumscribed, encapsulated, and movable ; it is 
 smooth, and often is spindle-shaped. In multiple neurofibromata the 
 diagnosis is not difficult, as tumors can be felt in the course of different 
 nerves. A plexiform neuroma can be distinguished from an arterial 
 angioma by the size of the tumor, by its undergoing no changes under 
 pressure, by placing the part in different positions, and by the absence 
 of pulsations and bruit. 
 
 Prognosis. — The prognosis in neuroma is favorable, aside from 
 the liability of the tumor to undergo transformation into sarcoma. 
 The tumor does not involve adjacent tissues, and metastasis has never 
 been observed. In the painful varieties the general health of the 
 patient is often undermined by the loss of sleep and by inadequate 
 out-door exercise. The rapid growth of a neuroma that has been sta- 
 tionary for a long time is a probable indication that malignant trans- 
 formation has occurred. 
 
 Treatment. — Operative treatment in multiple neurofibromata is con- 
 traindicated unless some of the tumors should cause pain by pressure, 
 when, if accessible, such nodules are to be removed by excision. 
 Amputation-neuroma must be excised with the surrounding scar-tissue, 
 and the section of the nerve must be made beyond the limits of the 
 disease. If the nerve above the bulbous tumor is enlarged, it must be 
 followed sufficiently far and excised with the tumor in order to guard 
 against a- recurrence of the neuroma. A plexiform neuroma must be 
 excised if all parts of the tumor can be reached, as eventually the 
 tumor may attain great size, and the nerves imbedded in the fibrous 
 mass are destroyed in the course of time. Painful subcutaneous 
 tubercles should be excised. The removal of circumscribed tumors 
 of nerve-trunks must be effected without destroying the continuity of 
 the nerve. This can be done without difficulty by enucleation. After 
 the affected nerve has been exposed the capsule of the tumor is 
 incised in the direction of the nerve-fibres and the tumor is enucleated. 
 The writer recently removed from the median nerve above the wrist- 
 joint a tumor the size of a hickory-nut. The patient was a girl twenty 
 years of age, and the tumor had been growing for five years. It was 
 centrally located. On the surface of the tumor could be seen bundles 
 of nerve-fibres. The capsule of the tumor was incised between the 
 visible nerve-fibres, after which the tumor was enucleated without diffi- 
 culty. The nerve-sheath was sewed with fine catgut. The wound. 
 
532 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 which was sutured throughout and was then sealed with aseptic cotton 
 and iodoform collodion, healed by primary intention. The pain and 
 the prickling sensations which the tumor had produced disappeared 
 slowly after the operation. 
 
 Topography. 
 
 Multiple Neurofibromata. — Superficial multiple neurofibromata of 
 the skin have been described in the section on Fibroma. The relation 
 of these tumors to the nerve-sheath was first pointed out by Reckling- 
 hausen. The deeper nerves are occasionally the seat of multiple neuro- 
 fibromata in which nearly all the nerves of the body may become 
 involved. The tumors are due to multiple matrices of fibroblasts or 
 of fibroblasts and neuroblasts. 
 
 Sorzka does not believe that the development of multiple neuro- 
 fibromata is caused by metastasis, as has been claimed by some authors ; 
 he attributes them to a congenital disposition of the nerves, so that the 
 tumors may appear simultaneously or in rapid succession at different 
 points independently of the primary tumor. In nearly all cases the 
 patients were children or young adults. 
 
 Heusinger records the case of a sailor twenty-three years old in 
 whom all the nerves were affected by numerous nodular enlargements. 
 Not a nerve in the entire body was found normal. The enlargements 
 were caused by increase in the connective tissue. The axis-cylinders 
 were normal. There was neither pain nor tenderness. 
 
 Prudden reports the case of a girl twenty-five years of age who 
 during convalescence from variola became paraplegic, and during this 
 time multiple neuromata appeared. At the post-mortem more than 
 a thousand tumors were found, affecting not only the peripheral 
 branches and the sympathetic, but also the cranial nerves and the 
 pneumogastric. Under the microscope these tumors showed an enor- 
 mous increase of the intrafascicular as well as the perivascular con- 
 nective-tissue fibres. The nerve-fibres were not increased in size or in 
 number. Only one tumor, in connection with a branch of the lumbar 
 plexus, contained within its capsule cells resembling ganglion-cells of 
 the sympathetic nerve. 
 
 Virchow collected thirty cases of multiple neurofibromata, which he 
 calls " general neuromatosis." In one case he found five hundred, in 
 others from eight hundred to a thousand, tumors. 
 
 In multiple neurofibromata operative treatment is contraindicated 
 unless one or more of the tumors, occupying localities in which pain 
 from pressure is produced, are accessible, in which case the tumors 
 should be excised. 
 
 
NEUROMA. 533 
 
 Cranial Nerves. — The cranial nerves are frequently the seat 
 of neuromata. If the tumor occupies that part of a nerve which 
 passes through a bony canal, intense pain, usually diagnosticated and 
 treated as neuralgia, is the result. Sensory nerves are more fre- 
 quently affected than motor nerves. According to Virchow, among the 
 nerves of special sense the acoustic nerve is the most frequent seat of 
 neuroma. Neuroma of the facial nerve is exceedingly rare. Jocqs col- 
 lected sixty-two cases of neuroma of the optic nerve. Myxofibroma is 
 the kind of tumor most frequently found in this locality. Myofibromata 
 do not extend to the globe, but are apt to involve the intracranial por- 
 tion of the nerve. They are painless tumors, but affect and destroy 
 vision at an early stage. Perls has described a true neuroma of the 
 optic nerve the size of a hen's egg. The new nerve-fibres were not 
 supplied, like the normal fibres of the optic nerve, with a nucleated 
 sheath. The specimen showed also that the new nerve-fibres were 
 formed, not by coalescence of spindle-cells, but by prolongations of 
 the individual cells. Toynbee reported several cases of neurofibroma 
 of the acoustic nerve, and in every case the tumor produced progres- 
 sive deafness. 
 
 Spinal Nerves. — The roots of the spinal nerves are frequently the 
 seat of neuroma. Owing to the depth of the location of the tumor, 
 it is seldom recognized during life. Chavasse reports a case in which 
 the tumor, occupying the cervical region, was removed with a fatal 
 result, the patient dying of septic spinal meningitis. 
 
 Upper Extremity. — Neuroma of the axillary plexus has been 
 observed and has successfully been removed. The operation in this 
 locality is difficult, owing to the proximity of the large vessels and to 
 the number of large nerve-trunks. The ulnar, radial, and median 
 nerves are more favorably situated for the successful removal of neur- 
 omata. The writer has referred to a case that came under his observ- 
 ation, in which the tumor, which involved the median nerve just above 
 the wrist, simulated ganglion almost to perfection. A case of plexi- 
 form neuroma of two digital branches of the same nerve has also been 
 alluded to by the writer. 
 
 Lower Extremity. — The sciatic nerve below its exit from the pelvis 
 is occasionally the seat of a neuroma, but is more frequently the seat 
 of neuro-sarcoma. Benign tumors may occur in any part of its course, 
 and are occasionally multiple (Fig. 367). 
 
 The removal of tumors of a benign character from larsre nerve- 
 trunks calls for special care. Nerve-resection is unjustifiable. The con- 
 tinuity of the nerve must be preserved. The tumor is exposed by an 
 incision parallel with the nerve ; if the tumor is centrally located, the 
 
534 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 mantle of overlying nerve-tissue is incised between the visible bundles 
 of nerve-fibres, after which the tumor is enucleated. In central neuro- 
 
 Fig. 367. — Lower extremity from a case of multiple neurofibromata ; one-third natural size (after Perls) : 
 a, superficial peroneal ; b, sural nerve ; c, superficial branches of saphenous major nerve ; d, tumor upon 
 deep peroneal. 
 
 fibromata that are accessible to operation removal should be advised, as 
 the pressure-atrophy caused by the tumor will ultimately destroy the 
 function of the nerve. 
 
 Plexiform Neuroma. — Plexiform neuroma is always congenital. 
 The tumor may not be detected at the time of birth, but it is always 
 found in children and young adults, and the clinical history frequently 
 dates back to early infancy. In most of the cases that have been ex- 
 amined carefully the mass of the tumor was composed of fibrous tissue 
 in which the nerves were found imbedded. Bruns found in some speci- 
 mens a marked increase of nerve-fibres. The tumors are found most 
 frequently in the temporal region, the neck, and the side of the face, 
 but they may affect almost any part of the body. Christot reports 
 two cases in which the tumors were located upon the cheek and the 
 neck. Czerny observed a case in which the tumor involved the lumbar 
 
NEUROMA. 535 
 
 plexus. In this case the patient was also the subject of a very large 
 congenital fibroma of the skin. He found in the tumor, besides fibrous 
 
 FlG. 368. — Arm in which the musculo-spiral nerve was neuromatous (after Campbell de Morgan). 
 
 tissue, new non-medul.lated nerve-fibres. Campbell de Morgan met 
 with a plexiform neuroma of the musculo-spiral nerve and its branches 
 (Fig. 368). The patient was a young lady. The tumor, which was not 
 painful, had undergone myxomatous degeneration. 
 
 Plexiform neuromata are painless tumors which grow slowly, but 
 which may attain large size. The affected nerves become tortuous, 
 because they increase in length as well as in circumference. The rami- 
 fications correspond with the directions of the branches of the nerves 
 that become successively involved. Thorough excision of the tumor 
 is the only proper surgical treatment. 
 
 Vulva. — Neuroma of the vulva is a pathological curiosity. In one 
 case reported by Simpson the tumor appeared as a painful nodule near 
 the urinary meatus. Another case is reported by Kennedy. In this 
 case the tumor appeared as multiple subcutaneous tubercles exquisitely 
 tender to touch. 
 
 Prepuce. — A number of authors have described a very painful 
 recurring herpes of the prepuce, which they regarded as being of a 
 nature similar to herpes zoster (Hebra, Mauriac, Verneuil, Kaufmann). 
 The attacks occur every four or five weeks, are preceded by pain in the 
 back and along the thighs, and subside in the course of a few days. 
 In i860, Verneuil resorted to circumcision in the treatment of this 
 obstinate affection, and effected a permanent cure. He found in the 
 specimen removed a peculiar form of neuroma {neurome cylindrique 
 plexiforme), which in its distribution and structure resembled plexiform 
 neuroma. 
 
XXVIII. SARCOMA. 
 
 It is less than fifty years since all malignant tumors were included 
 under the one term " carcinoma." Johannes Mueller found and de- 
 scribed in some malignant tumors spindle-shaped cells, but he regarded 
 them as a variety of carcinoma-cells. A description of similar cells 
 was later given by Valentin. Lebert in 1845 made these cells the basis 
 for his fibroplastic tumor. In 1847, Virchow introduced the term 
 " sarcoma," and upon a histological basis separated from carcinoma 
 a large group of malignant tumors. He asserted that the spindle-cells 
 were not characteristic of sarcoma, and he called attention to the dif- 
 ferent forms of sarcoma-cells. He relied upon the relation of cells to 
 the reticulum in making a differential diagnosis between carcinoma and 
 sarcoma. He placed special stress upon the absence of a well-marked 
 stroma and alveolar grouping of the cells. Follin called sarcoma 
 plasmome. Rindfleisch called attention to the histological resemblance 
 of sarcoma to granuloma. By degrees pathologists were brought to 
 admit that under the term sc sarcoma " must be included all malignant 
 tumors originating from tissue of mesoblastic origin. Carcinoma repre- 
 sents the malignant tumors of the tissues of epiblastic and hypoblastic 
 origin. Sarcoma represents the malignajit tumors of the tissues of meso- 
 blastic origin. As the typical tumor-element of the former the embry- 
 onal epithelial cell is recognized ; of the latter, the embryonal con- 
 nective-tissue cell is the prototype. 
 
 Definition. — Sarcoma is an atypical proliferation of connective-tissue 
 cells from a matrix of fibroblasts of congenital or post-natal origin. 
 This definition acknowledges the connective tissue as the sole origin 
 of sarcoma. Histological investigations have shown that sarcoma 
 originating in the different parts and organs always begins in the 
 connective tissue primarily, and that the other tissues are involved 
 secondarily — that is, by extension. Sarcoma springs from the subcu- 
 taneous or intermuscular connective tissue, fascia, submucous and 
 subserous connective tissue, the neuroglia of the central nervous sys- 
 tem, the lymphoid tissue, the periosteum, the marrow of bone, and the 
 stroma of other tumors. Only the cartilage is exempt as a primary 
 starting-point of sarcoma. The atypical proliferation of the connective- 
 tissue cells is evidenced from the fact that the sarcoma-cells do not 
 
 536 
 
SARCOMA. 537 
 
 reach maturity, and that they invade the adjacent tissues and very 
 frequently give rise to metastasis. We have already shown, in connec- 
 tion with carcinoma, that mature normal cells never take an active part 
 in the formation of a malignant tumor. The same remarks apply to 
 the essential cause of sarcoma. The mature connective tissue is acted 
 upon by microbic causes, and if these causes are not sufficiently intense 
 in their action to destroy the tissue, it proliferates and forms granula- 
 tion-tissue, of which the different infective swellings, the granulomata, 
 are composed. 
 
 It is impossible to explain satisfactorily the origin of a tumor from 
 pre-existing normal connective tissue without assuming the presence 
 of a localized specific microbic cause. It is true that the different forms 
 of sarcoma resemble more closely chronic inflammatory processes than 
 does carcinoma, but we are not yet, and probably never will be, in 
 possession of demonstrative proof of the microbic origin of sarcoma. 
 We are therefore forced to conclude that sarcoma-tissue is produced 
 from a matrix of embryonic connective-tissue cells of congenital or 
 post-natal origin. 
 
 Of all tumors, sarcoma probably develops more frequently from a 
 matrix of embryonic connective-tissue cells or fibroblasts than any 
 other tumor. The matrix is composed of the same kind of cells as 
 the matrix of fibroma, except that the cell-development was arrested 
 at an earlier stage. The cells of a sarcoma as compared with those 
 of a fibroma possess greater reproductive power, but do not reach the 
 same degree of development, owing to a more imperfect specialization 
 of the cells of which the matrix is composed. Every surgeon knows 
 that trauma plays a more important role in the etiology of sarcoma 
 than in that of carcinoma. The trauma in sarcoma not only acts as 
 an exciting cause in stimulating a latent matrix to active proliferation, 
 but it frequently produces at the same time the essential cause, a post- 
 natal matrix of granulation-tissue. It would be difficult to explain satis- 
 factorily in any other manner the frequent origin of sarcoma in inflam- 
 matory products and at the seat of a fracture. As the endothelial cells 
 are only a modified form of connective-tissue cells, malignant endothe- 
 lial tumors will be included among the sarcomata. 
 
 Histology and Histogenesis. — The presence of a reticulum in 
 sarcoma was formerly denied. Ackermann and others have shown that 
 a reticulum is always present. In some specimens the stroma is well 
 marked ; in others it is so fine that it is almost hidden by the tumor- 
 cells. Teasing preparations of hardened specimens shows the fibril- 
 lated structure best. Ackermann claims that the reticulum of sarcoma 
 is the product of sarcoma-cells. Schwann asserted that embryonal 
 
538 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 connective-tissue cells elongate and break up into fibrillae until the cells 
 are lost. His views were supported by Virchow, Danders, and K61- 
 liker. Virchow denied that fibrillae are produced by the breaking up 
 of cells. Liicke and Rindfleisch were of the same opinion. The 
 origin of normal connective tissue from a blastema was asserted by 
 Bizzozero, Kollmann, Valentin, M. Schulze, and Bruecke. Ackermann 
 studied fibrillation in spindle-celled sarcoma, and observed that fibrillae 
 were produced by splitting up of the protoplasm of the cells. The 
 fibrillae in sarcoma resemble the same structures in connective tissue. 
 The reticular arrangement of the fibrillae has been explained by union 
 occurring between projections of different cells. The meshes of this 
 reticulum become apparent when filled with fluid or cells. If the 
 meshes are empty, they collapse. A jelly-like substance is always 
 present in embryonal connective tissue, and is always found in the 
 connective-tissue spaces. This substance, which is a mucin-serum, can 
 be seen best around transverse sections of fibrillae. In old portions 
 of the tumor this material is scanty, as the fibrillae become more com- 
 pact by contraction. Cicatricial contraction does not occur from loss 
 of substance, but from the disappearance of the intercellular substance. 
 Many authors consider this substance, with the fibrillae, as one body 
 which constitutes the cement-substance. Bizzozero says the stroma of 
 a sarcoma is either soft, amorphous, mucoid, or jelly-like, at times more 
 compact and fibrillated. 
 
 The intercellular substance holds a relation to the question of the 
 origin of fibrillae. If the fibrillae originate from the blastema, they 
 form a part of the cement-substance ; if they are a product of cells, 
 they are derivatives of these structures, which would leave the mucin- 
 serum only as the proper cement-substance. 
 
 In sarcoma cell-proliferation takes place in the immediate vicinity 
 of blood-vessels, and is controlled and influenced by them. Spindle- 
 cells are formed in the adventitia ; these cells either cannot be distin- 
 guished from the cells of this part of the vessel-wall or they differ only 
 in size. The cells either come in direct contact with the vessel-wall or 
 are separated from it only by a gelatinous layer. The latter contains 
 the sarcoma-cells, few in number, imbedded in a fine net-like ground- 
 substance, the wide meshes of which contain the mucin-serum. There 
 grow into the tumor young buds of capillary vessels which have imper- 
 fect walls ; the cells arrange themselves into minute cylinders, the cen- 
 tres of which correspond with new blood-vessels. 
 
 The intimate relations of the walls of nezv blood-vessels with the paren- 
 chyma of the tumor is the characteristic feature of sarcoma. As sarcoma, 
 starting from a central point, extends almost equally in all directions, 
 
SARCOMA. 539 
 
 the resulting tumor usually approaches a globular shape, unless at 
 some points obstacles to its growth are presented. In organs where 
 the structure is uniform throughout, as in the brain, tumors grow in 
 a globular shape, while in organs presenting parallel arrangement of 
 
 .C., r 
 
 
 Fig. 369. — Sarcoma of skull, showing capillary vessels, the walls of which are composed in part of sar- 
 coma-cells (Surgical Clinic, Rush Medical College, Chicago): a, delicate stroma of connective tissue; b, 
 groups of small round cells; c, new capillary vessels. 
 
 the structures the tumor assumes an oblong shape, as is the case in 
 muscles and long bones. In bone the tumor either destroys the bone- 
 tissue or pushes the compact layer before it. All these properties of 
 the tumor indicate the presence of great tension, which can be referred 
 to increased blood-pressure. This increased pressure can be explained 
 readily in the case of sarcoma from the presence of numerous and 
 dilated blood-vessels. In many cases the tumor is composed largely 
 of new blood-vessels with the characteristic cells interposed between 
 them. In the vascular variety of sarcoma the tumor differs from an 
 angioma in the greater amount of tissue which exists between the 
 vessels and in the greater firmness of this tissue. In fibro-sarcoma the 
 vessels are scanty, but are gradually increased in size. The vessels in 
 sarcoma remain patent in the cut surface, as in cases of papilloma. 
 
54o 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The spindle-cells with a scanty intercellular substance constitute the 
 walls of the new capillary blood-vessels, as was first shown by 
 Waldeyer. In all capillary vessels the endothelial cells are preserved. 
 In a new sarcomatous growth the vessels increase in size and are later 
 pushed apart by the cellular elements. The walls are thin and remain 
 thin, so that finally the lumina of the vessels appear to be surrounded 
 by only a single layer of endothelial cells (Fig. 369, c). The circula- 
 tion in the capillaries is active and the blood-pressure is considerable, 
 and, as the walls are weak, the blood-pressure is communicated to the 
 tissues of the tumor, in which event the tumor pulsates. 
 
 In all histological varieties of sarcoma the cells are characterized 
 by the existence of a large nucleus, which in young tumors almost 
 obscures the cell-protoplasm. In the spindle-cells the nucleus is 
 centrally located (Fig. 370). The giant-cells are multinuclear (Fig. 
 
 Fig. 370. — Spindle-cells from sarcoma (after Liicke). 
 
 371). The cells vary greatly in size and shape, but a certain uniformity 
 is observed in each tumor. The shape of the cell is not only greatly 
 influenced by the structure of the mesoblastic tissue in which the tumor 
 originates, but also by the cell-environments. The cells are often 
 moulded into different shapes by pressure. The shape of the nucleus 
 is determined by the shape of the cell. The nucleus is always clear, 
 well-defined, and surrounded by a proper nuclear membrane. The con- 
 tents of the nucleus vary according to the age of the cell. In young 
 and rapid-growing sarcoma the contents are rich in chromatin ; later 
 the chromatin is diminished and there appears a beautiful network of 
 chromatin threads that do not readily absorb staining material. One or 
 two nucleoli which are deeply stained are always present. In young 
 
SARCOMA. 
 
 Plate 14. 
 
 Fibrosarcoma of the base of the tongue, recurrent seven times : X 5°°; a , longitudinal fibres of vessel 
 b, circular fibres of vessel; c, vessel cut transversely; d, endothelial layer of vessel. ; 
 
SARCOMA. 
 
 541 
 
 tumors, besides cells, leucocytes are always present, but their number 
 is usually limited. They are most numerous along the course of blood- 
 vessels. Although the imperfect condition of the capillary walls would 
 appear to favor emigration of leuco- 
 cytes, the escape of leucocytes is limited. 
 Leucocytes are found in abundance only 
 in young and rapid-growing tumors. In 
 a specimen examined by Klebs he found 
 the large vessels of the tumor partly 
 closed by normal white thrombi. The 
 existence of the leucocytes in the tumor 
 is of short duration. 
 
 Sarcoma-cells reproduce themselves 
 by karyokinesis, as was first observed 
 and described by Van Henkelem. The 
 same method of cell-reproduction in 
 sarcoma has been studied by Aryama 
 and Klebs. Distinct alveolation of the 
 stroma of sarcoma is observed only in 
 exceptional cases. 
 
 Billroth in 1869 introduced the term alveolar sarcoma, and included 
 in this variety of sarcoma all tumors in which the connective-tissue 
 stroma showed a reticulated structure, in the meshes of which the 
 sarcoma-cells are arranged in groups (Fig. 372). He insists that such 
 tumors are often wrongly considered as carcinomatous from the size 
 of the cells and the alveolated structure of the reticulum. As such 
 tumors are found in localities devoid of epithelial cells, they must be 
 classified with the sarcomata. In these cases the reticulum is composed 
 of the pre-existing connective tissue of the part in which the tumor 
 grows. A good illustration is furnished by the malignant primary 
 tumors of the lymphatic glands. Although the alveolated structure 
 of the reticulum of some sarcomatous tumors is undisputed, the 
 arrangement of the cells in the alveoli is different from that in carci- 
 noma, in that the cells are not arranged in concentric compact layers. 
 Alveolation is observed most frequently in sarcoma of endothelial 
 
 Fig. 371. — Giant-cells from sarcoma (after 
 Liicke). 
 
 Pacinotti demonstrated the existence of lymphatics in sarcoma by 
 injections of asphalt dissolved in chloroform. Lymphatics were found 
 both in the parenchyma and in the capsule of such tumors. 
 
 Morphology of Sarcoma-cells. — The morphology of sarcoma-cells 
 is less uniform than that of carcinoma-cells. Many pathologists, but 
 more especially Rindfleisch, have considered different forms of cells as 
 
542 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 belonging to the same kind, differing only in reference to the degree 
 of development. Rindfleisch believed that round-cells are converted 
 into spindle-cells, and vice versa. Ackermann and Klebs have seen no 
 such transition. No intermediate forms have been found. 
 
 Histological Varieties. — Round-celled Sarcoma. — It is not neces- 
 sary to make a histological or clinical distinction between large and 
 small round-celled sarcoma. Some tumors are composed exclusively 
 of round cells, and as these cells, according to Ackermann, lack the 
 power of fibrillation, the tumors possess a minimum amount of inter- 
 
 Fig. 37 2 - 
 
 -Alveolar sarcoma; X i°o (Surgical Clinic, St. Joseph's Hospital, Chicago). 
 
 cellular substance, are soft, and grow rapidly. The appearance of 
 sections of round-celled sarcoma under the microscope bears a strong 
 resemblance to granulation-tissue, from which, without the aid of a 
 clinical history, it is difficult to distinguish it (Fig. 373). In some 
 tumors the round cells are scattered between the spindle-cells and the 
 giant-cells (Fig. 374). In the genuine round-celled sarcoma starting 
 in tissues other than lymphatic glands, the separate phases of develop- 
 ment occur in the same order as in spindle-celled sarcoma, and are 
 more accurately defined than in the latter. In the first place, the ves- 
 sels are dilated and new ones are formed, which show the same character 
 as in spindle-celled sarcoma. According to Ehrlich, the round cells 
 always appear in close proximity to the vessel-wall. The vessel-lumina 
 are more patent, and the walls of the vessels are lined with well-devel- 
 
SARCOMA. 
 
 543 
 
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 usa 
 
 
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 S F 
 
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 > 
 
544 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 oped endothelia. The round cells which compose the principal mass 
 of the new tissue are distinguished by their large nuclei containing an 
 abundant supply of chromatin. A superficial examination reveals the 
 picture of an inflammatory process. A careful examination, however, 
 shows that the cells are arranged in rows along the course of blood- 
 vessels, which peculiar arrangement constitutes one of the most reliable 
 diagnostic evidences of the character and variety of the tumor. If 
 these rows of cells are examined more carefully, it becomes evident 
 that they are the product of connective-tissue proliferation. Very 
 frequently short rows of four or five quadrangular cells are met with, 
 densely packed, which are joined on the sides by triangular cells. 
 The cells in such circumstances lose their round shape from mutual 
 pressure. Round cells differ from spindle-cells in that the cell-seg- 
 mentation by indirect division more speedily extends from the nucleus 
 to the cell-proliferation. Mitotic figures are never present. Between 
 the round cells are found leucocytes, which are recognized by their 
 small and intensely stained nuclei. 
 
 Spindle-celled Sarcoma. — This is the " fibro-plastic tumor " of Lebert, 
 the "fasciculated sarcoma" of Cornil and Ranvier, the "recurrent 
 fibroid " of Paget. The subdivision into small and large spindle-celled 
 sarcoma is superfluous ; the difference is simply one regarding the size 
 of the cells, the structure of the tumors representing these varieties 
 being the same. Spindle-celled sarcomata are the commonest of this 
 group of tumors, and are found most frequently in dense fibrous tissues, 
 
 Fig. 375. — Small spindle-celled sarcoma ; X 300 (after D. J. Hamilton): a, the spindles exposed entire; b, 
 
 the same cut across. 
 
 such as the skin, the periosteum, and the sheaths of muscles. The inter- 
 cellular substance is very variable : in some cases the tumor is com- 
 posed almost exclusively of cells ; in others the stroma is so copious 
 as to justify the name fibrosarcoma or fasciculated sarcoma — terms 
 which are frequently used in the designation of hard sarcomatous 
 
SARCOMA. 
 
 545 
 
 tumors. The cells are frequently arranged in fascicles which surround 
 the blood-vessels. The spindle shape of the cells can be shown best 
 in separating the cells from hardened specimens by teasing. In sec- 
 
 Fig. 376. — Large spindle -celled sarcoma ; X 400 (after D. J. Hamilton) : a, ordinary spindle; b, branched flat 
 
 cell; c, flat endothelium-like cell. 
 
 tions the shape of the cells will depend on the direction of the section. 
 Cells that are cut transversely appear as round or oblong nucleated 
 
 Fig. 377.— Oat-seed-like spindle-celled sarcoma ; X 300 (after D. J. Hamilton). 
 
 cells ; if the section is made oblique, the cells appear ovoid, and the 
 spindle shape is preserved only if the cut falls parallel with the cells (Fig. 
 375). The spindles interlace in bundles at somewhat obtuse angles. 
 35 
 
546 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The large spindle-cell is three or four times larger than the small cells, 
 and some of the cells frequently show a number of terminal prolonga- 
 tions (Fig. 376). 
 
 Another variety of sarcoma-cell, differing from spindle-celled sar- 
 coma only in that the terminations of the spindles are more obtuse, has 
 been described by D. J. Hamilton under the name of " oat-seed-like 
 spindle-celled sarcoma " (Fig. 377). The reticulum is composed of 
 connective-tissue fibrils and the fibrillated prolongations of the spindles. 
 The spindle-cells possess the maximum power of fibrillation. In sec- 
 tions in which the cells have been brushed out the reticular spaces are 
 not empty, as in carcinoma, but contain a network of the finest fibrils. 
 The large spindle-celled sarcoma is usually softer than tumors com- 
 posed of small spindle-cells. Spindle-celled sarcoma grows less 
 rapidly than tumors composed of other histological varieties of cells. 
 The degree of malignancy is determined by the abundance of the 
 stroma. If the connective-tissue stroma is well developed, the tumor 
 is hard and grows slowly ; if the stroma is scanty, the tumor is corre- 
 spondingly soft and more malignant. 
 
 Giant-celled Sarcouta. — This tumor consists of various forms of cells, 
 of which the large, many-nucleated cell, resembling the myeloplaques 
 or osteoclasts in the bone, is the prototype. Giant-celled sarcoma 
 arises pre-eminently from bone (Fig. 378), but similar tumors are also 
 
 Fig 
 
 Giant-celled sarcoma from upper jaw ; X 230 (after Perls). 
 
 found in other tissues. In bone, giant-cells, the " myeloplaques " of 
 Robin, are found in a normal condition. According to Kolliker, these 
 cells act the part of osteoclasts, or bone-destroyers. In connection 
 with bone giant-celled sarcomata occur as tumors which are clinically 
 very different from one another. The periosteal form is most frequently 
 found in the alveolar sockets of the teeth (epulis), where the tumors 
 
SARCOMA. 547 
 
 manifest the lowest degree of malignancy. The myelogenous form is 
 productive of early metastasis — an occurrence which often takes place 
 before the primary tumor is detected. The so-called " malignant epulis " 
 is composed mostly of spindle-cells (and between them, here and there, 
 a giant-cell with multiple nuclei in the centre of the cells) and round- 
 cells (Fig. 379). If such a tumor is carefully examined, it will be seen 
 
 $*1 
 
 '?■>■■ ' • y 
 
 Fig. 379. — Sarcomatous epulis; X 480 (Surgical Clinic, Rush Medical College, Chicago) : a, small round cells ; 
 b, spindle-cells ; c, c, giant-cells ; d, d, blood-vessels. 
 
 that the giant-cells are derived from the bone ; hence it is easily under- 
 stood that a local recurrence can be prevented only by removing with 
 the diseased gingiva the superficial portion of the bone where the 
 tumor is attached. Another diagnostic sign may be mentioned, the 
 brownish color of the tumor-tissue — an appearance which charac- 
 terizes all giant-celled sarcomata. The greater danger which attaches 
 to the central or myelogenous form consists in the greater vascularity 
 of the tumors, as within them the vessels undergo an astonishing 
 degree of development and dilatation. The arteries are frequently so 
 numerous and so large, and their walls are so thin, that the pulsations 
 are imparted to the tumor-tissue. Other tumors of the same kind have 
 undergone angiomatous degeneration to such an extent that the}' are 
 
548 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 often mistaken for blood-cysts, and their true nature can often be ascer- 
 tained only by the aid of the microscope. The great vascularity of 
 these tumors makes a diagnosis between aneuiysm of bone and sar- 
 coma difficult. Distinguished surgeons have ligated large arteries on 
 the proximal side on the supposition that the pulsating tumor was 
 an aneurysm, when the subsequent clinical history revealed the sar- 
 comatous nature of the tumor. 
 
 During the earliest stage of the tumor no swelling of the bone can 
 be detected, the pain is slight, and tenderness is frequently wanting. 
 If the bone is opened at this stage, its interior presents the appearances 
 of a hemorrhagic focus. The blood in some parts is fluid, in others 
 coagulated. More important from a diagnostic standpoint is the absorp- 
 tion of bone, if such has already taken place. If considerable of the 
 bone has been removed by absorption, or if perforation has already 
 taken place, the diagnosis no longer remains doubtful. The earliest 
 stages of the development of myeloid sarcoma consist of dilatation of 
 the medullary vessels in the immediate vicinity of the tumor-matrix, 
 followed by active cell-proliferation. Sections of the tumor show a 
 variety of color : some parts of the cut surface are dark red, brownish, 
 or yellow ; others are of a pearly whiteness. The brownish-red spots 
 which appear isolated and scattered through the substance of the tumor 
 are most characteristic. Some tumors contain cysts with clear con- 
 tents. The white parts of the tumor are frequently dotted with small 
 pigmented points. All these different parts of the tumor correspond 
 with definite histological changes. In the red patches the blood-vessels 
 have undergone the greatest degree of dilatation. In the brown spots 
 the cells are pigmented with the coloring material of the blood. In 
 the white portions of the tumor the blood-vessels are scanty and the 
 tumor-tissue is composed largely of spindle-cells. 
 
 The nuclei of giant-cells, like those in other forms of sarcoma, have 
 a granular structure. They are surrounded by a nuclear membrane, 
 and they contain often large nucleoli of a homogeneous structure; 
 others can be considered as compound or giant-nuclei. 
 
 From a histological point of view two kinds of giant-cells are found 
 in sarcoma. In one kind the cells appear as aggregations of nuclei, in 
 the interior of which a well-defined nuclear space may be seen occupied 
 by nucleoli which lie free in the space or are imbedded in a somewhat 
 clearer granular ground-substance ; in the other form proliferating 
 nuclei are found within the nuclear membrane. The giant-cells cannot 
 be considered as a further development of the normal giant-cells, as 
 they are found in localities where the latter are absent. In a case of 
 primary sarcoma of the epistropheus and secondary aneurysm of the 
 
SARCOMA. 549 
 
 vertebral artery, quoted elsewhere in detail, Klebs was able to trace 
 the origin of giant-cells to osteoblasts in the decalcified bone 
 specimen. 
 
 Van Henkelem claims that sarcoma-cells cannot produce mature 
 tissue, and that in this respect they differ from ordinary embryonal 
 connective-tissue cells. This function, however, is not entirely wanting, 
 but is greatly diminished. In epulis this tissue-transformation is seen 
 to a certain extent, as most of the sarcoma-cells are converted into 
 tissue of a higher physiological type, and in periosteal sarcoma new 
 bone is frequently found as one of the constituents of the tumor. The 
 giant-cells are endowed with fibrillating power, in this respect being 
 closely allied to the fibroplastic cells ; this function explains the more 
 benignant character of giant-celled as compared with round-celled sar- 
 coma. Arnold found in tumors giant-cells surrounded by small 
 spindle-cells. 
 
 Destruction of giant-cells by fibrillation may be seen in the oldest 
 portions of tumors. In giant-celled sarcoma there may always be 
 found spindle-cells in greater or lesser abundance. 
 
 Mixed-cell Sarcoma. — In mixed-cell sarcoma none of the cells which 
 have been described are found as the exclusive tumor-elements. Pure 
 round-celled and spindle-celled sarcomata are not infrequent. In the 
 remaining sarcomatous tumors there is a mingling of spindle-cells, 
 round cells, and giant-cells in varying proportions. Such a tumor is 
 shown in Figure 379. 
 
 Mixed-cell sarcoma is found most frequently in myeloid and peri- 
 osteal sarcomata. The degree of malignancy of such tumors depends 
 on the preponderance of non-fibrillating tumor-elements. In the most 
 benign forms the fibrillating cells are present in abundance, the tumor 
 is hard and of slow growth, while the reverse histological structure 
 results in opposite conditions which determine greater malignancy. 
 
 Melano-sarcoma. — Pigmented sarcomata, which form a distinct and 
 separate group of tumors, surpass any other histological form of 
 sarcoma in malignancy. These tumors are characterized by early 
 regional and general dissemination. The primary tumor is always 
 found in tissues which, in a normal state, contain pigment ; hence the 
 tumors occur most frequently in the skin and the eye. Melano-sarco- 
 mata are particularly prone to develop in pigmented warts and moles. 
 If the primary tumor occurs in tissues in which, in a normal condition, 
 pigment material is absent, we must assume the presence of pigmented 
 cells deposited in the tissues by errors of development — that is, the 
 existence of a matrix of pigmented cells. The pigment is not derived 
 from the coloring material of the blood, as was formerly supposed, as 
 
550 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Nenski has shown the presence in the pigment material of sulphur, 
 which is a constituent of some of the mesoblastic tissues. It is possible 
 that iron may take a part in the pigmentation, but this supposition is 
 improbable. Dressier found iron in the coloring material melanin. 
 Rindfleisch was quite positive that the melanin is derived from the 
 hematin of the red blood-corpuscles. Kolaczek, who made a careful 
 study of eight cases of melanotic tumors with a view of ascertaining 
 the source of melanin, maintains that it is not produced by metabolic 
 activity of cells, but is derived from the coloring material of the blood. 
 Gussenbauer claimed that thrombosis is the cause of pigmentation in 
 tumors, but this position is no longer tenable. Virchow was the first 
 to show that the pigmented cells are first stained diffusely a yellow 
 color, and that the pigment-granules form later. Eiselt found that the 
 
 
 irT 
 
 ^3 
 
 
 x 
 
 '" # 
 
 i 
 
 
 
 *■ 
 
 m 
 
 I W- 
 
 4 * 
 
 
 %: 
 
 - rM 
 
 Fig. 380.— Cells from melano-sarcoma of skin ; X 720 (after Karg and Schmorl). The protoplasm of the 
 large tumor-cells is filled with fine granules of pigment material, so that the cells appear as though they were 
 covered with a thin film of coal-dust. 
 
 pigment material which is eliminated through the urine in persons 
 suffering from melano-sarcoma is identical with the coloring material 
 of the blood. 
 
 In Oppenheimer's case, studied by Nenski, the epithelial cells in the 
 kidneys and alveoli of the lungs were stained yellow. The pigmented 
 cells receive their material from the tissue-juices. A few years ago 
 Lanz injected an emulsion of fragments of melanotic tumors of the 
 skin, brain, liver, and spleen of a man into the spleen of a guinea-pig. 
 The health of the animal was not at once affected, but it died six 
 weeks later with an accumulation of pigment in almost every part of 
 its body, so that Lanz felt assured there was a new formation of pig- 
 
SARCOMA. 
 
 Plate 15. 
 
 Melano-sarcoma of the skin, showing irregular distribution of pigment material with tumor- tissue : a, pigmented 
 part of tissue; b, tumor-tissue without pigment (Surgical Clinic, Rush Medical College, Chicago). 
 
SARCOMA. 55 1 
 
 ment. The presence of pigmented cells of normal or abnormal origin 
 is essential for the occurrence of melano-sarcoma. The tumor-growth 
 takes place by proliferation of pigmented cells. Pigmentation of the 
 tumor-cells follows the course of blood-vessels, but is irregularly dis- 
 tributed through the tumor-tissue (Fig. 380). 
 
 The unequal distribution of the pigment is particularly well marked 
 in the metastatic tumors. The pigmented cells are the carriers of the 
 coloring material. The cut surface of melanotic tumors presents often 
 almost a black appearance, and shows certain parts of the tumor more 
 deeply stained than others. The metastatic tumors closely resemble 
 the primary tumor so far as the pigmentation is concerned. Pigmented 
 sarcoma-cells do not fibrillate, which fact explains the great malignancy 
 of melanotic sarcoma. The fibroplastic part of such tumors is always 
 composed of spindle-cells which are not pigmented. 
 
 Alveolar Sarcoma. — In alveolar sarcoma, as has been stated pre- 
 viously, the reticulum of the tumor is composed of a meshwork of 
 
 l 1 —*T' 
 
 m 
 
 - I - 
 
 
 C 
 Fig. 381.— Alveolar sarcoma of skin ; X 85 (Surgical Clinic, Rush Medical College, Chicago): a, alve- 
 olated connective-tissue stroma; b, group of round sarcoma-cells somewhat shrunken from hardening ; c, a 
 space, surrounded by connective-tissue recticulum, from which the cell-contents have been lost during prepa- 
 ration of specimen. 
 
 delicate fibres of connective tissue, in the spaces of which are found 
 
55 2 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 groups of round sarcoma-cells not arranged in compact concentric 
 layers as in carcinoma (Fig. 381). 
 
 Alveolar sarcoma grows very rapidly, and the tumor-tissue is sub- 
 ject to early degenerative changes. The blood-vessels follow the 
 connective-tissue stroma, but do not traverse the alveoli, the cell- 
 contents of which, owing to an inadequate blood-supply, undergo early 
 regressive metamorphosis. This form of tumor, which in some cases 
 at least is determined by the new formation and the peculiar arrange- 
 ment of the blood-vessels, is found most frequently in the skin, the 
 lymphatic glands, the bones, and the pia mater. 
 
 Angiosarcoma. — Kolaczek described this variety of sarcoma, known 
 also as siphonoma, cylindroma, etc. These tumors are usually of a more 
 or less tuberous structure ; their consistence varies from a jelly-like 
 
 ■ / 
 
 Fig. 382. — Angiosarcoma of the orbit; X 75 (Surgical Clinic, Rush Medical College, Chicago) : a, con- 
 nective-tissue capsule or stroma; b,b, cells lining the spaces; c, c, c, lumina of dilated new capillary vessel; 
 d, a tear in the specimen caused by handling 
 
 mass to the density of cartilage. On section the surface presents an 
 alveolar structure, but seldom regular, to which, in addition to great vas- 
 cularity, occasionally blood-cysts and hemorrhages impart a variegated 
 appearance. Under the microscope angio-sarcomata present usually 
 a reticulated, seldom an alveolar, structure (Fig. 382). The cells are 
 
SARCOMA. 553 
 
 arranged in the form of strands corresponding with the blood-vessels 
 located in their centre ; if the vessels do not contain blood, the tumor 
 simulates carcinoma. The cells, which are epithelioid in shape and are 
 normally multinuclear, often show prolongations, and their margins are 
 not so sharply defined from the ground-substance as in carcinoma. 
 
 The ground-substance is composed of all possible forms of con- 
 nective tissue — homogeneous, granular, myxomatous, cellular, and 
 fibrillary. The vessels are numerous, large, and always capillary, and 
 the intercellular tissue is scanty, imparting to the structure an angioma- 
 tous appearance. In many forms the cells are closely grouped around 
 the vessels, as if they were developed in their wall and had closed 
 sheaths around them. The masses of cells thus formed, with a blood- 
 vessel for a centre, may be packed closely together in long strings with 
 more or less frequent anastomoses, or they may be arranged in rounded 
 groups, giving the tumor an alveolar appearance. Sometimes the walls 
 of the blood-vessels and the adjacent tissues, in these as in other forms 
 of tumors, undergo hyaline degeneration, giving to the whole or to 
 parts of the tumor a more or less gelatinous appearance. 
 
 v h 
 
 Fig. 383.— Endotheliomatous sarcoma of the pleura; X 35° (Surgical Clinic, Rush Medical College. Chi 
 cago): a, round cells; l\b, oblong cells; c. delicate reticulum. 
 
 Angio-sarcomata are quite rare, and are most frequently found 
 
554 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 about the head. In 46 out of 60 cases this part of the body was affected. 
 In the only case which came under the writer's observation the tumor 
 involved the skin over the frontal bone, at a point near the hairy scalp. 
 Ackermann saw a case of angio-sarcoma of the corpora cavernosa of 
 the penis. The growth of the tumor is slow. Recurrence after excis- 
 ion is rapid. Only in five cases did the tumor give rise to metastasis. 
 
 Endotheliomatous Sarcoma. — It is very probable that in angio- 
 sarcoma the angioblasts take an active part in the production of the 
 tumor, in which event this tumor should be classified with the sar- 
 comata of endothelial origin. Malignant tumors which spring from 
 matrices of embryonal endothelial cells are sarcomata. The structure 
 and vascularization of endotheliomatous sarcoma (Fig. 383), as seen in 
 primary malignant tumors of the serous membranes, are almost identical 
 with sarcoma of connective-tissue origin. The cells are round, oval, 
 and sometimes cylindrical or cuboidal, the latter modifications in shape 
 occurring in consequence of pressure. The connective-tissue stroma 
 is more abundant than in round-celled sarcoma, and is packed more 
 densely in the stroma-spaces. 
 
 R. Volkmann, on the basis of 54 cases of endothelioma, believes that 
 these tumors are of mesoblastic origin, and that although they resemble 
 in many respects sarcoma they should be classified separately. 
 
 Endotheliomatous sarcoma not infrequently contains cholesterin- 
 crystals. The tumor, which may be nodular and of considerable size, 
 or multiple, is found most frequently in the pleura, the peritoneum, the 
 pia mater, the ovary, the testicle, the lymphatic glands, and the brain. 
 Nepvue describes an endothelial sarcoma of the pleura in a child 
 seven years of age, the tumor simulating pyothorax. The tumor was 
 the size of an adult's head, and displaced the lung. Exploratory punc- 
 ture made the diagnosis of a solid tumor possible, and no operation 
 was undertaken. 
 
 Glioma. — Sarcoma of the connective tissue of the central nervous 
 system, the neuroglia, is called " glioma." It is the most frequent of all 
 
 brain-tumors. The tumor is composed 
 of small round or oval cells in a mesh- 
 work of exceedingly delicate fibrillar 
 (Fig. 384). In some cases the tumor- 
 cells are spider-like (Fig. 385). The 
 quantitative relation of cells to the fibril- 
 lated reticulum varies greatly, and, as 
 fig. 384—GiioiTia of the corpora quadrigem- Mj ura pointed out, the cells may be 
 
 ina; X 250 (after Perls). r ' J 
 
 more abundant at the margin of the 
 tumor. In exceptional cases the cells assume a spindle shape. 
 
SARCOMA. 
 
 555 
 
 Owing to the delicate structure of the reticulum and its great vas- 
 cularity, glioma is a soft tumor, and when centrally located in the brain 
 is globular in shape. Gliomata sometimes have a well-defined border, 
 but more frequently it is impossible to determine where the tumor 
 ends and the healthy tissue begins. They are found most frequently 
 in the posterior segment of the lateral ventricles, but they may occur in 
 any part of the brain and spinal cord, and not infrequently they attain 
 
 Fig. 3 8 5 .-Gliomatous tumor of the brain, from a boy; X 35<> (after D. J. Hamilton): a, blood-vessels-, 
 b, spider-cell with double nucleus ; c, small round cell. 
 
 the size of a fist or a child's head before death ensues. The tumor is 
 grayish-white in color, with reddish-pink lines indicating the location 
 of the blood-vessels. Klebs and Bertheau insist that the nerve-cells 
 
556 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 take part in the production of the tumor, as they found nerve-cells as 
 one of its component parts. This opinion is not generally endorsed. 
 
 The growth of a glioma is slow, and in other ways it pursues a 
 more benign course than the connective-tissue or the myeloid sarcoma. 
 Metastasis in the pia mater of the brain and the spinal cord was 
 observed in one case by Lemcke. The liability to hemorrhage con- 
 stitutes one of the immediate sources of danger. Gliomata have also 
 
 Fig. 386. — Microscopical appearance of a typical psammoma. 
 
 been found in the spinal cord by different observers, and in the acoustic 
 nerve by Virchow. Glioma of the retina is an affection of childhood. 
 In the cases reported the ages of the children varied from two to four 
 years. The tumors often extend along the optic nerve and form large 
 retrobulbar tumors. Recurrence after enucleation of the eyeball is 
 frequent. From the orbit the tumor frequently extends to the cranial 
 cavity, either along the optic" nerve or through the orbital fissure. As 
 a heterotopic tumor glioma has been found in exceptional cases in the 
 kidney, the ovary, and the testicle. Knapp reported the first case in 
 which the tumor gave rise to metastasis. Similar cases have since been 
 reported by Schiess-Gemuseus, Hofmann, Rusconi, Bizzozero, Dresch- 
 feld, Nellessen, and Heymann and Fiedler. 
 
 Helfreich reported a case of congenital glioma of both retinae. 
 Eisenlohr believes that glioma of the retina develops from nests of 
 mesoblastic cells from the vitreous body that fail to undergo complete 
 development, and from which the tumor subsequently takes its origin. 
 
 Psammoma. — Psammoma is an endothelial growth of the envelopes 
 of the brain that was first described by Virchow as a separate tumor. 
 Although this tumor lacks the clinical features of sarcoma, Virchow 
 
SARCOMA. 
 
 557 
 
 included it with the sarcomata. Sutton refers it to an epithelial matrix 
 in the villous processes of the choroid plexus ; but as it is found more fre- 
 quently in localities where there are normally no epithelial cells, it is 
 advisable to include it among the connective-tissue type of tumors. 
 The tumor is composed of onion-like cell-masses separated by a stroma 
 of connective tissue. These concentric bodies consist of endothelium- 
 like cell-nests arranged around blood-vessels, which in the course of 
 time become infiltrated with calcareous salts. The relation of the 
 tumor-tissue to blood-vessels is well shown in Figure 387. 
 
 Fig. 387.— Psammoma from choroid plexus ; X 300 (after D. J. Hamilton) : a, branching vessels with the 
 cell-nest-like bodies upon them ; b, cell-nests calcined. 
 
 It was first believed that the dura mater was the favorite seat of 
 psammoma, but more extended observations have shown that it occurs 
 most frequently in the choroid plexus and in the ventricles of the 
 brain. Progressive growth of the tumor is arrested by fatty degen- 
 eration of the tumor-cells and by calcification. The tumors, which 
 usually vary in size from a pea to that of a walnut, are often sym- 
 metrical, occupying in the brain the same location on both sides. 
 In the lateral ventricles a tumor of fair size may not give rise to 
 any symptoms ; in other cases it has caused cerebral disturbances 
 of different kinds, and focal symptoms which pointed to the loca- 
 tion of the tumor. If the tumor does not undergo calcification, its 
 growth is progressive, and it eventually destroys the life of the 
 patient. 
 
 Psammoma of the spinal membranes is very rare. The clinical his- 
 tory of all such cases has been one of slow progressive paralysis and 
 death. 
 
558 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Regressive Metamorphoses. — The absence of a well-developed 
 reticulum, the great proliferating activity of the cells, and the atypical 
 vascularization of sarcoma render the tumor liable to early and exten- 
 sive degenerative changes. Fatty degeneration is common, but calci- 
 fication is only observed in psammoma. The granular detritus in fatty 
 degeneration is either absorbed or, by the addition of serum, remains 
 as a turbid fluid which occupies spaces surrounded by tumor-tissue, 
 forming cysts without a proper cyst-wall. 
 
 The imperfect development of the walls of blood-vessels is the 
 cause of frequent hemorrhages into the substance of the tumor, where 
 the blood either coagulates, is absorbed, or remains in a fluid state. 
 
 h 
 
 Fig. 388. — Myxomatous degeneration in sarcoma ; X 75 (Surgical Clinic, Rush Medical College, Chicago) : 
 a, connective-tissue stroma; b, b, sarcoma-cells ; c, c, c, myxomatous tissue. 
 
 The staining of the tissues of the tumor in the vicinity of ruptured 
 capillaries is one of the characteristic features of most of the sarcoma- 
 tous growths. The liability to hemorrhage is increased by the exten- 
 sion of fatty degeneration to the capillary walls. ' If the hemorrhage is 
 copious, the tumor-tissue is compressed by the extravasated blood, and 
 a blood-cyst forms, which frequently adds to the difficulty in diagnosis. 
 
SARCOMA. 559 
 
 The sudden increase in the size and tension of the tumor should lead 
 to the suspicion that a free hemorrhage has taken place into the sub- 
 stance of the tumor." In subcutaneous sarcomata this accident is often 
 announced a day or two later by discoloration of the skin. Hyaline 
 degeneration is not as frequently observed in sarcoma as in carcinoma. 
 Myxomatous degeneration is of frequent occurrence in sarcoma. 
 The myxomatous degeneration, as seen in Figure 388, begins at dif- 
 ferent points at the same time, usually in the oldest parts of the tumor, 
 when, by confluence of the spaces, a large territory of myxomatous 
 tissue is formed. Both stroma and cells undergo this change, but the 
 blood-vessels remain intact for a long time (Fig. 389). In myxo-sar- 
 
 \\ ? ' 7$ ^ '-" ft. v^fcfe^ , 
 
 '- " ^ e:,, -'*&.> 
 
 &f*&mM^'-; -M^ 
 
 ■& 
 
 mwKz-miz 
 
 :f^, :.,/7.v.°-^^7 ; :77. ; :«' V'7J8#^^ 
 
 
 s*^ 
 
 Fig. 389.— Myxomatous cavity in the centre of a sarcomatous tumor; X 40 (after D. J. Hamilton): 
 a, substance of the tumor as yet unaffected with the degeneration ; b, the clear myxomatous part ; c, a vein ; 
 d, an artery in the midst of the mucoid. 
 
 coma the cells become macerated in the sero-mucin — several delicate 
 processes which form a network in the meshes of which the myxoma- 
 tous material is deposited— and the tissues assume the appearance of 
 what was formerly called " net-cell sarcoma." With the myxomatous 
 degeneration the tumor becomes softer, and a sense of fluctuation is felt 
 on palpation if the degeneration has become extensive. 
 
 Caseation has been observed in sarcoma as another form of regres- 
 sive metamorphosis. It begins in different parts of the tumor at the 
 same time, and by the coalescence of different foci large cavities filled 
 with cheesy material are formed. It is questionable if such a regres- 
 
5 6 ° 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 sive metamorphosis is possible without infection of the tumor with 
 tubercle bacilli. The structure of the vessels in the tumor is such that 
 localization of floating microbes easily occurs, and it is more than prob- 
 
 Fig. 390. — Portion of the edge of the myxomatous space shown in Figure 400; X 450 (after D. J.Hamil- 
 ton): a, the edge of the tumor; b, the branching cells lying in the clear mucoid. 
 
 able that future investigations will show that caseation in sarcoma 
 follows in consequence of infection with tubercle bacilli. 
 
 Ulceration and sloughing take place as soon as the tumor, by 
 invasion and pressure, reaches a free surface. The sloughing is often 
 very extensive, attended by a foul-smelling discharge caused by infec- 
 tion with putrefactive microbes. Sloughing of the skin relieves the 
 tension, and the tumor-tissue projects beyond the surface defect in the 
 form of fungous masses, furnishing a good representation of what was 
 called by the old authors the fungus hcematodes. Infection of the 
 tumor may occur without ulceration by localization of floating pus- 
 microbes in the defective capillary vessels by mural implantation. 
 With the occurrence of this complication the symptoms of an acute 
 phlegmonous inflammation are superadded to the symptoms caused by 
 the tumor. When extensive sloughing is the result of such an acute 
 inflammation, although the inflammatory process may destroy appar- 
 ently the entire tumor, a spontaneous cure is never effected in this way. 
 
 The transformation of sarcoma-tissue into tissue of a higher physio- 
 logical type is observed most frequently in connection with sarcoma- 
 tous epulis and periosteal sarcoma, and in rare instances in glandular 
 sarcoma. In periosteal sarcoma new bone is almost constantly pro- 
 duced. Frequently, if not always, the new bone is produced through 
 
SARCOMA. 561 
 
 the medium of cartilage-cells, as cartilage-cells and bone-cells are often 
 found side by side in the same specimen (Fig. 391). In some cases the 
 process of development is arrested with the formation of cartilage. 
 Especially is this the case in glandular sarcoma (Fig. 392). 
 
 Durham observed two cases of ossifying sarcoma. One of the 
 patients was a man seventy-three years of age, who, when a boy twelve 
 years of age, sustained a severe burn in the iliac region, extending 
 to the median line. The tumor originated in the scar, and contained, 
 besides the usual sarcoma-cells, cartilage-cells and well-developed bone. 
 
 d^t 
 
 V ^^k-^^M$- 
 
 Fig. 391.— Ossifying periosteal sarcoma of the humerus; X 75 (Surgical Clinic, Rush Medical College, 
 Chicago): a, connective-tissue stroma ; b, round sarcoma-cells ; c, cartilage-cell ; d, d, d, bone-cells. 
 
 The other case was a sarcoma of the breast in a woman twenty-seven 
 years old. Ossification of a sarcoma tends to retard tumor-growth, 
 and it must be regarded as an indication that the tumor will pursue 
 a chronic course. 
 
 Local and General Infection.— The growth of a sarcoma takes 
 place exclusively by proliferation of the cells composing the embry- 
 onal matrix. The type of the cells is determined by the location and 
 the stage of arrest of development of the cells of the matrix. A 
 matrix representing lymphoid tissue will produce, as a rule, round cells 
 
 36 
 
562 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and giant-cells, while a connective-tissue matrix produces more fre- 
 quently spindle-cells. If the cells of a connective-tissue matrix are 
 arrested at an early stage in their development, the probability is strong 
 that the tumor produced from the matrix will be a round-celled 
 
 m 
 
 JW 
 
 
 
 Fig. 392. — Myxo-chondro-sarcoma of parotid ; X 38 (after Karg and Schmorl). The upper half of 
 the picture consists of the subcutaneous tissue, in which hair-follicles and sweat-glands may be seen. From 
 this tissue the tumor can be distinguished sharply by its peculiar structure. In the ground-substance, which 
 is composed partly of connective tissue (a), partly of myxomatous tissue (&), and partly of cartilage (c), are 
 imbedded strings of cells (d). These are made up of small endothelial cells. 
 
 sarcoma. The rapidity of the growth of the tumor is largely influenced 
 by the stroma. An abundant stroma retards tumor-growth, whereas a 
 tumor composed almost exclusively of cells will grow rapidly. The 
 stroma acts like a filter : the denser it is, the greater will be the diffi- 
 culties met with by the cells in leaving the primary tumor and reaching 
 the surrounding tissues. 
 
 A great deal has been written concerning the capsule of a sarcoma. 
 To the naked eye many sarcomata appear to be encapsulated. Micro- 
 scopical examination of the capsule and of the tissues immediately outside 
 
SARCOMA. 
 
 563 
 
 of it shows that what appears to be a capsule is the connective tissue 
 around the periphery of the tumor, which tissue has become condensed by 
 pressure, but which holds in its meshes young sarcoma-cells, which are 
 also found in a zone of lesser or greater width in the adjacent tissues. 
 The enucleation of a sarcoma is invariably followed by a speedy local 
 recurrence — the best possible proof that the capsule does not i?idicate the 
 limits of the tumor, and is in reality a pathological delusion. 
 
 The growth of a sarcoma is rapid in proportion to the activity of 
 cell-migration. The young sarcoma-cells leave the primary or mother- 
 tumor and migrate into the surrounding connective-tissue spaces, estab- 
 lishing wherever they become located independent centres of tumor- 
 growth. The pre-existing connective tissue serves the purpose of a 
 temporary framework or stroma, which is later removed and replaced 
 
 i :> 
 
 r <'<// 
 
 Fig. 393.— Small round sarcoma-cells infiltrating muscular fibre at some distance from the tumor ; X 450 
 
 (after D. J. Hamilton). 
 
 by the product of fibrillation of the sarcoma-cells. Sarcoma displaces 
 tissue to a greater extent than carcinoma, but it eventually invades and 
 destroys adjacent tissues regardless of their anatomical structure. The 
 tumor grows in the direction offering the least resistance, in this respect 
 resembling benign tumors, but no tissue, no matter how dense it may 
 
564 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 be, offers an impermeable barrier to its local extension. Of all the tis- 
 sues, cartilage offers the greatest resistance to progressive local exten- 
 sion of sarcoma. In sarcoma of the epiphyseal region of the long 
 bones the articular cartilage is often found completely detached, show- 
 ing but slight traces of the destructive action of the tumor ; but ulti- 
 mately even this structure gives way and the joint becomes involved. 
 In sarcoma of the intermuscular connective tissue the muscle-fibres are 
 destroyed some distance from the tumor by cell-infiltration (Fig. 393). 
 
 Sokolow made some very interesting investigations concerning the 
 behavior of muscle-fibres in sarcomatous tumors. He came to the 
 conclusion that the muscle -fibres take no active part in the growth of 
 sarcoma, but are removed by the infiltrating cells. 
 
 While the central part of a sarcoma is undergoing regressive meta- 
 morphoses the peripheral growth adds to the size of the tumor. It is 
 in the periphery that the most active tissue-changes are observed. If 
 the tumor is located in parts that offer equal resistance to the extension 
 of the tumor, it always assumes a globular shape. Surface sarcomata 
 are flat tumors. The tumor also becomes flattened beneath firm fascise. 
 If the tumor perforates a dense structure at a point corresponding with 
 the centre of a tumor, the tumor grows with great rapidity on the sur- 
 face upon which the perforation opens. It is in this manner that a 
 sarcoma of the dura mater, after perforation of the cranium, assumes 
 the shape of a sleeve-button, the contracted portion corresponding with 
 the perforation in the bone, and the flattened masses with the primary 
 tumor of the dura and its external pericranial portion. 
 
 Regional extension of a sarcoma takes place along the sheaths of 
 blood-vessels and nerves, seldom through the lymphatics except in cases 
 of lympho-sarcoma. As lymphatics have been demonstrated in sarcoma, 
 it is somewhat singular that regional infection so seldom takes place 
 through the lymphatic vessels. That local and regional extension takes 
 place by migration of sarcoma-cells is well shown in cases of central 
 sarcoma of bone. In these cases minute sarcomatous tumors are often 
 found in the medullary tissue at a distance from the primary tumor, 
 with perfectly healthy tissue between them. We can only assume that 
 cells have wandered away from the mother-tumor into the myeloid 
 tissue, and that the young daughter-tumors are the product of tissue- 
 proliferation of these cells, which have reproduced the tumor in the 
 same tissue in the neighborhood of the primary tumor. Barth ascer- 
 tained that in local recurrence of spindle-celled sarcoma the disease 
 is rendered much more malignant by an increase of the round cells 
 and a decrease of the spindle-cells. 
 
 Metastasis. — General dissemination in sarcoma takes place much 
 
SARCOMA. 
 
 565 
 
 more frequently and at an earlier stage than in carcinoma. In this 
 regard sarcoma is much more malignant than carcinoma. Small 
 round-celled sarcoma gives rise to metastasis much more frequently 
 than do spindle-celled and giant-celled sarcoma. The smaller the cells, 
 the greater the liability to early and extensive general dissemination. 
 The intimate relations which exist between the blood-vessels and the 
 tumor-tissue in sarcoma serve to explain the frequency of metastasis. 
 Isolated cells can permeate the vessel-wall, and are then carried with 
 the blood-current to distant parts or organs, where, after the cells have 
 
 Fig. 394-— Metastasis of a round-celled sarcoma in the liver; X 40 (after Karg and Schmorl). Both 
 tumor-nodules are composed of round cells, and can be distinguished clearly from the adjacent liver-tissue. 
 In the vicinity of the sarcomatous nodules the liver-cells are flattened. Several capillary vessels in the 
 vicinity of the tumors are blocked by tumor-cells. 
 
 become implanted upon a vessel-wall, there are produced secondary or 
 metastatic tumors which resemble the primary tumor in every respect. 
 In round-celled sarcoma the metastatic tumor is composed of round 
 cells; in spindle-celled sarcoma the metastatic tumor is composed of 
 spindle-cells ; and in melano-sarcoma the metastatic tumor is composed 
 of pigmented cells. In the very rare cases of myosarcoma the meta- 
 static tumors contain muscular fibres which answer in their structure to 
 
566 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the fibres of the primary tumor. Brodowsky recorded a case of myo- 
 sarcoma of the stomach with metastases, and found in the secondary 
 metastatic tumors small unstriped muscular fibres. Birch-Hirschfeld 
 examined a case of myosarcoma of the uterus which contained, besides 
 flat muscular fibres, many small muscular fibres and cells which appeared 
 to be a transition into spindle-cells. The metastatic tumors which were 
 found in the liver and the bronchial glands showed a similar structure 
 (Fig. 394). 
 
 Very frequently the tumor grows into the lumen of the vessel, 
 which then becomes closed by a sarcomatous thrombus from which 
 fragments may become detached ; these fragments may form emboli 
 and become arrested in the distal branches of the pulmonary artery, 
 where new centres of tumor-growth are established. 
 
 Melano-sarcoma has the reputation of giving rise frequently to early 
 and diffuse metastasis. The whole surface of the body is at times 
 studded with innumerable pigmented nodules, and many of the internal 
 organs may be affected similarly. Mr. Holden reports the case of a 
 boy ten years old upon whom two operations were performed for 
 sarcoma of the parotid. After the second operation both testicles 
 became sarcomatous almost simultaneously. At the post-mortem very 
 diffuse metastasis was found involving the subcutaneous and internal 
 lymphatic glands. 
 
 The extent to which various organs become implicated in some 
 cases of general dissemination of sarcoma is well illustrated by a case 
 minutely reported by Forster. The patient was a man thirty-seven 
 years of age. The primary tumor was a small round-celled sarcoma 
 of the thigh. A year later the post-mortem showed metastatic tumors 
 in the right and left submaxillary regions, the scalp, the axillae, the skin 
 covering the breast, the thyroid gland, the pleurae, the large bronchi, 
 the pericardium, the peritoneum, the mesenteiy, the omentum, the pan- 
 creas, the duodenum, the ascending colon, the stomach, the dura mater, 
 and the pituitary body. In the brain there were six nodules. Strange 
 as it may appear, the liver and the spleen were free. 
 
 Etiology. — An hereditary predisposition to sarcoma must be recog- 
 nized. In a few instances sarcoma occurred as a congenital tumor. 
 Although no age is exempt, sarcoma is. met with most frequently in 
 children and in young adults. Sarcoma of bone is rare in the aged. 
 Glandular sarcoma is more frequent during old age. At the age of 
 puberty the genital organs are more frequently the seat of sarcoma 
 than at any other period of life. That sarcoma not infrequently starts 
 in chronic inflammatory products is well known. Chronic irritation is 
 often an exciting cause. The inflammatory tissue produced under 
 
SARCOMA. 5 6 7 
 
 such circumstances undoubtedly furnishes frequently the essential 
 tumor-matrix. Sarcoma occurs at times in scar-tissue in which there 
 are buried unspecialized connective-tissue cells which only await the 
 influence of conditions, local or general, which will enable them to 
 assume active tissue-proliferation. The subcutaneous and the deep 
 connective tissues are frequently the starting-points of sarcoma. The 
 serous membranes are more commonly affected than the submucous 
 connective tissue. The lymphatic glands, the periosteum, and the 
 marrow of bone are favorite localities for the development of the 
 primary tumor. Of the glandular organs, the thyroid, the testicle, the 
 ovary, and the mammary gland are most frequently affected. Sar- 
 coma of the central nervous system and its envelopes is of common 
 occurrence. 
 
 The influence of trauma is more pronounced in the etiology of 
 sarcoma than in that of carcinoma. Not infrequently a bruise or a 
 contusion acts as the exciting cause. The development of a sarcoma 
 at the seat of a fracture has repeatedly been observed. The writer has 
 referred to such a case that came under his observation. Mr. Griffith 
 records a very similar case. The patient was a man twenty-one years 
 of age who sustained a fracture of the femur at the junction of the 
 middle and lower thirds. The usual treatment by rest and fixation 
 of the fragments was carried out for five weeks, when the limb was 
 immobilized in a plaster-of-Paris bandage. Ten weeks after the acci- 
 dent a swelling was observed where the bone had been fractured. The 
 patient refused an amputation at this time. Five months after the acci- 
 dent the thigh was enormously enlarged, the skin was tightly stretched, 
 the superficial veins were coursing in the form of dark broad bands, 
 and the whole surface was intersected with silvery streaks. The patient 
 died less than eight months after the injury. The post-mortem revealed 
 that the shaft of the femur had disappeared, except two small pieces 
 of detached bone about an inch in length, forming the anterior wall 
 at the lower end, and a piece about four inches long and one inch 
 in width at the upper end. The articular cartilages were intact. 
 The tumor was a spindle-celled sarcoma that weighed twenty-five 
 pounds. 
 
 The influence of trauma in the production of sarcoma should be 
 remembered in the examination of remote swellings appearing at the 
 site of an injury. The immature callus in fractures, failing to undergo 
 transformation into tissue of a higher physiological type, in rare cases 
 becomes the sarcoma-matrix. In injuries of the soft tissues there may 
 be produced a similar matrix, which becomes the starting-point for the 
 sarcoma. The influence of trauma and of chronic irritation in the pro- 
 
568 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 duction of sarcoma is shown most conclusively in connection with the 
 origin of sarcoma in warts and pigmented moles. A wart which is the 
 seat of chronic irritation not infrequently becomes the starting-point of 
 a sarcoma. The subepithelial connective tissue in a state of chronic 
 inflammation reverts to its embryonal condition and furnishes the essen- 
 tial tumor-matrix (Fig. 395). A pigmented mole may remain harmless 
 
 Fig. 395. — Sarcoma which originated in a wart of the scalp (after Liicke) : a, granulating ulcer of the surface; 
 b, sarcoma-tissue ; c, level of the skin ; d, cutis. 
 
 throughout a lifetime, but when it is exposed to chronic irritation or 
 becomes the seat of an injury it is exceedingly prone to undergo trans- 
 formation into a melano-sarcoma. 
 
 Symptoms and Diagnosis. — The diagnosis of sarcoma must be 
 based upon a careful study of the clinical history of the case and a 
 minute examination, which, if need be, should be supplemented by 
 exploratory puncture and by microscopical examination of sections of 
 fragments of tissue removed with the harpoon-trocar. A failure to 
 elicit from the patient and his friends a clear clinical history has led to 
 many serious mistakes in diagnosis and treatment. The most import- 
 ant points to be brought out in the clinical history are the length of 
 time the tumor has existed and its primary anatomical starting-point. 
 The statements made by patients are often vague and unreliable. For 
 instance, a tumor may have existed for several months, when from the 
 patient's statements it often appears that it has developed suddenly; or 
 the tumor is often discovered accidentally after it has existed for some 
 time and has attained considerable size. This fact should be borne in 
 mind, as otherwise the tumor might be mistaken for an infective 
 swelling. 
 
 As inflammation always affects vascular connective tissue, and thus 
 shares with sarcoma the same anatomical location, an accurate know- 
 ledge of the primary anatomical starting-point of a sarcoma is of special 
 value in the differential diagnosis between sarcoma and carcinoma and 
 benign mesoblastic tumors. Let us take, for the purpose of illustration, 
 a malignant tumor involving the bones of the cranial vault. In differ- 
 entiating between a sarcoma and a carcinoma it is important to ascer- 
 
SARCOMA. 569 
 
 tain from the patient whether the growth began in the skin as an 
 ulcer, or whether the tumor made its appearance first under the 
 intact skin, as it is plain that in the former instance the tumor would 
 be a carcinoma with secondary implication of the bone, whereas in the 
 latter case there could be no further doubt of the sarcomatous nature 
 of the tumor. It would be immaterial, so far as the nature of the 
 tumor is concerned, whether it originated in the dura mater, the bone, 
 the periosteum, or the subcutaneous connective tissue. The subcu- 
 taneous origin of the tumor would exclude the possibility of its being 
 a carcinoma, unless the tumor developed from a displaced tumor- 
 matrix composed of epithelial cells — a very rare occurrence indeed in 
 this locality. In the differential diagnosis it is exceedingly important to 
 ascertain whether the tumor originated in epiblastic, hypoblastic, or meso- 
 blastic tissues. With few exceptions malignant tumors originating in 
 mesoblastic tissues are sarcomata, whereas all malignant tumors of 
 epiblastic or hypoblastic origin are carcinomata. In the examination of 
 ulcerating malignant tumors the surgeon is often unable to make 
 this distinction, and must rely upon the patient's statement regarding 
 the early history of the tumor. With veiy rare exceptions primary 
 malignant tumors of the lymphatic glands, the bone, and the connec- 
 tive tissue are sarcomatous. In malignant tumors of the glands it is, 
 of course, impossible to decide whether the tumor started in the paren- 
 chyma or in the connective tissue — in other words, whether it had an 
 epithelial or a connective-tissue matrix. In such cases we must rely 
 upon the shape of the tumor and its relations to the adjacent tissue in 
 distinguishing between a sarcoma and a carcinoma. 
 
 As a rule, sarcoma grows more rapidly than carcinoma. There are, 
 however, exceptions to this rule. Malignant epulis and psammoma 
 grow slowly, and in the latter tumor limitation of growth is often 
 brought about by fatty degeneration and calcification. Billroth relates 
 a case of sarcoma in the occipital region in which, during twenty years, 
 fifty operations were performed. 
 
 Sarcoma is usually not attended by much pain unless a nerve is 
 involved directly or by pressure. In a case of neuro-sarcoma of the 
 median nerve reported by Volkmann the pain was severe in the region 
 of the distribution of the nerve. Muscular atrophy was also a marked 
 feature. Even in central sarcoma of bone the pain is usually not 
 severe. 
 
 A sarcomatous tumor is usually globular, oblong, flat, or spindle- 
 shaped, according to the location of the tumor and the anatomical 
 arrangement of the tissues in which it is located. Its surface is 
 smooth ; its consistency is variable. In the soft tissues the tumor 
 
57° PATHOLOGY AND TREATMENT OF TUMORS. 
 
 is movable, in this respect differing greatly from carcinoma, in which 
 fixation of the tumor is present almost from the beginning of the 
 growth. Sarcoma attains greater size before ulceration occurs. The 
 principal reason for this difference in the clinical behavior of sarcoma 
 and carcinoma undoubtedly is to be found in the fact that sarcoma is 
 always covered by intact skin or mucous membrane, while carci- 
 noma begins as a surface affection. In large sarcomata the superficial 
 veins are always enlarged. In soft tumors a sense of fluctuation is 
 imparted to the palpating fingers. The margins of the tumor are more 
 defined in sarcoma than in carcinoma. In carcinoma of the breast the 
 tumor can be moved without moving the surrounding gland-tissue. 
 In myelogenous sarcoma pulsations and bruit are often present. True 
 aneurysm of bone is very rare. Klebs has never seen such a case. 
 The differential diagnosis between an infective swelling and a sarcoma 
 can often be made only by resorting to an exploratory puncture. If 
 the diagnosis between a gumma and a sarcoma is not clear, the patient 
 should be given the benefit of the doubt and should be placed on a 
 vigorous antisyphilitic treatment for several weeks. 
 
 Billroth was the first to point out that regional glandular infection 
 is very rare in sarcoma, while it is the rule in carcinoma. The regional 
 infection is in the direction of intermuscular septa and along the sheaths 
 of blood-vessels and nerves. Metastasis occurs earlier and more fre- 
 quently in sarcoma than in carcinoma. The general health is usually 
 little impaired until ulceration or general dissemination takes place. 
 
 In sarcoma of the serous surfaces the primary tumor gives rise 
 to multiple growths by cells becoming detached, displaced, and im- 
 planted at different points. In sarcoma of the internal organs the 
 presence of the tumor is usually not suspected until symptoms are 
 produced from pressure. Mr. Barclay reports a case of sarcoma of 
 the anterior mediastinum in which the only subjective symptom was 
 dyspnea. The sternum was slightly elevated, and the tumor extended 
 above it into the tissues of the neck. 
 
 It has been ascertained by Ebstein, Pel, Renvers, Erb, Volkers, and 
 Kast that the temperature rises in irregular curves in sarcoma of the 
 internal organs. Priestly recently reported a case of sarcoma of the 
 liver in which this phenomenon was regularly observed. In a case 
 of sarcoma of the pancreas, mentioned to the writer by Drs. Vande- 
 venter and Northrop of Marquette, Michigan, the evening rise in the 
 temperature was so constant and persistent that the case was diagnosed 
 as typhoid fever by a most competent practitioner. The thermometer 
 should be employed as a diagnostic resource in cases of suspected 
 sarcoma of internal organs. 
 
SARCOMA. 571 
 
 Pathological fracture is frequently caused by myelogenous sarcoma 
 and by metastatic carcinoma. In melano-sarcoma the color of the 
 tumor and its origin in pigmented tissue render the diagnosis suf- 
 ficiently positive. In glioma and psammoma of the central nervous 
 system a probable diagnosis can often be made from the focal symp- 
 toms that are sometimes, but not always, present. 
 
 Prognosis. — The most malignant forms of sarcoma are soft and 
 small-celled, and they are attended by rapid regional extension and 
 early generalization. The degree of malignancy is determined by the 
 rapidity of growth. In some cases the growth is so rapid that clin- 
 ically the sarcoma resembles more closely an inflammatory process 
 than a tumor. In one of Billroth's cases the tumor grew so rapidly 
 that a diagnosis of furuncle was made. The patient died of pulmonary 
 sarcoma in less than three months. 
 
 Mistakes in diagnosis are oftenest made in the most malignant forms 
 of sarcoma. Slow growth indicates a more benign tendency of the 
 tumor. Sometimes the primary tumor grows slowly, the secondary 
 tumors very rapidly. Sarcoma leads to a fatal termination sooner than 
 carcinoma. Melano-sarcoma is the most malignant of all tumors and 
 the least amenable to successful treatment by operation. Local recur- 
 rence after operation is more frequent and takes place sooner in sar- 
 coma than in carcinoma. Billroth maintained that a local recurrence 
 may take place twenty years after the removal of the tumor. The 
 same author was of the opinion that in may cases the recurrence after 
 a thorough operation was due to inoculation of the margins of the 
 wound with sarcoma-cells deposited there by the knife used in the 
 operation. 
 
 Giant-celled and spindle-celled sarcomata offer the most favorable 
 prognosis. The prognosis is, of course, greatly modified by the loca- 
 tion of the tumor, the physiological importance of the adjacent tissues 
 or organs, the degree of accessibility of the tumor, and the presence 
 or absence of metastasis, but, on the whole, it is much graver in sarcoma 
 than in carcinoma. The most favorable cases for successful operative 
 treatment are sarcomatous epulis and myeloid sarcoma of bone. 
 
 Treatment. — If we have found it necessary to urge the necessity of 
 early and thorough removal of carcinoma, this advice applies with 
 double force to the necessity of early and thorough operations in the 
 treatment of sarcoma. Sarcoma gives rise to local, regional, and 
 general infection at an earlier stage than carcinoma ; hence the disease 
 passes sooner beyond the limits of a successful operation. In sarcoma 
 the lymphatic glands do not stand guard between the primary tumor 
 and the general circulation as in carcinoma, and metastasis follows 
 
57 2 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 more frequently by the direct route through the blood-vessels of the 
 tumor. Not infrequently a sarcomatous thrombus which does not quite 
 block the blood-vessel forms in one of the vessels of the tumor and 
 extends far beyond the limits of a radical operation. Billroth relates 
 an instance in which such a thrombus formed in the spermatic vein in 
 connection with a sarcoma of the testicle. The thrombus by proximal 
 growth finally reached the right side of the heart, where it became 
 attached to the septum between the ventricles, and the septum was 
 finally perforated by the tumor. It is not difficult to conceive that the 
 existence of such an intravascular extension of the tumor would pre- 
 clude all possibility of a successful operation. Operative treatment 
 slwnld be resorted to before regional and general dissemination of the 
 tumor has taken place. 
 
 The employment of efficient caustics in the treatment of incipient 
 surface carcinomata is sometimes excusable, but in the treatment of 
 sarcoma caustics should invariably be avoided. As soon as a diagnosis 
 can be made the tumor should be removed by excision or by amputa- 
 tion. A radical operation by excision offers the only reasonable pros- 
 pect of success. Local recurrences should be dealt with in the same 
 manner as soon as their existence is discovered. 
 
 In the excision of a sarcoma a zone of apparently healthy tissue at 
 least an inch in width should be removed with the tumor, if this can 
 be done without coming in conflict with tissues and organs that do not 
 admit of such a radical procedure. The skin overlying a sarcoma 
 should invariably be removed with the tumor. In sarcoma of glands 
 and of the uterus the whole organ must be removed. The incisions 
 should be made in the direction of the large vessels of the part affected, 
 not only for the purpose of exposing the vessels well with a view of 
 guarding against unintentional injury, but also with the object of 
 removing as much as possible of the connective tissue between the 
 tumor and the vessels. In the radical operation for carcinoma the 
 surgeon has in view the removal of the lymphatics in the region of the 
 tumor; in operations for sarcoma he seeks to remove not only the 
 proximal lymphatics — a possible route for regional infection — but he 
 aims to remove as much as possible of the connective tissue in the 
 region of the tumor, through which tissue local and regional infection 
 takes place. In extensive sarcoma of the extremities amputation at 
 some distance from the tumor is indicated in the majority of cases; 
 Avhether the tumor has started in soft parts or in bone is immaterial. 
 
 Fascial sarcoma of the limbs so often involves important vessels and 
 nerves that amputation is the only alternative. Resection in the con- 
 tinuity of a long bone is applicable in the case of the radius, the ulna, 
 
SARCOMA. 573 
 
 and the fibula if the disease has not extended beyond the periosteum. 
 Removal of central myeloid tumors by scraping has in a few cases 
 recently been practised with success, but the cases are few for which 
 this procedure is adapted, and it is always attended by great risks of 
 a speedy recurrence, which, after it has manifested itself, calls for an 
 amputation without delay. Operations for glioma of the brain have 
 yielded a number of brilliant immediate results, but with few exceptions 
 the operations were followed, as would be expected, by an early local 
 recurrence. Sarcoma of large nerve-trunks usually requires amputa- 
 tion, as excision of an extensive section of a nerve would be followed 
 by permanent paralysis and an early local recurrence. Operative 
 treatment is contraindicated in the presence of metastasis and if the 
 tumor cannot be removed completely, either on account of its size, its 
 insufficient accessibility, or its implication of structures the removal of 
 which with the tumor is not feasible or justifiable. 
 
 The administration of drugs has very generally been abandoned, 
 as ample experience has demonstrated that we are not in possession 
 of any remedy that exerts a curative effect upon sarcoma. Arsenic, 
 so strongly advised by Billroth and others, has yielded negative results. 
 It was urged that Fowler's solution should be given in gradually 
 increasing doses both by the mouth and by parenchymatous injections 
 until symptoms of intoxication are produced, when the use of the drug 
 should not be suspended, but the doses should be diminished. The 
 writer has resorted to this treatment in a number of instances, but has 
 never witnessed even a retarding effect. 
 
 The beneficial effects of an intercurrent attack of erysipelas in cases 
 of sarcoma have been noticed by different surgeons for a long time. 
 Bush was the first to intentionally inoculate with erysipelas patients 
 suffering from sarcoma, but his expectations were not realized. After 
 the discovery of the streptococcus of erysipelas by Fehleisen numerous 
 inoculations with pure cultures of this microbe were made in cases of 
 inoperable carcinoma and sarcoma. A few cases appear to have been 
 cured permanently ; some were benefited, others were not improved, 
 and in some death was caused by the erysipelas. These inoculations 
 have been deprived of the risk to life by using sterile cultures of the 
 streptococcus erysipelatis in place of active cultures. Coley and Bull 
 report a series of cases in which this method of treatment appears to 
 have been followed by encouraging results. It seems that the toxines 
 of the micrococcus prodigiosus increase the curative effect of the tox- 
 ines of the microbe of erysipelas. The treatment of inoperable cases 
 of sarcoma by this method should be encouraged and persistently 
 carried out. The directions for this treatment are laid down in the 
 
574 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 section on the Treatment of Tumors. The writer has recently treated 
 six cases of inoperable sarcoma with the combined sterilized cultures 
 without any appreciable effect. It would be advisable to treat cases of 
 sarcoma by this method after all operations, with the expectation that 
 the treatment would prove useful in preventing a local recurrence. 
 
 The palliative treatment of inoperable cases of sarcoma is the same 
 as in carcinoma. 
 
 Topography. 
 Skin. — With the exception of the pigmented variety, sarcoma of 
 the skin is rare. It occurs most frequently in scars, or by the trans- 
 formation of the connective tissue of a wart or the stroma of a papil- 
 loma or a fibroma into a sarcoma. Independently of such pre-existing 
 
 *". **r <s» 
 
 9 "Ifc 
 
 Fig. 396.— Large round-celled sarcoma of skin ; X 250 (after Karg and Schmorl). The tumor is composed 
 of large round cells, which in some places, by crowding together, have been somewhat flattened. Most of 
 the cells contain one nucleus ; some of them are multinuclear. The intercellular granular substance is scanty, 
 and can be seen only in certain parts of the field. 
 
 pathological conditions, its starting-point is in the subcutaneous con- 
 nective tissue. That sarcoma is often caused by chronic irritation there 
 is no doubt. In a case of sarcoma over the scapula the writer found 
 that the location of the tumor corresponded exactly with a point where 
 the suspender had produced the greatest amount of pressure and fric- 
 tion. Sarcoma may be composed either of round cells or of spindle- 
 
SARCOMA. 575 
 
 cells, or these two kinds of cells may be present in varying proportions 
 in the same tumor (Figs. 396, 397). 
 
 The most frequent form of sarcoma of the skin is the melano-sar- 
 coma. This tumor originates either in a pigmented nevus, a wart, or 
 the bed of a finger-nail. In either locality the tumor is so near the 
 surface of the skin that ulceration is an early occurrence (Fig. 398). 
 A melano-sarcoma seldom attains great size, because, as a rule, the 
 tumor at an early stage reaches the surface of the skin and ulcerates. 
 
 Much of the pigment produced in melanotic tumors is eliminated 
 through the urine. It not infrequently happens that the secondary 
 
 A 
 
 
 
 yg* v 
 
 Fig. 397.— Small spindle-celled sarcoma of the skin; X 250 (after Karg and Schmorl). The tumor con- 
 sists of numerous bundles of spindle-cells, which have been cut longitudinally in the centre of the field, 
 transversely in the periphery. A kw cells contain fine granules of pigment, which appear in the picture as 
 minute black dots. 
 
 lymphatic tumors grow very rapidly, while the primary tumor grows 
 slowly or remains stationary. In melano-sarcoma regional infection is 
 followed soon by general dissemination, although there are exceptions 
 to this rule. Melano-sarcoma occurring in the matrix or the neighbor- 
 hood of the nail presents itself at first as a black nodule which ulcer- 
 ates early, and local, regional, and general dissemination follows rapidly. 
 The great toe is most frequently thus affected. In a case which came 
 under the writer's notice the matrix of the nail of the right index finger 
 was the starting-point of the tumor. The patient, a tailor thirty-five 
 
576 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 years of age, attributed the tumor to the prick of a needle. In this 
 case the whole chain of glands from the primary tumor to the apex 
 of the axilla became infected in less than three months, and death 
 resulted from general dissemination within a year from the time the 
 tumor was discovered. The case was treated repeatedly with caustics, 
 which greatly aggravated the local conditions and hastened the fatal 
 termination. 
 
 Melano-sarcoma of the skin is characterized by the pigmentation 
 
 - 
 
 
 Fig. 398 — Melano-sarcoma of the skin; X 9 (after Karg and Schmorl) : vertical section through a 
 melano-sarcoma of the skin of the arm. The tumor (a), which projects mushroom-like beyond the level of 
 the surrounding skin (6) and penetrates into the underlying cutis (c), is composed of dense streaks of large 
 round cells, which, with the magnification used here, cannot be seen. On the surface the tumor is ulcerated 
 and covered with crusts which appear as dark homogeneous masses ; at the margins the tumor is covered by 
 epithelium (d) which has proliferated irregularly ; at the border of the tumor, under the cutis, masses of pig- 
 ment material are deposited (e). 
 
 of the primary and secondaiy tumors and by the rapidity with which 
 local, regional, and general dissemination occurs. 
 
 The only proper treatment for melano-sarcoma of the skin is early 
 excision of the primary tumor. If the tumor starts in the neighbor- 
 hood of a finger-nail or a toe-nail, amputation is preferable to excis- 
 ion. In sarcoma of the skin occurring in other parts of the body, 
 whether pigmented or not, the incisions should be made at least an 
 inch distant from the visible and palpable margins of the tumor. It 
 is very doubtful whether anything can be gained from an operation 
 after extensive regional infection has occurred. Such cases should be 
 treated by sterilized cultures of the streptococcus of erysipelas admin- 
 istered subcutaneously. 
 
 Submucous Connective Tissue. — As a primary tumor of the sub- 
 
SARCOMA. 577 
 
 mucous connective tissue sarcoma is an exceedingly rare tumor. The 
 
 Fig. 399. — Melanotic sarcoma. 
 
 tumor in this locality does not become pedunculated : it remains ses- 
 
 Fig. 400. — Sarcoma of the skin of the back. 
 
 sile 4 and ulceration sets in early and progresses with the growth of the 
 37 
 
578 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumor. The oedema of the tumor-tissue that is almost a constant con- 
 dition in submucous sarcoma imparts to the tumor under the micro- 
 
 Fig. 401. — Fascial sarcoma of axillary space involving scapula, requiring amputation of the entire upper 
 
 extremity. 
 
 scope a myxomatous appearance at an early stage and hastens the 
 actual myxomatous degeneration. Sarcomata of the uterus and of the 
 intestinal canal usually begin as submucous tumors. 
 
 Fascial Sarcoma. — Fascial sarcoma may appear anywhere in the 
 deep connective tissue ; it occurs most frequently, however, between 
 the planes of large muscles, presenting itself as a smooth, globular, 
 painless tumor which displaces and infiltrates the adjacent tissues. 
 Unless bound down by resisting structures, the tumor is quite movable, 
 and when it is soft pseudo-fluctuation is present. The tumor is com- 
 posed of spindle-cells or of round cells, or these two kinds of cells may 
 
SARCOMA. 
 
 Plate 16. 
 
 i. Sarcoma of breast. 2. Enormous fascial sarcoma between scapula 
 
SARCOMA. 579 
 
 occur in the same tumor. In some of the soft tumors the round cells 
 are unusually large and multinuclear. The tumor, which develops 
 within a few weeks after a contusion, follows the intermuscular septa 
 and the sheaths of vessels and nerves ; it differs from a myxoma and 
 a lipoma by its rapid growth, and from inflammatory swellings by the 
 absence of pain and tenderness. In large tumors central necrosis occa- 
 sionally takes place. Hemorrhages into the substance of the tumor 
 and myxomatous degeneration are of frequent occurrence. Regional 
 infection takes place along connective-tissue routes, seldom through the 
 deep lymphatics. 
 
 Sarcoma is met with most frequently in the deep connective tissue 
 of the neck, the thigh, the leg, the arm, the abdomen, and the scapular 
 region. During the college session of 1894 the writer removed from 
 the interscapular region such a tumor, the circumference of which 
 equalled that of a large soup-plate. Portions of the scapular muscles 
 were removed with the tumor on both sides. The enormous wound was 
 greatly diminished in size by the use of tension-sutures. About a week 
 after the operation the patient contracted erysipelas, which commenced 
 at the borders of the wound and spread over the entire surface of the 
 chest, abdomen, neck, and upper extremities. The entire wound healed 
 by granulation in two months, leaving a circular pale scar the size of the 
 palm of the hand. No recurrence had taken place six months after the 
 operation. 
 
 In fascial sarcoma of the trunk and neck the tumor should be 
 removed as early as possible by a thorough excision, including with 
 the tumor a wide zone of apparently healthy tissue. In fascial sar- 
 coma of the limbs involving the principal vessels and nerves, ampu- 
 tation is indicated, and the operation should be performed at a safe 
 distance from the tumor. If the tumor is located some distance from 
 important structures and is limited in extent, excision may be tried. 
 It has been the experience of the writer that such tumors deeply 
 located return almost without exception after excision ; this cannot be 
 said of sarcoma of the superficial fascia. In the deep sarcomata the 
 adjacent muscular fibres become infiltrated at an early stage, and the 
 disease creeps along the connective-tissue spaces far beyond the pro- 
 posed line of incision long before the operation is performed. 
 
 Fascial sarcoma in children is an exceedingly malignant tumor. In 
 the winter of 1893-94 the writer had under his care, at the clinic of 
 Rush Medical College, a girl eight years of age, who was otherwise 
 in good health. Within two months a tumor the size of a child's fist 
 had formed among the deep muscles of the calf of the leg, about three 
 inches below the knee-joint. There was no pulsation ; neither pain nor 
 
580 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tenderness existed. The skin over the tumor was normal. An explor- 
 atory puncture yielded blood. A diagnosis of fascial sarcoma was 
 made, and the limb was amputated by the Gritti-Stoke supracondyloid 
 operation. Primary healing of the wound took place. Two months 
 after the operation a soft tumor appeared among the deep muscles over 
 the posterior aspect of the stump, and unconnected with the scar. As 
 soon as the parents' consent could be obtained amputation through the 
 hip-joint was made; from this operation the little patient recovered 
 without any untoward symptoms. 
 
 From his own experience the writer has come to regard amputation 
 as preferable to excision in cases of deep fascial sarcoma of the limbs. 
 It is possible that with the aid of sterilized injections of the microbe 
 of erysipelas we will be able more frequently to dispense with muti- 
 lating operations. 
 
 Lymphatic Glands. — Primary sarcoma of the lymphatic glands, 
 lympho-sarcoma, is a comparatively rare affection. The primary tumor 
 
 Fig. 402.— Lympho-sarcoma; X 2 7° (after Karg and Schmorl). The cells of which the tumor is com- 
 posed show the character of lymphoid corpuscles. Besides these small round cells there are seen larger cells 
 with pale nuclei. 
 
 infects adjacent glands of the same region. The tumors, as a rule, 
 present to the palpating finger a sense of elastic resistance. They are 
 smooth and movable before the tumor perforates the capsule of the 
 gland. The pre-existing glandular tissue takes no part in the growth 
 of the tumor, and is gradually displaced by the tumor-tissue. The 
 cells of which the tumor is composed are small round cells which are 
 imbedded in an exceedingly delicate reticulum, the meshes of which 
 frequently are occupied by a single cell (Fig. 402). The regional 
 
SARCOMA. 5 81 
 
 infection is usually followed sooner or later by general infection, which 
 in these cases is more frequently the result of migration of sarcoma- 
 cells in the lymph-stream than of direct infection through a vessel- 
 wall. The metastatic tumors present the same lymphoid appearance 
 as the primary tumor. As soon as the capsule of the tumor is per- 
 forated by the tumor, the sarcoma involves the surrounding connective 
 tissue ; and when the disease in neighboring glands has reached the 
 same stage, the glandular tumors are incorporated with the perigland- 
 ular tumor-tissue in one mass, in which the separate glands can no 
 longer be identified. At this stage the common tumor-mass frequently 
 implicates the overlying skin, when ulceration and sloughing take place. 
 Before dissemination and ulceration occur the health of the patient 
 is but little impaired. When the glands occupy the region of the 
 neck or the mediastinum, the tumors may cause great suffering and 
 death from pressure. 
 
 The characteristic features of lympho-sarcoma are the successive 
 enlargement of the glands of the region occupied by the primary 
 tumor, followed by metastasis without leucocythemia. In leukemia 
 other blood-producing organs become successively affected, and the 
 blood under the microscope shows the characteristic textural changes. 
 In pseudo-leukemia the glands in different parts of the body become 
 enlarged. In tuberculosis the glands never attain such large size as in 
 lympho-sarcoma without the occurrence of extensive regressive meta- 
 morphoses. In primary syphilis the enlargement of the glands can be 
 traced to the proper source of infection ; and in secondary and tertiary 
 syphilis the glandular hyperplasia is universal and the swellings seldom 
 exceed an almond in size. 
 
 The prognosis in glandular sarcoma is very grave, as recurrence 
 after extirpation is the rule. An operation holds out encouragement 
 if it be performed before the capsules of the affected glands have become 
 perforated. As the deep glands are more frequently affected by sarcoma 
 than the superficial glands, the operation is often very difficult on 
 account of the close proximity to the tumors of important vessels and 
 nerves. Sarcomatous glands should never be enucleated. Even if the 
 capsides of the glands are not perforated, young sarcoma-cells have passed 
 through them into the periglandular connective-tissue spaces. The opera- 
 tive treatment of lympho-sarcoma consists in a clean and thorough excision 
 of the glands with the surrounding connective tissue. 
 
 An operation is justifiable only if there is reasonable hope, from the 
 number and location of the glands, that all diseased tissue can be 
 removed. Incomplete operations increase the malignancy of the tumor 
 and hasten the fatal termination. The only exception to this rule arises 
 
582 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 when the glandular masses threaten life from compression of an import- 
 ant organ, when the largest glands may be removed to meet urgent 
 symptoms. In attempting to remove sarcomatous glands by a radical 
 operation the region affected should be exposed freely by a large incis- 
 ion in a direction parallel with the chain of glands. If necessary, the 
 overlying skin is included in two elliptical incisions. No blunt instru- 
 ments should be used, and no attempt should be made to remove the 
 glands by enucleation. The whole chain of glands, with the connecting 
 lymphatic channels and the connective tissue surrounding the glands, 
 should be removed by a clean dissection with scalpel and dissecting 
 forceps. In the region of the neck, when the deep glands are the seat 
 of sarcoma, it is often necessary to include also in the part to be 
 removed several inches of the internal jugular vein, and sometimes it is 
 necessary to include also the carotid artery and the pneumogastric 
 nerve. Any or all of these structures should be saved if possible, but 
 when they are implicated in the tumor they must be sacrificed fear- 
 lessly. The vessels are to be resected between two ligatures. Resec- 
 tion of the pneumogastric nerve has been performed by Kocher, Kap- 
 peler, the writer, and other surgeons without any immediate disastrous 
 results ; the operation is invariably followed, however, by permanent 
 paralysis of the vocal cords on the affected side. Healing of the 
 wound by primary intention should be aimed at in all operations for 
 sarcoma, as healing by granulation cannot but favor a local recur- 
 rence. 
 
 Bones. — Sarcoma of bone is met with clinically more frequently 
 than sarcoma of any other organ or tissue. 
 
 Muller assigned the name " osteoid tumor " or " ossifying fungus 
 growth " to what we now recognize as sarcoma. Stanley called the 
 same kind of tumor of bone " malignant osseous tumor." Muller was 
 inclined to classify it with carcinoma. Similar tumors are occasionally 
 met with independently of bone. Pott described such a tumor which 
 lay " loose between the sartorius and vastus internus muscles." In the 
 museum of St. Thomas's Hospital, London, there is a tumor like an 
 osteoid carcinoma that was removed from near a humerus, and another 
 from a popliteal space. In all these cases the removal of the tumor 
 was followed by the growth of an ordinary sarcoma devoid of osteoid 
 material. 
 
 The osseous part of the tumor is always attached to the bone from 
 which the growth had its origin. The microscopic characters of the 
 ossified part are those of true bone, but rarely of well-formed bone. 
 
 Among 19 cases collected by Paget, 5 of the patients were between 
 ten and twenty years old, 9 between twenty and thirty, 4 between thirty 
 
SARCOMA. 5 8 3 
 
 and forty, and I between forty and fifty. In more than one-half the 
 cases the immediate cause of the tumor was attributed to an injury. 
 
 Although no age is exempt, sarcoma of bone occurs more fre- 
 quently in children and young adults. The active physiological changes 
 which take place during the development of the skeleton constitute 
 a potent exciting cause. Sarcoma is found most frequently in that 
 part of the bone where the circulation is most active — that is, in the 
 epiphyseal extremities of the long bones and in the inner layer of the 
 periosteum, the cambium. The most malignant form is the periosteal, 
 and the most benign form is sarcomatous epulis. 
 
 Histological Varieties. — Giant-celled or Myeloid Sarcoma. — A sar- 
 coma should be called " myeloid " or " giant-celled " if the tumor 
 
 
 Fig. 403. — Giant-celled sarcoma of upper jaw; X 250 (after Karg and Schmorl). Between the densely 
 packed spindle-cells and round cells of the tumor are numerous multinuclear giant-cells variously shaped. 
 The nuclei, which contain distinct nucleoli, are distributed equally through the protoplasm of the cells, in 
 contrast to the giant-cells in tubercular products, in which the nuclei occupy the peripheral zone of the cells. 
 
 is composed in at least one-half of giant-cells. Many sarcomata 
 contain giant-cells, but when these cells do not predominate the 
 tumor is designated according to the cell-elements which form the 
 greater bulk. A pure giant-celled sarcoma does not exist : we find 
 at the same time between the giant-cells round cells, spindle-cells, or 
 both (Fig. 403). The intercellular substance is scanty, amorphous, 
 or in the shape of fibrillar The prototypes in normal tissue of the 
 
5§4 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 giant-cells are the myeloplaques in the marrow of bone. Giant-celled 
 sarcoma is rare in children and in the aged, and is found most fre- 
 quently in the lower jaw, the femur, and the tibia. The tumor, which is 
 not encapsulated, but is circumscribed, is of slow growth, of a red or 
 brownish color, and is not prone to ossify or degenerate. 
 
 Cysts are produced by hemorrhage or by degenerative changes in 
 tumors of large size. The vascular supply of these tumors is so great 
 that pulsation and bruit are frequently present (Fig. 404). 
 
 Fig. 404. — Myeloid cystic giant-celled sarcoma of the lower epiphysis of the femur, from a girl twenty-two 
 years old ; longitudinal section, one-half natural size (after Ziesing). The lower end of the tumor is round 
 and is covered by the articular cartilage (d) ; e, patella. The dark streak (a) indicates thickness and direc- 
 tion of the secondary shell of bone, which can be traced a certain distance along the outer and inner surfaces 
 of the shaft of the bone (a'). The cyst-walls were smooth; some of the cysts contained serum, others extrav- 
 asated blood (_/"). 
 
 The bone-producing function of myeloid sarcoma is always limited, 
 and in many cases is entirely wanting — a circumstance which frequently 
 results in pathological fracture. 
 
 Round-celled Sarcoma. — In this variety of sarcoma the round cells 
 compose the entire tumor or the bulk of the tumor, the balance being 
 represented by spindle-cells and a few giant-cells. Round-celled is 
 more malignant than giant-celled sarcoma, more especially if the repre- 
 
SARCOMA. 
 
 Plate 17. 
 
 Osteosarcoma of the head of the tibia ; X 200 : a, remnants of epiphyseal cartilage ; b, giant-cells of 
 tumor; c, giant-cells of tumor assuming osteoclastic function; d, vessels; e, tumor-stroma ; f, large area of 
 absorbed cartilage with infiltrating tumor-cells. 
 
 Osteo-sarcoma of the head of the tibia 
 infiltrating the area of absorbent cartilage ; < 
 Medical College, Chicago.) 
 
 >< 500 : a, remnant of epiphyseal cartilage 
 giant-cells with osteoclastic function. ^Suv 
 
 b, sai 
 
 cal CI 
 
 :oma-cells 
 
SARCOMA. 5 8 5 
 
 sentative cells are small and when the tumor is located near the trunk. 
 The long bones are most frequently affected, especially their epiphyseal 
 extremities. The tumors are found oftenest in the upper end of the 
 humerus, the lower end of the radius, the lower end of the femur, and 
 the upper end of the tibia. The flat bones are also frequently affected. 
 The round sarcoma-cells possess no fibrillating power; the tumor is 
 therefore soft, is not encapsulated, and grows more rapidly than giant- 
 celled sarcoma. 
 
 In both giant-celled and round-celled sarcoma the tumors, instead 
 of producing new bone, destroy the pre-existing bone-tissue, thus in 
 the case of the long bones leading to weakening of the shaft, so that 
 often upon the slightest application of force, as turning in bed, a path- 
 ological fracture is produced. If the tumor is located centrally, the 
 resistance being equal on all sides, a spindle-shaped enlargement of 
 the bone is produced, the centre of the spindle corresponding with the 
 primary location of the tumor. This enlargement is not caused by 
 tumor-tissue of the bone, but by the expansion of the compact layer 
 of the bone and the periosteum under the greatly increased intra-osse- 
 ous tension. The compact layer is weakened by the destruction of 
 pre-existing bone-tissue from within outward by the tumor. The 
 sarcoma-cells act in the capacity of osteoblasts. New bone is produced 
 by the periosteum when this is reached by the tumor (Fig. 404, a). 
 If the tumor is not centrally located, or if it starts in the compact 
 layer of bone, the tumor occupies one side of the bone, and will 
 grow in the direction offering the least resistance — that is, away from 
 the bone. In such cases pathological fracture is of less frequent 
 occurrence. 
 
 Round-celled sarcoma gives rise to regional and general infection 
 more constantly and at an earlier stage than giant-celled sarcoma. 
 Round-celled sarcoma may originate from the inner layer of the 
 periosteum, when the resulting tumor soon encircles the bone, and 
 almost from the beginning implicates the connective tissue outside the 
 periosteum, where the tumor exhibits more of the phenomena of a 
 deep connective-tissue sarcoma than sarcoma of bone. 
 
 Spindle-celled Sarcoma. — A spindle-celled sarcoma is very rare in 
 the interior of bone as a primary tumor. It originates most frequently 
 in the periosteum, where, by continuity of tissue, it soon extends around 
 the shaft of long bones, appearing as a fusiform tumor. Between the 
 spindle-cells there are often found, in varying proportions, round cells, 
 and sometimes giant-cells. 
 
 Periosteal sarcoma very often produces new bone, when we speak 
 of an ossifying sarcoma. Ossification of the tumor takes place fre- 
 
586 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 quently in sarcoma of the flat as well as in sarcoma of the long bones. 
 The tumor is hard if ossification takes place on a large scale or if the 
 tumor is composed almost exclusively of spindle-cells ; it is soft in non- 
 ossifying tumors composed in part at least of round cells and giant-cells. 
 
 C.T.Wl^iady 
 
 Fig. 405. — Periosteal bone producing sarcoma of the leg; starting-point in the tarsus. Vertical section 
 through the limb removed by amputation : a, tumor-tissue; b, shaft of tibia; c, new bone. 
 
 In ossifying periosteal sarcoma the bone left after maceration con- 
 sists of beautiful spiculae, which radiate and branch from the affected 
 bone (Fig. 405). Decalcified specimens show delicate trabecular, usu- 
 ally perpendicular to the old bone, and between them a very cellular 
 tissue containing spindle-cells and round cells. 
 
SARCOMA. 
 
 587 
 
 Pathological fracture does not occur in periosteal sarcoma, as the 
 affected bone is not much weakened by the tumor. Clinically, perios- 
 teal sarcoma differs from primary sarcoma of bone by the existence of 
 
 Fig. 406. — Periosteal sarcoma of the tibia (Surgical Clinic, Rush Medical College, Chicago). 
 
 greater pain and tenderness, by its greater malignancy, manifested by 
 its more rapid growth, and by its tendency to give rise to regional 
 and general dissemination. Sarcomata of some of the bones present 
 such peculiar clinical features that a special reference to them is 
 necessary. 
 
 Cranial Bones. — Periosteal sarcoma of the cranial bones forms at 
 first an external tumor which attacks the bone beneath, often leading 
 to diffuse secondary sarcoma of the dura mater, and even of the brain 
 itself. Anatomically the tumor is characterized by massive radiating 
 spiculse of bone. 
 
5 88 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Myeloid sarcoma begins in the connective tissue or myeloid tissue 
 of the diploe, and by its growth causes destruction of both tables of the 
 bone, resulting in the formation of large intracranial and extracranial 
 tumor-masses connected by a constricted portion which corresponds 
 with the primary location of the tumor and the perforation in the 
 skull. New bone is produced when the tumor has reached the peri- 
 osteum, so that the tumor is covered externally by a thin shell of bone, 
 
 Fig. 407. — Perforating myeloid sarcoma of the skull (Bruns). 
 
 which, however, yields to the increasing intracranial tension when the 
 tumor pulsates synchronously with the heart's action ; the tumor also 
 presents other symptoms which point to its partly intracranial location. 
 In some cases no new bone forms, and pulsation appears as soon 
 as perforation takes place. The tumor gradually becomes softer and 
 softer, and finally implicates the overlying skin, when ulceration and 
 sloughing hasten the fatal termination. The external tumor has been 
 known to attain a bulk of half the size of the head. The intracranial 
 extension of the tumor often causes well-marked cerebral symptoms. 
 
 Formerly, for obvious reasons, myeloid sarcomata of the cranial 
 bones were regarded as absolutely fatal. Bold operation under strict 
 antiseptic precautions has placed them within the reach of successful 
 operations, provided the operative treatment be resorted to in time. 
 The extension of the tumor to the dura mater does not preclude a 
 successful operation, as during the last ten years large pieces of the 
 
SARCOMA. 
 
 589 
 
 dura mater have been removed with the tumor without any immediate 
 or remote unfavorable complications. During one of these operations 
 Volkmann accidentally injured the superior longitudinal sinus, and the 
 patient died on the table from the immediate effects of the entrance of 
 air. Extirpation of these tumors requires the removal of the cranial 
 wall as far as the limits of the intracranial part of the tumor, when, 
 if the dura mater is affected, it is removed with the tumor. Special 
 care is necessary to prevent the entrance of air and undue hemorrhage 
 if a part of the superior longitudinal sinus has to be excised with the 
 tumor. Air-embolism can be prevented with certainty by keeping the 
 head on a level with the body during the operation ; hemorrhage is 
 guarded against by preliminary compression of the sinus outside the 
 
 Fig. 408. — Macerated specimen of periosteal sarcoma of the skull (Bruns). 
 
 line of incision on both sides, or by excising the sinus between two 
 ligatures. Hemorrhage from the sinus in accidental injuries is arrested 
 by ligature, by suture, or by compression-forceps which are allowed to 
 remain and are incorporated in the dressings and removed on the second 
 or third day. The interruption of the circulation in the sinus is a harm- 
 less procedure if the wound remains aseptic ; should suppuration set in, 
 the patient is exposed to the dangers of septic sinus-phlebitis and its 
 remote results, sepsis and pyemia. If a large part of the cranial wall 
 has to be excised, the defect should be filled with an accurately-fitting 
 plate of perforated decalcified bone, which furnishes a temporary pro- 
 tection for the exposed brain and aids the bone-producing tissues in 
 greatly diminishing the size of the cranial defect. The wound is closed 
 over the bone-plate by sutures except at the most dependent part, 
 where tubular or capillary drainage is established. Serious brain- 
 
59° PATHOLOGY AND TREATMENT OF TUMORS. 
 
 symptoms usually indicate the extension of the tumor beyond the dura 
 mater, and contraindicate an attempt to perform a radical operation. 
 
 Sarcomatous Epulis. — Sarcomatous epulis is a spindle-celled sarcoma 
 of slow growth that usually springs from the alveolar border of the 
 jaws, and involves the gum secondarily. Such tumors, although of 
 slow growth, may attain considerable size and cause great deformity. 
 
 Malignant epulis is found most frequently in persons more than 
 twenty years of age, and occasionally is seen in children. The tumor 
 is sometimes so much contracted at its base that it appears as a 
 pedunculated growth. The teeth are loosened, and are often extracted 
 under the belief that the swelling is caused by disease of their roots. 
 The tumor sometimes undergoes in part transformation into cartilage. 
 The harder the tumor, the slower its growth and the less the liability 
 to regional and general dissemination. If the tumor is allowed to 
 pursue its own course, extension to the periosteum, usually over the 
 outer surface of the bone, and destruction of the bone, are sure to 
 follow. The small-celled variety of epulis is particularly destructive. 
 
 Tumors with intercellular substance are soft and grow rapidly. In 
 soft tumors the round, non-fibrillating cells predominate. After the 
 tumor has attained considerable size it is subjected to all kinds of 
 injuries on the part of the teeth and by eating, and inflammation and 
 ulceration set in, aggravating the local conditions and increasing the 
 malignancy of the tumor. 
 
 Fibrous epulis is only attached to the bone ; sarcomatous epulis grows 
 into the bone. A careful distinction between the benign and malignant 
 forms of epulis is important from a practical standpoint, as in the former 
 instance it is not necessary to extend the operation beyond the bone, 
 whereas in malignant epulis, in order to remove all of the diseased 
 tissue, it is necessary to resort at least to the removal of the alveolar 
 border of the jaw, and in advanced cases, where the periosteum has 
 become extensively involved, nothing short of resection of the jaw in 
 its entirety will fulfil the pathological indications. 
 
 Sarcoma of the Jaws. — With few exceptions, tumors of the jaws are 
 sarcomata. Giant-celled, round-celled, and spindle-celled tumors occur 
 in the jaws. In the majority of cases the tumors are mixed-cell sar- 
 comata. Their degree of malignancy is determined by the abundance 
 of non-fibrillating cells. The round-celled variety is the most malig- 
 nant, giant-celled the most benign, and in mixed-cell tumors the malig- 
 nancy increases with the number of round cells. Myeloid central 
 sarcoma is much less malignant than periosteal sarcoma, sarcomatous 
 epulis excepted. Periosteal sarcoma of the lower jaw is especially a 
 very malignant tumor. Myeloid central sarcoma of the lower jaw, on 
 
SARCOMA. 
 
 59 1 
 
 the contrary, is a comparatively benign tumor. Sarcomata starting in 
 the follicles of the teeth are mixed-cell tumors. In the early stages 
 these tumors are encapsulated, but later they give rise to regional 
 and general infection. " Sarcoma of a tooth-follicle only occurs in 
 children, and is particularly apt to involve the germ of the first per- 
 manent molar" (Sutton). Myeloid sarcomata are rarely met with 
 after the twenty-fifth year, whereas the periosteal variety occurs more 
 frequently in persons advanced in years. 
 
 Naso-pharynx. — Spindle-celled sarcomatous tumors of the naso- 
 pharynx usually spring from the under surface of the body of the 
 sphenoid bone. Both nasal cavities are often occluded, and processes 
 of the tumor extend forward into the nostrils and backward into the 
 pharynx. These tumors are the source of great distress in preventing 
 nasal breathing and sometimes in- 
 terfering with deglutition ; they 
 are also attended by excruciating 
 frontal headache. Hemorrhage 
 is of frequent occurrence. 
 
 Nose. — Sarcoma of the nose 
 is seldom seen except in persons 
 between the ages of fifteen and 
 twenty years. Nasal sarcomata 
 frequently involve one or both 
 antrums. A case of this kind 
 is shown in Figure 409. In this 
 instance pain was absent, the sense 
 of smell was lost, and the sight 
 of the right eye was impaired. 
 Moore attempted to remove the 
 tumor, but the patient died on 
 the table in consequence of some interference with the respiration. 
 Subsequent examination showed that the tumor was surrounded by a 
 bony capsule and that its wall was continuous with that portion of the 
 nasal septum formed by the mesethmoid. 
 
 Vertebra. — Primary sarcoma of the vertebrae is rare ; metastatic 
 tumors are of frequent occurrence. The writer has seen two patients 
 die from the remote effects of metastatic sarcoma of the vertebrae. 
 In the first case the patient was a girl fourteen years old suffering from 
 a round-celled fascial sarcoma in the deltoid region. A few weeks after 
 the operation she complained of pain in the lower part of the dorsal 
 region. Kyphosis and complete paraplegia soon appeared, and were 
 followed by a very extensive sacral decubitus, from the immediate 
 
 Fig. 
 
 Deformity produced by a sarcoma of the 
 nasal septum (after Moore). 
 
592 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 effects of which the patient died in less than six months after the opera- 
 tion. The second patient was a man sixty-five years of age, from 
 whom there was removed a small round-celled sarcoma of the seventh 
 rib on the right side. During the operation the pleural cavity was 
 opened, the lung collapsed, and the patient nearly died on the table 
 from the effects of the accident. The wound in the pleural cavity was 
 stuffed with iodoform gauze, and the tumor was rapidly removed with 
 a considerable portion of the parietal pleura. The patient rallied and 
 recovered rapidly from the operation. The wound healed by primary 
 intention, in a few days the air in the pleural cavity was absorbed, and 
 the lung expanded. Several weeks after the operation, after the patient 
 was able to leave his bed, intense pain in the middle dorsal region set 
 in. A slight projection of one of the spinous processes of the middle 
 dorsal vertebra was noticeable in a few weeks. Progressive paraplegia, 
 retention of urine, and decubitus followed in rapid succession, from 
 the combined effects of which the patient died four months after the 
 operation. 
 
 Sarcoma of the vertebra?, whether primary or secondary, in its clinical 
 aspects bears a close resemblance to acute spondylitis. 
 
 Diagnosis. — Mistakes in diagnosis are frequently made in cases 
 of sarcoma of the bones. More than this, the diagnosis is often only 
 made after the clinical history of the tumor has revealed its malignant 
 nature. All histological forms of sarcoma of bone are characterized 
 by progressive growth. The tumor is either soft or hard according to 
 the histological type of the cells of which it is composed. Encapsula- 
 tion, which may be present at first in some forms of sarcoma, disap- 
 pears during the growth of the tumor, when, in degrees of intensity, 
 local, regional, and general infection manifests itself. Local exten- 
 sion from tissue to tissue, irrespective of its anatomical structure, 
 constitutes the distinctive feature between sarcoma and benign tumors 
 of bone. In central sarcoma the extension to other tissues takes place 
 through the blood-vessels of the bone, the Haversian canals, and after 
 the compact layer of the bone has become perforated. Regional infec- 
 tion takes place in preference along the course of blood-vessels, nerves, 
 and intermuscular septa, but in some cases the lymphatics are impli- 
 cated. General dissemination may take place through the lymphatic 
 channels, but in the majority of cases the tumor-cells enter the blood- 
 vessels, or tae tumor grows into a vein, and the emboli, large or small, 
 are derived from the intravenous, sarcomatous thrombus. 
 
 Round cells and giant-cells destroy bone. In periosteal sarcoma 
 bone-destruction and the production of new bone take place side by 
 side. Periosteal sarcoma presents itself usually as a firm tumor attached 
 
SARCOMA. 593 
 
 to or encircling- the bone. Round-cell periosteal sarcoma is the most 
 malignant of all bone-tumors. In its clinical aspects it more closely re- 
 
 Fig. 410. — Sarcoma of the femur invading the knee-joint (Surgical Clinic, Rush Medical College, Chicago). 
 
 sembles an inflammatory affection than a tumor. Its great malignancy 
 is manifested by rapidity of growth and by early regional and general 
 infection. Local extension takes place along the periosteum to the 
 underlying bone and the adjacent tissues. No new bone is produced. 
 In central sarcoma of the long bones, as long as the tumor is covered 
 by a thin shell of bone, pressure produces a crackling sensation. Pulsa- 
 tions are felt in perforating, non-ossifying sarcoma of the skull and in 
 vascular myeloid central tumors of the long bones. A bruit is often 
 heard in very vascular central sarcomata of the long bones. Glandular 
 infection occurs most frequently in round-celled sarcoma of the jaws, 
 the tarsus, the sternum, and the ilium. The signs and symptoms of 
 sarcoma of the vertebrae resemble acute spondylitis. Pathological frac- 
 ture is one of the consequences of central sarcoma of the long bones. 
 The affections most frequently mistaken for sarcoma are infective 
 swellings, cysts, aneurysm, carcinoma, and actinomycosis. 
 
 Infective Swellings. — Subacute and chronic suppurative osteomye- 
 litis has frequently been mistaken for myeloid and periosteal sarcoma, 
 and vice versa. Primary osteomyelitis is a disease of childhood and 
 young adults, the same as myeloid sarcoma. Periosteal sarcoma affects 
 most frequently persons between twenty and sixty years of age. Cen- 
 tral osteomyelitis is a very painful affection, whereas myeloid sarcoma 
 produces little or no pain. Inflammatory affections occur more fre- 
 quently in the young than tumors, the proportion being about 3:1. 
 Injury may precede and constitute an etiological factor in both affec- 
 tions. Paget related an instance of a malignant tumor within and 
 around the fibula that attained a large size within eight weeks after 
 a strain or perhaps a fracture of the bone. The swelling both in osteo- 
 
 38 
 
594 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 myelitis and in sarcoma of the long bones may be either fusiform or 
 one-sided. The consistency of the swelling often offers no clue as to 
 the nature of the enlargement. An inflammatory swelling may be very 
 hard, and a sarcoma may be soft. A sarcoma may increase in size as 
 rapidly as an inflammatory swelling. In chronic central osteomyelitis 
 no external swelling may appear for months or years. If, however, 
 careful observation shows that the enlargement is not increasing, this 
 circumstance would be suggestive of osteomyelitis rather than of a 
 malignant tumor. The condition of the skin over the swelling affords 
 no trustworthy indication of the nature of the swelling. Enlargement 
 of the subcutaneous veins is found in sarcoma and in deep-seated osteo- 
 myelitis before the abscess has reached the skin. The soft parts have 
 their circulation uninterfered with until the tumor or the inflammatory 
 process has implicated the skin by extension of the morbid process. 
 CEdema is more suggestive of the presence of pus than of a tumor. 
 Tenderness is always present over an osteomyelitic focus, and is absent 
 or slight in central sarcoma. In periosteal sarcoma pain and tenderness 
 are more conspicuous symptoms. The temperature may be normal in 
 chronic osteomyelitis, and a slight rise of temperature is observed in 
 pure cases of sarcoma. In periosteal sarcoma the temperature not infre- 
 quently rises three or four degrees above normal. 
 
 An exploratory puncture may prove useful as a diagnostic aid. 
 In obscure cases an exploratory operation will often be the only means 
 of differentiating a sarcoma from an infective swelling. The exploration 
 in central disease of the bones should be carried not only down to, 
 but into, the bone by the use of mallet and gouge. If the disease is 
 inflammatory, the bone removed will present the structure of can- 
 cellous bone — that is, it will be more or less porous — and when the 
 abscess-cavity is reached at least a few drops of pus will be discovered. 
 If a tumor is exposed by the operation, tumor-tissue and no pus will 
 be found. At this stage of the operation, in case of doubt the micro- 
 scope may prove of great value in making a positive diagnosis. 
 
 Tuberculosis of the long bones usually affects the epiphyseal ex- 
 tremities, and the adjacent joint is frequently found implicated, while in 
 sarcoma in the same localities joint-complications seldom occur, as the 
 articular cartilage, although not impermeable to sarcoma, protects the 
 joint for a long time. In advanced tuberculosis of the short and flat 
 bones that has terminated in the formation of a tubercular abscess an 
 exploratory puncture will reveal the true nature of the swelling. 
 
 Syphilitic gummata of bone or of periosteum have frequently been 
 mistaken for sarcoma. Careful inquiry into the history of the case is 
 important in cases in which there is any doubt as to the syphilitic nature 
 
SARCOMA. 595 
 
 of the bone-affection. Gummata often appear as a multiple affection, and 
 careful examination of the patient will often reveal the presence of marks 
 of antecedent syphilitic lesions or the existence of additional syphilitic affec- 
 tions. The histological structure of gummata under the microscope bears 
 such a close resemblance to small round-celled sarcomata that micro- 
 scopical examination should not be relied upon in making a differential 
 diagnosis between gumma and round-celled sarcoma. In doubtful cases 
 the patient should be placed upon a vigorous antisyphilitic treatment 
 for a few weeks, during which time the enlargement should be exam- 
 ined frequently in order to observe the effects of the treatment. If the 
 enlargement is a sarcoma, the treatment will make no impression on 
 the tumor ; if it is syphilitic, a decided improvement will be noticeable 
 in a few weeks. 
 
 Cysts of bone, parasitic and non-parasitic, grow very slowly, remain 
 local, and are not apt to give rise to any subjective symptoms. They 
 are also extremely rare. 
 
 In pulsating myeloid tumors of the long bones a careful examination 
 must be made to distinguish them from true aneurysm. In many 
 pulsating sarcomata no bruit can be heard, while in true aneurysm this 
 symptom is present almost without exception. In aneurysm a more 
 decided impression is made upon the swelling by compression of the 
 principal artery on the proximal side than in pulsating sarcomata. In 
 sarcoma a distinct crackling sensation is produced on making pressure 
 upon the tumor as long as it is covered with a thin shell of bone. 
 
 The differential diagnosis between sarcoma and actinomycosis can 
 only come in question in cases in which the jaws are the seat of the 
 affection. Microscopical examination of fragments of tissue will show 
 the presence of the essential cause, the actinomyces, if the enlarge- 
 ment is an actinomycotic swelling. 
 
 Treatment. — The operative treatment of sarcoma of bone is indicated 
 in all cases in which there is reasonable hope that all diseased tissue 
 can be removed and in which metastasis has not occurred. The last 
 point is difficult to determine, as some sarcomata give rise to metastasis 
 at a very early stage, and the metastatic tumors may be very small or 
 may be located in internal organs, thereby eluding detection. Meta- 
 static tumors of the brain are often attended by impairment of vision 
 and by other focal symptoms. Metastatic tumors of the lungs and 
 the pleurae must be suspected if the patient has a hydrothorax. Ascites 
 is another condition which sometimes develops in consequence of 
 metastatic tumors of some of the abdominal viscera. 
 
 It is superfluous to insist that sarcoma of the bones should be 
 operated upon at the earliest possible moment. Although the chances 
 
596 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 for a permanent cure after early operations are not so favorable as in 
 carcinoma, there can be no doubt that thorough operations in cases 
 of sarcoma, performed before regional and general dissemination has 
 occurred, will in a fair percentage of cases not be followed by recur- 
 rence of the tumor. 
 
 In central sarcoma the disease often has become diffused through 
 the numerous imperfect blood-vessels before such a condition is sus- 
 pected ; and in periosteal sarcoma regional dissemination through the 
 surrounding connective-tissue spaces often takes place at a very early 
 period. 
 
 Long Bones. — In myeloid sarcoma of the long bones a conservative 
 operation is justifiable in small tumors if the disease is limited to the 
 bone. In slow-growing myeloid tumors favorably located removal of 
 the tumor with the sharp spoon, the chisel, and the hammer has in a 
 few instances yielded a satisfactory result. The cases adapted for this 
 operation are, however, few "and far apart. Resection of the bone in 
 its continuity is another operation adapted for well-selected cases. It 
 is inapplicable if the tumor involves the pancreas or the femur. This 
 operation must be limited to the bones of the forearm, the clavicle, 
 and the ribs. Many years ago the writer excised the inner two-thirds 
 of the clavicle for central sarcoma. The patient was a boy sixteen 
 years of age. The tumor, which was located near the sternal end, was 
 larger than a hen's egg, had not extended beyond the periosteum, and 
 was covered by an imperfect thin shell of bone. The boy recovered 
 almost perfect use of the arm, and the tumor never returned. In 1876, 
 Henry Morris excised the lower end of the right radius and the lower 
 fourth of the ulnar for sarcoma. No recurrence had taken place six- 
 teen years after the operation (Fig. 411). The patient recovered con- 
 siderable use of the hand. A few other cases have been reported in 
 which excision of a part of the shaft of the long bones yielded satis- 
 
 Fig. 411. — Forearm of a woman four years after excision of the lower fourth of the ulnar and the radius for 
 a myeloid sarcoma of the radius (after Henry Morris). 
 
 factory results. In the majority of cases it is necessary to resort to 
 amputation in sarcoma of the long bones. 
 
SARCOMA. 597 
 
 Periosteal sarcoma invariably necessitates a mutilating operation. 
 As a rule, the entire bone should be removed. In sarcoma of the 
 bones of the forearm amputation should be performed at or above the 
 elbow-joint ; if the bones of the leg are the seat of the tumor, Gritti- 
 Stokes's supracondyloid amputation will fulfil the pathological indica- 
 tions and will yield the most serviceable stump. In sarcoma of the 
 humerus amputation through the shoulder-joint, and in sarcoma of 
 the femur hip-joint amputation, is necessary. If the upper part of the 
 humerus is affected, removal of the scapula and of part of the clavicle 
 may become necessary ; in myeloid sarcoma of the lower end of the 
 femur amputation at the junction of the upper and middle thirds of 
 the femur will in all probability remove all the diseased tissue. 
 
 Lower Jaw. — In sarcomatous epulis and in central limited myeloid 
 tumors the continuity of the bone can often be preserved. In the 
 former case the alveolar border and as much of the bone as may be 
 deemed necessary are removed with the chisel. The tumor is exposed 
 by an incision along the lower border of the jaw, the incision being 
 large enough to give free access to the parts to be removed. With the 
 bone a corresponding piece of the periosteum is removed. In central 
 limited myeloid sarcoma the compact layer of the bone is removed 
 with chisel and hammer, and the same instruments are employed in 
 removing the tumor, including with it a zone of bone-tissue adjacent 
 to the tumor. In periosteal sarcoma and in large myeloid tumors one- 
 half of the bone must be removed, even if the tumor does not extend 
 to the ascending ramus, as the proximal fragment is rather detrimental 
 than useful to the patient later, and the severity of the operation is not 
 increased by disarticulating the bone at the temporo-maxillary joint. 
 The bone is exposed by an incision shown in Figure 412. 
 
 In operating for malignant disease no attempt should be made to 
 preserve the periosteum. After the hemorrhage has been arrested by 
 the employment of hemostatic forceps the symphysis of the bone 
 is divided. One or two incisor teeth are extracted, when the bone is 
 divided either with a Butcher saw or a chain-saw, as shown in Figure 
 41 2. If Butcher's saw is used, the section is made from without inward ; 
 if the chain-saw is employed, a tunnel is made with a narrow-bladed 
 knife behind the symphysis mentis ; through this tunnel the chain-saw 
 is passed, and the bone is divided from behind forward. After the jaw 
 has been detached from the soft parts to near the temporo-maxillary 
 joint the disarticulation is effected by twisting the bone forcibly in the 
 direction shown in Figure 413. The bone is wrenched from the joint 
 for the purpose of preventing injury to the internal maxillary artery, 
 which would be likely to occur if the disarticulation were done bv the 
 
598 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 use of cutting instruments. The mucous membrane should be sutured 
 from the side of the mouth by a separate row of catgut sutures, to 
 exclude the cavity of the mouth from the wound. The external wound 
 
 Fig. 412. — Excision of one-half of the lower jaw; Fig. 413. — Disarticulation of one-half of the lower 
 external incision (after Esmarch). jaw by twisting (after Esmarch). 
 
 is sutured and drained in the usual manner. In some cases it is neces- 
 sary to divide the lower lip in the centre, affording additional room. 
 Upper Jaw. — Localized myeloid tumors of the upper jaw and epulis 
 
 Fig. 414. — Incisions for resection of the upper jaw (after Esmarch) : a, Gensoul's ; b, Velpeau's ; c, Syme's ; 
 d, Malgaigne's ; e, Nelaton's ; f, Fergusson's ; g, Dieffenbach's ; h, Weber's ; i, Von Langenbeck's. 
 
 are treated in the same manner as similar affections of the lower jaw. 
 In periosteal sarcoma and in tumors involving the antrum excision of the 
 entire jaw is absolutely necessary. The incisions proposed by different 
 
SARCOMA. 
 
 599 
 
 surgeons in exposing the upper jaw are shown in Figure 414. Of all 
 incisions so far proposed, Weber's incision (Fig. 41 5) gives best access to 
 the bone and leaves the least deformity. The upper lip is divided in the 
 median line as far as the septum of the nose, when the incision is 
 carried below the nostril on the affected side to the base of the nose, 
 and along the side of the nose to a point a little below the level of the 
 inner canthus of the eye, when it is extended outward below the eye- 
 lid as far as the external angle of the eye. The flap is now detached 
 
 Fig. 
 
 -Weber's incision for excision of 
 the upper jaw. 
 
 Fig. 416. — Bone-section in excision of the upper jaw 
 (after Esmarch). 
 
 and turned downward and outward. In resecting the upper jaw for 
 malignant disease the periosteum is removed with the bone. The 
 orbital contents are carefully separated from the floor with a periosteal 
 elevator. The malar bone is divided with a chain-saw fastened by a 
 strong silk thread to a large curved needle. The needle, thus armed, 
 is passed through the orbital fissure, along the posterior surface of the 
 malar bone, and is brought out at the malar fossa, where the bone is 
 divided (Fig. 416, a). The nasal process is next divided with cutting 
 forceps (Fig. 416, b). The section through the junction of the maxil- 
 lary bones is made with a chain-saw. The tampon which was inserted 
 into the nostril before the operation was begun is next removed. 
 A drainage-trocar is now inserted into the nostril, and is pushed into 
 the mouth at the junction of the hard with the soft palate, and with it 
 the chain-saw is drawn through the cavity of the mouth and nose 
 (Fig. 417, a). After the extraction of one or two teeth at the point 
 where the bone is to be divided, the section is made with the saw. The 
 next step is to separate with the knife transversely the soft from the 
 hard palate (Fig. 417, b). The bone is now loosened with an elevator 
 inserted into the section made through the malar bone, whereupon the 
 
600 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 bone is seized with Fergusson's lion-jaw forceps and twisted from its 
 
 Fig. 417. — Showing line of median bone-sec- 
 tion and method of applying chain-saw (after 
 Esmarch). 
 
 Fig. 418.— Removal of bone with Fergusson's 
 lion-jaw forceps (after Esmarch). 
 
 location (Fig. 41. 
 
 The internal maxillary artery is tied at the bottom 
 of the large wound if it bleeds. After hemor- 
 rhage has been arrested the cavity of the 
 wound (Fig. 419) is packed with iodoform 
 gauze and the external wound is sutured. 
 Great care is required in the after-treatment. 
 The patient should be kept in a half-sitting 
 position for several days. Frequent use of 
 an antiseptic mouth-wash and careful feeding 
 constitute important features in the after-treat- 
 ment. The tampon is removed at the end of 
 three or four days, and, after carefully cleansing 
 the wound, is replaced by a smaller one. The 
 writer has frequently dispensed with the chain- 
 saw in resection of the upper jaw, and has 
 relied on the chisel and strong cutting forceps. The operation, by sub- 
 stituting the chisel for the chain-saw, can be performed in half the 
 time — an important matter in performing the operation without a full 
 general anesthetic. The writer has been in the habit of administering 
 subcutaneously \ grain of morphia immediately before the anesthetic 
 is administered, and 2 ounces of whiskey by the mouth. As soon as 
 the patient is unconscious the external incision is made, but the sections 
 through the bone are not made until the patient can be roused suf- 
 ficiently to spit out the blood which accumulates in the mouth. By 
 pursuing this plan there is no danger of the entrance of blood into the 
 bronchial tubes, and, although the patient continues to talk during the 
 
 Fig. 419. — Wound-cavity after 
 resection of the upper jaw (after 
 Esmarch). 
 
SARCOMA. 
 
 601 
 
 balance of the operation, his recollection of the operation is very 
 imperfect and indefinite — the best proof that the pain experienced was 
 not severe. In some cases of extensive sarcoma of the upper jaw the 
 writer has been obliged to remove the entire malar bone and the septum 
 of the nose, and in several instances has followed the disease as far as 
 the frontal sinus. In two cases, at the time of operation the orbital 
 contents were removed, as the sarcoma had perforated the orbital floor. 
 By using the chisel these additional operations can be done with ease 
 and without adding much to the gravity of the operation. 
 
 Mammary Gland. — As compared with carcinoma, sarcoma of the 
 mammary gland is a rare affection. It is met with most frequently in 
 
 Fig. 420.— Cysto-sarcoma proliferum (after Konig) : a, cysts ; b, proliferating masses of sarcoma-tissue ; 
 c, cellular lining of cysts ; d, stroma. 
 
 young women. It is composed either of round cells, of spindle-cells, 
 or of a mixture of these two kinds of cells in varying proportions. 
 The tumor begins in the periacinous connective tissue. During the 
 growth of the tumor a part of the acini are destroyed by pressure ; the 
 ducts remain open, and as new tumor-tissue is added to their walls 
 they become greatly distended (Fig. 420). In this way the dilated 
 
602 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 ducts, compressed by the tumor-masses, become spaces which contain 
 a mucoid material, and which are encroached upon by leaf-like masses 
 of tumor-tissue. Virchow compares the appearance of sections of the 
 tumor to that of a cabbage-head. The cyst-walls project into the 
 spaces in the form of papillomatous dendritic branching formations. 
 At other times the walls are perforated by the tumor-tissue, which then 
 appears in the spaces as polypoid leaf-like masses. Johannes Mueller 
 applied to this tumor the term cysto-sarcoma proliferum pliyllodes 
 (Fig. 421), and Astley Cooper called it "hydatid tumor." The peri- 
 canalicular proliferation projects into the dilated ducts and constitutes, 
 with the intracanalicular excrescences, the proliferating masses. Gland- 
 tissue is sometimes found in the tu-mor-substance which has grown 
 around it, but it is soon removed by degeneration and by pressure- 
 atrophy. The stroma of the tumor is very apt to undergo myxomatous 
 degeneration. 
 
 V 
 
 \ 
 
 / 
 
 Fig. 421. — Cysto-sarcoma proliferum phyllodes ; two-thirds natural size (after Haeckel) : a, normal gland- 
 tissue; b, myxomatous part ; c, great proliferation in a cyst. 
 
 Round-celled sarcoma grows very rapidly ; the tumor is soft (medul- 
 lary sarcoma), and life is often destroyed in three or four months after 
 the discovery of the tumor. The rapidity with which such tumors 
 grow has often led surgeons to mistake them for abscesses, and 
 abscesses have not infrequently been mistaken for sarcomata. A few 
 years ago a woman forty years of age was sent to the writer by 
 an able practitioner with the diagnosis of sarcoma. The enlargement 
 
SARCOMA. 603 
 
 of the breast had begun two months before, had increased slowly, 
 and was not attended by any considerable pain. The breast was the 
 size of a child's head, smooth, and fluctuated on deep palpation. The 
 skin over the swelling was movable and only slightly discolored. 
 As the swelling came on some time after the patient ceased to nurse 
 her child, the writer was led to resort to an exploratory puncture, and, 
 somewhat to his astonishment, pus was withdrawn. The case revealed 
 itself as a subacute submammary abscess. The cases are perhaps more 
 frequent in which a rapid-growing sarcoma is mistaken for an abscess. 
 The bistoury has often been plunged into such tumors with the inten- 
 tion of opening an abscess, when, to the great chagrin of the operator, 
 only blood escaped. A puncture made under such circumstances often 
 does an incalculable amount of mischief. It becomes the starting- 
 point of ulceration and sloughing, which convert the subcutaneous sar- 
 coma into a fungous bleeding mass and initiates the danger incident 
 to suppuration, sepsis, and pyemia. 
 
 In spindle-celled sarcoma the tumor is firm, and regional and gen- 
 eral dissemination is a later occurrence. Firm tumors are also less 
 subject to cystic and myxomatous degeneration. Sarcoma of the breast 
 manifests itself clinically as a rapid-growing tumor with a smooth sur- 
 face, and it is more movable than sarcoma. The rapidity of growth 
 distinguishes it sufficiently from adenoma, fibroma, and cystoma. The 
 absence of cicatricial contraction in sarcomata explains why the nipple 
 and the skin over the tumors are not retracted, as is often the case in 
 carcinoma of the breast. Sarcoma of the breast is not attended by 
 pain. The tumor attains greater size before it ulcerates than does 
 carcinoma. In very rare instances patients suffer from sarcoma and 
 carcinoma at the same time. Billroth relates an instance in which one 
 breast was the seat of a carcinoma, and the other of a sarcoma. As 
 young round-celled sarcoma-tissue resembles granulation-tissue, the 
 microscope cannot be relied upon in making a differential diagnosis 
 between sarcoma and chronic infective swellings. Enlargement of the 
 axillary glands, so constantly observed in carcinoma, is seldom seen in 
 sarcoma of the breast. After the tumor has perforated the capsule of 
 the gland regional infection takes place in the direction of the con- 
 nective-tissue spaces. Chronic suppurative mastitis and submammary 
 abscess can be distinguished from sarcoma by resorting to an explora- 
 tory puncture. 
 
 The proper treatment in cases of -sarcoma of the breast is an early 
 and thorough excision. If the disease has not extended beyond 
 the limits of the gland, the prospects of a radical cure are better in 
 sarcoma than in carcinoma. It is essential not only to remove the 
 
604 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 entire gland, but also to include with it the overlying skin and as much 
 of the periglandular connective tissue as may be deemed necessary. 
 As regional infection is very prone to extend along the connective 
 tissue accompanying the axillary glands from the margin of the breast, 
 the writer has been in the habit of laying the axilla freely open and 
 clearing it out much in the same way as in operations for carcinoma, 
 removing at the same time the fascia of the pectoralis major and the 
 serratus magnus muscles. By undermining the skin for some distance 
 on both sides and using tension-sutures the wound can usually be 
 closed throughout : this procedure should be carried out whenever it is 
 practicable in all operations for malignant disease of the breast. 
 
 In cases beyond the reach of a radical operation, treatment by sub- 
 cutaneous injections of the sterilized toxines of the streptococcus of 
 erysipelas recommends itself. Partial operations in sarcoma of the 
 breast are not permissible, as they invariably increase the malignancy 
 of the remaining portion of the tumor. In open fungous tumors the 
 employment of strong antiseptic solutions will accomplish much in 
 diminishing the intensity of the fetor and in retarding the sloughing 
 process. 
 
 Thymus Gland. — Virchow pointed out that sarcomatous tumors 
 of the anterior mediastinum having a regular outline are usually 
 thymic in their origin ; and recent observers, especially Letulle, have 
 argued for a still more frequent recurrence of this place of origin than 
 Virchow believed. In a paper on " The Clinical Study of Intrathoracic 
 Tumors," by Pepper and Stengel, allusion is made to three cases of 
 sarcoma of the thymus gland that came under the observation of the 
 authors. As in the histological structure of this gland the lymphatic 
 tissue is greatly in excess of the epithelial cells, it is to be expected 
 that it would be more frequently the seat of mesoblastic than epithelial 
 tumors. 
 
 Sarcoma of the thymus gland occurs more frequently in young 
 adults than in persons advanced in years ; but old age is not exempt, 
 as in one of Pepper's cases the patient was fifty-six years of age. The 
 tumor by its progressive growth gives rise to gradually increasing 
 pressure-symptoms, upon which the physician must largely rely in 
 making a probable diagnosis, combined with a careful study of the 
 physical signs. 
 
 Salivary Glands. — The parotid gland is more frequently the seat 
 of sarcoma than the submaxillary gland. The tumor presents itself 
 as a smooth or lobulated, rapid-growing mass, which in a short 
 time involves the entire gland, and after perforation of its capsule 
 extends in all directions, notably beneath the sterno-mastoid muscle 
 
SARCOMA. 605 
 
 toward the pharynx and the external ear, very frequently implicating 
 the facial nerve as it issues from the stylo-mastoid foramen. The 
 writer has seen two cases of parotid sarcoma in which the facial nerve 
 was completely paralyzed at the time of the operation. In each 
 instance it was found that the tumor had extended to the point of exit 
 of the nerve from the stylo-mastoid foramen. Billroth estimated that 
 three-fourths of all tumors of the parotid gland are of a sarcomatous 
 nature. The largest number of patients suffering from parotid sarcoma 
 are between thirty and forty years of age. Of the cases which have 
 come under the writer's observation, the youngest was twenty-five and 
 the oldest seventy-two years of age. Kaufmann, who has investigated 
 the histology of sarcomatous tumors of the parotid gland more thor- 
 oughly than any other author, classifies these tumors, according to 
 their structure, into pure sarcomata, fibro-sarcomata, myxo-sarcomata, 
 and chondro-sarcomata. The pure sarcomata are composed either 
 of round cells or of spindle-cells, and are encapsulated from the 
 beginning. Fibro-sarcomata appear as hard, smooth, or lobulated 
 tumors composed of spindle-cells. The tumors are also encapsulated, 
 and the results of operation in this as well as in the first variety are 
 favorable. Myxo-sarcomata often grow to the size of a child's head. 
 The tumors are round and soft ; the tissue is of a yellowish or red- 
 dish tint. The tumors contain myxoma-cells, spindle-cells, and round 
 cells. 
 
 Chondro-sarcomata present a nodulated surface. From the capsule 
 bundles of interlacing fibres extend into the substance of the tumor. 
 The cartilage-tissue appears in islands dispersed throughout the tumor, 
 some of them being as large as peas. 
 
 The great variety in the histological structure of sarcoma of the 
 parotid renders the diagnosis often very difficult. From benign tumors 
 it can be differentiated by the rapidity with which the tumor grows and 
 by the regularity with which it extends ultimately beyond the limits of 
 the gland. In carcinoma of the parotid lymphatic infection is observed 
 at an early stage ; in sarcoma regional infection takes place through 
 the periglandular connective tissue. It is more probable that in chon- 
 dro-sarcoma the islands of cartilage-tissue are formed from chondro- 
 blasts derived from the pinna and deposited in the substance of the 
 parotid gland, than that they result from a development of sarcoma- 
 tissue into tissue of a higher physiological type. In the more benign 
 forms of sarcoma of the parotid extirpation of the tumor should be 
 performed without division of the facial nerve. If the tumor grows 
 rapidly or if it has involved the entire gland, a radical operation is 
 necessarily followed by permanent facial paralysis. The technique of 
 
606 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the operation has been described fully in connection with Carcinoma 
 of the Parotid Gland. In sarcoma of the submaxillary gland the 
 whole gland and the surrounding connective tissue should be removed 
 with the tumor. 
 
 Tongue. — Butlin regards sarcoma of the tongue as an exceedingly 
 rare affection. Mr. Targett reports a case in which, in a patient twenty- 
 five years of age, a sarcoma developed on the under portion of the 
 left side of the tongue, involving at the same time the floor of the 
 mouth. The tumor appeared as a hard, painless mass, and the mucous 
 membrane over it was not ulcerated. It was removed through an 
 incision of the cheek extending in a backward direction from the left 
 angle of the mouth. Examination of sections of the tumor under 
 the microscope showed it to be a round-celled sarcoma. In fifteen 
 months it returned in the left submaxillary region and below the 
 zygoma of the right side. Mr. Targett gives the history of two 
 additional cases which occurred in Guy's Hospital. Sarcoma of the 
 tongue must be distinguished from carcinoma, tuberculosis, gumma, 
 and actinomycosis. 
 
 Tonsil. — Sarcoma of the tonsil is of more frequent occurrence than 
 carcinoma. It also grows more rapidly and attains larger size before 
 ulceration occurs than does carcinoma. Infection of the deep lymphatic 
 glands, of such constant occurrence in carcinoma and primary syphilis, 
 is absent in sarcoma. Excision of the tumor through Cheever's or 
 Kocher's incision is the only proper surgical treatment, and should 
 be done if all the diseased tissue can be removed and no indications of 
 metastasis are present. 
 
 Intestinal Canal. — Sarcoma of the intestinal canal as compared 
 with carcinoma is an extremely rare affection. It occurs most fre- 
 quently in the upper part of the small intestines, about the ileo-cecal 
 region, the colon, and the rectum. Rokitansky described spindle-celled 
 sarcoma of the intestines that projected in a nodulated form into .the 
 lumen of the bowel. Billroth and Esmarch have reported cases of 
 alveolar sarcoma of the rectum. Frerichs and Meyer have seen speci- 
 mens of melano-sarcoma involving the intestinal canal. A sarcoma 
 of the intestines never comes to the attention of the surgeon until 
 the tumor has given rise to some form of intestinal obstruction. 
 A sarcoma produces intestinal obstruction either by the tumor-mass 
 filling the lumen of the bowel, by invagination, or by volvulus, and 
 never by cicatricial contraction, as is so often the case in circular carci- 
 noma. Sarcoma of the intestines begins in the submucous connective 
 tissue, and is composed either of spindle-cells or of round cells ; in 
 both varieties and in mixed-cell sarcoma myxomatous degeneration is 
 
SARCOMA. 607 
 
 a constant and early occurrence. A correct diagnosis is only made 
 in the operating- or the post-mortem room. 
 
 If in operating for intestinal obstruction a sarcoma is found as its 
 cause, an enterectomy is indicated if the tumor has not extended 
 beyond the intestinal wall ; if this extension has taken place, a radical 
 operation is out of the question, and the surgeon must content himself 
 with making an artificial anus above the tumor, or, what is better, an 
 intestinal anastomosis. 
 
 Omentum. — The great omentum is occasionally the seat of primary 
 sarcoma, and the tumor in this locality often attains an enormous size. 
 The writer removed, in a man fifty years of age, the entire omentum 
 for a tumor that weighed over thirty pounds. 
 
 Kidney. — Sarcoma of the kidney is more common than carcinoma. 
 It is met with most frequently in children and young adults. The 
 growth of the tumor is rapid, and the tumor usually reaches an enor- 
 mous size before it destroys life. The mass is smooth, and pseudo- 
 fluctuation is generally present. The tumor is composed usually of 
 round cells. The malignancy of sarcoma of the kidney is very great, 
 and recurrence after extirpation of the kidney is the rule. 
 
 Diagnosis. — The diagnosis of sarcoma of the kidney is usually not 
 very difficult. The only affections for which it is liable to be mistaken 
 are hydronephrosis, pyonephrosis, and on the right side a distended gall- 
 bladder. Hemorrhage from the kidney in sarcoma occurs frequently, 
 and its occurrence in children is very suggestive of malignant disease 
 of the kidney. The retroperitoneal location of the tumor can be 
 determined positively by inflation of the colon. If the tumor is intra- 
 peritoneal, it will be displaced by the distended colon ; if it is retroperi- 
 toneal, the tumor can be felt less distinctly in front, and where dulness 
 existed before the inflation there is resonance due to the location of the 
 distended colon in front of the kidney. Soft sarcomata of the kidney 
 present pseudo-fluctuation on palpation, and if a large cyst occupies 
 the anterior surface of the kidney, true fluctuation can be felt. In some 
 cases tumor-tissue escapes with the urine, and examination under the 
 microscope will be of great value in rendering the diagnosis positive. 
 Buhl in his lectures on pathological anatomy used to cite and show 
 a specimen in which the sarcoma-tissue extended from the pelvis of 
 the kidney in a string-like projection to the meatus urinarius. In hydro- 
 nephrosis and pyonephrosis, if any doubt exists between these affec- 
 tions and sarcoma, an exploratory puncture through the lumbar region 
 is harmless, and will enable the surgeon to make a positive diagnosis. 
 If the tumor is large, it can be felt immediately under the abdominal 
 wall, when it feels like the back of a turtle. Ascites is usually present. 
 
6o8 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Extension to other organs and over the peritoneal surfaces is of com- 
 mon occurrence. If the disease is limited to the omentum, a radical 
 operation is indicated. 
 
 Girls appear to be more predisposed to primary sarcoma of the 
 kidney than boys. The tumor is composed of spindle-cells and large 
 and small round cells. The origin from a matrix of embryonal cells 
 is well shown in sarcoma of the kidney by the frequency with which 
 striped muscular fibres are found in the tumor. Sarcoma of the kid- 
 ney grows very rapidly and often reaches an enormous size. Tumors 
 weighing ten pounds are not rare. The tumor is usually soft, and 
 
 Ureter. 
 
 ^^H^^**^ Kidney. 
 
 Fig. 422.— Renal tumor originating in an accessory adrenal (after Henry Morris). 
 
 cysts, large and small, are common. Hemorrhage into the cysts occurs 
 frequently. In pyonephrosis an examination of the urine will throw 
 much light on the kidney affection, and in case the ureter is completely 
 obstructed, lumbar exploratory puncture will demonstrate the presence 
 of pus in the pelvis of the kidney. In two cases of sarcoma of the 
 kidney the writer found a large renal calculus in the pelvis. In one 
 case the calculus was a perfect mould of the dilated pelvis and was 
 in direct contact with the tumor-tissue. It is a question whether the 
 calculus acted as an exciting cause of the tumor or whether it devel- 
 oped in consequence of the tumor. 
 
 Treatment. — As sarcoma of the kidney destroys life in such a short 
 time, an early operation is indicated, provided the opposite kidney is 
 in a healthy condition. This question can be determined by a careful 
 
SARCOMA. 
 
 Plate i! 
 
 72v 
 
 Sarcoma of the kidney. Nephrectomy. Recovery, a, Secondary tumors; /'.polypoid projection of 
 primary tumor into the pelvis of the kidney ; c, c, invasion by tumor of the adjacent kidney-substance 
 (St. Joseph's Hospital, Chicago). 
 
SARCOMA. 609 
 
 analysis of the urine, and in females by catheterization of the ureter 
 with Kelly's catheter. The mortality after the operation has been 
 great. According to S. W. Gross, of 64 nephrectomies for malignant 
 disease, 33 died — a mortality of 52.45 per cent. A number of the 
 cases died later of metastasis or local recurrence, so that of all the 
 cases, only 5 were alive and well two years after the operation. Not- 
 withstanding these discouraging results, it is the duty of the surgeon to 
 operate if the patient's strength is such as to warrant the operation, 
 and if no indications are present that the tumor has extended beyond 
 the organ primarily affected. Age is no contraindication to the opera- 
 tion. Steele of Chicago in 1894 successfully removed an enormous sar- 
 coma of the kidney from a child only a little more than a year old. The 
 child not only recovered from the operation, but afterward gained in 
 general health. The mortality of intraperitoneal operation is over 50 
 per cent.; that of lumbar nephrectomy, about 25 per cent. If the 
 tumor is ?iot too large to be removed through a lumbar incision, this 
 method of operating should invariably be resorted to. Konig's incision 
 is the one that should be selected, as it affords more room than Simon's 
 and inflicts less traumatism than Bardenheuer's. Tumors too large 
 for the lumbar operation should be removed by an incision through 
 the linea semilunaris. A tumor that is too large to be removed by 
 lumbar nephrectomy cannot be removed by an extraperitoneal opera- 
 tion through an anterior incision, as has been claimed by some surgeons. 
 If an extraperitoneal operation in part is attempted, the peritoneum will 
 surely be torn during the operation. The external border of the rectus 
 muscle serves as a guide in making the incision. The incision through 
 the abdominal wall is made in the usual manner. After the abdominal 
 cavity has been opened to the requisite extent, the kidney, covered by 
 the parietal peritoneum, will at once come in view. The intestines are 
 kept out of the way by aseptic gauze compresses. The peritoneum 
 covering the tumor is then carefully incised, and when the capsule of 
 the kidney has been identified the kidney with the tumor is enucleated. 
 If the hilum of the kidney cannot easily be reached, and the vessels and 
 the ureter cannot be tied separately, these structures are grasped with 
 a covered compression-forceps, the kidney is removed, and the ureter 
 and the vessels are tied later. After arresting all hemorrhage the 
 peritoneal incision through which the kidney was removed is carefully 
 closed with fine silk or catgut sutures, and the external wound is closed 
 in the usual manner. As the incision has been made through the 
 abdominal muscles, at least four rows of sutures should be employed 
 in closing the external incision. If for any reason it is deemed neces- 
 sary to drain the retroperitoneal wound, a counter-opening should be 
 39 
 
610 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 made in the lumbar region by tunnelling the tissues with a pair of 
 strong and long hemostatic forceps from within outward, when the 
 skin in the lumbar region over the point of the instrument is cut, and 
 with the forceps either a tubular drain or a strip of iodoform gauze is 
 drawn through. After this has been done the peritoneal wound and 
 the abdominal incision are dealt with in the manner just described. 
 From a woman thirty-eight years of age the writer removed a sarcoma 
 of the kidney by laparotomy according to the method described. The 
 tumor weighed eight pounds. No outward symptoms followed the 
 operation, and the patient left the hospital at the expiration of five 
 weeks. For several weeks her general health continued to improve, but 
 four months after the operation a local recurrence could clearly be 
 made out. The patient succumbed six months later, ten months after 
 the operation. The tumor in this case was so large that intestinal 
 obstruction was threatened on several occasions. The intestinal symp- 
 toms were produced by pressure of the tumor upon the colon. At 
 the time of operation the colon was found in front of the tumor, 
 stretched and flattened by it. 
 
 Uterus. — The first case of sarcoma of the uterus was described in 
 i860 by Mayer. The diagnosis was verified by a microscopical exam- 
 ination of the specimen by Virchow. Soon afterward Langenbeck 
 reported a case of inversion of the sarcomatous uterus. In 1867, 
 Veit was able to find only three recorded cases. In 1871, Keegar 
 based his investigations on sarcoma of the uterus on nine cases which 
 had been reported up to that time. 
 
 Diffuse sarcoma of the submucous connective tissue of the endo- 
 metrium is much more frequent than sarcoma of the muscular wall 
 of the uterus. Of 144 cases collected by Williams, one-third were 
 limited to the mucous membrane of the cavity of the uterus. The 
 tumor occurs as a diffuse infiltration or as a polypoid growth. In the 
 diffuse infiltrating form the tumor is composed of round cells and 
 spindle-cells with a very scanty intercellular substance (Fig. 423). 
 
 Klebs and Abel have found in the uterine mucous membrane a 
 combination of carcinoma and sarcoma — a carcino-sarcoma. Diffuse 
 sarcoma of the uterine mucous membrane grows very rapidly, destroy- 
 ing the glands and the mucous membrane and infiltrating the muscular 
 wall of the uterus. Local infection spreads much more rapidly than 
 in carcinoma. 
 
 The polypoid variety appears as a firmer tumor and contains more 
 spindle-cells (Fig. 424). 
 
 In the more circumscribed form of sarcoma of the uterine mucous 
 
SARCOMA. 
 
 611 
 
 membrane the tumor attains considerable size before it ulcerates and 
 invades at its base the uterine wall (Fig. 425). 
 
 Fig. 423. — Diffuse sarcoma of the uterine mucous membrane (after Wyder). The neoplasm is separated 
 from the peritoneum on the left by a well-marked layer of healthy muscular tissue several millimeters thick; 
 the superficial portions toward the cavity of the uterus, on the right, are beginning to disintegrate. In the 
 deeper parts are seen the connective-tissue fibres, rich in fusiform cells with long and short processes. Be- 
 tween them is an amorphous basement-substance with a large accumulation of cells, the nuclei of which 
 appear to resemble those of the others. In the superficial portions the bands of the connective and muscular 
 tissues have entirely disappeared, being replaced by round cells. The tumor is rich in vessels about which 
 are foci of hemorrhage. In no part of the tumor can we find any trace of mucous membrane or of glands. 
 
 Fig. 424.— Cells from a spindle-celled sarcoma of the neck of the uterus (after Pernice). Some of the cells 
 
 present a cross-striation. 
 
 Sarcoma of the muscular wall of the uterus is also either circum- 
 scribed or diffuse. The circumscribed form resembles myoma. In 
 the diffuse variety the whole body of the uterus becomes enlarged. 
 
612 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Cyst-formation by degeneration or dilatation of lymphatics is common 
 in both forms. In a few cases cartilage has been found in uterine 
 sarcomata. 
 
 Sarcoma is most frequently met with in young women. It presents 
 many of the clinical aspects of carcinoma. The discharge is, however, 
 
 Fig. 425. — Sarcoma of the uterine mucous membrane (after Pozzi). 
 
 less fetid during the early stages, ulceration appears later, and the cer- 
 vix is not so much dilated as in carcinoma. Infection of the retro- 
 uterine glands, so common in advanced cases of uterine carcinoma, is 
 absent in sarcoma. 
 
 The prospects of a permanent cure by operation are not so good in 
 sarcoma as in carcinoma, as recurrence has followed early operations. 
 Vaginal hysterectomy is indicated in all cases in which the sarcoma 
 has not extended beyond the uterus. 
 
 Deciduoma Malignum. — This is a malignant tumor of the chorionic 
 villi, first described by Sanger in 1888. Since that time it has been 
 described by different authors; and in 1895, when J. W. Williams wrote 
 on this subject, he found 25 cases recorded, including his own. Histo- 
 logically, this tumor differs according to the structure and nature of 
 the cells of which it is composed. In some cases the tumor presented 
 a carcinomatous structure, in others the structure corresponded with 
 sarcoma, and in rare cases a combination of sarcoma and carcinoma. 
 In the majority of cases, however, the sarcomatous nature of the tumor 
 was unquestionable. In the sarcomatous form the tumor is composed 
 
SARCOMA. 
 
 613 
 
 of spindle-shaped cells, containing large nuclei and polygonal or round 
 multinuclear cells, with a very scanty or no well-defined reticulum. 
 Pregnancy is the most important etiological 
 element ; all the cases having followed labor 
 at full term, abortions, or hydatiform moles. 
 Sanger divides the cases into two groups, 
 according as they followed hydatiform moles 
 or pregnancy. The age of the patients varied 
 from seventeen to fifty-five years ; the largest 
 number of patients were between twenty and 
 thirty years of age. The most important 
 symptom is uterine hemorrhage following 
 some form of pregnancy. The hemorrhage, 
 as a rule, is not continuous, and appears 
 either soon after delivery or some months 
 later. The uterus is enlarged in proportion 
 to the size of the tumor, and its walls are 
 infiltrated by the growth. Recurrence after 
 removal of the mass is the rule. The tumor 
 gives rise to early and diffuse metastases. 
 Secondary vaginal tumors constitute a char- 
 acteristic clinical feature of this disease. The 
 prognosis is very grave, as death usually 
 occurs within six months from the appear- 
 ance of the first symptoms. In the diagnosis the clinical history of 
 the case, uterine hemorrhages, and vaginal metastases are the most 
 important evidences to be taken into consideration. As the disease is 
 so rapidly fatal, and, as a rule, the patients do not come under the care 
 of a surgeon before metastasis has taken place, the treatment is of 
 necessity only of a palliative nature. If the disease could be recog- 
 nized before it has resulted in metastases, complete removal of the 
 uterus would offer a fair chance of permanent recovery. Of eight hys- 
 terectomies performed for this condition, four died from recurrence of 
 the growth ; the other four recovered from the operation, but sufficient 
 time has not elapsed to show that the operation proved curative. 
 
 Ovary. — Sarcoma of the ovary is of rare occurrence. Cohn 
 estimates its frequency at about 1 per cent, in relation to cystic disease. 
 It is usually bilateral, and it gives rise to ascites at an early stage. 
 It is composed of spindle-cells or of round cells, the former variety 
 being more frequent. According to Eckhardt and Pomorski, many 
 sarcomata are of endothelial origin, springing from lymphatics or from 
 blood-vessels (Figs. 426, 427). 
 
 ■ < 1, 
 
 a 
 Fig. 426. — Endothelioma of the 
 ovary ; commencing proliferation of 
 endothelium in the lymphatic spaces 
 (after Pomorski) : /, lymphatic 
 space, with endothelial cells in the 
 midst of an interstitial substance of 
 the nature of connective tissue; 
 a, alveolar dilatation of lymphatic 
 space; p, proliferation of cells, 
 which arrange themselves like a 
 row of beads. (Hartnack ; oc. 3, 
 ob. 7.) 
 
614 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The symptoms of an ovarian sarcoma are those of rapidly-develop- 
 ing malignant tumors. The tumor is found in preference in young 
 women. Ascites with hard nodular masses on one or both sides of 
 the uterus should arouse suspicion regarding the malignant nature of 
 the pelvic difficulty. The extension of the tumor to the tissues out- 
 side the tumor often renders an operation very difficult and results in 
 early local recurrence. If the tumor is removed before it has ex- 
 tended to the broad ligament, the uterus, and other adjacent parts, 
 a permanent cure is possible. Braun removed a sarcoma of the 
 
 Fig. 427. — Endothelioma of the ovary ; reticular modification of connective tissue under the influence of the 
 endothelial proliferation (after Pomorski) : /, lymphatic space elongated and becoming transformed into an 
 alveolus ; b, bundles of interstitial connective tissue; r, transformation of fibrous connective tissue in a retic- 
 ulum ; ep, transformation of epithelial cells into epithelioid cells ; connection of the large cells with the ground- 
 substance. (Magnification same as that of Figure 426.) 
 
 ovary, and the patient remained in good health eleven years after the 
 operation. 
 
 Of 36 cases of ovarian sarcoma recently collected by Zangenmeister, 
 and which were subjected to radical treatment, 4 died from the imme- 
 diate and 3 from the remote effects of the operation, 3 from metastasis, 
 3 from local recurrence ; in 6 cases the ultimate result could not be 
 ascertained ; 1 1 remained in good health and free from recurrence over 
 four years, 2 after two years, and 1 died sixteen years after the opera- 
 tion from other causes. 
 
 Vagina. — Sarcoma of the vagina is found as a diffuse affection in 
 children; in the adult it presents itself as a firm, circumscribed tumor 
 manifesting little tendency to degeneration. As pathological curiosities 
 
SARCOMA. 
 
 615 
 
 in this location there must be mentioned sarcomatous tumors, contain- 
 ing striated muscular fibres, and melanotic carcinoma. 
 
 Vulva. — Among 10,000 patients Winckel saw only 2 cases of 
 sarcoma of the vulva. In one case the tumor was as large as a 
 man's head, and was attached to the vulva by a pedicle the size of 
 a child's arm. The patient was then twenty-five years of age. The 
 tumor, which was first noticed when she was seventeen years old, 
 was removed, and microscopical examination showed that it was a 
 round-cell sarcoma. In the second case the patient was a multi- 
 para forty-six years of age. The tumor, which was as large as a 
 child's head, sessile, hard, and lobulated, was removed, and exam- 
 ination showed it to be a myxo-sarcoma. Hildebrandt reports two 
 similar cases. Other cases have been recorded by Kleeberg and by 
 Gustav Simon. 
 
 Testicle. — Sarcoma of the testicle is not of frequent occurrence. 
 Virchow maintains that it is found most frequently in children, boys, 
 and old men. The writer has seen several cases of sarcoma in men 
 from twenty to forty years of age. The tumor is composed of spindle- 
 cells or of round cells, or it presents itself as a mixed-cell tumor. The 
 round cells are very large and are often multinuclear. The tumor is 
 quite firm, and on section presents a yellowish- or grayish-red color. 
 It frequently begins in the epididymis. As the tumor increases in size 
 the parenchyma of the testicle is displaced and destroyed. If perfora- 
 tion of the tunica albuginea has taken place, the tumor grows very 
 rapidly. Extension along the spermatic cord results in speedy and 
 extensive regional infection. Metastasis fre- 
 quently precedes the fatal termination. Very 
 often the same affection appears in the opposite 
 testicle. 
 
 In the differential diagnosis of sarcoma of the 
 testicle it is important to exclude carcinoma, tuber- 
 culosis, gumma, and hematocele. Figure 428 
 represents a sarcoma of the testicle that occurred 
 in a child three and a half years old, and which 
 was carefully reported by Neumann. 
 
 Castration is indicated if the spermatic cord is 
 not affected or if the diseased part of the cord can 
 be removed. In all operations for malignant dis- 
 ease the cord should be removed as high as pos- 
 sible. For this purpose the inguinal canal should 
 be laid open, and by gradual traction as much of the cord as practicable 
 should be brought down and liberated. Enlargement of the retroperi- 
 
 Fig. 428.— Myosarcoma of 
 the testis (after Neumann). 
 
616 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 toneal glands in the inguinal region contraindicates castration. Some 
 of the sarcomatous tumors of the testicle contain striated muscular 
 fibres, and in very rare cases the tumor is pigmented. 
 
 Brain and its Envelopes. — In the brain we have described, as 
 peculiar varieties of sarcoma, psammoma and glioma. The dura mater 
 is not infrequently the starting-point of sarcoma. The tumor destroys 
 the bone over it, and appears, after perforation has taken place, as 
 a pulsating tumor. 
 
 Operative treatment is contraindicated in psammoma and is of 
 doubtful propriety in glioma. Bergmann for good reasons opposes 
 intracranial operation for malignant disease. Surgeons, however, will 
 continue to operate for glioma, as the tumor frequently produces focal 
 symptoms which enable them to locate it with precision, and a positive 
 diagnosis is usually made only after the tumor has been exposed or 
 after operation, by examination of sections of the tumor under the 
 microscope. 
 
 Sarcoma of the dura mater, if it could be diagnosed at an early 
 stage, should be removed by operation. After the tumor has perforated 
 the skull the intracranial part of the tumor is usually so extensive that 
 an operation would prove of no avail. 
 
 Bye. — The optic nerve and its branches are not infrequently the 
 seat of glioma. In the interior of the eye the malignant tumors are 
 represented by melano-carcinoma and melano-sarcoma, the latter being 
 much the more frequent. Pigmented sarcoma may arise from any part 
 of the uveal tract — that is, from the pigmented tissue of the iris, the 
 ciliary body, and the choroid. The commonest seat is the choroid. 
 
 The intraocular sarcomata are either round-celled, spindle-celled, or 
 mixed-cell sarcoma. Sarcoma of the eye occurs most frequently in per- 
 sons from forty to sixty years of age, but is occasionally seen in children. 
 The tumor extends along the blood-vessels and the optic nerve. The 
 increased intraocular tension results in sloughing of the cornea, when 
 the tumor protrudes in the form of a pigmented fungous mass. Exten- 
 sion of the tumor along the optic nerve into the cranial cavity does 
 not often take place. Metastasis at quite an early stage is of frequent 
 occurrence, the tumor in this respect resembling melano-sarcoma of 
 the skin. 
 
 Early enucleation is the only surgical resource in all cases of melano- 
 sarcoma of the interior of the eye. This operation should be performed 
 as soon as the tumor can be detected and diagnosed by the aid of the 
 ophthalmoscope. 
 
 Bladder. — Sarcoma is a very rare affection of the bladder, and 
 most of the cases so far reported were in young females. Kuster 
 
SARCOMA. 617 
 
 reported five cases, and one case came under the observation of Konig, 
 who removed a pedunculated round-celled sarcoma the size of a hen's 
 egg from the neck of the bladder by perineal section. Sarcoma in the 
 bladder, in its structure and its manner of local extension, very closely 
 resembles sarcoma of the uterus. It starts most frequently in the 
 submucous connective tissue. In the differential diagnosis between 
 sarcoma and carcinoma of the bladder it is important to remember 
 that sarcoma is much the more rare, that it is found in preference in 
 young females, and that ulceration occurs later than in sarcoma. The 
 differential diagnosis between sarcoma of the bladder and benign 
 tumors, and the treatment, are the same as in carcinoma. 
 
 Prostate. — Malignant tumors of the prostate start primarily in this 
 organ, as the prostate is seldom affected secondarily either by extension 
 of the tumor from an adjacent organ or by metastasis. Wyss collected 
 28 cases of malignant disease of the prostate in young boys less than 
 ten years old. In all of the cases the prostate was the primary seat of 
 the tumor. The symptoms resemble those of carcinoma of the same 
 organ. Thompson has reported 18 cases of primary malignant tumors 
 of the prostate. Kapuste has shown by his investigations that tumors 
 of the prostate in children are usually sarcomatous, while carcinoma 
 of this organ is a disease of advanced age. Besides the functional 
 disturbances produced by the tumor, spontaneous pain, hemorrhages, 
 and the escape of fragments of the tumor after ulceration has set in 
 are the most conspicuous clinical phenomena. 
 
 Radical operations for tumors of the prostate have been performed 
 by Billroth, Demarquay, Nussbaum, and others. In Nussbaum's and 
 Billroth's cases a part of the rectum was removed with the prostate 
 and a part of the bladder-wall. If the disease has not extended beyond 
 the prostate — and these are the cases to which radical operations should 
 be restricted — the prostate and as much of the neck of the bladder as 
 is endangered by the tumor should be removed through the perineal 
 incision devised by Zuckerkandl. The efficiency and safety of the 
 operation would be enhanced by a preliminary suprapubic cystotomy. 
 
XXIX. TERATOMA. 
 
 So far we have considered tumors composed of a single representa- 
 tive histological element. We have studied tumors composed of cells 
 derived from one of the germinal layers — the epiblast, the hypoblast, 
 and the mesoblast — and have found that the different classes of tumors 
 represented the tissues of only one of these embryonal layers. The 
 epiblast and the hypoblast were represented by papilloma, adenoma, 
 and carcinoma ; the mesoblast, by the different tumors representing the 
 connective-tissue type of benign tumors and sarcoma. We now come 
 to the last class of tumors that contain tissues and organs derived 
 from two or all of the germinal layers. 
 
 Definition. — A teratoma is a tumor composed of various tissues, 
 organs, or systems of organs which do not normally exist at the place 
 where the tumor grows. The highest type of a teratoma is a foetus 
 in foetu. In the simpler varieties the tumor is composed of heterotopic 
 tissues, such as bone, teeth, skin, mucous membrane, etc. All teratoid 
 tumors are congenital ; that is, the tumor either exists at the time of 
 birtli or the patient is born with the essential tumor-matrix. A teratoma 
 never springs from a matrix of post-natal origin. 
 
 Origin of Teratoid Tumors. — A tumor composed of a single rep- 
 resentative histological element frequently starts from a matrix of post- 
 natal origin, as the writer has aimed to show in connection with all the 
 tumors so far discussed ; but the more complicated matrix of a tera- 
 toma has invariably a congenital origin, and is produced in the embryo 
 by errors of growth and by displacement of tissue by inclusion. Klebs 
 classifies teratoma according to their origin into endogenous and ecto- 
 genous, the former arising from a matrix formed in the same individual, 
 the latter from foetal inclusion. The latter mode of origin is possible, 
 but certainly very rare. A case of this kind was recently reported 
 from Gussenbauer's clinic by Pupovac. The patient was an infant, and 
 the congenital tumor involved the side of the neck. Examination of 
 the tumor showed embryonic tissue representing different parts of the 
 body — bone, cartilage, muscle-, gland-, and brain-tissue. One of the 
 strongest arguments in support of the correctness of Cohnheim's theory 
 concerning the origin of tumors is furnished by the teratomata. Maas 
 succeeded in producing dermoid cysts artificially in animals by implan- 
 
 618 
 
TERATOMA. 619 
 
 tation of dermoid fetal tissue. He produced dermoid cysts in young rats 
 by introducing into the peritoneal cavity pieces of skin and parts of limbs 
 of new-born rats. After two and a half months he found small cysts 
 containing pus, cholesterin, and hair. The lining of these cysts was com- 
 posed of tissues representing all the histological elements of true skin. 
 A great deal of speculation has been rife in reference to the origin 
 of the higher types of teratoma. Rauber pointed out that two embryos 
 may spring up in union in the same blastoderm or close to one another, 
 in which case they may afterward fuse. Fusion is more frequent at 
 the caudal extremity, but occasionally it occurs at the cephalic end or 
 elsewhere along the vertebral axis. In the subsequent growth the 
 embryos usually develop unequally until one becomes a mere parasite 
 on the other. In conformity with this explanation is the fact that der- 
 moid teratoid formations in the region of the coccyx are proportionately 
 common. At the cephalic end, in the region of the hypophysis, tera- 
 toid tumors are occasionally met with, the origin of which could be 
 explained upon the same hypothesis. Williams, on the contrary, is 
 firmly convinced that such tumors are produced not by blending of 
 two distinct embryos, but by giant growth of undifferentiated cells : 
 " Occasionally a mass of undifferentiated protoplasmic cells manifests 
 reproductive properties similar to those of the hydra, so that from a 
 single cell two or more individuals may proceed. Thus, when the 
 division of the undifferentiated embryo into two symmetrical parts is 
 complete, and each of these develops into a new being, homologous 
 twins are the result ; and this, so common a mode of reproduction in 
 the lower animals and plants, is the only instance of reproduction by 
 gemmation in the highest animals. In this way double monsters arise. 
 The locality and degree of fusion present many variations. The usual 
 points of attachment are the sacrum, sternum, umbilicus, and head. 
 The sex of the individuals in homologous twins and double monsters 
 is invariably the same. In other instances the distribution of proto- 
 plasmic cells in the embryo is unequal, so that only one of the two 
 fetuses attains full development. The former are called 'autosites;' 
 the latter, ' parasites,' because they depend for nutrition upon the body 
 to which they are attached. The parasite is either attached to the sur- 
 face of the autosite by implantation or is surrounded by the tissues of 
 the autosite by inclusion. Sometimes only a part of a new individual 
 is formed in such a manner, which gives rise to tumor-like formations 
 called by Virchow 'teratoma.' Such tumors are found most fre- 
 quently in the region of the ovaries, testicles, sacrum, and sella turcica. 
 They represent imperfect parasitic fetuses. Partial fission of the embryo 
 at the cephalic end gives rise, according to the degree of fission, to 
 
620 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 duplication of the pituitary body, to the formation of two distinct and 
 complete faces. Additional masses of protoplasmic cells result in the 
 formation of all kinds of deformities, as supernumerary fingers and toes, 
 supernumerary mammary and thyroid glands, and, if the cells only 
 possess the intrinsic capacity to produce one tissue, all conceivable forms 
 of local hypertrophies, such as angiomas, moles, warts, lipomas, etc." 
 
 There can be but little doubt that double monstrosities are the 
 result of fusion of two distinct embryos, as symmetrical segmentations 
 of an embryo to this extent in man and the higher animals is not likely 
 to occur. We have also reason to believe that ectogenous and en- 
 dogenous parasites originate in a similar manner, while the different 
 varieties of dermoids, the teratomata proper, originate in the manner 
 indicated by Williams and others. 
 
 Endogenous Teratomata. — These tumors are represented by the 
 histioid and organoid varieties. The histioid variety is represented by 
 heterotopic tumors, such as chondroma branchiogenes, branchial cysts, 
 and the simplest forms of dermoid cysts. The organoid tumors spring 
 from displaced embryonal matrices representing different tissues and 
 organs, and occur in localities where in the embryo displacement of 
 tissue has taken place. The capacity of tissue-proliferation of the cells 
 of which the matrix is composed does not exceed that of the cells of 
 the corresponding normal tissue. For instance, a dislocated tooth- 
 germ will produce a* tooth not larger than a normal tooth, and a dis- 
 located acinus of a gland will produce an acinus which in size does 
 not exceed the acinus of a corresponding normal gland. 
 
 Sutton describes a rare case of ovarian mamma removed from a 
 woman twenty-six years of age, supposed to be suffering from tubercu- 
 lar peritonitis. Upon opening the abdomen a considerable quantity of 
 pus escaped, mixed with hair and sebaceous material, showing it to be 
 the remains of a dermoid cyst. On examination, a peculiar, rounded 
 body, growing from the wall of the cyst, was found, recognized as an 
 ovarian mamma, and removed. It presented an ordinary nipple and 
 a cluster of glandular material, the ducts of which traversed the nipple. 
 
 The endogenous skin-teratoma is the most frequent form of fetal 
 inclusion. Portions of the embryonal skin become buried in the meso- 
 blast and are isolated by constriction from the skin, and serve later as 
 matrices for dermoid tumors. In many endogenous teratoid tumors 
 the matrix, derived in a similar manner, has a more complicated struc- 
 ture, and from it develop teeth, bone, portions of the alimentary canal, 
 etc. In such a manner originate, in the interior of the skull, tumors 
 containing striated muscular fibres (Arnold) and teeth (Hugo Beck). 
 
 Ectog-enous Teratomata. — Ectogenous teratomata are produced by 
 
TERATOMA. 
 
 621 
 
 the blending or fusion of two distinct embryos. The tumors originate 
 either by the allantois of one fetus entering the cavities of the body of 
 the other fetus, where its vessels enter into communication with those 
 of the other, or by attachment between two impregnated ova, of which 
 one grows around the other. In the first case inclusions, allantoid 
 inclusions, are formed in connection with the umbilical cord and the 
 placenta-like productions ; in the latter instance the development of the 
 included fetus is impaired by the greater development of the organs 
 and tissues of the autosite, and often only remnants are found in the 
 place formerly occupied by the parasitic fetus. 
 
 In the museum of the College of Physicians and Surgeons in Lon- 
 don is the most perfect specimen of foetus in fcetu. The autosite, a boy, 
 lived to be fourteen years of age and was well developed. At the post- 
 mortem there was found in the abdominal cavity a perfect, full-grown 
 fetus surrounded by a sac or membrane. 
 
 Ahlfeld collected 20 cases of foetus in foetu, but he believes that in 
 perhaps half of them the diagnosis was erroneous, dermoid cysts hav- 
 ing been mistaken for inclusio foetalis. Inclusion-cysts not only contain 
 a diversity of tissue elements and organs, but they are almost always 
 multilocular ; while, on the other hand, dermoid cysts are lined with 
 skin, which presents all the structures of normal skin — epidermis, rete 
 
 Fig. 429.— The inclusion of one embryo within the cephalic fold of the other (Ahlfeld). 
 
 Malpighii, papillae, sweat and sebaceous glands, hair, teeth, etc. — and in 
 most cases the cyst is unilocular (Fig. 429). 
 
 In some of these cases of fetal inclusion parts of the parasitic fetus 
 grow, while other parts are dwarfed by insufficient vascular supply, 
 cease to grow, and are removed by absorption. 
 
 To the pre-allantoid teratomata belong the fetal implantations in 
 
Fig 430. — Laloo, a Hindoo with an acardiac parasite attached to the thorax. 
 
 Fig. 431.— Dipygus (Wells). 
 
TERA TOMA. 623 
 
 which parts of the parasitic fetus are contained in cysts. Such cysts 
 are found in the mediastinum, the brain, the abdomen, the ovaries, and 
 the testicles. Ahlfeld separated from these tumors what he calls " fetal 
 transplantation " — cases in which rudimentary fetal parts are engrafted 
 upon the surface of the body. In partial fetal inclusions the acardiac 
 parasite may present externally to the autosite all limbs (Fig. 430), or 
 the upper part of the body may be destroyed by inclusion and the 
 lower limbs may project from the autosite (Fig. 431). 
 
 The included parasitic fetus is often blighted at a very early stage, 
 and none of its organs reaches a full degree of development. The more 
 important organs either are absent or are present in only a rudimentary 
 form. This form of teratoma has been well described by Sutton as 
 " acardiac fetus." 
 
 In some cases the fetus consists simply of a shapeless mass in 
 which only traces of the skeleton and of the more important organs 
 are found. The sex is invariably the same as that of the autosite; the 
 acardiac can occur only in plural births. 
 
 Acardiacs may appear in plural births as separate beings, or they may 
 be attached to the twin autosite in a variety of ways. In a few instances 
 the autosite and the acardiac parasite have lived and attained maturity. 
 
 The diagnosis of included parasites according to their location is 
 usually impossible and is at all times uncertain. The recognition of 
 parasitic fetuses or parts of them on the surface of autosites is attended 
 by no difficulty. 
 
 Sutton has well said that parasitic acardiacs are in almost all cases 
 so valuable as sources of gain in dime museums, fairs, shows, and large 
 cities that the parents or the unscrupulous individuals who get pos- 
 session of these children will not permit operative interference, and 
 hence it is useless to discuss the propriety and feasibility of operation 
 in cases of autosites bearing an acardiac fetus. 
 
 The different forms of superfetation and blending of twins by attach- 
 ment or by allantoid inclusion, so interesting to embryologists and 
 pathologists, are of little practical value to the surgeon. The surgical 
 interest of teratoma attaches itself to those tumors caused by displace- 
 ment of fetal tissues, parts, or organs, to which Virchow applied the 
 term "teratoma," or, from their resemblance to a terato, "teratoid 
 tumors." We shall discuss at greater detail the tumors included in 
 this class — branchial and dermoid cysts. 
 
 Branchial Cysts. 
 Tumors in the branchial clefts are not so very rare as was formerly 
 believed. Chondroma branchiogenes was described in the section on 
 
624 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Chondroma. Branchial ftstnlce and cysts result from imperfect oblitera- 
 tion of one of the branchial clefts. 
 
 Anatomy and Embryology. — Toward the end of the first month 
 of fetal life we see under the frontal process, open in front and bounded 
 on the sides by four plates, the pharyngeal cavity. The upper pair 
 of plates constitute the first branchial arch. The next three pairs of 
 plates make up the second, third, and fourth branchial arches, which 
 decrease in size from above downward, so that their median interspaces 
 in front are narrow above and wider lower down. Between each pair 
 of branchial arches on each side remains a transverse cleft, the branchial 
 clefts, which are obliterated during early fetal life, with the exception 
 of the first one, from which the external auditory canal, the cavity of 
 the tympanum, and the Eustachian tube are developed. From the 
 second branchial arch are developed the styloid process, the stylo- 
 hyoid ligament, and the lesser horn of the hyoid bone. The third arch 
 forms the large horn and the body of this bone. The fourth arch 
 assists in forming the soft tissues of the neck. The larynx, the 
 trachea, and the adjacent glands are developed from other centres 
 of fetal growth. 
 
 The primary starting-point of branchial cysts must necessarily cor- 
 respond with the location of one of these branchial clefts, and clinical 
 
 observation has demonstrated that branchial 
 cysts are most frequently found in the region 
 of the second and third clefts, in the vicinity 
 of the larynx and pharynx, and in intimate 
 relation with the sheath of the large vessels 
 of the neck, in contradistinction to dermoid 
 cysts about the orbits and the scalp, which 
 are more superficially located (Langenbeck). 
 We shall have frequent occasion to allude 
 to the intimate connection of these tumors 
 with the sheath of the large vessels of the 
 neck, and consequently it is very important 
 to study their anatomical relations to these 
 important structures. The jugular vein is 
 surrounded throughout its whole course in 
 the neck by a distinct and separate sheath of areolar tissue, which on 
 the outer side of the artery penetrates into the deep tissues of the neck, 
 thus completely separating the two vessels. The jugular, enclosed in 
 its sheath, may easily be drawn over the artery toward the median 
 line without producing any change of location of the artery. The 
 
 Fig. 432.— Branchial cyst of the 
 third branchial cleft in a woman 
 thirty-eight years old. 
 
TERATOMA. 625 
 
 vein being in front of the artery and covering half of the circumference 
 of the latter, it can readily be understood that when the vein is drawn 
 forward with its sheath it can be injured, while the artery is not exposed 
 to the same danger. Branchial cysts of the second and third clefts 
 are always found in the sheath of the large cervical vessels, usually in 
 the carotid triangle above the omo-hyoid muscle. These cysts, which 
 appear to occur more frequently on the left side of the neck, are 
 invariably round or oval, with a smooth surface. The contents of 
 these cysts being either fluid or semi-fluid, fluctuation can be felt, more 
 particularly if the tumor is palpated between two fingers from the 
 pharynx or the floor of the mouth and the external surface. Only 
 lateral motion of the tumor is possible, on account of its peculiar 
 attachments to the deep tissues of the neck. If the tumor is of only 
 moderate size, the pulsations of the carotid artery can be felt on its 
 inner margin. If the tumor is large, it overlaps the artery, and the 
 pulsations of the vessel are communicated to the tumor. Small tumors 
 can be made to pulsate by bending the head backward and in a direc- 
 tion opposite to the tumor. 
 
 History. — Branchial fistulae, persistent branchial clefts, have been 
 known longer than branchial cysts. It appears that Hunczowski 
 more than a hundred years ago described two cases of congenital 
 fistulous openings in the side of the neck. About fifty years later Roser 
 made the statement that many of the so-called " ranulas " about the 
 base of the tongue, the mucoid and dermoid cysts of the upper cer- 
 vical region, are due to imperfect closure of one of the branchial tracts. 
 All these tumors he included in one group under the name " branchial 
 cysts." He described three distinct conditions which may result from 
 entire absence or from imperfect obliteration of any one of the branch- 
 ial clefts: 1. Branchial fistula, in case the entire tract remains open; 
 2. Cystic fistula, in case only one end of the cleft is obliterated, while 
 the other open end communicates with the pharynx or with the cutane- 
 ous surface; 3. Branchial cysts, in the event that the cleft is closed 
 at both ends, while between them it remains open, and by proliferation 
 from the inner surface produces an accumulation — the contents of the 
 cyst. 
 
 Hensinger in 1862 collected a number of cases of branchial cysts, 
 and associated them with the branchial clefts discovered by Rathke. 
 Branchial fistulae are always congenital. Branchial cysts are congenital 
 in the sense that patients are born with the tumor-matrix, which con- 
 sists of the unobliterated . portion of a branchial cleft ; but the tumor 
 frequently does not appear until the person arrives at the age of 
 puberty, when, by the stimulus imparted by an increased physiological 
 
 40 
 
626 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 function of the skin, active tissue-proliferation of the cells composing 
 the cyst-wall sets in, resulting in the formation of the cyst-contents. 
 
 Although these cysts are by no means common, being less frequent 
 than congenital branchial fistulae, a sufficient number of cases have been 
 placed on record to remove all doubt as to the etiological relations 
 existing between imperfectly obliterated branchial clefts and the serous, 
 the dermoid, and the so-called " deep-seated " atheromatous tumors of 
 congenital origin located in the regions formed by the branchial arches. 
 These tumors have been made a special object of study by Langen- 
 beck, Liicke, Gurlt, Virchow, Schede, Esmarch, and Hensinger. 
 
 Classification. — Branchial cysts must be classified according to 
 their contents. The cyst-wall being lined with epithelium displaced 
 from the pharynx or from the skin, the only histological element in 
 the contents is epithelium (Fig. 433). The wall is composed of con- 
 
 Fig. 433.— Structure of wall of branchial cyst, from case represented in Figure 444 ; X 280 : a, blood- 
 vessel; b, inflammatory infiltration; c, connective tissue; d, epithelial lining of cyst; e, contents of cyst. 
 
 nective tissue lined on the inside with epithelial cells. In most instances 
 the epithelium lining the cyst-wall and contained in the cyst-contents 
 represents the epithelium of the skin (Fig. 434) ; but Rehn discovered, 
 in a blind congenital fistula ending near the mucous membrane of the 
 pharynx, ciliated epithelium, which, of course, must have been derived 
 from the pharynx. Neumann found cylindrical and pavement epithe- 
 lium in two cystic tumors of the neck ; one of the tumors was con- 
 genital, while the other was developed in later years. The presence 
 of ciliated epithelium may be explained by assuming its origin to have 
 been in the upper part of the cleft, the fornix pharyngis, where these 
 
TERATOMA. 
 
 627 
 
 fistulae oftentimes end and where ciliated epithelium normally exists. 
 The lower end was probably derived from the skin, and was lined with 
 flat cells. 
 
 The physical and chemical properties of the cyst-contents will 
 depend largely on the kind and degree of regressive transformation 
 
 Fig. 434. — Contents of branchial cyst; X 140. 
 
 of the epithelial proliferation. In making the character of the cyst- 
 contents a basis for classification it is, however, important to remember 
 that, as in ordinary retention-cysts, the contents of a branchial cyst are 
 liable to undergo changes depending on the retrograde changes of the 
 epithelial product, on hemorrhage and other transudations into the sac, 
 or on the occurrence of inflammation in the cyst-wall itself. It is only 
 during the earliest stages that the characteristic secretion is found in 
 its purity. In the course of time the original character of the cyst- 
 contents may be lost completely by retrograde metamorphosis or by the 
 addition of new material. 
 
 Clinical experience and pathological investigations have shown that 
 branchial cysts, according to the physical properties of their contents, 
 may be divided into the following principal varieties : I. Mucous cysts ; 
 2. Atheromatous cysts ; 3. Serous cysts ; 4. Hemato-cysts. Variable 
 as the contents of these different varieties of cysts may be, more 
 uniformity is observed in the structure of the cyst-wall. In the begin- 
 ning the cyst-wall consists of a connective-tissue capsule with an 
 epithelial lining on its inner surface (Fig. 433), and a delicate layer of 
 a loosely connected reticulum of connective tissue, the pericystium, 
 which is very vascular and which covers the outer surface of the cyst. 
 
628 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 A high degree of intracystic pressure may cause atrophy of the 
 epithelial lining and thinning of the walls of the sac ; on the contrary, 
 inflammatory proliferation produces great thickening of the cyst-wall. 
 While dermoid cysts contain the characteristic secretions of the skin 
 and its appendages, the branchial cysts contain the product of epithelial 
 cells, because their walls do not contain any hair-follicles, sebaceous 
 glands, or sweat-glands, as the branchial clefts close before these 
 appendages are formed. 
 
 Mucous Branchial Cysts. — As a primary tumor this form of 
 branchial cyst is found in the upper part of the branchial clefts. The 
 origin of mucous branchial cysts is attributable to an imperfect closure 
 of the upper portion of a branchial tract ; consequently the cyst-wall 
 may derive its lining from the mucous membrane of the pharynx, and 
 the retention of the physiological secretion produces a mucous cyst. 
 Many of the so-called " ranular " cysts about the base of the tongue 
 belong to this variety of tumors. 
 
 Congenital mucous cysts in the region of the base of the tongue 
 and the sides of the larynx in the majority of cases are due to an 
 imperfect closure of the upper portion of one of the branchial tracts. 
 
 Atheromatous Branchial Cysts. — This form of branchial cyst has 
 been described as a deep-seated atheromatous cyst of the neck (Schede) 
 and as a dermoid cyst of the sheath of the large vessels of the neck 
 (Langenbeck). The cysts are usually located in the second or third 
 branchial tract, in the region of the hyoid bone, and they are inti- 
 mately connected with the sheath of the large vessels. They contain 
 an atheromatous material resembling the contents of an ordinary reten- 
 tion-cyst of the sebaceous glands. They never contain lanuginose 
 hair, as do many of the dermoid cysts. Gurlt mentions the great 
 similarity existing between the contents of these tumors and those of 
 some ovarian cysts. Besides fat-globules and epithelial debris these 
 cysts contain an abundance of cholesterin-crystals and of small pris- 
 matic crystals which seem to be some form of inorganic salt, as well 
 as lime in granular form. In some cases the inner surface of the cyst- 
 wall is covered with papillomatous excrescences, the product of epithe- 
 lial proliferation. 
 
 These atheromatous branchial cysts may occur in the first branchial 
 cleft, as is shown by a case reported by Virchow, who described the 
 cyst as an " auricular teratoma." The patient was a seamstress twenty- 
 four years of age. The tumor was first noticed when she was fourteen 
 years old, when it was as large as a filbert ; it increased slowly in size, 
 and when first seen by Virchow it was as large as a goose-egg ; it was 
 located between the angle of the jaw and the mastoid process, and was 
 
TERATOMA. 629 
 
 firmly attached to the sheath of the carotid artery. The cyst was filled 
 with a creamy yellowish fluid which contained free fat and epithelium. 
 The portion attached to the sheath of the vessels contained a plate of 
 cartilage resembling the cartilage of the ear ; hence Virchow designated 
 the tumor as an " auricular teratoma." Virchow, who attributed the 
 origin of this and of analogous growths to an imperfect obliteration 
 of the first branchial cleft, in his classification of tumors includes among 
 the teratoid tumors the cysts developed from branchial clefts. 
 
 Serous Branchial Cysts. — This form of branchial cyst is composed 
 of thin cyst-walls and serous contents. The cysts very much resemble 
 in structure and contents the lymphangiectatic cysts of the neck, for 
 which cysts they have often been mistaken. They occupy one of the 
 branchial clefts, and they are lined by epithelial instead of endothelial 
 cells, as is the case in cysts originating from lymphatics. The lymph- 
 angiectatic cysts are usually congenital. We have seen that branchial 
 cysts are not necessarily developed during intra-uterine life or soon 
 after birth. All that is necessary is that the matrix for the cyst be 
 present at the time of birth ; from this matrix, at some future time, the 
 tumor is developed. These tumors appear as either single or multiloc- 
 ular cysts with thin membranous walls ; their internal surface is lined 
 with epithelial cells. Besides serous fluid they contain epithelial cells 
 and cholesterin-crystals. Clinically, they may be recognized from their 
 location, their globular form, their soft fluctuating feel, and their pain- 
 less growth. The existence of pavement epithelium upon the inner 
 surface of these cysts has been demonstrated by Neumann and Baum- 
 garten. When these cysts spring from the second or third branchial 
 clefts they are usually deeply located. Hueter, in extirpating a tumor 
 of this kind in a child two years of age, found that the tumor extended 
 between the two carotid arteries back to the pharynx. That these 
 tumors may sometimes grow to an enormous size is evident from a case 
 reported by Treves. The tumor, which occurred in an infant, took its 
 origin in the region of the inferior maxilla and occupied the whole side 
 of the neck and the upper part of the thorax on the same side, whence 
 it extended as far as the umbilicus. It contained one large and numer- 
 ous smaller cysts, and it corresponded with the region of the second 
 branchial tract. No histological report of the specimen was made. 
 Vonwiller reports a case of double serous branchial cyst. The writer 
 has seen a number of such cysts in young children. The cysts wore 
 either present at the time of birth or developed a few months later. 
 
 Hemato-cysts of Branchial Clefts. — In some instances of serous 
 branchial cysts the fluid is discolored by an admixture o( blood from 
 minute hemorrhages into the sac ; but when the contents are of such 
 
630 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 dark color as to resemble venous blood the cysts are properly called 
 " hemato-cysts," and from a pathological, clinical, and diagnostic point 
 of view they constitute a distinct and well-marked variety of branchial 
 cysts. Albert remarks that two kinds of these cysts have been ob- 
 served : I. Those which can be emptied by pressure and which are 
 in direct communication with blood-vessels ; 2. Those which are not 
 affected by pressure, and which simulate the appearance of an ordinary 
 serous cyst so closely that their nature is recognized only by explora- 
 tory puncture. The latter class of cysts, when they occur in the neck, 
 usually belong to the branchial cysts, because they are observed during 
 early life and originate in places which correspond with the location of 
 branchial clefts. This variety of cysts has been called hematocele colli 
 by Michaux, and hematocele by J. P. Frank. Aside from their origin 
 from branchial clefts and the admixture of blood with the contents of 
 serous cysts, hemato-cysts may develop from dilated veins, both extrem- 
 ities of the dilated portion undergoing contraction and finally complete 
 obliteration, completely isolating the contents of the cyst from the 
 general circulation. Again, a vein may dilate at one point, forming 
 a pouch or a sac, and by contraction and obliteration of the orifice 
 a blood-cyst is formed. 
 
 Hemato-cysts resemble serous cysts in every particular, with the 
 exception of the presence of blood in their contents. Their diagnosis, 
 however, is more difficult than that of serous cysts, and it should 
 always be made by exclusion, due attention being given to the location 
 of the cyst, its time of development, and the character of its contents. 
 The last point can be settled definitely by an exploratory puncture. 
 
 Etiology. — Branchial cysts of the neck, as compared with other 
 tumors in this locality, are of rare occurrence. The statistics of 
 branchial tumors cannot be relied upon in estimating the comparative 
 frequency with which these tumors occur, as many branchial cysts have 
 been classified and described under the generic and indefinite term 
 " cystic tumors of the neck," without regard to their etiology. Gurlt 
 in 1855 compiled 44 cases of serous and 6 cases of atheromatous cysts. 
 Since that time a great many more cases have been reported. The 
 serous variety is more apt to develop early. The tumors are often 
 congenital or appear during infancy or childhood, while the athe- 
 romatous cysts are most frequently met with in young adults. Of 53 
 cases tabulated by Schede, 9 occurred between the first and tenth years, 
 21 between the eleventh and twentieth, 10 between the twenty-first and 
 thirtieth, 6 between the thirty-first and fortieth, 5 between the forty-first 
 and fiftieth, and 2 between the fifty-first and sixtieth years. Like the 
 dermoid cysts, the branchial cysts show a tendency to develop during 
 
TERATOMA. 631 
 
 the period of puberty, at a time when the tissue of epiblastic origin 
 enters upon a new and more active phase of development. The 
 remnant of a branchial cleft may remain dormant as a matrix for 
 the future growth of the tumor for an indefinite period of time, and 
 become the seat of tissue-growth during puberty or upon the advent 
 of any other determining cause or causes. There are undoubtedly 
 many instances where remnants of fetal tissue remain latent in the 
 branchial tracts throughout a long lifetime for want of an adequate 
 exciting cause, which is necessary to stimulate into morbid activity the 
 slumbering forces inherent in the histological elements of the matrix. 
 
 Diagnosis. — To diagnose the presence of a branchial cyst is often 
 no easy task. The importance of the tissues and organs in close and 
 intimate relation with these tumors renders it imperative upon the 
 surgeon to make a correct diagnosis before an operation is undertaken 
 for their removal. All signs and symptoms should be investigated 
 carefully, and every diagnosis should be fortified by eliminating by 
 exclusion the existence of all other forms of tumors and infective 
 swellings. The following conditions may stimulate a branchial cyst : 
 
 1. Aneurysms; 2. Hemato-cysts and lymphangioma ; 3. Dermoid 
 cysts; 4. Retention-cysts; 5. Lymphangiectatic cysts; 6. Struma 
 cystica. After eliciting a careful clinical history as to the location and 
 the time of development of the tumor, these affections should be gone 
 over seriatim in making a differential diagnosis between them and 
 a branchial cyst. The exploratory syringe will frequently be called 
 into requisition to ascertain the character of the cyst-contents. 
 
 Prognosis. — Branchial cysts, although heterologous formations, 
 always remain purely local affections, manifesting no tendency to 
 destroy life except when they are of a size sufficient to interfere by their 
 presence with the performance of important functions of neighboring 
 organs. The tumor may encroach upon the cavity of the mouth, inter- 
 fering with speech, mastication, and deglutition, or it may compress the 
 larynx or the trachea, thus interfering with respiration. 
 
 Branchial cysts manifest no tendency to spontaneous cure, and prove 
 exceedingly rebellious to all kinds of treatment short of complete 
 extirpation. In a case of branchial cyst of the second branchial cleft 
 with mucous contents, the writer was informed by the patient that she 
 had been operated upon more than fifty times, the tumor reappearing 
 each time within a few weeks after the operation. That part of the 
 cyst-wall which had not been extirpated was found greatly thickened 
 and firmly attached to the internal carotid artery and the hyoid bone. 
 
 The serous variety is most amenable to the milder forms of treat- 
 ment. Frequently the tumor attains a certain size and then remains 
 
632 PATHOLOGY AND TREATMENT OE TUMORS. 
 
 stationary, but the tendency is to increase in size progressively until 
 important organs are encroached upon, when the suffering and distress 
 occasioned demand prompt operative interference. 
 
 Treatment. — The inner surface of branchial cysts being lined with 
 epithelium, it is evident that obliteration of the sac can be secured only 
 after the destruction or removal of this epidermal lining. The surgical 
 treatment must have for its object the production, in the interior of the 
 sac, of an artificial inflammation of sufficient intensity to destroy the 
 epidermal matrix, or complete extirpation of the cyst. The former 
 procedure is exceedingly unreliable in its results, and extirpation in 
 many instances may be looked upon as a formidable and dangerous 
 operation. The following methods have been resorted to in the treat- 
 ment of branchial cysts: 1. Incision; 2. Actual cautery; 3. Seton; 
 4. Puncture, with subsequent injection; 5. Extirpation; 6. Antiseptic 
 drainage. In all cases where incision was practised the relief from 
 existing symptoms was prompt. The cyst collapsed ; a certain amount 
 of inflammation followed"; usually, after the healing of the wound there 
 remained a small nodule which in a few weeks became the seat of 
 active tissue-growth, and a speedy recurrence followed. The result 
 was not materially modified in case the sac was drained and injected 
 with iodine or with other irritating solutions. 
 
 In infants the laying open of cysts of the neck is a perilous plan 
 of treatment. Volkers relates a case where a cystic tumor was laid 
 open in a new-born child, which died sixteen days later in consequence 
 of the operation. 
 
 In the case of serous cysts where the seton and iodine injections 
 have occasionally been successful in producing obliteration, it seems 
 to the writer that the same object would be accomplished more 
 speedily and safely by incision and drainage, practised in a manner 
 similar to that in Volkmann's operation for hydrocele. 
 
 Dieffenbach employed the actual cautery in opening the cyst in one 
 of his cases, after he had made an unsuccessful attempt at removal by 
 extirpation, and after incision had failed in producing obliteration of the 
 sac. The use of the cautery also failed in producing obliteration of 
 the sac. 
 
 It would seem to the writer that incision, combined with a use of 
 the actual cautery sufficiently energetic to destroy the entire thickness 
 of the epithelial lining, would be most applicable in the more danger- 
 ous and formidable class of cases — namely, in cysts that have become 
 firmly adherent to the sheath of the larger vessels by repeated attacks 
 of inflammation provoked by inefficient treatment. After cauterization 
 the wound should be packed with iodoform gauze. If, during the 
 
TERATOMA. 633 
 
 progress of the healing of the wound from the bottom by granulation, 
 it becomes apparent that the entire matrix has not been destroyed, the 
 use of the actual cautery can be repeated. 
 
 The seton has resulted in a permanent cure in a few cases of serous 
 cysts, but its use should be abandoned, as the result is uncertain and 
 the consequences are often disastrous. Butlin reports a case where, 
 in a young child, a seton was passed through a serous cyst : death 
 from inflammation followed on the third day. For this and other 
 obvious reasons the seton should never be employed in the treatment 
 of branchial cysts. 
 
 Esmarch's experience with puncture and injection of Lugol's solu- 
 tion of iodine (iodini, pot. iod., gm. 1.25 ; aquae, 30.0) has been favorable. 
 The following remarks were made by him on this subject at the fourth 
 meeting of the Congress of German Surgeons : 
 
 " I have cured about a dozen cases by puncture and subsequent 
 injection of Lugol's solution of iodine. Against this treatment it has 
 been urged that complete extirpation of the cyst can always be done 
 and is free from danger. I must deny this assertion, because in a 
 majority of cases the cyst is adherent to the sheath of the internal 
 jugular vein — a fact which may remind you of a paper on this subject 
 by Prof, von Langenbeck, which served as an introductory to his 
 Archiv in i860. In this paper Langenbeck called special attention to 
 the dangers connected with this operation. But even if the operation 
 were free from danger, yet by resorting to it we obtain an unsightly 
 cicatrix in the neck, to which the female sex objects. I can, on the 
 other hand, recommend injections of iodine as an efficacious and en- 
 tirely safe procedure. If some of you have failed to see its benefits, 
 it is, I believe, because you have not had the necessary patience and 
 perseverance. As a rule, I have repeated the operation whenever oblit- 
 eration did not promptly follow the first puncture. It is very essential 
 to irrigate the sac thoroughly before the introduction of the iodine. 
 I have generally proceeded as follows : By means of a fine hydrocele 
 trocar I empty the sac of its contents, and then make repeated injec- 
 tions of a 1 per cent, solution of carbolic acid. This removes the 
 masses of epithelium adherent to the cyst-wall. I continue these injec- 
 tions until the water returns perfectly clear, and then I inject 10 to 20 
 grams of Lugol's solution of iodine, which, after gentle pressure to 
 bring it in contact with the inner surface of the sac, is allowed to escape. 
 The patient is then directed to return in six or eight weeks. Like a 
 hydrocele, the cyst refills rapidly and becomes somewhat painful. 
 If, after the lapse of time mentioned, it has not greatly decreased in size, 
 I repeat the same operation and tell the patient to return in six months, 
 
634 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 when the cyst will be found atrophied to a small tubercle. In most 
 cases the cure has been permanent." 
 
 In the discussion which followed Langenbeck said : " I have treated 
 a number of dermoid cysts with fatty contents by means of injections 
 of iodine, but the injections always required repetition. I punctured 
 the cyst with a large trocar, introduced a piece of elastic catheter, and 
 made daily injections. A few cases were cured after three or four 
 injections. In one case the tumor returned. I consider it very diffi- 
 cult to cure these fatty cysts with injections of iodine or any other 
 substance." 
 
 Roser admitted that injections of iodine might succeed in serous and 
 mucous cysts, but that they would prove of no avail in atheromatous 
 cysts. Baum asserted that extirpation was an easy matter, and that 
 these cysts could be removed without difficulty. 
 
 Bardeleben believed that some of these cysts, especially those which 
 extend behind the sternum, could not be extirpated, but obliteration 
 in one instance was accomplished by antiseptic drainage. Volkmann 
 spoke in favor of extirpation, and warned against injections of iodine, 
 as in case of failure they would render a subsequent excision more 
 difficult. 
 
 It is evident that most German surgeons who have given attention 
 to this subject have no confidence in the efficacy of iodine injections 
 in obliterating branchial cysts. If we consider the numerous failures 
 of iodine injections in cases of hydrocele, where the anatomical con- 
 ditions for success are so much more favorable than in branchial cysts, 
 we will be better prepared to appreciate the causes of the still more 
 frequent failure of this method when used in the treatment of branchial 
 cysts. Again, clinical experience has shown that a branchial cyst can 
 be extirpated with comparative ease and safety before the cyst has 
 become firmly fixed to the subjacent cervical vessels by inflammatory 
 infiltration, and that in this class of cases iodine or any other injections 
 will not only prove useless, but will render a subsequent extirpation 
 still more difficult. In infants even simple tapping is not always devoid 
 of danger, as one instance is recorded of death caused by puncture. 
 The case occurred to Volkers, who tapped a cystic cervical tumor in 
 an infant eight days old, the child dying of trismus on the third day. 
 
 Extirpation. — A positive diagnosis made, the best plan to pursue 
 is to make an incision over the most prominent portion of the tumor, 
 parallel with the sterno-mastoid muscle ; in case the adhesions can 
 be separated without endangering the deep cervical vessels, the entire 
 cyst should be removed. If inflammatory infiltrations obscure the field 
 of operation at the base of the tumor, and after careful examination 
 
TERATOMA. 635 
 
 it is deemed inadvisable to perform complete extirpation, the sac 
 should be opened and the lateral walls excised, and the epidermal 
 matrix, which remains adherent to the sheath of the cervical vessels, 
 can be destroyed completely by a careful but vigorous use of the 
 actual cautery. The treatment of the wound should be conducted as 
 in cases of complete excision. If an early diagnosis is made and prompt 
 treatment is instituted, complete extirpation should always be attempted, 
 and will in the majority of cases prove successful and comparatively 
 free from danger. 
 
 Antiseptic Drainage. — In the case of infants and very young children 
 suffering from large serous cysts it would be imprudent to resort to 
 any of the severer measures with a view to a radical cure. In such 
 instances drainage under antiseptic precautions should be resorted to as 
 a temporary measure, and in some cases it may be followed by perma- 
 nent results. The same course of treatment should be adopted in 
 adults suffering from cysts which are inaccessible to any other opera- 
 tion and in which irritating injections are contraindicated. 
 
 The writer's experience in the extirpation of branchial cysts, amount- 
 ing now to about fifteen cases, has been uniformly favorable. No deaths 
 occurred from the operation, and in every case the result was permanent. 
 In one case the internal jugular vein was cut in dissecting away the 
 adherent inflamed sac from the vessels of the neck. The hemorrhage 
 was controlled by the use of hemostatic forceps on both sides of 
 the wound. The forceps were allowed to remain until the cyst was 
 removed, when the jugular vein was completely divided and both ends 
 were tied with catgut. The patient made an uneventful recovery. 
 
 Dragging upon the vein if the cyst-wall has become adherent should 
 be avoided. Branchial cysts which have not become adherent by 
 antecedent attacks of inflammation can readily be removed by enu- 
 cleation. 
 
 Dermoid Cysts. 
 
 A dermoid cyst is a teratoid tumor. It is called "dermoid" because 
 it contains skin derived from the epiblast by displacement of an embry- 
 onal epiblastic matrix, from which, during the development of the 
 tumor by proliferation of the skin and its appendages, the principal 
 contents of the tumor are formed. In the simplest varieties of dermoid 
 cysts the contents of the cyst are composed of epithelial proliferation 
 alone, when nothing is found in the cyst but epithelial cells and their 
 detritus mixed with serum, forming the peculiar atheromatous material 
 which constitutes the characteristic contents of retention-cysts o\' the 
 sebaceous glands. This kind of cyst is produced from a matrix derived 
 
636 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 from the epiblast before differentiation has advanced to the formation 
 of the appendages of the skin. A matrix derived from the epiblast 
 after its differentiation into appendages of the skin (hair-follicles, seba- 
 ceous glands, and sweat-glands) has taken place not only yields epithe- 
 lial cells, but produces also hair and the secretion of sebaceous glands 
 and sweat-glands. In tumors from such a matrix hair is constantly 
 found. 
 
 Superficial dermoid cysts are due to inclusions of parts of the 
 epidermis, and which Chiari taught remained connected with the 
 superficial epithelium. The fissural position of the dermoids — that 
 is, their presence in places where fcetal fissures had existed or 
 where clefts were closed — supports such a conclusion. The deep- 
 seated dermoids, in the abdomen, lungs, etc., must be explained by 
 a complete separation of the epithelial cells from which they take 
 their origin. 
 
 According to Epstein, in new-born infants it is not uncommon to 
 find isolated pearls of epithelial cells which have become buried in the 
 connective tissue by inclusion. It would therefore be more proper to 
 look upon subcutaneous atheroma as the product of tissue-prolifera- 
 tion from such an isolated island of epithelial tissue, as was done by 
 Heschl, than as a sebaceous cyst. 
 
 The difference between a dermoid and such an atheroma would be 
 that in the former a whole section of skin had become buried, while in 
 the latter only a projection of epidermis with a single hair had taken 
 place. 
 
 Heiberg demonstrated the identity of the lining of a dermoid cyst 
 of the neck with normal skin from a practical standpoint. He utilized 
 the lining membrane as grafts in the healing of a large ulcer of the leg. 
 The grafts united promptly with the granulating surface, and the new 
 skin showed the same properties and structure as in cases of skin- 
 grafting. 
 
 Some dermoids contain not only skin, but also mucous membrane, 
 the latter owing its existence to a matrix derived from the hypoblast. 
 The term " dermoid " is, however, also used to designate cysts with 
 more complicated contents, such as teeth, bone, cartilage, and combina- 
 tions of different parts and organs that could originate only from a 
 displaced matrix representing different tissues and organs. 
 
 Definition. — A dermoid cyst is a heterotopic tumor containing the 
 product of epithelial proliferation, hair, teeth, etc. Dermoid cysts were 
 first described in 1852 by Lebert, who applied the term "dermoid" to 
 all cysts lined by a cyst-wall resembling in structure that of the exter- 
 nal skin. Dermoid cysts are found most frequently in the ovary and 
 
TERATOMA. 
 
 637 
 
 in parts of the body where, during development, the different germinal 
 layers meet, as about the orbita, the neck, and the coccygeal region. 
 In 188 cases of dermoid cysts Lebert found that the ovary was the 
 seat of the tumor in 129. 
 
 Histology. — The wall of a dermoid cyst is composed of connective 
 tissue; its inner surface is often smooth, resembling a serous surface, 
 but microscopical examination always reveals an epithelial lining com- 
 posed, according to the character of the epithelial cells, of one or more 
 A 
 
 B 
 
 fart 
 
 tee 
 fee 
 
 nap 
 
 rasps 
 
 Fig. 435. — Section from a congenital teratoma of the coccygeal region ; X 90 (after Perls), a : a, ciliated 
 epithelial lining of cysts ; b, smooth muscle-fibres in which the striations are indistinct ; c, cartilage ; d, fatty 
 tissue, b, wall of a cyst lined by ciliated epithelium ; X 350 (after Perls). 
 
 layers (Fig. 435). If the cysts are lined with columnar or ciliated 
 epithelium, the cells arc arranged, as a rule, in a single layer ; if, on the 
 
 Fig. 436.— Sacral tumor (Mutter Museum, College of Physicians, Philadelphia). 
 
 contrary, the matrix represents skin in place of mucous membrane, 
 pavement cells in many layers line the cyst. In cyst-walls supplied 
 
638 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 with the appendages of the skin these appendages are seen and occupy 
 the same relations to the cutis as in normal skin. 
 
 Hair is the most frequent of the many cutaneous appendages in 
 dermoids. The hair in a dermoid, called by Virchow lanugo, is fine 
 and of a blonde or light-brown color, even in negroes. In birds 
 dermoids contain feathers ; in pigs, bristles. In sequestral dermoids 
 the hair is short ; in ovarian dermoids it is often several feet in length. 
 The hair in dermoids of aged persons turns white, and baldness of the 
 
 Fig. 437. — Dermoid cyst of ovary; section through wall ; X 18 (after Karg and Schmorl). On the sur- 
 face, to the left of the picture, the cyst is covered with a thin layer of flat epithelial cells (a), with remnants 
 of glands and hair; next follows the infiltrated corium (b), beneath which are bundles of flat muscle-fibres (c) 
 cut transversely and longitudinally ; d, hollow spaces surrounded by a layer of unstriped muscular fibres and 
 lined with cylindrical epithelium; between these hollow spaces is myxomatous tissue. 
 
 inner surface of dermoid cysts is as often met with as baldness of the 
 scalp. The hair grows, as on the skin, from perfect hair-follicles 
 
 (Fig. 437)- 
 
 Teeth and bone are found most frequently in ovarian dermoids. 
 Teeth have also been found in dermoid cysts of the rectum and behind 
 the rectum, in cysts of the first and second branchial clefts, and in 
 exceptional cases in dermoids of the brain. The teeth are composed 
 of dentine, enamel, and cementum, arranged in the same manner as 
 in normal teeth, and they are developed on the same plan. 
 
TERATOMA. 
 
 639 
 
 The so-called " epithelial pearls," resembling in structure the 
 cholesteatomata, are also found in some dermoid cysts. They form 
 where the epithelial cells are crowded together ; they arrange them- 
 selves in onion-like layers (Fig. 438). 
 
 The cutaneous lining of dermoid cysts, like the external skin, is 
 subject to the formation of benign and malignant tumors. Carcinoma 
 may develop in a dermoid cyst. Benign epithelial tumors, papilloma, 
 and adenoma are frequently met with. 
 
 Regressive Metamorphoses. — The degenerative changes which 
 take place in a dermoid cyst consist in retrograde metamorphoses of 
 the cells which constitute its lining, and which are detached and con- 
 stitute a part of the cyst-contents. Squamous epithelium undergoes most 
 frequently fatty degeneration. The contents of the cyst are then com- 
 posed of granular detritus, free fat-globules, and cholesterin-crystals. 
 
 Fig. 438.— Epithelial pearl (after Kanthack). 
 
 Fatty degeneration of the epithelial cells in dermal tumors is often so 
 extensive that the cyst contains pure oil. Mr. Hunter preserved a 
 specimen of what he marked " oil from an adipose encysted tumor," 
 taken from a cyst that grew between the bony orbit and the upper eye- 
 lid of a young man. The liquid fat burned with a very clear light and 
 did not mix with water, and when it was exposed to cold it became as 
 solid as human fat. 
 
 The hair which falls out in a dermoid cyst forms masses suspended 
 in the emulsion. In cysts lined by columnar epithelial cells the gland- 
 ular secretion is mucus, which accumulates in the cyst. In old cysts 
 
640 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 the mucus is frequently transformed into serum. Inflammation of the 
 interior of the cyst by the entrance into it of pyogenic microbes occa- 
 sionally takes place, whereupon the products of the suppurative inflam- 
 mation of the cyst-wall are added to the contents of the cyst, resulting 
 in great distention; frequently the inflammation extends beyond the 
 limits of the sac, producing, in the case of ovarian dermoids, peritonitis, 
 and in other localities a phlegmonous inflammation. Inflammation 
 always results in firm adhesion of the outer surface of the cyst-wall 
 to the adjacent tissues or organs. 
 
 A dermoid cyst is not infrequently the starting-point of a carcinoma. 
 Carcinoma of the branchial clefts, "carcinoma branchiogenes," was first 
 described by Volkmann. Primary carcinoma in localities in which no 
 epithelial cells exist not infrequently starts from a dermoid cyst that 
 perhaps had never been discovered, or from a dermoid cyst-matrix. 
 
 Sarcoma may develop from a matrix of a dermoid cyst containing 
 the essential tumor-matrix of embryonal connective tissue. 
 
 Diagnosis. — Dermoid cysts grow slowly and, as a rule, do not attain 
 a very large size. With the exception of dermoids of the ovary, tumors 
 larger than a hen's egg are rare. They produce no pain except from 
 pressure or when they become the seat of inflammation. They develop 
 most frequently during the age of puberty, although they occur some- 
 times as congenital tumors. They occupy localities where, during 
 embryonal life, the most complicated tissue-changes take place. It has 
 been asserted that the ovary is the most frequent seat of dermoids : 
 this is probably a mistake ; the impression has been caused by the 
 fact that subcutaneous dermoids, constituting insignificant affections 
 from an operative standpoint, are not recorded so constantly as der- 
 moids of the ovary, which have a peculiar fascination for the abdominal 
 surgeon. We have reason to believe that the subcutaneous tissue is 
 the most frequent seat of dermoid tumors. 
 
 Dermoid cysts accessible to palpation fluctuate in proportion as the 
 contents have undergone liquefaction. If the contents are solid and 
 the cyst-wall is tense, fluctuation is absent. Subcutaneous dermoids 
 are frequently mistaken for retention-cysts of the sebaceous glands. 
 Retention-cysts of the sebaceous glands commonly occupy the hairy 
 scalp, where dermoid cysts are comparatively rare. The retention- 
 cysts usually retain their connection with the skin, while, the skin is 
 not connected with the subcutaneous dermoid. In dermoids of the 
 ovary, as compared with other cysts, the slow growth of the tumor 
 serves as an important point in the differential diagnosis. The differen- 
 tial diagnosis of sacral dermoids and of spina bifida is often very diffi- 
 cult, and conclusions should be postponed in doubtful cases until an 
 
TERATOMA. 641 
 
 exploratory puncture has demonstrated the character of the contents 
 of the cyst. 
 
 Prognosis. — The prognosis in dermoid tumors is generally favor- 
 able, as these tumors grow slowly and often reach only a certain 
 definite size, thereafter remaining stationary. Ovarian dermoids often 
 become dangerous to life from inflammatory complications. The con- 
 tents of a dermoid cyst of the ovary must always be regarded as of 
 an infectious nature. The escape of the contents into the peritoneal 
 cavity during removal of a cyst has frequently caused septic peri- 
 tonitis of a most violent character. The sudden increase in size of a 
 dermoid cyst that has for a long time been in a quiescent state indicates 
 either the existence of an inflammation or the transformation of a 
 benign into a malignant tumor. 
 
 Treatment. — The proper surgical treatment of a dermoid cyst 
 is complete extirpation. Tapping, seton, irritating injections, and 
 caustics are all inappropriate measures in the treatment of dermoid 
 cysts. In the removal of dermoid cysts it must be remembered that 
 the tumor will surely return if the slightest particle of the lining of 
 the cyst-wall is allowed to remain. The dissection is frequently a very 
 difficult one, and recesses of the cyst-wall are often overlooked ; these 
 recesses become the starting-point of the recurrent tumor. If possible, 
 the cyst should be removed without rupturing the cyst-wall. If this 
 can be done, the surgeon has the satisfaction of knowing that the 
 lining has been removed completely, and he can give the patient the 
 assurance that no recurrence will take place. 
 
 In the extirpation of dermoid cysts a knife not much larger than 
 a tenotomy-knife should be employed, and very little traction upon the 
 cyst-wall should be made, as this is sometimes exceedingly fragile and 
 easily torn. 
 
 Topography. 
 
 Dermoid cysts are found most frequently in those parts of the 
 body where, during the development of the embryo, the different 
 germinal layers meet and blend ; this is more especially the case with 
 tumors of complicated structure, in the production of which all the 
 germinal layers take part. 
 
 Trunk. — In the embryo the two lateral halves of the body blend in 
 the median line posteriorly from the occipital protuberance to the 
 coccyx. It is in the centre of the body, following the line of coalescence, 
 that dermoids are found, more especially in the region of the sacrum 
 and the coccyx. In this locality dermoid cysts are very apt to be 
 mistaken for spina bifida if the opening in the spinal canal is small 
 
 41 
 
642 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and the integument covering it is normal. The difficulty in diagnosis 
 is increased if, as sometimes happens, the spina bifida is associated 
 with a dermoid. Wild has reported the case of a man twenty-two 
 years old who was born with what was supposed to be a spina bifida 
 in the lumbo-sacral region. The swelling never caused him any pain 
 or inconvenience until it became inflamed, when it suppurated and 
 opened spontaneously, discharging a large quantity of offensive pus, 
 hair, and sebaceous material. The cyst was freely incised. Its wall 
 showed numerous openings of sweat-glands, from which drops of 
 sweat escaped when the patient perspired. 
 
 At the junction of the sacrum with the coccyx, and over the coccyx 
 at a point corresponding with the post-anal dimple, dermoid cysts are 
 quite frequently found. They are usually small, and they are often 
 associated with a blind fistulous tract. In a number of cases where 
 cysts in this locality had suppurated a small fistulous opening remained, 
 and when this opening became closed the swelling reappeared and 
 again suppurated. 
 
 In the removal of suppurating dermoids in the sacro-coccygeal 
 region the careful use of the probe is necessary to ascertain the extent 
 and exact location of the cyst. The writer has usually found more or 
 less hair as a part of the cyst-contents. The displacement of skin 
 takes place here so frequently because of the early adhesion of the 
 skin to the underlying bone, and the subsequent growth of the sur- 
 rounding fat and muscle-tissue, causing the dimpling, sinus-formation, 
 or epithelial inclusions as the case may be. 
 
 No operation for a supposed dermoid anywhere over the spine 
 should be undertaken until spina bifida has positively been excluded 
 by an exploratory puncture, which can be repeated if necessary. 
 
 Thorax. — Dermoid tumors of the thorax are rare. They are 
 found usually over the median part of the chest, over the sternum, or 
 in the anterior mediastinum. Bramann reported a case in which a 
 dermoid cyst of small size was located over the sternum, at the junc- 
 tion of the manubrium with the gladiolus, and a similar cyst in the 
 anterior median line of the neck near the left cornu of the hyoid bone 
 (Fig. 439). Cahan saw a dermoid cyst over the sternum in a child 
 eight months old. The tumor at birth was not larger than a pea. 
 Chitten removed a dermoid having the same situation from a female 
 thirty-nine years of age ; the cyst contained eleven ounces of atheroma- 
 tous material. 
 
 The dermoids in the mediastinum spring from a matrix of skin that 
 in the embryo became imprisoned between the two lateral halves of 
 the sternum, becoming detached when coalescence of the sternum 
 
TERA TO MA. 6 43 
 
 took place. A remarkable specimen of this kind was presented by 
 Mr. Kingdon to the museum of St. Bartholomew's Hospital, London. 
 In the anterior mediastinum of a woman twenty-one years old a 
 tumor, probably of congenital origin, contained portions of skin and 
 fat, serous fluid, sebaceous material, and two pieces of bone, like parts 
 of an upper jaw, in which seven well-formed teeth were imbedded. 
 
 Fig. 439. — Dermoid situated over the junction of the manubrium and the gladiolus of the sternum ; there was 
 also a dermoid near the left cornu of the hyoid bone (after Bramann). 
 
 In a case of substernal dermoid which projected above the manu- 
 brium of the sternum, Roser incised the tumor ; after decomposition 
 of its contents had taken place he trephined the sternum, securing in 
 this way efficient drainage. 
 
 A large dermoid cyst in the mediastinum may simulate inflamma- 
 tory disease of the lungs or pleura or a malignant tumor. A suppurat- 
 ing dermoid with rupture into the bronchial tubes would perfectly 
 resemble empyema unless hair were to be discovered in the expec- 
 torated material, making the diagnosis of dermoid cyst positive. In 
 suppurating substernal dermoid it would be necessary to resort to 
 resection of a part of the sternum over the cyst to secure efficient 
 drainage and disinfection. Farther than this it would not be prudent 
 
644 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 to extend the operative procedure, owing to the importance of the 
 various organs to which the cyst-wall would necessarily be attached 
 firmly. 
 
 Face. — Facial dermoids occur in the lines of the facial fissure in 
 the embryo. The central portion of the face in the early embryo is an 
 opening from which five fissures radiate (Fig. 440). " The upper pair 
 are the orbito-nasal ; the two lower fissures are 
 termed 'mandibular;' and a fifth, not shown in 
 the figure, the ' intermandibular ' fissure. The 
 median fold projecting into the opening from 
 above is the fronto-nasal process, which ulti- 
 mately forms the nose. As it develops, a rounded 
 prominence known as the ' globular process ' 
 forms at each angle and gives rise to a portion 
 of the ala of the nostril and the corresponding 
 premaxilla. These globular processes fuse to- 
 gether in the middle line to form the central 
 piece, or philtrum, of the upper lip. The elon- 
 
 Fig. 440.— Head of an early r r rsr r 
 
 human embryo, showing the gation of the fronto-nasal process necessarily 
 
 '2°r S Hfs).° fthefaCialfiSSUreS len g thens the orbito-nasal fissures. Eventually 
 the sides of the fronto-nasal plate coalesce super- 
 ficially with the maxillary processes in such a way as to leave a cleft 
 on each side, which becomes the orbit, the line of union being perma- 
 nently indicated in the adult by the naso-facial sulcus or groove, and 
 indicated still more deeply by the lachrymal duct, which is a persistent 
 portion of the original orbito-nasal fissure. The union of the fronto- 
 nasal plate with the maxillary processes completes the nose, cheeks, 
 and upper lip " (Sutton). 
 
 From the foregoing description of the development of the face it 
 will be understood that dermoid cysts will appear in certain definite 
 positions, such as the inner and outer angles of the orbit, the upper 
 eyelid, in the naso-facial sulcus, on the cheek slightly posterior to 
 the angle of the mouth, in the middle line of the chin, and on the 
 nose. Dermoid cysts in all these localities seldom exceed a filbert 
 in size. They often contain hair, and they sometimes contain pure 
 oil. The underlying bone shows a shallow or deep depression after 
 their removal. They are firmly attached to the bone ; they are 
 frequently congenital; fluctuation is distinct; and the skin overlying 
 them is normal. The most frequent location of dermoid cysts of 
 the face is at the outer angle of the eye. In this situation the 
 orbital arch of the frontal bone often shows a depression deep enough 
 to hold one-half of the cyst. If the cyst occupies the inner angle of 
 
TERATOMA. 
 
 645 
 
 the eye, the nasal process of the frontal bone suffers from pressure- 
 atrophy. The depression in the bones of the face caused by tumors 
 
 Fig. 441. — Dermoid arising in naso-facial sulcus (after Bramann). 
 
 that have existed for a long time diminishes somewhat after their 
 removal, but is never entirely effaced — a matter 
 to be taken into consideration when patients, 
 especially young girls, request an operation 
 for cosmetic reasons. 
 
 Nasal dermoids are situated either on the 
 side or over the centre of the nose (Fig. 
 441). 
 
 Palate and Pharynx. — In the hard palate 
 very complicated teratoid tumors containing 
 even a part of a limb have been found. The 
 soft palate is more frequently the seat of ordi- 
 nary dermoids than the hard palate (Fig. 442). 
 The tumors may attain the size of a hen's f*g. ^.-Pedunculated dermoid 
 egg; they contain often numerous epithelial tumor from the pharyngeal aspect 
 
 of the soft palate (after Arnold). 
 
 pearls, and the stroma frequently undergoes 
 
 myxomatous degeneration. As these tumors are always encapsulated 
 
 even when pendulous, they can be removed by enucleation. 
 
646 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Scalp and Dura Mater. — Retention-cysts of the sebaceous glands 
 of the scalp may occur on any part of its surface, while dermoid cysts, 
 owing to the manner of development of the cranium in the embryo, are 
 found almost exclusively in the median line, at the occipital fontanelle, 
 and over the anterior fontanelle. Occasionally these tumors are con- 
 nected with the dura mater. Sutton describes such a specimen. 
 Cases have been recorded in which the tumor reached the size of a 
 cocoanut. As these tumors are congenital and are most frequently 
 located over the anterior fontanelle (Fig. 443), it is not astonishing 
 
 Fig. 443. — Congenital tumor over the anterior fontanelle (after Hutchinson). 
 
 that they have usually been mistaken for meningocele. This decep- 
 tion is increased from the fact that in some cases the tumor pulsates. 
 Such a case was published by Arnott. In the case recorded by 
 Giraldis aspiration was performed and a clear serous fluid was with- 
 drawn, but when the tumor was removed some time later it was found 
 to be a typical dermoid. 
 
 Dermoids of the scalp are underneath the periosteum ; they pro- 
 duce great defects in the bone from pressure. In some instances 
 the pressure-atrophy was so extensive that the bone was perfo- 
 rated. In other cases the tumor was surrounded by a new wall of 
 bone. In rare cases dermoids originate in the bones of the skull. 
 According to Mikulicz, the petrous portion of the temporal bone, the 
 occipital bone, and the frontal bone are the most frequent seats of 
 dermoids. 
 
 In the differential diagnosis between retention-cysts of the scalp and 
 dermoid cysts it is important to remember that the former never appear 
 before puberty, while the latter are either congenital or, at any rate, 
 occur during infancy or childhood. The wall of a dermoid cyst is much 
 thinner than that of a retention-cyst. Dermoid cysts are less apt to 
 become infected than retention-cysts. 
 
TERATOMA. 647 
 
 In the operative treatment of dermoid cysts the possibility of a 
 connection with the dura mater should not be forgotten. 
 
 Bye. — The first cases of open dermoids of the bulb were described in 
 1853 by Riba. Sutton classifies open dermoids of the conjunctiva with 
 moles. They occur most frequently at 
 the margins of the cornea, and usually in 
 the line of the palpebral fissure. In the 
 embryo the tissue which becomes the 
 conjunctiva is continuous with the skin, 
 and by differentiation is derived from the 
 skin. If a part of the epiblast that is 
 intended to form conjunctival tissue 
 should become transformed into skin, Fig. 444.— Mole on the caruncle, as- 
 
 .11 • 1 • j\ -11 r sociated with an eccentric pupil (after 
 
 it will remain as skin and will form an Demours) 
 
 open dermoid, such as that shown in 
 
 Figure 444. Open dermoids of the bulb are consequently frequently 
 
 complicated by congenital defects of the upper eyelid, especially the 
 
 one known as " Colombo," which corresponds in its location with the 
 
 dermoid of the conjunctiva. 
 
 Tongue. — Barker collected sixteen cases of dermoid tumors of the 
 tongue and made a special study of their anatomical location. Bryk, 
 who made a most valuable contribution to this subject, removed a 
 tumor, the size of a fist, which filled the entire cavity of the mouth and 
 formed a large swelling in the upper anterior part of the neck, whence 
 it was successfully removed. Bauer and Linhart reported similar cases. 
 Giiterbock removed from the lateral aspect of the base of the tongue 
 a cyst of this kind that contained atheromatous material and fine 
 hairs. 
 
 Central lingual dermoids are rare. Richet removed one from a 
 child a few days old. Sutton reports, in a man twenty-four years 
 of age, a case of central lingual dermoid which during nine years 
 had been operated upon, without success, seven times. Sutton 
 found the cyst firmly adherent to the body of the hyoid bone, and 
 extending from the genio-hyoglossi to the foramen cecum. Dermoids 
 lying in the middle of the tongue arise in the lingual duct, which 
 extends from the foramen cecum on the dorsum of the tongue to the 
 posterior surface of the body of the hyoid bone. They originate from 
 unobliterated parts of the duct, in the same manner as the branchial 
 cysts originate from partially obliterated branchial clefts. An enormous 
 tumor of this kind was removed from a negro by Wellington Gray 
 (Fig. 445). The tumor contained forty ounces of atheromatous material. 
 In a case operated upon by Stephen Paget, in a child four years old, the 
 
PATHOLOGY AND TREATMENT OF TUMORS. 
 
 tumor was congenital and cc: ed a yellowish serum. A rare form 
 of tumor of the tongue ir the neighborhood of the foramen cecum 
 resembles in structure thyroid tissue. Bernays, who removed such a 
 tumor from a girl seventeen years of age, traced its origin to the lingual 
 
 Fig. 445-— Large lingual dermoid protruding from the mouth (after Gray). 
 
 duct. Similar cases have been reported by Butlin, Rushton, Parker, 
 and Wolf. Wolf believed that thyroid tumors of the tongue originate 
 from accessory thyroid glands. 
 
 Small lingual and sublingual dermoids can be removed successfully 
 through the mouth by enucleation, as the tumors are always well 
 encapsulated ; and, unless the walls have become firmly adherent in 
 consequence of inflammation or of inadequate treatment, enucleation 
 can be effected without difficulty. If the tumors are too large for 
 intra-oral operation, they should be removed through a median incis- 
 ion extending from the symphysis mentis to the upper border of the 
 thyroid cartilage. As soon as the pericystium is reached the enuclea- 
 tion is begun. The operation is facilitated by removing the contents 
 of the cyst, after which the sac can be removed through a small incision. 
 In several cases the writer has been able to remove sublingual der- 
 moids the size of a goose-egg through a small incision in the mouth 
 by first evacuating their contents, and then dragging the sac out in the 
 same manner as in the removal of the sac of a retention-cyst of the 
 sebaceous glands. 
 
TERATOMA. 
 
 649 
 
 Rectum.— Dermoids of the rect Kind of the space between the 
 rectum and the sacrum are not uncommon j. they usually occur as con- 
 genital tumors. Sutton explains their embryological origin as follows : 
 " In the early embryo the central canal of the spinal cord and the ali- 
 mentary canal are continuous around the caudal extremity of the noto- 
 chord. This passage, which brings the developing cord and gut into 
 such intimate union, is known as the ' neurenteric canal' When the 
 proctodeum invaginates to form part of the cloacal chamber, it meets 
 the gut at a point some distance anterior to the spot where the neuren- 
 teric canal opens into it ; hence there is for a time a segment of intestine 
 extending behind the anus, and termed in consequence the ' post-anal 
 gut.' Afterward this post-anal 
 section of the embryonic intes- 
 tine disappears, leaving merely a 
 trace of its existence in the small 
 structure at the tip of the coccyx, 
 known as the ' coccygeal body.' " 
 
 There is good reason to re- 
 gard the post-anal gut as the 
 source of that variety of congen- 
 ital sacro-coccygeal tumor named 
 by Braun and several writers who 
 followed him " congenital cystic 
 sarcoma." What was regarded 
 by Braun as tumors of Luschka's 
 gland and congenital cystic sar- 
 coma are thyroid-dermoids. 
 
 Diverticula from the central 
 spinal canal forming cysts are 
 sometimes displaced laterally, as 
 in a case operated upon by Wolff 
 in Central Africa, the specimen of which was examined by Virchow. 
 Manuel refers to two dermoid tumors situated in the loose connective 
 tissue between the peritoneum and the levator ani. Konig observed 
 in a young girl a case of suppurating dermoid in the same location ; 
 from the tumor numerous pieces of bone, teeth, and hair escaped. 
 In rare cases such tumors are also found between the bladder and the 
 rectum. 
 
 Thyroid-dermoids in the coccygeal region acquire a large size (Fig. 
 446). Middeldorpf first associated them with the post-anal gut. In the 
 interior of the tumor are spaces or cysts lined by columnar epithelium ; 
 these spaces contain a ropy mucus. 
 
 Fig. 446.— Thyroid-dermoid (after Hutchinson). 
 
650 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Dermoid cysts between the rectum and the sacrum often attain great 
 size, and frequently they suppurate. They are found as frequently in 
 men as in women. Interesting cases of dermoids in this location have 
 been reported by Bryant, Ord, and Page. 
 
 Open dermoids of the rectum and bladder were first described in 
 1874 by Danzel and Martini (Fig. 447). The tumors are furnished 
 
 Fig. 447.— Rectal dermoid (after Danzel). 
 
 with long locks of hair that protrude from the anus ; sometimes they 
 also contain teeth. It was formerly supposed that dermoids of the 
 rectum originated in the ovary and reached the rectum by invagination 
 — an opinion which is no longer tenable. In Danzel's case the tumor 
 was as large as an apple and was said to contain brain-substance en- 
 closed in a bony capsule ; a tooth projected from the tumor. Clutton 
 removed a rectal dermoid from a girl nine years of age. In the rec- 
 tum as well as in the pharynx dermoid tumors eventually become 
 pedunculated. 
 
 Auricle. — The external ear in the embryo is formed by coalescence 
 of a number of tubercles. If, during the process of fusion, an island 
 of skin becomes buried, it forms a matrix from which at any time a 
 dermoid cyst may grow. Dermoids of the auricle never attain large 
 size, and they are usually mistaken for sebaceous cysts. The tumor 
 sometimes occupies the groove between the pinna and the mastoid 
 process. 
 
 The removal of pedunculated open dermoids of the rectum offers 
 no difficulties ; on the contrary, the extirpation of perirectal tumors 
 requires often a formidable operation. Usually the difficulties of ope- 
 rative removal are increased by inflammation and suppuration, which 
 render the dissection tedious and difficult. The writer remembers dis- 
 
TERATOMA. 
 
 651 
 
 tinctly a case of post-rectal dermoid which had suppurated and ruptured 
 just below the coccyx. When the 
 case was examined there was found 
 
 Fig. 448. — Dermoid of the auricle and nevus of 
 the palpebral conjunctiva (after Lannelongue). 
 
 large enough to admit 
 
 an opening 
 
 three fingers, lined by skin and lead- 
 ing into a cavity, the size of a child's 
 head, lined with hairy skin. In this 
 case the decision was against opera- 
 tive interference, as the cyst-wall gave 
 rise to no inconvenience, and the 
 writer could hardly imagine in what 
 manner such a large cavity could be 
 made to heal after dissecting out the 
 entire sac. 
 
 In suppurating dermoids it may 
 become necessary to make counter- 
 incisions for the purpose of establish- 
 ing more efficient drainage ; and the removal of the entire cyst-wall 
 in suppurating post-rectal dermoids may require excision of the coccyx 
 and of one or more of the sacral vertebrae as a preliminary step to the 
 removal of the tumor. 
 
 Tumors which are attached to the sacrum should not be removed, 
 as they may be connected with the spinal canal. 
 
 Ovary. — Olshausen, who collected from different sources statistics 
 of 3275 cases of ovariotomies, ascertained that dermoid tumors were 
 represented by about 3^ per cent. Ponpinel collected 44 cases in which 
 both ovaries were similarly affected. 
 
 Histology a,7id Histogenesis. — Waldeyer offered a novel explanation 
 of the origin of dermoid tumors in the ovary. He maintained that the 
 normal epithelial cells of the ovary, which must be considered as unde- 
 veloped ovum-cells, under certain circumstances, without intercurrence 
 of spermatozoa, undergo a parthenogenetic development during which 
 they furnish, in the direction of an imperfect embryonal development, 
 products different from themselves. This theory could hardly be enter- 
 tained seriously at the present time, in view of the embryological inves- 
 tigations which have been made regarding the origin of similar tumors 
 in other organs. Epithelial cells cannot produce bone ; and teeth only 
 grow from a matrix of cells producing their essential histological parts, 
 dentine, enamel, and cementum. 
 
 Dermoids of the ovary arise, as do dermoids of any other part or 
 organ, from matrices derived from an erratic development in the em- 
 bryo. In the embryo the ovaries develop from the genital ridge, which 
 
652' PATHOLOGY AND TREATMENT OF TUMORS. 
 
 at an early date is intimately associated with the cells lining the peri- 
 toneum and connected with the peritoneal funnels. The origin of the 
 Wolffian duct is intimately connected with the epiblast ; consequently 
 the ovaries are the seat of the most complicated histological processes 
 during their development, and must necessarily frequently become the 
 seat of rests which, when excited to active tissue-proliferation, furnish 
 
 Fig. 449. — Dermoid cyst of the ovary (after Wyder). The cyst-wall was filled by a fatty mass enclosing 
 reddish hairs. The structure of the wall is seen to be like that of the skin. The upper stratum in the illus- 
 tration (the inner layer of the cyst) is formed of closely-packed cells, flattened toward the surface by mutual 
 pressure. Beneath are two layers of fibrous tissue separated by loose adipose tissue. The fibrous stroma 
 of the latter is formed by fibrillar from the two connective layers. An important detail of this specimen is 
 the presence of sweat-glands by the side of sebaceous glands and hair-follicles. 
 
 the material for the different kinds of dermoids. We observe here the 
 simplest kinds of dermoid cysts, containing nothing but atheromatous 
 material, as well as the most complicated forms, in which there are 
 found not only hair and teeth, but also brain-tissue, mucous mem- 
 brane, and incomplete skeletons. So many fetal parts are sometimes 
 found in dermoid tumors of the ovary that they have been regarded 
 as instances of ovarian pregnancy, and have been the means of ques- 
 tioning the morality of many innocent patients. 
 
 Cyst-walls which represent the external skin in their structure fre- 
 quently contain all the appendages of the skin (Fig. 449). The papillae 
 of the skin are usually not well developed ; in other instances they 
 
TERATOMA. 653 
 
 become the seat of papillomatous excrescences. Cysts with a dermal 
 lining contain the product of epithelial proliferation, which forms a pul- 
 taceous mass, variable in its consistency, resembling in every respect 
 the contents of sebaceous cysts. The lanuginose hair may consist of 
 a fine down or may grow to the length of several feet (Fig. 450). The 
 hair is of a yellowish or reddish color, and as it is shed from the fol- 
 licles it accumulates in the cyst in masses pasted together by the seba- 
 ceous material. 
 
 Plates of compact bone are frequently found in the cyst-wall ; they 
 are sometimes connected by a fibrous union, as was first pointed out 
 by Labbe and Verneuil. The teeth, which are never perfect, project 
 
 Fig. 450. — Switch of hair five feet long taken from dermoid cyst (after Munde). 
 
 into the cavity ; they are often loosely inserted into imperfect alveoli, 
 and they may vary in number from one to several hundred. Auten- 
 rieth found in one dermoid cyst over three hundred teeth. The teeth 
 are often surrounded by tufts of hair (Fig. 451). Cruveilhier quotes 
 a case where nails were found in a dermoid cyst. In a specimen 
 examined by Baumgarten, besides skin, hair, and teeth, there was 
 found a body which represented an imperfect eye. Brain-matter was 
 found by Virchow, Key, and Rokitansky ; other pathologists have 
 found nerve-filaments supplying the teeth. Cholesterin-crystals are 
 usually present in abundance in the atheromatous material in der- 
 moid cysts. 
 
 Mucous cysts in dermoid cysts of the ovary are derived from rests 
 
654 PATHOLOGY AMD TREATMENT OF TUMORS. 
 
 of the embryonic intestinal canal. They are lined with columnar 
 epithelium. The contents of such cysts consist of mucus, and in 
 cases of long standing the mucus is often converted into a serous 
 
 Fig. 451. — Part o\ cyst-wall from dermoid cyst of ovary (after Winckel) : a, canine tooth; b, two molar 
 
 teeth. 
 
 fluid and the stroma is very likely to undergo myxomatous degen- 
 eration. 
 
 Clinical Aspects— -Ovarian dermoids grow very slowly, but they 
 may eventually attain great size. The beginning of the growth can 
 usually be traced to the age of puberty. The tumor-matrix participates 
 in the increased physiological activity observed in the skin and its 
 appendages at this time. At first the tumor is movable and painless. 
 Localized peritonitis, which undoubtedly occurs frequently in conse- 
 quence of a mild infection, is productive of pain and is followed by 
 adhesions. If the tumor is movable and pedunculated, it may rotate 
 on its axis, thus leading to torsion of the pedicle. This accident results 
 in serious disturbances of the circulation in the tumor. If the veins 
 are more obstructed than the arteries, there results intense venous con- 
 gestion, manifested by pain and by an increase in the size of the tumor. 
 If the circulation is completely interrupted in acute torsion, gangrene 
 of the tumor and death from septic peritonitis will follow. If the cir- 
 culation is interrupted more gradually, the tumor often receives a new 
 blood-supply from adjacent organs through adhesions. In a few cases 
 of this kind the pedicle disappeared entirely and the tumor was found 
 attached to adjacent organs. Such a tumor, which had become attached 
 to the omentum, from which it received its blood-supply exclusively, 
 was removed by Sir George Humphrey. 
 
 Very often a dermoid tumor is associated with cystic disease of the 
 ovary, in which case it is overshadowed by the symptoms produced by 
 the cystic part of the tumor, which is frequently the largest part of the 
 
TERATOMA. 655 
 
 mixed tumor. There may be a dermoid cyst on one side and a mucoid 
 cyst upon the other. Rupture of a dermoid is often the cause of a fatal 
 peritonitis. In a few instances this accident has been followed by mul- 
 tiple secondary dermoids on the peritoneum. The secondary tumors, 
 each of which is furnished with a tuft of lanugo-like hair, are usually 
 the size of a cherry, and occur in clusters or imbedded in adhesions. 
 
 The entrance of pyogenic microbes into a dermoid cyst, either 
 through a small perforation in the intestine, by puncture with an aspirat- 
 ing needle, or by the localization of floating microbes, produces a sup- 
 purative inflammation with all its immediate and remote consequences. 
 Death from peritonitis is a frequent termination of this complication. 
 If the peritonitis is circumscribed, rupture of the cyst occurs, with 
 escape of its contents at the umbilicus or through the rectum, vagina, 
 or bladder. 
 
 The escape through the sinus of hair, teeth, or fragments of bone 
 indicates the character of the cyst. Spontaneous healing of the fistula 
 in such cases seldom if ever takes place unless the entire cutaneous 
 lining of the cyst is destroyed by the inflammation. 
 
 In the removal of ovarian dermoids the trocar must be used with 
 caution, as the escape of the contents of the cyst may cause septic 
 peritonitis or dissemination of the tumor by epithelial infection. 
 
 The removal of suppurating dermoid cysts which have ruptured 
 on the surface or into one of the adjacent organs is always an exceed- 
 ingly difficult operation, and one attended by great risks to life. Many 
 cases of suppurating dermoid cysts have been mistaken for extra- 
 uterine pregnancy. 
 
 In dermoid cysts which are adherent to the floor of the pelvis 
 extirpation through the sacral route offers great advantages. 
 
 Scrotum. — There is no doubt that most of the cases of dermoid 
 tumors of the testicle that have been reported were not within the 
 testicle, but were upon it — that is, were dermoids of the scrotum. 
 That dermoids in this locality are not common is evident from the 
 fact that Kocher found only fourteen cases recorded in literature. The 
 teratoid tumors of the scrotum are always congenital, and a correct diag- 
 nosis is generally made only after the character of the contents has been 
 ascertained by suppuration and rupture or during an operation for 
 removal of the tumor. Verneuil attributed their origin to fetal inclu- 
 sion — inclusion scrotale et testiculaire fcetus in fcctu. Lebert and Paget 
 regarded them as heterotopic tumors. They originate undoubtedly, 
 like the dermoids of the ovary and of other organs, from misplaced 
 matrices of embryonal tissue. Scrotal dermoids present often a very 
 complicated structure. The simplest cysts contain sebaceous material 
 
656 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and hair. In the more complicated cysts brain-substance, striated 
 muscular fibres, and bone have been found. The cysts grow slowly ; 
 occasionally they suppurate and rupture spontaneously, in which event 
 the character of the escaping material indicates the nature of the cyst. 
 The testicle is usually found atrophied from pressure and function- 
 ally useless. If the cyst is extirpated, the testicle should be removed 
 with the tumor. Extirpation of the tumor without castration has not 
 yielded satisfactory results. 
 
XXX. RETENTION-CYSTS. 
 
 All true tumors are composed of new tissue produced from 
 matrices of embryonic cells. All inflammatory swellings are composed 
 of, or are derived from, pre-existing tissue. It remains for us to discuss 
 in this section a form of swelling composed of a sac of pre-existing 
 tissue, with an accumulation of some one of the secretions or excre- 
 tions of the body as its contents. 
 
 Definition. — A retention-cyst is a swelling due to the retention in a 
 pre-existing space of a physiological secretion or excretion by obstruction 
 of the outlet of a gland. 
 
 The enlargement of a part should be named in accordance with the 
 histogenetic source of its cellular elements, according to which a 
 " hypertrophy " consists of a numerical increase of the tissue-elements 
 of a part or an organ. The term " tumor " should be restricted to 
 a localized production of tissue independently of mature normal cells ; 
 " inflammatory swellings " should include all enlargements consisting 
 of cells derived from the blood or by proliferation of mature tissue, or 
 of accumulations of serum or synovia in pre-existing spaces ; and 
 " retention-cysts " should occupy the ground covered by the definition 
 preceding this paragraph. 
 
 The greatest confusion exists in the minds of the student in differ- 
 entiating, from etiological and pathological standpoints, between the 
 different kinds of cysts ; this confusion is largely due to the manner in 
 which the subject is treated even in the most recent text-books. A 
 cystoma is a true tumor in which both walls and contents are new 
 products derived from a tumor-matrix. 
 
 We have seen that all tumors undergo cystic degeneration by 
 regressive metamorphoses or by the cells producing a secretion which 
 accumulates in the tumor-tissue, owing to the absence of an excre- 
 tory duct. A cyst may also form in consequence of the extravasation 
 of blood into tumor-tissue or into normal tissue ; and, lastly, many 
 so-called " pseudo-cysts " are produced by transudations into pre- 
 existing serous spaces. It would be just as proper to call a hydrops 
 of the knee-joint a " hydrothorax," or a hydrocephalus a "cyst," as 
 a hydrocele. 
 
 Pathological accumulations of synovia or of scrum in serous cavi- 
 
 42 657 
 
658 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 ties and in parasitic cysts do not come under the head of retention- 
 cysts. They are inflammatory products, and have no place in a treatise 
 on tumors. The writer will therefore exclude from this section the 
 hydroceles, diverticula, bursae, neural cysts, and parasitic cysts. A true 
 retention-cyst can form only in organs that produce a physiological 
 secretion or excretion which is discharged by an outlet upon the skin 
 or upon a mucous or serous surface ; in other instances the secretion 
 is absorbed at the place where it is produced. 
 
 The only instance in which, normally, a glandular secretion is dis- 
 charged into a serous cavity is furnished by the Graafian follicles of the 
 ovary. The secretion of the follicles of the thyroid gland in a normal 
 condition is absorbed; but if, for any reason, absorption is suspended, 
 the follicles become dilated and eventually form retention-cysts. 
 
 Histology. — The cyst-wall is composed of the connective tissue, 
 basement membrane, and epithelial lining of the follicle, tubule, acinus, 
 
 Fig. 452.— Wall of atheromatous cyst (after Boyce) : a, fibrous wall ; b, epithelial layer ; c, horny amorphous 
 transformation of epithelium. (Obj. £ inch, without eye-piece.) 
 
 or duct which has become obstructed. The amount of connective tis- 
 sue as compared with the normal structure of the part affected varies 
 greatly. If the obstruction is acute and the part on the distal side con- 
 tinues to secrete, the pre-existing spaces, according to the activity of 
 the physiological function of the part affected, dilate rapidly, resulting 
 in distention of the gland or duct, with thinning of the wall. If the 
 obstruction forms slowly and the amount of the retained secretion 
 
RE TENTION-CYSTS. 
 
 659 
 
 accumulates slowly, the cyst-wall is often enormously thickened by the 
 formation of new connective tissue. The best illustration of the former 
 condition is furnished by acute hydronephrosis, and of the latter by 
 sebaceous cysts. The epithelial cells which line the cyst-wall corre- 
 spond in structure and manner of arrangement with the epithelial cells 
 which exist normally in the lining of the obstructed space. 
 
 Cysts of glands lined by stratified epithelium show stratified layers 
 of squamous epithelium (Fig. 452). If the cyst forms in a duct or 
 a gland lined by columnar epithelium, the cyst, at least in its early 
 stages, is lined by columnar epithelium. 
 
 Fig. 453. — Section of the wall of a cyst of the vagina (after Schroder). The external surface is the pavement 
 epithelium of the vagina; the internal, the cylindrical epithelium of the cyst. 
 
 In branchial cysts, as well as in retention-cysts of other tubes or 
 ducts lined by similar epithelium, the cyst-wall is always found lined 
 by ciliated epithelium. Through great pressure the columnar epithe- 
 lium is often flattened, resembling squamous epithelium, but it always 
 retains its intrinsic capacity to produce, under more favorable auspices, 
 cells of its original type. 
 
 Retention-cysts result from mechanical obstruction of the outlet 
 of glands, leading to the accumulation of the secretion behind the point 
 of obstruction. If the obstruction is located near the point at which 
 the secretion is produced, the cyst forms at this point, as is the case 
 in obstruction in a ductlet of an acinus of a gland. If the obstruction 
 is located in a duct some distance from the point at which the secretion 
 is produced, the obstructed duct becomes distended and forms the wall 
 of the retention-cyst. 
 
 The cyst-contents are subject to various changes. If inflammation 
 of the cyst-wall occurs, the contents of the cyst are modified by the 
 addition of inflammatory products. Hemorrhage into the cyst, accord- 
 ing to its amount, may simply stain or may constitute the bulk of the 
 
66o 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 cyst-contents. In cysts lined by stratified epithelium the product of 
 epithelial degeneration forms the well-known atheromatous material, 
 which is subject to still further changes. In young cysts this material 
 appears as a hard mass composed of cells arranged in concentric layers, 
 while in old cysts the cells disintegrate and the detritus is suspended 
 in a serous fluid, presenting the appearance of a thin emulsion. The 
 addition of fat- and cholesterin-crystals further modifies the appearance 
 of the cyst-contents. In mucous cysts the mucoid material is fre- 
 quently transformed into a clear serous fluid. Cysts frequently become 
 isolated from the gland in which they originated by complete oblitera- 
 tion and detachment of the duct. In retention-cysts that have not been 
 the seat of inflammation the outside of the cyst-wall is surrounded by 
 
 /&&&£$£ 
 
 Fig. 454. — Chronic interstitial nephritis (after Boyce) : a, glomerulus with connective-tissue cell-proliferation; 
 b, commencing cystic dilatation of renal tube ; c, fibroid glomerulus. (Obj. £ inch, without eye-piece.) 
 
 a delicate, loose, vascular layer of connective tissue which supplies the 
 cyst with blood-vessels, and which is such an important structure in 
 removing cysts by enucleation — the pericystium. 
 
 Etiology. — The mechanical obstruction which is invariably the cause 
 of retention-cysts maybe — 1. Inflammation; 2. Cicatricial stenosis; 3. 
 Tumors; 4. Flexion of a duct, and 5 valvular closure; 6. Altered secre- 
 tion ; 7. Impaction in the duct of a foreign body, a concretion, or a 
 parasite. By far the most frequent cause of mechanical obstruction is 
 inflammation and its consequences. 
 
 The effect of inflammation in the production of an obstruction to the 
 
RETENTION-CYSTS. 66 1 
 
 outflow of a secretion can be studied most profitably in the kidney. In 
 chronic interstitial nephritis the over-production of connective tissue 
 obstructs the outflow of urine by obstructing the tubules (Fig. 454). 
 The cicatricial contraction of the connective tissue narrows the tubules, 
 resulting in increased intratubular pressure and destruction of the 
 tubule above the seat of obstruction. 
 
 The immediate effects of acute inflammation of the mucous mem- 
 brane of a gland-duct is well illustrated in catarrhal duodenitis, which 
 so constantly results in retention of bile and in icterus. Catarrhal in- 
 flammation of the mucous membrane of the cecum is a frequent cause 
 of retention of secretion in the appendix vermiformis, resulting from 
 narrowing of the lumen of the organ on the cecal side. Acute inflam- 
 mation, as a rule, gives rise to temporary obstruction, which disappears 
 with the subsidence of the inflammation. The acute inflammation, 
 however, may be followed by conditions resulting in permanent obstruc- 
 tion from cicatricial contraction or flexion of a gland-duct. Cicatricial 
 stenosis of a duct follows most localized ulcerative processes. Valvular 
 obstruction may exist as a congenital affection, as is the case in hydro- 
 nephrosis developing in consequence of a valvular obstruction at a point 
 where the ureter expands into the pelvis of the kidney ; or it may exist 
 in consequence of inflammation. The secretion of a gland may be so 
 altered that it cannot escape through the normal outlet of the gland : 
 this condition in itself would result in accumulation and progressive 
 increase of the mechanical difficulties, as the retention of the secretion 
 would naturally produce irritation, and the irritation would give rise to 
 progressive stenosis of the outlet of the gland. 
 
 The effect of the impaction of a concretion in the gland-duct in 
 producing obstruction is well shown in cases of impaction of a biliary 
 calculus in the cystic or common duct, and of a renal calculus in the 
 ureter. In rare cases a gland-duct is made partially or completely im- 
 permeable by the impaction of a foreign substance or of one of the large 
 parasites which infest the human body. Tumors may produce obstruc- 
 tion of a duct by growing into its lumen, by compression, or by the 
 production of a flexion. 
 
 Symptoms and Diagnosis. — The swelling increases in size slowly 
 or quickly according to the degree of obstruction, the size of the gland, 
 the character of its secretion, or the quantity of secretion produced. 
 An atheromatous cyst increases very slowly in size, while an acute 
 obstruction of the duct of the gall-bladder or of the ureter results in 
 rapid destruction of the obstructed organ and the formation of a swell- 
 ing of considerable size in a short time. The writer has made numerous 
 experiments on dogs to ascertain the immediate effects of complete 
 
662 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 obstruction of the ureter. The ureter was cut transversely about 
 three inches below the pelvis of the kidney ; the proximal end was 
 tied in a knot, and loosening of the knot was prevented by tying it 
 with a catgut ligature. Almost all the animals survived the operation. 
 They were killed in from a few days to six months after the operation. 
 Considerable destruction of the pelvis of the kidney and the ureter was 
 observed a week after the operation. The distention continued pro- 
 gressively, so that after three months the kidney on the side operated 
 upon was at least four times as large as the opposite one. After six 
 months the kidney consisted simply of a large bag filled with a clear 
 fluid. To the naked eye all kidney-tissue appeared to have been 
 removed by pressure-atrophy, but under the microscope sections of 
 the thin cyst-wall showed normal kidney-tissue, but in an exceedingly 
 atrophic condition. 
 
 It is of interest in this connection to relate the effects of nephrotomy 
 on the kidney. Soon after a lumbar renal fistula was established the 
 amount of secretion began to increase, and it was shown by examination 
 of the kidney at different periods after the nephrotomy that regeneration 
 of kidney-tissue occurred, so that in a few months the kidney nearly 
 recovered its normal size and function. 
 
 Rapid growth of the cyst in some organs which produce large 
 quantities of secretion — as, for instance, the liver and the pancreas — is 
 prevented by the absorption of the secretion. Mechanical obstruction 
 of the common bile-duct does not produce marked distention of the 
 bile-duct or gall-bladder, because the bile is removed by absorption, 
 which in this instance is well demonstrated by the progressive icterus 
 which follows the obstruction. The intensity of the icterus is a 
 good indication of the extent of the obstruction. Obstruction of 
 the cystic duct leads to distention of the gall-bladder, because the 
 secretions of the gall-bladder are not removed to the same extent by 
 absorption. 
 
 The writer made a long series of experiments on dogs for the pur- 
 pose of studying the effects of obstruction of the pancreatic duct in 
 the production of cysts of the pancreas. He had been led to believe 
 that mechanical obstruction to the escape of pancreatic juice was the 
 principal factor in the etiology of pancreatic cysts. The pancreatic 
 duct was divided near the duodenum, and the distal end was obstructed 
 in various ways. In some of the cases the distal end was left open, 
 the gland continued to secrete, and the pancreatic juice was absorbed 
 from the abdominal cavity as rapidly as it escaped into it, without any 
 detriment to the animal ; in fact, animals thus treated were after several 
 weeks in a better condition than when the distal end was tied. In the 
 
RETENTION-CYSTS. 663 
 
 numerous experiments made by dividing the duct and ligating the 
 distal end, only in one case did the writer find, after many weeks, the 
 duct uniformly dilated to the size of an ordinary lead-pencil ; in the 
 other cases little or no dilatation of the duct was produced by the 
 ligation. The pancreatic juice was absorbed as fast as it was produced, 
 and in the case in which the dilatation of the duct reached the size of 
 a lead-pencil there were found in the pancreas textural changes which 
 must have seriously interfered with auto-absorption of its secretion. 
 Cyst-formation to any considerable extent is therefore only to be 
 expected in obstruction of the outlet of glands the secretion of which 
 is not amenable to auto-absorption and in which the obstruction to the 
 escape of the secretion is complete. 
 
 Pain is present, as a rule, only in cases in which rapid distention 
 takes place and the swelling acquires considerable size. Pain becomes 
 a conspicuous clinical feature in all cases of retention-cysts complicated 
 by infection and inflammation. 
 
 Retention-cysts are much more liable to become infected than other 
 cysts, because the spaces which serve as starting-points for the cysts 
 not infrequently contain, in a normal condition, pathogenic microbes, 
 or when the obstruction is incomplete, as is most often the case, 
 microbes enter later. The microbes in retained secretions are much 
 more liable to assert their specific pathogenic qualities than when the 
 same number are present in the space in a normal condition, because 
 they are retained with the secretion, and the latter frequently constitutes 
 a favorable culture-medium for their growth and reproduction. The 
 retention of the secretions can often be ascertained by evidences 
 pointing to their absorption, as is the case in absorption of the com- 
 mon bile-duct ; or it can be learned from examination of the secretion, 
 as is always done by examination of the urine in suspected renal affections. 
 
 The location of the cyst is of great importance in the differential 
 diagnosis between retention-cysts and other cysts. A retention-cyst 
 always occupies the location of the affected organ. An atheromatous 
 cyst can occur only in parts of the skin in which sebaceous glands 
 normally exist. A retention-cyst of the gall-bladder will occupy the 
 position in which the gall-bladder is normally situated. A hydro- 
 nephrotic kidney will be found in the location normally occupied by 
 the kidney. A retention-cyst, from its size, may wander away from 
 the place at which it had its starting-point, but the early history of the 
 case usually points to the position normally occupied by the affected 
 organ. 
 
 The character of the contents of a retention-cyst can often be ascer- 
 tained only by an exploratory puncture. 
 
664 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Prognosis. — The danger to life from a retention-cyst depends upon 
 the physiological importance of the organ affected and upon the occur- 
 rence of complications. Small retention-cysts of unimportant glands 
 not only are harmless, but give rise to no symptoms. Retention of 
 urine caused by obstruction of one or of both ureters may destroy 
 life in a short time. Rupture of a retention-cyst of any of the 
 abdominal organs often results in fatal peritonitis. All retention- 
 cysts are apt to become infected, when the complicating suppurative 
 inflammation and its consequences constitute the chief sources of 
 danger. 
 
 Treatment. — The treatment of a retention-cyst has for its aims the 
 removal of the primary cause, the obstruction, and, if this cannot be 
 done, the establishment of an external fistula or the extirpation of 
 the cyst. If the outlet of the gland has become obstructed by inflam- 
 mation, the rational treatment consists in combating the inflammation. 
 If the duct of a gland has become blocked by the impaction of a con- 
 cretion or a foreign substance, the removal of the impacted body, if 
 this can be done, is indicated. If the duct has become completely 
 obliterated by cicatricial stenosis, the formation of an external or an 
 internal fistula or extirpation of the cyst constitutes the proper surgical 
 treatment. If the lumen of the duct has become narrowed by inflam- 
 matory thickening of its mucous lining, the removal of intracystic 
 pressure by the formation of a temporary external fistula is often the 
 most efficient way in which to subdue the inflammatory affection and 
 to restore the normal size of the passage. Should this treatment not 
 yield the desired result, a radical, operation will prove safer after inflam- 
 mation has subsided. 
 
 In the extirpation of retention-cysts surrounded on all sides by 
 tissues, the cyst should be exposed by an incision made in such a way 
 as to render the cyst most accessible, and as soon as the pericystium 
 is reached the cyst should be enucleated by the use of the fingers and 
 of blunt instruments, and, if the cyst is not too large, without rupturing 
 the sac. If the sac, as the result of inflammation, has become adherent 
 to the adjacent tissues, it can be removed safely and completely only by 
 a careful dissection. In retention-cysts which have ruptured externally 
 and which cannot be removed safely a radical cure can often be effected 
 by enlarging the fistulous opening sufficiently to render the whole 
 interior of the cyst accessible, after which the epithelial lining may be 
 destroyed by deep cauterization with the Pacquelin cautery ; the cavity 
 is then packed with iodoform gauze until the surgeon can satisfy him- 
 self that every particle of mucous membrane has been destroyed, when 
 the wound is allowed to heal by granulation. 
 
RE TENTION- C YS TS. 665 
 
 Topography. 
 
 Thyroid Gland. — The thyroid gland is one of the ductless glands, 
 and in case the secretion from any part of the gland fails to become 
 absorbed, it accumulates in one or more follicles of the gland, resulting 
 in a simple cyst or in follicular cysts. We have already described 
 cystoma and adenomatous cysts of the thyroid gland, as well as cystic 
 degeneration of other tumors of this organ, but follicular cysts are the 
 genuine retention-cysts of the thyroid gland. The pre-existing con- 
 nective tissue of the gland forms the capsule of the cyst, which in its 
 interior is lined by endothelial cells ; these cells, as cystic dilatation pro- 
 ceeds, are very apt to disappear, leaving the cyst-wall bare or barren. 
 By the coalescence of several follicular cysts there are formed cysts 
 of considerable size that fluctuate distinctly. Cholesterin-crystals are 
 frequently found in retention-cysts of the thyroid gland. 
 
 Unless complicated by inflammation, retention-cysts of the thyroid 
 gland can readily be removed by enucleation. Their treatment by 
 tapping followed by the use of irritating injections is uncertain and 
 unsatisfactory. 
 
 Ovary. — The ovary is another organ in which we find genuine 
 retention-cysts. If, from thickening of the walls of a Graafian follicle, 
 rupture and escape of the ovum fail to take place, the follicle becomes 
 distended and a follicular cyst is the result. All the large ovarian cysts 
 are tumors which develop from a tumor-matrix, as an adenoma, a 
 cystoma, or a dermoid. The impression still prevails that many of the 
 large cysts of the ovary are retention-cysts. This view is no longer 
 tenable, as it has been shown that single follicular cysts of the ovary 
 do not acquire a size larger than that of a walnut, and that by coales- 
 cence of several cysts masses larger than a fist are seldom met with. 
 (See Fig. 100, p. 193.) The imprisoned ovum in the hydropic follicle 
 is destroyed. These cysts contain a clear yellowish or bloody serum. 
 In one case Pozzi found, besides serous cysts, others which contained 
 a cheesy or lardaceous material which he regarded as the product of 
 epithelial degeneration. The cysts are lined by cylindrical epithelium, 
 and upon the most prominent parts of the cyst- wall small blood-vessels 
 are visible. Ovula have been found in retention-cysts of the ovary by 
 Ritchie and Webb, Lawson Tait, and Rokitansky. Very often both 
 ovaries are simultaneously affected. 
 
 The removal of retention-cysts of the ovary is more akin to a 
 castration than an ovariotomy, so far as the technique and the ease 
 with which the operation can be performed through a small incision 
 are concerned. 
 
666 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 Skin. — The skin is the seat of retention-cysts of the sebaceous 
 glands and the sweat-glands, the former of which are by far the most 
 frequently affected. The sebaceous cysts are also called " atheromatous 
 cysts," from the character of their contents. They are found most 
 frequently in the scalp, but they may occur in the skin of any part 
 of the body where sebaceous glands are present. As the sebaceous 
 glands are connected with hair-follicles, the retention-cysts frequently 
 contain fine lanuginose hair. 
 
 Comedo represents the smallest sebaceous cyst. The outlet of the 
 gland is obstructed by a minute black mass which completely blocks 
 the lumen of the duct. If the duct of a comedo becomes com- 
 pletely obliterated by cicatricial contraction, and its contents inspissate, 
 
 ^w 
 
 Fig. 455. — Atheromatous cyst of the skin of the cheek; X 18 (after Karg and Schmorl). Under the 
 normal epithelium (a) lies a small atheromatous cyst, the wall {b) of which is composed of connective tissue 
 in which can be seen remnants of sebaceous glands flattened by pressure ; the cyst is lined by stratified 
 layers of squamous epithelium; the pultaceous contents consist of fat-needles and plates of cholesterin ; 
 the cutis is infiltrated ; c, shaft of hair ; d, sebaceous gland ; e, sweat-glands. 
 
 it presents itself under the epidermis as a small white spot, but slightly 
 elevated, which is called a milium. The different forms of acne are 
 comedos in a state of inflammation. 
 
 In the deeper forms of sebaceous cysts the cyst-wall is separated 
 from the cutis and the connection with the skin is finally lost (Fig. 455). 
 
 Astley Cooper first pointed out that sebaceous cysts result from 
 obstruction. The obstruction is first the result of accumulation of the 
 secretion at the inflamed outlet of the gland, while material from with- 
 out forms the black plug in comedo ; later the inflammation results in 
 cicatricial stenosis, and finally in complete obliteration of the duct and 
 
RETENTION-CYSTS. 66j 
 
 isolation of the cyst from the skin. The cyst is surrounded by the 
 vascular pericystium and is lined by stratified epithelial cells. The 
 exfoliated cells in young cysts are closely packed together in concen- 
 tric layers. When they undergo fatty degeneration they form the cha- 
 racteristic pultaceous atheromatous contents. Besides this material 
 sebaceous cysts contain cholesterin-crystals, and often lanuginose hair. 
 In old cysts the sac becomes very much thickened, so that it can easily 
 be extracted. At the same time the atheromatous material frequently 
 undergoes liquefaction, so that the contents appear as a thin emulsion. 
 The contents of the cyst are apt also to undergo cretefaction, in which 
 event the cyst shrinks and can be felt as a hard mass under the skin. 
 In sebaceous cysts of the scalp a deep dent in the bone, produced by 
 pressure-atrophy, marks the location of the cyst after extirpation. 
 Sebaceous cysts often appear multiple in the scalp and other parts of 
 the body, notably the face and the scrotum. 
 
 Inflammation and suppuration of a sebaceous cyst may terminate 
 in a permanent cure if the entire lining of the cyst is destroyed ; if 
 this is not effected, suppuration continues, and sometimes a fungous 
 mass of granulations appears, suggesting a transformation of the lining 
 of the cyst-wall into a carcinoma. The origin of carcinoma in a cyst- 
 wall that had undergone this change has been observed. 
 
 A sebaceous cyst that has never been the seat of inflammation can 
 be removed quickly by enucleation. The skin covering a sebaceous 
 cyst is usually bald, but before performing this little operation it is 
 advisable to shave the surface a little beyond the margin of the cyst, 
 to disinfect the skin very thoroughly, and to resort to every other 
 antiseptic precaution, as infection is very liable to occur during this 
 operation, and has occasionally resulted in the death of the patient. 
 Carelessness in performing this otherwise insignificant operation is 
 inexcusable. 
 
 The best method in removing a sebaceous cyst quickly and 
 thoroughly is to transfix the base of the swelling with a narrow bistoury, 
 to cut through its centre from within outward, then to grasp the cyst- 
 wall where it is thickest — which is at one of the angles of the wound 
 — with a pair of rat-tooth forceps, and by gentle traction extract the 
 the cyst. Every particle of the lining of the cyst-wall must be removed, 
 otherwise a recurrence is sure to take place. After carefully arresting 
 the hemorrhage the wound is closed by two or three sutures of fine 
 catgut ; over the sutures an antiseptic dressing is applied ; this dressing 
 is held in place in such a manner as to exert gentle pressure, in order 
 to keep the skin in contact with the opposite side of the wound. If 
 compression is omitted the parenchymatous oozing will furnish enough 
 
668 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 blood to form a swelling the size of the cyst, preventing an ideal heal- 
 ing of the wound, besides increasing the risk of infection. 
 
 Inflamed sebaceous cysts must be removed by excision, as enucle- 
 ation usually fails on account of the presence of firm adhesions between 
 the capsule and the adjacent tissue. If the scalp is the seat of numer- 
 ous sebaceous cysts, and the patient desires their removal at one sit- 
 ting, it is better, from a cosmetic as well as a surgical point of view, to 
 shave the entire scalp, thereby enabling the surgeon to procure for the 
 different fields of operation a perfectly aseptic condition. 
 
 Very little is known' regarding retention-cysts of the sweat-glands. 
 Verneuil described adenoma, and Foerster described retention-cysts of 
 the sweat-glands, and there can be no doubt, owing to their great 
 resemblance, that one has been mistaken for the other. As a pathog- 
 nomonic symptom is mentioned the occasional appearance of moisture 
 upon the surface of the swelling, caused by leakage through a partially 
 obstructed duct. 
 
 Cysts of the sweat-glands are naturally of a very glandular type, 
 resembling the cystic adenomata in general. The few cases that have 
 been recorded were found in the skin of the face and in the vicinity of 
 the external ear. The cyst-wall is so delicate that the swelling can be 
 thoroughly removed only by excision. 
 
 Mucous Membrane. — The mucous membrane anatomically resem- 
 bles very closely the external skin ; but, instead of stratified layers of 
 squamous epithelium, it is with few exceptions lined by columnar 
 epithelium in a single layer, and is more richly supplied with glands. 
 The mucous crypts present in all of the mucous membranes are the 
 analogues of the sebaceous glands of the skin, and retention of their 
 secretion results in the formation of cysts resembling the three varieties 
 of sebaceous cysts — comedo, milium, and deep cysts. Crypts are 
 found in the mucous membrane of the bladder, the ureters, and the biliary 
 ducts. In the neck of the uterus they are normally in a cystic condi- 
 tion, and are described as the ovules of Naboth. They are especially 
 well developed and very long in the mucous membrane of the intestinal 
 canal and the uterus. 
 
 The post-tracheal glands occupy the entire thickness of the tracheal 
 wall, and when obstructed they form retro-tracheal cysts. If the crypts 
 are superficial, their cysts resemble the comedos and acne of the skin ; 
 if they are deep, retention of their secretion results in the formation of 
 larger swellings. 
 
 The columnar epithelial cells are attached to the basement mem- 
 brane of the delicate cyst-wall, and they produce the mucus, the 
 characteristic contents of a cyst of the mucous membrane. By pres- 
 
RE TENTION-CYSTS. 
 
 669 
 
 sure the columnar epithelial cells are often flattened, appearing under 
 the microscope as squamous cells. The mucus in old cysts is usually 
 liquefied and converted into a serous fluid, so that old mucous cysts 
 present themselves as serous cysts. These cysts were called by the old 
 authors " hydatids." 
 
 Inflammation of the cysts transforms mucous cysts into acne and 
 molluscum in the same manner as retention-cysts of the sebaceous 
 glands of the skin are formed. If the larger mucous cysts become 
 elongated, polypoid, we speak of polypi cystici or liydatidosi. This 
 form of mucous cyst is seen frequently in the rectum and in the neck 
 of the uterus. 
 
 Mucous cysts of the mucous membrane of the mouth are quite 
 common. They contain a viscid fluid, and after spontaneous rupture 
 
 Fig. 456.— Transverse section through the upper part of the cervix, showing the entire mucous mem- 
 brane (after Cornil). The central cavity is the cervical canal; b,b, internal surface of mucous membrane, 
 presenting small folds, superficial glandular depressions, and large incisions of the arbor vita: (d) ; g,g, deep 
 glands ; a, «, ovules of Naboth ; m, m, muscular tissue of the uterine wall. 
 
 they often leave a circular deep ulcer, which usually heals promptly 
 after thorough cauterization with nitrate of silver. They are met with 
 most frequently in the mucous membrane of the lips. Their walls are 
 exceedingly delicate, and the mucous membrane covering them is so 
 thin that it is generally excised with the cyst. 
 
 Multiple mucous cysts of the inner surface of the lips result in 
 
670 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 such great thickening of the lips that they appear to be double. The 
 removal of the cysts restores the normal size and shape of the lips. 
 
 Cysts of the soft palate, especially of the pillars in the vicinity of 
 the tonsils, which are of such frequent occurrence, are retention-cysts. 
 They never attain large size, and they can be destroyed effectually by 
 ignipuncture. 
 
 In the antrum of Highmore there have been found mucous cysts 
 of such enormous size that they not only filled the entire cavity, but 
 also caused distention of the bony walls (Giraldes). Such cases have 
 usually been mistaken for hydrops of the antrum, as the cyst-wall 
 was not discovered. Retention-cysts of this size in the antrum of 
 Highmore should be removed after making a temporary resection of 
 the anterior wall by detaching from the mouth, with a small chisel, 
 a quadrangular muco-osseous flap on three sides, and fracturing its 
 
 fourth or upper side, and by 
 raising the flap exposing the an- 
 trum so thoroughly that every 
 part of it is accessible to direct 
 treatment. Free drainage through 
 the nose should be established be- 
 fore the flap is brought down and 
 fastened in place by a few points 
 of chromicized catgut sutures. 
 
 The ovules of Naboth are of 
 special interest to gynecologists. 
 These mucous crypts are of un- 
 usual size in a normal condition ; 
 when the cervix is in a condition 
 of chronic inflammation they be- 
 come greatly enlarged, frequently 
 acquiring the size of a filbert 
 (Fig. 456). The cyst-wall of 
 dilated Nabothian glands is ex- 
 ceedingly delicate, and the mu- 
 cous membrane over the glands 
 is atrophied. They often rupture 
 spontaneously, and they are fre- 
 quently punctured in the treat- 
 ment of chronic cervical metritis. 
 The glands of Bartholin, which Henzier called " vulvo-vaginal " 
 from their location, and which have also been called " Duverney's " 
 or " Cowper's glands," are frequently affected by chronic inflammation 
 
 Fig. 457. — Retention-cyst of Bartholin's gland (after 
 "Winckel) : a, left labium minus ; b, left labium majus ; 
 c, cyst laid open. 
 
RETENTION-CYSTS. 671 
 
 of their excretory duct and retention of their contents. The cysts 
 are located on the internal aspect of the labium majus (Fig. 457). 
 The swelling, which often acquires the size of a walnut, is either 
 unilocular or multilocular, is generally unilateral, and is elongated in 
 the axis of the greater lip. Either the duct or the gland, or both, may 
 be affected. In the former case the cyst is superficial ; in the latter 
 instance it is more deeply located. The cysts contain mucus, to which 
 is often added blood or inflammatory products. 
 
 In the differential diagnosis of cysts of Bartholin's glands it is 
 important to consider solid tumors in that locality, hydrocele, hemato- 
 cele, hernia, other cysts, and abscesses. Cysts of Bartholin's glands 
 are exceedingly apt to become infected ; they then appear clinically 
 as abscesses. Incision affords prompt relief, but seldom effects a cure. 
 Retention and inflammation repeat themselves from time to time until 
 the whole cyst-wall is extirpated. In open suppurating cysts the advice 
 of Pozzi should be followed — to inject the cyst with hot spermaceti 
 before the dissection is commenced, as otherwise there is a great prob- 
 ability that the removal of the lining of the cyst will be incomplete. 
 Pozzi recommends the same procedure in the extirpation of non-sup- 
 purating cysts. After tapping the cyst and washing it out with hot 
 water he injects melted paraffin at a low temperature. When the cavity 
 is distended ice is applied, and after the mass has been solidified the 
 dissection is begun with the anesthesia produced by the cold, and by 
 cocaine if necessary. 
 
 Hydrokolpos. — A retention-cyst of the vagina is produced by oblit- 
 eration of the cervix above and atresia of the lower part of the vagina ; 
 the mucus secreted by the vaginal glands accumulates in the interven- 
 ing part of the vagina, which becomes the cyst-wall. Winckel describes 
 a case of this kind in a woman fifty-seven years of age who died of 
 carcinoma of the rectum. The atresia of the cervix and the vagina 
 occurred independently of the rectal carcinoma, as can be seen from the 
 illustration (Fig. 45 8). Atresia of the lower part of the vagina, acquired 
 or congenital, in menstruating women would result in hematokolpos 
 instead of hydrokolpos. 
 
 Hydrometra. — Hydrometra occurs in women after the menopause. 
 It is one of the conditions attending senile involution of the uterus ; 
 it results from stenosis or complete closure of the cervical canal pro- 
 duced by chronic catarrhal cervical endometritis, enlargement of the 
 Nabothian glands, and sharp posterior flexions of the uterus. Some- 
 times obliteration of the lower part of the uterine cavity leads to hydro- 
 metra of the upper part (Fig. 459). As the uterine glands continue to 
 functionate, and the escape of secretion is prevented by obstacles in the 
 
672 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 lower part of the uterus or cervix, accumulation leads to distention of 
 the cavity, and in the course of time the mucus is converted into 
 serum, hydrometra resulting. In women before the menopause the 
 
 same conditions result in hemato- 
 metra. Hydrometra in the aged, 
 resulting from imperfect closure of 
 the cervical canal or the lower part 
 of the uterine cavity from stenosis 
 or retroflexion, is very apt to be 
 followed by pyometra, and the offen- 
 sive discharge incident to this con- 
 dition has frequently been taken as 
 
 ^y&\ % 
 
 Fig. 458-— Acquired hydrokolpos in a woman fifty- 
 seven years of age (after Winckel) : a, vaginal cyst ; 
 b, several inches of vagina obliterated by cicatricial 
 contraction ; c, lower end of vagina. 
 
 Fig. 459- — Hydrometra in a woman past the 
 menopause (after Winckel): a, hydrometra; b, ob- 
 literation of lower part of uterine cavity. 
 
 an indication of the existence of malignant disease of the uterine 
 cavity. 
 
 Hydrosalpinx. — Hydrosalpinx results from partial or complete 
 closure of the fimbriated extremity of the Fallopian tube and obstruc- 
 tion to the escape of secretions on the uterine side, and retention of the 
 secretion produced by the mucous glands in the mucous lining of the 
 tube. The tubes may be partially or completely closed — the tubes 
 apertce and tubce occIuscb of Froriep. As closure of the distal end of 
 the tube occurs usually from adhesions produced by pelvic peritonitis, 
 
RE TENTION-CYSTS. 
 
 673 
 
 the affection is frequently bilateral, as is the case in pyosalpinx. The 
 lumen of the tube on the uterine side in a normal condition is quite 
 small ; frequently it is narrowed by the catarrhal salpingitis which pre- 
 cedes the peritonitis, or the escape of the tubal secretion is prevented 
 by valvular closure of the orifice. 
 
 By far the most frequent cause of catarrhal salpingitis, and of the 
 subsequent pelvic peritonitis which obliterates the fimbriated extremities 
 of the tubes, is gonorrheal infection. If the infection is of a mild cha- 
 racter, little or no pus is produced, and the retained secretion in the 
 tube consists at first of mucus which is later changed into serum, the 
 characteristic contents of a hydrosalpinx. The serum frequently leaks 
 into the peritoneal cavity, producing recurrent attacks of plastic peri- 
 
 FiG. 460.— Hydrosalpinx (after Winckel) : a, fundus uteri ; b, tube ; c, hydrops of tube. 
 
 tonitis if the fimbriated extremity of the tube is only partially closed ; 
 or it escapes at times through the uterus in the form of intermittent 
 profuse serous discharges. If the entire tube becomes distended, the 
 swelling assumes a sausage-like shape, as the tube is not only dilated, 
 but is also elongated (Fig. 460). The tube is often displaced by adhe- 
 sions. If only a small part of the tube remains patent, the swelling 
 is round or oval in shape. 
 
 Hydrosalpinx is rare as compared with pyosalpinx, but in the 
 majority of cases it precedes the latter affection. If gonococci are 
 present in sufficient quantity, the suppurative inflammation of the 
 43 
 
674 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 mucous membrane of the Fallopian tube converts the hydrosalpinx 
 into a pyosalpinx. This change in the pathology and clinical aspects 
 of the tubal affection is sure to occur if, as is so often the case, the 
 interior of the tubal swelling becomes the seat of secondary or mixed 
 infection with pus-microbes. 
 
 The removal of the uterine appendages in cases of single or double 
 hydrosalpinx is a much easier and less dangerous procedure than in 
 cases of pyosalpinx. There is here a rich field for conservative surgery, 
 as in many cases mutilating operations can be rendered unnecessary by 
 
 IW^i 
 
 
 Fig. 461. — Hydrosalpinx, tube laid open (after Winckel). 
 
 intelligent and persistent treatment aimed at restoring the free commu- 
 nication between the uterus and the tubes by appropriate intra-uterine 
 and intra-tubal applications combined with other treatment calculated 
 to eliminate the primary cause of the tubal obstruction. 
 
 Trachea and Bronchial Tubes. — Retention-cysts of the trachea are 
 rare. They occur in the posterior wall, because here the tracheal rings 
 are defective. The first indication of the formation of a cyst is the 
 appearance of a shallow depression, which as it deepens posteriorly is 
 deflected laterally by the oesophagus and the spine. As the cyst elongates 
 its base contracts, the cyst finally becoming pedunculated ; eventually 
 the pedicle may disappear, the cyst becoming completely isolated from 
 the trachea. Such cysts may appear behind the clavicle and may 
 otherwise mimic retro-sternal struma and dermoid cysts. Textor 
 operated upon a cyst of this kind successfully. In bronchiectasis sac- 
 culation may take place to such an extent that cavities of considerable 
 size communicate only through a small opening with the bronchial 
 tube from which they started. The bronchial secretion is usually 
 mixed with an offensive purulent discharge. 
 
 Appendix Vermiformis. — Affections of the appendix vermiformis 
 are attracting a great deal of attention. Virchow showed years ago 
 
RETENTION-CYSTS. 675 
 
 that the appendix is richly supplied with glands ; he also described a 
 retention-cyst of the appendix as large as a fist. In this case the long 
 narrow organ, obstructed on the cecal side, had become so much dis- 
 tended that the swelling was globular in shape. He also called atten- 
 tion to the fact that an obstructed appendix frequently gives rise to 
 typhlitis. 
 
 Attention has elsewhere been called to the pathological conditions 
 usually found in cases of stricture or of cicatricial closure in different 
 parts of the lumen of the appendix. The writer has never seen reten- 
 tion-cysts of the appendix holding more than a teaspoonful of mucus, but 
 he has been informed by Hecktoen of Chicago, who had an immense 
 experience in the post-mortem room, that on several occasions he found 
 retention-cysts of the appendix vermiformis of the size of a hen's Qgg. 
 It can readily be conceived that obstruction at the cecal end of the appen- 
 dix might result in considerable distention of the lumen of the appendix 
 on the distal side. In the cases which have come under the writer's 
 observation the stenosis or obliteration was characterized more by 
 increase in the thickness of the wall of the appendix than by dilata- 
 tion. In the absence of a sufficient number of pus-microbes in the 
 excluded portion of the lumen of the appendix, the mucous glands 
 being in an active functional activity, the intracystic pressure would 
 eventually lead to dilatation and cyst-formation. Cysts of the appendix 
 vermiformis should be borne in mind in the differential diagnosis of 
 obscure swellings in the ileo-cecal region. 
 
 The proper treatment of a retention-cyst of the appendix vermi- 
 formis is excision of the appendix. Rupture of the cyst should be 
 avoided if possible, and proper preparation should be made for this 
 accident by excluding the intestines from the field of operation with 
 aseptic compresses. The appendix should be amputated near the 
 cecum by the subserous circular method. 
 
 Bile-ducts. — Retention of bile in any part of the bile-ducts is fol- 
 lowed by absorption of the serous portion, leading to inspissation. In 
 the inspissated bile there remain cholesterin, bilifulvin, and hematoidin. 
 
 Cysts as large as a walnut, containing inspissated bile, are sometimes 
 found in the substance of the liver. In obstruction of the hepatic and 
 common ducts moderate distention of the bile-ducts takes place, but 
 the formation of large cysts is prevented by the absorption of the 
 retained bile. If this auto-absorption is interfered with by inflammatory 
 processes affecting the bile-ducts and the connective tissue of the liver, 
 retention of the bile produced by some intact portions of the liver takes 
 place, and the bile-duct, and, in case of obstruction of the common 
 duct, the gall-bladder, become greatly distended. 
 
676 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The gall-bladder is that part of the bile-tract most apt to undergo 
 cystic dilatation. Retention of the secretions of the mucous crypts of 
 the mucous membrane of the gall-bladder occurs most frequently in 
 consequence of obstruction of the cystic duct by impaction of a biliary 
 calculus or by cicatricial stenosis. The latter is not infrequently one 
 of the remote consequences of the injuries inflicted by the passage of 
 a gall-stone. The pressure exerted by the gall-stone and the irrita- 
 tion and inflammation caused by the calculus result in destruction of 
 the mucous membrane, and during the healing of the defect the lumen 
 of the duct becomes narrowed and even completely obliterated. The 
 gall-bladder under such circumstances may become enormously dis- 
 tended — much more so than if it contain bile. 
 
 As no bile can enter the gall-bladder if the cystic duct is obstructed, 
 and the bile that may be present is soon absorbed, the organ contains 
 at first mucus, which later is transformed into a serous fluid ; hence 
 the term " hydrops of the gall-bladder," or " hydrocholecyst." A mod- 
 erately distended gall-bladder presents a pyriform shape, with the nar- 
 row part of the swelling directed toward the liver. 
 
 Hydrops of the gall-bladder, unless complicated by localized peri- 
 tonitis, is not attended by much pain, nor does it give rise to much 
 inconvenience unless the swelling is very large. A dull aching pain is 
 occasionally complained of. The suffering frequently attending this 
 condition is referable to the presence of a stone in the cystic duct, 
 giving rise to those characteristic paroxysmal pains known as " biliary 
 colic." In obstruction of the cystic duct icterus either is entirely 
 absent or is slight and usually of short duration. Infection of the 
 interior of a gall-bladder either by extension of a suppurative inflam- 
 mation of the bile-ducts or through a small fistulous opening between 
 the gall-bladder and an adherent intestinal loop converts the hydrops 
 into an empyema of the gall-bladder. The inflammation of the mucous 
 membrane diminishes or arrests the functions of the mucous crypts, and 
 pus soon takes the place of the serous fluid. 
 
 Hydrops of the gall-bladder has occasionally, from the size of the 
 swelling, been mistaken for ovarian cyst. In distention of the gall- 
 bladder the early clinical history of the case points to a swelling in the 
 upper and right part of the abdominal cavity, while ovarian cysts are 
 first discovered by the patient when the tumor rises out of the pelvis. 
 An ovarian cyst can always be reached with the finger from the vagina, 
 while this can seldom, if ever, be done in a distended gall-bladder. 
 In distention of the gall-bladder the early clinical history points to the 
 existence of causes leading to obstruction of the cystic duct, while in 
 ovarian cyst the early symptoms are referred to the pelvis. Tumors 
 
RETENTION-CYSTS. 677 
 
 and cystic disease of the right kidney have often been mistaken for 
 a distended gall-bladder, and vice versa. In renal affections a careful 
 study of the clinical history of the case and chemical and microscopical 
 examination of the urine will yield valuable information. The retro- 
 peritoneal location of a tumor or a swelling of the kidney can usually 
 be demonstrated satisfactorily by rectal insufflation — an important diag- 
 nostic resource in differentiating between an intraperitoneal and a retro- 
 peritoneal tumor or swelling. Another condition rendering a positive 
 diagnosis of a distended gall-bladder often impossible is echinococcus- 
 cyst of the lower surface of the liver. Hirschberg strongly urged the 
 employment of the exploring needle in the differential diagnosis of 
 fluctuating tumors or swellings in the region of the gall-bladder. This 
 very useful diagnostic resource, if properly employed, is harmless in 
 case the tumor or cyst is adherent to the anterior abdominal wall. 
 We have no reliable means of ascertaining the presence and exact loca- 
 tion of mural adhesions. The writer believes, with Konig, that explor- 
 atory puncture should never be resorted to in the diagnosis of tumors 
 or cysts in this locality unless there is positive evidence that the punc- 
 ture can be made without invading the peritoneal cavity. The informa- 
 tion derived from an exploratory puncture does not balance the risks 
 to which it exposes the patient. Should the puncture be made through 
 the peritoneal cavity, and the cyst should prove to be an echinococcus- 
 cyst, the escape of its contents into the preperitoneal cavity would be 
 sure to result in dissemination of the parasitic disease and an early fatal 
 termination. Should the cyst prove to be an empyema of the gall- 
 bladder, escape of pus through the puncture could hardly fail to 
 produce a diffuse septic peritonitis. 
 
 Short of an exploratory puncture, we are not in possession of any 
 means to make a positive differential diagnosis between a hydrops and 
 an empyema of the gall-bladder. As we have advised against the 
 use of the exploring needle, it is evident that in doubtful cases the 
 surgeon should resort to an exploratory incision, fully prepared to do 
 what is necessary after a correct diagnosis has been made. The patient 
 should understand that the operation is performed in the first place for 
 the purpose of ascertaining the nature of the swelling, and that after 
 this has been done the necessary operative procedure will follow. An 
 exploratory incision, in the writer's estimation, is safer and will yield 
 more reliable diagnostic information than an exploratory puncture. 
 Several incisions have been suggested to expose the gall-bladder to 
 direct surgical interference. Billroth preferred an incision parallel with 
 and about a finger's breadth below the costal arch. Other surgeons 
 advise a vertical incision extending from the cartilage of the eighth 
 
678 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 rib downward. Langenbeck in performing cholecystectomy makes 
 a vertical incision from the costal arch to the outer border of the 
 rectus muscle, and joins it by a shorter incision extending from the 
 upper angle of the wound as far as the ensiform cartilage. Czerny 
 makes an incision from the ensiform cartilage to just above the umbil- 
 icus, and joins it by a transverse incision extending through the rectus 
 muscle on the right side. By reflecting the triangular flap the under 
 surface of the liver is well exposed. The exploratory incision should 
 be made over the centre of the swelling, from the costal arch down- 
 ward. This incision will answer well if the conditions revealed require 
 a simple cholecystotomy, and if it is deemed necessary to extirpate the 
 gall-bladder, the incision can readily be converted into Langenbeck's 
 incision. If a hydrops of the gall-bladder is found, the gall-bladder 
 should be emptied by aspiration, after which it is drawn forward into 
 the wound, and is held in place with forceps, or, still better, with two 
 silk threads passed through the serous and muscular coats, one on 
 each side of the proposed incision. After packing gauze around the 
 empty bladder to protect the peritoneal cavity, an incision large enough 
 to admit the index finger is made in the long axis of the gall-bladder, 
 and through this incision, with finger and probes, search is made for 
 the cause of obstruction. If a calculus is found in the cystic duct, it 
 should be removed or crushed, after which the margins of the visceral 
 wound are stitched to the parietal peritoneum in the upper angle of the 
 wound, for the purpose of establishing a temporary biliary fistula. The 
 balance of the external incision is closed by buried and deep sutures. 
 If the cystic duct is found completely obliterated, the gall-bladder 
 should be extirpated. In empyema the same surgical procedures are 
 indicated. A cholecystenterostomy is absolutely contraindicated except 
 in irremediable occlusion or obliteration of the common bile-duct. 
 
 Closely allied to hydrops of the gall-bladder are cysts of the 
 pancreas. 
 
 Pancreas. — The pancreas, like other secretory organs, is prone to 
 become the seat of cystic swellings, the result of obliteration or obstruc- 
 tion of the common duct or of one or more of its branches. Cysts 
 originating in this manner are true retention-cysts, containing the physi- 
 ological secretion from the distal portion of the gland-tissue, with per- 
 haps accidental products, such as altered secretions, blood, and the 
 products of inflammation. 
 
 Of the five cases of cyst of the pancreas which the writer has seen, 
 detailed mention will be made of the first case that came under his 
 observation : 
 
 Volz, aet. nineteen, laborer, German, was admitted to Milwaukee 
 
RETENTION-CYSTS. 679 
 
 Hospital November 28, 1884. He was small for his age and not robust, 
 but he claimed that with one exception he had never been sick, and 
 that no hereditary tendency to disease existed in his family. Five 
 weeks previously, while enjoying perfect health, he was thrown from 
 a wagon, striking the ground on the left side of the abdomen, a heavy 
 keg falling upon his back and increasing the force of the fall. The 
 pain felt immediately after the accident was confined to his back, at 
 the point where he was struck by the keg, but it was not sufficient in 
 intensity to prevent him from following his occupation as a mason's 
 apprentice. In a few days, however, diarrhea set in, persisting for two 
 weeks and greatly reducing his strength and weight. If he had any 
 fever during this time, it was not sufficiently severe to attract his atten- 
 tion. His appetite was not impaired, and, although he vomited occa- 
 sionally, neither the vomiting nor the diarrhea seemed to be aggravated 
 by the time of eating or the kind or variety of food. After two weeks 
 he noticed in the left hypochondriac region a tumor which was round, 
 smooth, and painless. The tumor increased rapidly in size, and soon 
 gave rise to a sensation of fulness in the stomach, and later on to 
 regurgitation and vomiting soon after meals. His appetite was slightly 
 impaired. At this time the patient was treated for a short time by 
 Dr. F. H. Day of Wauwatosa, Wisconsin, who resorted to symptomatic 
 treatment, and, observing no improvement, referred him to the writer 
 for diagnosis and, in case it should be deemed advisable, surgical treat- 
 ment. On his admission to the hospital he presented a considerable 
 degree of emaciation and complained principally of a sensation of 
 fulness and weight in the region of the stomach, which was always 
 aggravated after meals and only relieved by vomiting. On inspection 
 a tumor was found occupying nearly the whole epigastric and the entire 
 left hypochondriac region, its most prominent point being to the left 
 of the median line and about three inches below the xiphoid cartilage. 
 Percussion revealed a line of dulness extending from the left nipple 
 to within an inch of the umbilicus ; posteriorly the dulness reached 
 from the eighth to the lower margin of the twelfth rib ; in the epi- 
 gastric region a limited area of tympanitic resonance was discovered 
 along the costal arch of the lower ribs on the right side. Palpation 
 showed distinct fluctuation, the wave being conveyed from side to side 
 across the whole area of dulness. The tumor was round in contour 
 and presented a smooth surface. The measurements were as follows : 
 From the left nipple to the lowest point downward, 22 centimeters ; 
 transverse diameter, 21 centimeters; anterior circumference, 63 centi- 
 meters. The heart was pushed upward so that the impulse of the apex 
 could be felt distinctly in the fourth intercostal space. The stomach 
 
68o 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 was artificially distended with carbonic-acid gas, when it was ascer- 
 tained that it was pushed to the right and compressed by the tumor. 
 The liver appeared to be unaffected by the tumor, as on percussion it 
 was found in its normal location and of natural size. Both lumbar 
 regions were tympanitic. No evidences of ascites existed. Firm pres- 
 sure over any part of the tumor could be made without causing pain. 
 The peculiar fremitus often felt in cases of echinococcus-cysts was 
 absent. No pulsations could be felt in the tumor, and no impulse was 
 
 imparted to it by the underlying ab- 
 dominal aorta. The relative position 
 of the tumor was changed during 
 forcible inspiration and expiration. 
 For the purpose of ascertaining the 
 nature of the contents of the tumor 
 a hypodermic needle was thoroughly 
 disinfected and introduced at a point 
 where the tumor was most promi- 
 nent ; when in place, the distal end 
 fig. 462-cyst of the pancreas -space wnhin of the syringe moved upward and 
 
 dotted lines indicates area of dulness ; a-b, line downward Synchronously with the 
 of incision. 
 
 respiratory movements, showing that 
 the adhesions with the parietal peritoneum, if any existed, were slight. 
 The fluid removed, which was somewhat viscid and slightly opalescent, 
 was alkaline in reaction and contained a considerable proportion of 
 albumin, as it coagulated on applying heat and nitric acid. Under the 
 microscope it showed only a few morphological elements, epithelial 
 cells, a few leucocytes, and granular matter, but neither hooklets nor 
 cholesterin-crystals. 
 
 By exclusion the diagnosis was narrowed down to one of two things 
 — a sterile echinococcus-cyst or a cyst of the pancreas. Against the 
 former spoke the rapid growth of the tumor, its primary origin away 
 from the liver, its favorite location, the presence of a considerable 
 amount of albumin, and the absence of hooklets, the presence of which 
 are diagnostic of echinococcus-cysts. In favor of a pancreatic cyst 
 spoke the history of traumatism in the region of the pancreas, the rapid 
 growth of the tumor, and the early disturbance of digestion as mani- 
 fested by diarrhea and vomiting, presumably caused by the partial 
 or complete retention of the pancreatic secretion. As the treatment 
 remained the same in either case, it was decided to perform laparotomy, 
 to stitch the cyst-walls to the peritoneal covering of the wound in the 
 absence of adhesions, and to open and drain the cyst after adhesions 
 had formed. This procedure was deemed preferable to the use of the 
 
RETENTION-CYSTS. 68 1 
 
 trocar or the aspirator, as it would with certainty prevent extravasation 
 of the cyst-contents into the peritoneal cavity, and the drainage-tube 
 would guard against reaccumulation of the fluid, thus affording an 
 opportunity for the cavity to undergo obliteration by adhesion of the 
 inner surfaces of the cyst-walls. The patient, being cognizant of the 
 fact that no other form of treatment would promise any relief, readily 
 assented to the operation proposed. Every precaution was observed 
 to render the operation aseptic. The patient was given several baths ; 
 the parts were shaved, and were carefully disinfected with a 5 per cent, 
 solution of carbolic acid ; the instruments, sponges, and operating-room 
 were prepared as for an ovariotomy. Before ether was administered 
 the stomach was emptied and washed out by means of an elastic 
 stomach-tube, with a view to prevent retching and vomiting during 
 and after the operation. An incision five inches in length was made 
 obliquely over the most prominent portion of the tumor, about three 
 inches below, and parallel with, the left costal arch. A portion of the 
 rectus abdominis muscle was divided. After dividing carefully all the 
 tissues down to the peritoneum all hemorrhage was completely arrested. 
 On opening the peritoneal cavity the omentum was brought into 
 view, the portion exposed containing an artery and a vein of consider- 
 able size. As these vessels were placed in a vertical direction, they 
 crossed the wound, and it became necessary to apply, a double ligature, 
 the omentum being then incised between the ligatures to the extent of 
 about three inches. The omentum was slightly adherent to the pari- 
 etal peritoneum and the surface of the tumor. Through the omental 
 incision the tumor could be seen and felt distinctly, presenting a smooth, 
 whitish, and glistening surface. As it had formed at least slight adhe- 
 sions, it was decided to complete the operation. This plan was the 
 more willingly adopted as it was evident that the intracystic pressure 
 was great and the cyst-walls were thin, which would render stitching 
 them to the margins of the wound difficult and unsafe. The sur- 
 face of the tumor was then seized with two dissecting forceps about an 
 inch apart, and gentle traction was made during incision and evacuation 
 of the cyst, so as to prevent all risk of extravasation of fluid into the 
 peritoneal cavity. The peritoneal covering was picked up and nipped, 
 and a grooved director was inserted into the opening made : owing to 
 the thinness of the walls of the sac, it penetrated the interior, and fluid 
 escaped along the groove with considerable force. The opening was 
 enlarged with the knife, when the fluid gushed forth in jets and was 
 caught in basins. The contents were removed as completely as pos- 
 sible by making external pressure and by placing the patient on his 
 side. As the cyst was emptied its walls were drawn forward into the 
 
682 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 wound and stitched to the peritoneum, which had previously been 
 united with the skin. The interior of the cyst was explored by insert- 
 ing the index finger, which passed directly backward toward the tail 
 of the pancreas. The bottom of the cavity could, however, not be 
 reached. The inner surface of the cyst was smooth. Two large drain- 
 age-tubes were inserted to the bottom of the cyst, and the remaining 
 portion of the wound was united in the same manner as after ovariot- 
 omy, except that the rectus muscle was sutured separately. The fluid 
 removed, estimated at three quarts, presented the same appearance as 
 that removed by exploratory puncture. The wound was dressed with 
 a large antiseptic compress, which was retained in situ with an elastic 
 rubber bandage. This bandage of rubber webbing not only retains the 
 dressing perfectly, allowing at the same time the movements of the 
 chest and the abdomen, but has an additional advantage, inasmuch as 
 it exerts equable pressure — an important element in the after-treatment 
 of all abdominal operations. 
 
 The patient never vomited during or after the operation, and expe- 
 rienced immediate relief on removal of the pressure caused by the 
 tumor. The pulse never rose over 90 , and the highest temperature 
 observed was ioo° F., the day after the operation. The appetite 
 increased, and no unpleasant subjective symptoms were complained of 
 at any time. On the third day the dressing showed moisture on the 
 external surface, and it was changed. The gauze was saturated with 
 the secretions from the cyst. The wound looked healthy, but the 
 surrounding skin, as far as the dressing had extended, was red and 
 macerated, and the epidermis could be removed in large flakes, leaving 
 beneath a raw surface. The changes in the skin presented the appear- 
 ances described by Kulenkampff and Gussenbauer, and claimed by 
 them to be due to the digestive power of the pancreatic juice. The 
 excoriated surface was sprinkled with salicylic acid and was again 
 covered with a Lister dressing. On account of profuse secretion from 
 the cyst the dressings were changed every few days, and at every change 
 the skin was found excoriated as far as it had been moistened by the 
 secretion. At the end of the first week the sutures were removed and 
 no further dressings were applied, whereupon the skin healed without 
 suppuration, and only a minimum amount of pus escaped through the 
 fistulous opening with the secretion. The secretion became clearer 
 after the operation, and continued to be discharged in varying quantities 
 for almost four weeks. One of the drainage-tubes inserted at the time 
 of the operation was removed at the first change of the dressing, and 
 the second was gradually shortened, being entirely removed three weeks 
 after the operation. At the end of the second week the cyst was 
 
RETENTION-CYSTS. 683 
 
 explored with a disinfected probe which passed to a depth of eight 
 inches in the direction of the tail of the pancreas. The fistulous tract 
 soon became live with granulations and grew smaller in length and 
 diameter ; at the end of eight weeks it was very narrow, so as to admit 
 only a small probe, which could be passed only to a depth of four 
 inches. The skin around the fistulous opening was drawn inward, 
 forming a deep funnel-shaped depression. 
 
 January 22, 1885, the patient was discharged cured. The fistula 
 was completely closed. Retraction of cicatrix was very marked. The 
 general health was good, the digestion perfect. No swelling could be 
 felt in the region of the pancreas. 
 
 Remarks. — It was the intention of the writer to collect some of 
 the secretion for the purpose of ascertaining its digestive properties 
 on different articles of food, but before this could be done the 
 amount secreted daily became so small that it was impossible to 
 obtain corroborative diagnostic evidence from this source. The ana- 
 tomical location of the tumor, its relations to the surrounding organs, 
 its rapid growth, and the character of its contents can leave no pos- 
 sible doubt that we had to deal with a genuine retention-cyst of the 
 pancreas. The question naturally arises, What was the cause of the 
 obstruction ? The history of the case points clearly to traumatism as 
 the exciting cause. The patient had been in good health until he 
 received the injury, and since that time he had not been well, although 
 he continued at his work for some time afterward. Whether the diar- 
 rhea from which he suffered for the first two weeks resulted from injury 
 to the pancreas we are unable to prove, but it may be possible that a 
 retention of the pancreatic secretion occurred after the traumatism, and 
 that the diarrhea may have been produced by the absence of the fluid 
 in the intestinal tract. As the patient at this time was not under medical 
 observation, the character of the stools was not ascertained. As the 
 injury was inflicted in the region of the pancreas, it is reasonable to 
 assume that the pancreatic duct and the parenchyma of the gland were 
 lacerated at a certain point, producing obstruction to the outflow of the 
 secretion from the distal portion of the organ, the nature of the injury 
 and the manner of obstruction being the same as in cases of rupture 
 of the male urethra. It would be difficult to imagine that the com- 
 mon duct could be distended by the accumulation of the retained fluid 
 to such an enormous extent in such a remarkably short time, hence we 
 are forced to conclude that laceration of the duct took place, and that 
 the pancreatic fluid infiltrated the gland, the cyst being formed at the 
 expense of its parenchyma and by distention of the capsule of the 
 organ. The cyst-wall anteriorly was so thin that after cutting the 
 
684 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 peritoneal covering the grooved director penetrated directly into the 
 interior of the cyst without more than the slightest force being used, 
 showing that nothing but a little connective tissue was interposed 
 between the peritoneum and the cyst-contents. The rapid growth of 
 the cyst would indicate that the obstruction occurred at some distance 
 from the caudal extremity of the gland, thus making a considerable 
 portion of the secreting tissue contributory to the formation of the 
 cyst. The early cessation of the discharge of the secretion through 
 the abnormal outlet would tend to prove either that after the removal 
 of the intracystic pressure the duct again became permeable, and thus 
 furnished a free passage to the secretions into the intestinal canal 
 through the natural channel, or that the gland-tissue in the vicinity and 
 distal to the cyst had been destroyed. 
 
 In regard to the operation, it is necessary to say that the writer 
 deviated from the usual plan in not making the incision through the 
 linea alba. The incision was made over the most prominent part of 
 the tumor, for the following substantial reasons : 
 
 1. If adhesions had formed, they would naturally begin at a point 
 where the tumor impinged most firmly against the anterior abdominal 
 wall. 
 
 2. Incision over the most prominent portion of the cyst would 
 afford the best point for effective drainage. 
 
 The band of connective tissue which would result from atrophy and 
 obliteration of the cyst would form a permanent bridge between the 
 cicatrix of the abdominal wound and the gland, consequently it is 
 advisable to establish this necessary evil where it will do the least 
 harm by interfering with the functions of important organs. 
 
 Aspiration of the cyst was not practised, because the exploratory 
 puncture had demonstrated that firm adhesions had not taken place, 
 and in the absence of these it was feared that some of the cyst-con- 
 tents might escape into the peritoneal cavity and produce peritonitis. 
 The maceration of the skin was the result of the digestive action of 
 the pancreatic juice, and this phenomenon furnished strongly corrobo- 
 rative diagnostic evidence in this as well as in previous cases. 
 
 Since this case was reported with six others which the writer had 
 collected at that time, about thirty new cases have been recorded in 
 literature, and in nearly all of these the formation of an external fistula 
 resulted in a permanent cure. 
 
 Pathology and Morbid Anatomy. — Cysts in the pancreas always 
 result from retention of the secretion and subsequent dilatation of the 
 secretory duct, or, in case of laceration of this structure, from extrava- 
 sation of the secretion into the parenchyma of the gland and subse- 
 
RETENTION-CYSTS. 685 
 
 quent distention of its capsule. The size of the cyst is modified by 
 the character and seat of the obstruction and by its relative position to 
 the secreting gland-structure. The walls of the cyst are usually thin 
 from over-distention in cases of rapid-growing cysts, or much thick- 
 ened when the growth of the tumor has been slow and accompanied 
 by chronic proliferation and induration of the connective tissue. The 
 cyst-walls in chronic cases may become cartilaginous or even ossified. 
 The inner surface is either smooth or presents evidences of degenera- 
 tion similar to those occurring on the internal surface of arteries in 
 the later stages of endarteritis. If the canal of Wirsung is obstructed 
 at or near its proximal end, the entire duct and its branches may become 
 dilated, presenting the appearance of varicose veins, or a more uniformly 
 rounded cyst may form, of the size of an orange, a child's head, or 
 even so large as to occupy the whole abdominal cavity, as in Boze- 
 man's case. As the cyst increases in size the gland-structure disap- 
 pears by absorption in consequence of intracystic pressure. The cause 
 which constitutes the obstruction will often also lead to destruction of 
 the parenchyma of the organ by inducing a chronic interstitial pancre- 
 atitis which is followed by cirrhosis or fatty degeneration of the organ. 
 Virchow alludes to cysts of the pancreas under the name of ranula 
 pancreatica, and describes two essential and distinct varieties. In the 
 first class the entire duct is found dilated, resembling in appearance 
 a rosary. In the second variety the outlet of the excretory duct is 
 obstructed, and behind the seat of obstruction the duct undergoes 
 cystic dilatation. He mentions a case that came under his observation 
 where such a cyst had attained the size of a fist. He believes that 
 cicatricial contractions or the pressure of tumors upon the duct con- 
 stitutes the most frequent source of obstruction. Pancreatic juice in 
 its purity is found only in small and recent cysts. Later on, in old or 
 large cysts, various accidental products are added. Albuminoid degen- 
 eration or suppuration not infrequently takes place, or hemorrhage 
 may occur, so that the cyst-contents assume a bright-red or chocolate 
 color. Pepper found in such a cyst numerous crystals of hematoidin, 
 while Hoppe found in another instance urea in the proportion of 0.12 
 per cent, as one of the constituents of the contents of the cyst. The 
 pressure of the cyst upon neighboring organs will result in secondary 
 pathological conditions which will interfere with the physiological per- 
 formance of the functions of other organs, thus endangering the life 
 of the patient. 
 
 Etiology. — The causes which result in the formation of small cysts 
 of the pancreas, or cysts which result from compression by tumors 
 which in themselves do not admit of an operation for their removal, 
 
686 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 and which at the same time constitute a source of danger to life, do 
 not come within the scope of this discussion. In the latter instance 
 the cyst is simply a sequence of the primary cause, and as such it will 
 seldom, if ever, become the sole or direct object of surgical treatment. 
 The causes of retention in cysts amenable to operative treatment are 
 ones which in themselves do not imperil the life of the patient. They 
 maybe classified as follows : I. Obstruction to the outflow of the secre- 
 tion from impaction of calculi in the common duct or in its branches. 
 2. Partial or complete obliteration of a portion of the duct from cica- 
 tricial contraction. 3. Sudden or gradual obstruction of the duct, 
 without diminution of its lumen, from displacements of the pancreas. 
 
 Calculi. — The impaction of the pancreatic duct at its outlet may be 
 caused by the presence of a biliary calculus in the ductus communis 
 choledochus, at the junction of the former with the latter. A case of 
 this kind has been reported by Engel. In such cases the obstruction 
 gives rise to retention of the secretions from the liver and the pancreas 
 and to dilatation of the excretory ducts in both organs. Calculous 
 concretions in the pancreatic ducts have frequently been observed to 
 give rise to retention-cysts. Johnson has collected thirty-five cases in 
 which, upon post-mortem examination, stony concretions were found 
 in the pancreas. Incrustations are not as frequent as free concretions. 
 Gendrin has described a pancreatic cyst where the normal pancreatic 
 secretion was converted into a fatty, chalky pap. The causes which 
 produce a concretion in the pancreatic duct are chemical changes in 
 the secretion itself or an obstruction to its free exit by inflammatory 
 changes in or around the common duct. The degree of dilatation, 
 other things being equal, is in direct proportion to the completeness 
 of the obstruction to the outflow of the secretion. It may be well to 
 allude to the possibility that in some instances a pancreatic calculus 
 may remain stationary for an indefinite period of time in the duct, 
 giving rise to no symptoms and to only partial obstruction, until, by 
 the action of some determining cause, it is forced into a position where 
 it effects complete mechanical obstruction to the outflow of the fluid 
 and a rapid increase in the size of the cyst. As an impacted biliary 
 calculus may give rise to pancreatic obstruction, so a pancreatic calcu- 
 lus, when it is impacted at a point where compression of the common 
 bile-duct can take place, will produce icterus and dilatation of the gall- 
 bladder and the bile-ducts. Meckel has reported such a case. 
 
 Among the specimens of pancreatic cysts so far examined which 
 were caused by concretions, none of them had attained the size of those 
 which have been submitted to surgical treatment. As in most of these 
 preparations the calculi did not completely fill the calibre of the duct, 
 
RETENTION-CYSTS. 687 
 
 they caused only partial obstruction, which would furnish an explana- 
 tion of the slow growth and the comparatively small size of the tumor. 
 In the specimen described by Gould it appears that the common duct 
 at its entrance into the duodenum was completely closed by two 
 calculous concretions. This cyst had attained considerable size ; in 
 fact, it is the largest cyst on record where it was proved that the dila- 
 tation was caused by the presence of a calculus. As in the successful 
 operations on cysts of the pancreas it has been impossible to ascertain 
 the exact nature of the obstruction, the possibility of retention from 
 a calculus cannot be eliminated with certainty. 
 
 Cicatricial Contraction. — Cicatricial contraction is always the result 
 of an antecedent inflammation. The cicatrix may be located in the 
 peripancreatic tissue or in the substance of the gland itself. Hoppe 
 made a post-mortem examination of a patient who had been deeply 
 jaundiced during life. The gall-bladder and the bile-ducts were dis- 
 tended with bile which contained blood ; the pancreatic duct was also 
 cylindrically dilated, and many of its branches were distended into cysts 
 the size of a hazelnut. The cause of retention of both secretions was 
 found in a dense cicatrix which surrounded both ducts at their duodenal 
 termination. Interstitial inflammation in the gland itself, with subse- 
 quent cicatricial contraction, is one of the most frequent causes of 
 retention, Wyss has reported a case where the interstitial inflamma- 
 tion was limited to portions of the head of the pancreas through which 
 the common bile-duct and the ductus Wirsungii passed, and which had 
 resulted in dilatation of the latter and of its branches, which again com- 
 pressed the bile-duct, producing in this manner intense icterus. Becourt 
 has given a description of a similar specimen which he found in the 
 Strassbourg Pathological Museum. The patient had died of icterus. 
 The gall-bladder and the bile-ducts were found distended ; the pancreas 
 was converted into a dense tissue, which, being cut into, presented a 
 chalky deposit four to eight inches in length and of a yellowish color. 
 The duct of Wirsung was dilated to such an extent as to form a large 
 cyst which occupied the whole length of the pancreas, its walls being 
 inseparable from the substance of the gland. In this case the inter- 
 stitial inflammation was more extensive and the cyst was much larger. 
 In the cases reported by Pepper and Hjett the obstruction was due to 
 the same cause. In Curnow's case the common duct had become 
 obliterated at its entrance into the duodenum by catarrhal inflamma- 
 tion. The pancreas was atrophic, and its duct was filled with numerous 
 calculi. The pancreatic juice had become inspissated. The cystic duct 
 of the gall-bladder was impermeable, while in the common bile-duct 
 a number of small gall-stones were found. 
 
688 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The writer has failed to find in literature an allusion to stricture of 
 the duct the result of traumatism. The pancreas is an exceedingly 
 slender organ, of loose and somewhat friable texture, and hence, 
 although remotely located and well protected by surrounding organs, 
 it is more frequently the seat of injury than has generally been sup- 
 posed. If the stomach be empty and the abdominal muscles be 
 relaxed, a blow over the region of the pancreas may result in serious 
 contusion or laceration of the organ without rupture of its envelope. 
 Again, a well-directed blow over either extremity of the gland may 
 cause a laceration of its tissue by traction force, the organ being 
 securely fixed in its place by firm connective-tissue attachments. The 
 clinical history of several cases of rapid-growing cysts tends to prove 
 that obstruction occurred in this manner. If the duct escapes injury, 
 the cicatricial contraction attending and following the reparative process 
 in the lacerated gland-tissue will gradually compress the duct, or by 
 lateral traction change its direction and thus impede the outflow of the 
 secretion. If the duct is ruptured at the time of injury, its lumen may 
 become completely filled by a thrombus which renders it impermeable, 
 giving rise to retention and extravasation of the secretion primarily, and 
 secondarily to definitive occlusion of the duct by cicatricial contraction 
 at the point of injury. The writer is quite convinced that in the case 
 reported the retention was the direct result of traumatic stricture of 
 the common duct. Although this view is not supported by evidence 
 from post-mortem examinations, it is confirmed by analogous produc- 
 tion of cysts in other locations. It is evident that this class of cases 
 would furnish the most favorable conditions for successful surgical 
 treatment. 
 
 Obstruction from Displacement of the Pancreas. — As the pancreas 
 is retained in its normal transverse position by the surrounding organs 
 and connective-tissue attachments, a relative change of position of por- 
 tions of the gland would result in a bending of the organ and obstruc- 
 tion in the duct at the point of flexion. This condition was the cause 
 of retention in a case related by Engel, who found in a woman sixty 
 years of age that the tail of the pancreas formed a right angle upward 
 with the principal duct of the gland. A dislocation of this kind can 
 occur in one of the following ways : (i) Abnormal relaxation of the 
 connective-tissue attachments of the gland, permitting a portion of the 
 organ to descend by its own weight lower in the abdominal cavity. 
 (2) Pressure upon the gland by tumors or exudations. (3) Cicatricial 
 contractions in the substance of the organ or in the peripancreatic space. 
 
 That the whole pancreas can become displaced is proven by the 
 case reported by Dobrzycki. A man fifty years of age fell a distance 
 
RETENTION-CYSTS. 689 
 
 of some yards. After the fall there arose symptoms similar to those of 
 a floating kidney. By palpation the displaced organ could be located. 
 Saline fluid resembling pancreatic juice was vomited. In the hypo- 
 gastrium could be felt a movable tumor corresponding in position and 
 shape with the pancreas. 
 
 Diagnosis. — The question of diagnosis can be entertained only in 
 cases where the cyst has attained very considerable proportions. The 
 most important points to be taken into consideration are the history of 
 the case, the anatomical location of the tumor, and its relations to 
 the surrounding organs. The cases which have been reported have 
 occurred exclusively in adults. Sex appears to exert no determining 
 influence. In a number of cases the clinical history points distinctly 
 and forcibly to traumatism as the exciting cause. In Gussenbauer's 
 case the beginning of the illness was traced to indiscreet eating and 
 drinking. 
 
 In all instances of cystic tumors in the region of the pancreas close 
 inquiry should be made to ascertain the existence of antecedent inflam- 
 matory affections of the organ or in its immediate vicinity. A history 
 pointing toward the existence of a biliary or a pancreatic calculi will 
 also prove valuable in arriving at positive conclusions. Rapid growth 
 of the tumor speaks in favor of its pancreatic origin. In Gussenbauer's, 
 Kulenkampff's, and the writer's cases the tumors attained an enormous 
 size within a few weeks. Considering the relations of these cysts to 
 important surrounding organs, it is remarkable that they give rise to 
 no serious symptoms aside from the pressure they exert upon adjacent 
 organs. Pain is not a constant symptom, and when it is present it is 
 due more to the causes which produce the cyst than to the cyst itself. 
 In this respect cysts of the pancreas form a counterpart to malignant 
 disease when it affects this or neighboring organs. Emaciation is due 
 either to coexisting affection of the gland or to the impairment of function 
 of important organs by pressure of the cyst. It is never as marked in 
 these cases as in malignant disease. The supervention of fatty stools 
 would point toward the existence of some coexisting serious lesion of 
 the pancreas rather than to the existence of a simple cyst of the organ. 
 This symptom was not found present, or it was overlooked, in all cases 
 which have been operated upon. Of 28 cases of stearrhea which were 
 compiled by Ancelet, 16 were examined post-mortem. In 5 of these 
 there was occlusion of the ductus choledochus and pancreaticus ; in 3, 
 occlusion of the pancreatic duct alone ; in 1 , inflammation of the pan- 
 creas and some of the adjacent organs. In the remaining cases disease 
 of the liver and the bowels, or only marasmus, was found. In 13 cases 
 of pancreatic calculi collected by Johnson only in 3 were fatty stools 
 
 44 
 
690 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 observed ; in 6 cases, diarrhea ; in 4 cases, melena ; and constipation 
 in the remaining 6. The presence of fat in the stools is a symptom of 
 great importance in the recognition of pancreatic disease, but that it is 
 not of absolute diagnostic significance is proved by the well-known 
 fact that the same condition will follow upon the obstruction of the 
 biliary passages and affections which impair the functional activity of 
 other organs of digestion. 
 
 Obstruction of the principal duct impairs digestion more than when 
 its distal extremity or one of the accessory ducts is involved. The 
 actual illness of the patient is usually preceded for a variable length of 
 time by more or less marked symptoms of gastro-intestinal derange- 
 ment, accompanied in some instances by pain in the region of the 
 pancreas. 
 
 A peculiar color of the skin, which is believed by some to be cha- 
 racteristic of pancreatic disease, must be mentioned, as it was observed 
 in several cases of calculous affection and cysts of the pancreas. The 
 appearance presented by these patients is variously described as being 
 unhealthy, pale-yellow, dirty, or earthy. The intimate relations of the 
 cyst to the celiac plexus will explain the cause of celiac neuralgia which 
 is met with in some of these cases. Atrophy of the celiac plexus from 
 long-continued pressure may give rise to mellituria for the same reason 
 that Klebs has affirmed — that partial extirpation or atrophy of the 
 celiac plexus will cause the presence of sugar in the urine. Diverse 
 diseases of the pancreas have also been known to produce diabetes 
 mellitus. Cases of this kind have been reported by Cowley (1788), 
 Bright, Elliotson, Frerichs, Fles, Hartsen, Silver, Recklinghausen, 
 Munk, Seegen, and Friedreich. Klebs demonstrated by his experi- 
 ments that complete extirpation of the pancreas or ligature of its duct 
 invariably gave negative results so far as diabetes was concerned, and 
 this may account for the fact that no sugar was found in the urine of 
 the case reported on page 679. The cyst, when examined early, before 
 it has attained considerable size, is always found in the region normally 
 occupied by the pancreas. The exact location, however, is not always 
 uniform, as it will depend upon the portion of the pancreas from which 
 the cyst has taken its primary origin. It may be situated below the 
 right lobe of the liver, as in Kulenkampff's case ; in the epigastric 
 region, as in Gussenbauer's case; or in the left hypochondrium, as 
 noted in the writer's case. When the tumor has attained a large size 
 or occupies the whole abdominal cavity, it will be difficult, and in the 
 latter instance impossible, to determine by any known means its pri- 
 mary origin. In such cases it is of paramount importance to study 
 its relations to adjacent organs. The tumor is invariably situated 
 
RETENTION-CYSTS. 691 
 
 in the bursa omentalis, and from this point, as it increases in size, it 
 encroaches upon the space occupied by adjacent organs. The stomach 
 is pushed forward in all cases, and later to the right. The transverse 
 colon is displaced downward, the spleen to the left, and the diaphragm 
 and the contents of the chest upward. The cyst being in direct con- 
 tact with the diaphragm, it usually ascends and descends with the 
 respiratory movements of the chest. 
 
 In doubtful cases it will become necessary to inflate the stomach 
 and colon, with a view to ascertain their position relative to the cyst. 
 If the patient is a female and the tumor occupies the entire abdominal 
 cavity, it will simulate cystic disease of the ovary so closely that a dif- 
 ferential diagnosis between the two is impossible. The cases reported 
 by Liicke, Bozeman, and Rokitansky furnish adequate proof of the 
 correctness of this statement. The proximity of the abdominal aorta 
 is such that the impulse of the artery is imparted to the tumor, which, 
 however, pulsates only in one direction — away from the artery — a fact 
 which will always distinguish it from an aneurysm. Unless the cyst is 
 exceedingly tense, a sense of fluctuation is always imparted by palpa- 
 tion. Palpation is rendered difficult on account of the deep location 
 of the pancreas and the rigidity of the recti abdominis muscles. The 
 normal pancreas can be felt under certain favorable conditions. Concern- 
 ing this point Sir William Jenner says : " By deeply depressing the 
 abdominal walls about a hand's breadth below the umbilicus, by then 
 rolling the subjacent parts under the hand (the stomach and colon must 
 be empty), it might be possible to detect it in an individual who is thin 
 and whose tissues are lax." In case the examination is rendered diffi- 
 cult on account of great rigidity of the abdominal muscles, this obstacle 
 can be overcome by examining the patient while under the influence 
 of an anesthetic. An exploratory puncture with a fine and perfectly 
 aseptic needle of a hypodermic syringe will not only add material 
 diagnostic information by revealing the character of the cyst-contents, 
 but the procedure will also settle the question as to the existence or 
 the absence of adhesions between the cyst-walls and the parietal peri- 
 toneum. In the differential diagnosis the following affections w r ill come 
 up for consideration: 1. Malignant disease of the pancreas or of the 
 adjacent organs ; 2. Aneurysm ; 3. Echinococcus-cysts of the liver, 
 spleen, or peritoneum ; 4. Affections of retroperitoneal lymphatic 
 glands; 5. Hydronephrosis or pyonephrosis; 6. Cystic disease of the 
 suprarenal capsule ; 7. Circumscribed peritonitis with exudation ; 8. 
 Ascites ; 9. Cystic disease of the ovary. 
 
 Malignant Disease of the Pancreas and of the Adjacent Organs. — 
 Carcinoma and sarcoma of the pancreas or of the adjacent organs, as 
 
692 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 in every other locality, always manifest their presence by their most 
 characteristic clinical features — pain, emaciation, and progressive local 
 and general infection. The age of the patient and the previous history 
 of the case will also furnish important diagnostic information. Large 
 pancreatic cysts are unilocular, while, on the contrary, if a malignant 
 tumor has undergone cystic degeneration, usually more than one cyst 
 can be recognized. Hardness and irregularity of surface speak in favor 
 of malignancy ; smoothness and a regular round or oval contour of 
 the tumor are constant features of a pancreatic cyst. The time that 
 has elapsed since the beginning of the illness is also of importance. 
 A rapid-growing pancreatic cyst will in two or three weeks assume 
 a size which even for a malignant tumor would require as many 
 months. 
 
 Aneurysm. — An aneurysm of the abdominal aorta can be distin- 
 guished from a pulsating pancreatic cyst by its pulsations being felt in 
 all directions and by the presence of a bruit. As a further test the 
 suggestion of Dr. Pepper may be resorted to — that of placing the 
 patient in the genupectoral position, when the tumor, by gravitation, 
 will leave the aorta and all pulsation will cease. Steady pressure will 
 diminish the volume of an aneurysm, but it will have no effect on a 
 cyst of the pancreas. 
 
 Echinococcus-cysts. — An echinococcus-cyst of the liver, the spleen, 
 or the peritoneum could easily be mistaken for a cyst of the pancreas. 
 The peculiar fremitus sometimes felt on palpating an echinococcus-cyst 
 should always be sought for. Multiplicity of cysts would decide in 
 favor of something else than a pancreatic cyst. The presence of hook- 
 lets in the aspirated fluid would furnish positive evidence in favor of the 
 presence of an echinococcus-cyst, while their absence would not exclude 
 the possibility of the tumor being a sterile echinococcus-cyst. As the 
 surgical treatment in both instances would be identical, it is sufficient 
 for practical purposes to narrow the diagnosis down to a probable 
 existence of either affection. 
 
 Affections of Retroperitoneal Lymphatic Glands. — Neoplasms, inflam- 
 mation, suppuration, or hypertrophy of the retroperitoneal glands 
 behind the pancreas might simulate a pancreatic cyst, and as a wrong 
 diagnosis in such an event might prove disastrous to the patient and 
 reflect discredit upon the surgeon, every diagnostic resource should be 
 exhausted in order to prevent such an error. Enlargement of the lym- 
 phatic glands sufficient in extent to simulate a pancreatic cyst would 
 almost of necessity give rise to serious constitutional disturbances and 
 to extension of the disease to neighboring organs. 
 
 Hydronephrosis or Pyonephrosis. — In hydronephrosis or pyonephro- 
 
RETENTION-CYSTS. 693 
 
 sis the early clinical history will present a group of symptoms pointing 
 toward some lesions in the pelvis of the kidney or in the ureter. A 
 chemical and microscopical examination of the urine may furnish con- 
 clusive evidence of the existence of some renal affection which has 
 produced the obstruction. Tumors of the kidney usually occupy a 
 lower place and are more laterally located than tumors originating in 
 the pancreas. In case of a pancreatic cyst the lumbar region below 
 the kidney is tympanitic, which is not the case in hydronephrosis or 
 in pyonephrosis. In case of doubt an exploratory puncture may enable 
 us to arrive at a positive conclusion. 
 
 Cystic Disease of the Suprarenal Capsule. — The suprarenal capsule 
 may be the seat of cystic degeneration, and may simulate a cyst of the 
 pancreas so closely that a differential diagnosis is impossible. In Gus- 
 senbauer's case the diagnosis remained doubtful between a cyst of the 
 pancreas and a cyst of the suprarenal capsule. The bronzed skin so 
 frequently observed in diseases of the suprarenal capsule has also been 
 seen in affections of the pancreas. As the operative treatment in either 
 case would be the same, it is not essential for practical purposes to 
 make a positive diagnostic distinction between the two. 
 
 Circumscribed Peritonitis with Exudation. — Primary peritonitis with 
 a circumscribed exudation in the region of the pancreas would reveal 
 a history pointing toward an inflammatory affection accompanied by 
 the usual symptoms attending inflammation of the peritoneum. Fever, 
 pain, and tenderness are Symptoms which are either foreign to the 
 history of cysts of the pancreas, or, when present, are less intense than 
 in peritoneal inflammations. In peritonitis the exudation would neces- 
 sarily be in the peritoneal cavity, while pancreatic cysts always occupy 
 the omental bursa. 
 
 Ascites. — The question of diagnosis between a cyst of the pancreas 
 and ascites can arise only in case the whole abdominal cavity is dis- 
 tended by the tumor or the effusion. The causes which produce ascites 
 must be considered separately and individually ; as they are usually of 
 such a character as to exclude a suspicion of pancreatic disease, a satis- 
 factory diagnosis can be reached without an exploratory puncture, but 
 if any doubt remains, this harmless procedure will furnish the requisite 
 information. 
 
 Cystic Disease of the Ovary. — From the cases reported we have 
 gleaned that in at least three cases large cysts of the pancreas were 
 mistaken for cystic disease of the ovary by surgeons of prominence 
 and ability who made thorough and repeated examinations. It is not 
 difficult to conceive that in case the tumor has assumed such dimen- 
 sions as to fill the entire abdominal cavity, it would be impossible to 
 
694 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 differentiate between a cyst of the pancreas and one of the ovary, even 
 by a most scrutinizing examination. The physical signs presented by 
 either condition resemble those of the other so closely that they can- 
 not be relied upon in discriminating one from the other. The early 
 history of the case, if it can be obtained from a reliable source, is of 
 more diagnostic value. In pancreatic cysts the early symptoms are 
 usually referred to disturbance of the digestive functions, and the 
 patient has been aware of the presence of a tumor in the upper 
 portion of the abdominal cavity. An ovarian tumor necessarily begins 
 in the opposite portion of the abdominal cavity, and gives rise to pelvic 
 distress and disturbances of the menstrual function. As the surgical 
 treatment in both instances would be the same, it is practically not 
 essential to make a positive distinction between the two before an 
 exploratory incision will reveal the true nature and origin of the cysL 
 In recapitulation it may be stated that a positive diagnosis has so far 
 not been made in a single instance, and that for all practical purposes 
 it is only essential to make a probable diagnosis between a pancreatic 
 cyst, or some other kind of a cyst which would call for the same kind 
 of surgical treatment. In very obscure cases an exploratory incision, 
 under antiseptic precautions, for diagnostic purposes is a justifiable 
 procedure. 
 
 Prognosis. — Physiologists are agreed in assigning to the pancreas, 
 a most important function in the digestion of organic food. We know 
 that by a special ferment it assists in the transformation of starch into 
 dextrin and sugar, and aids in the digestion of albumins and fat. We 
 should naturally expect that in diseases of this organ the digestion of 
 these substances would be impaired in proportion to the amount of 
 gland-tissue destroyed. On the contrary, we have abundant evidence 
 to show that even total disorganization or destruction of the pancreas 
 is not incompatible with normal digestion and perfect health. It would 
 seem that in the absence of the pancreatic secretion other organs assume 
 a vicarious action, and digestion proceeds unimpaired. It is also 
 important to remember that even a large cyst of the pancreas does not 
 necessarily result in extensive destruction of the gland, and that the 
 remaining gland-tissue continues to secrete and discharge a sufficient 
 amount of pancreatic juice. In Bozeman's case the cyst occupied 
 the entire abdominal cavity, and yet at the operation the greater 
 portion of the gland was found healthy in structure. The integrity 
 of the structure and function of the gland depends less on the pres- 
 sure of the cyst than on the causes which were concerned in its 
 production. The dangers arising from the cyst itself consist in — 1. Its 
 interference with the functions of other abdominal organs by pressure ; 
 
RE TENTION- C YS TS. 695 
 
 2. Rupture of, the cyst and escape of its contents into adjacent hollow 
 organs or into the peritoneal cavity. Compression of the stomach 
 and interference with its normal peristaltic action are constant when 
 the cyst has developed to any considerable size. When such is the 
 case, vomiting soon after meals takes place, as was noted in a number 
 of cases reported. When the cyst is of very large size, almost all the 
 abdominal organs suffer by compression, and both digestion and absorp- 
 tion are impaired by mechanical pressure. The diaphragm being at the 
 same time pushed upward, the heart and the lungs are displaced in 
 the same direction, and embarrassment of circulation and respiration 
 follows as a necessary sequence. Like any other benign abdominal 
 tumor, the cyst proves dangerous to life by interfering mechanically 
 with the functions of more essential and important organs. The sec- 
 ond source of danger is rupture of the cyst and escape of its contents 
 into adjacent organs — an accident which may be followed by immediate 
 death from hemorrhage, or by which the life of the patient is placed in 
 jeopardy by suppurative inflammation in the interior of the cyst, or by 
 peritonitis in case the contents have escaped into the peritoneal cavity. 
 In Pepper's case the immediate cause of death was hemorrhage conse- 
 quent upon rupture of the cyst into the stomach. At the post-mortem 
 examination there was found in the stomach and the intestines a large 
 quantity of blood which had entered through an opening, about half 
 an inch in diameter, close to the proximal termination of the ductus 
 communis. A probe passed through this opening directly entered a 
 cyst in the head of the pancreas. A communication with any portion 
 of the gastro-intestinal tract would almost of necessity lead to infection 
 and suppurative inflammation in the interior of the cyst ; this infection, 
 under unfavorable circumstances, might lead to a fatal termination from 
 septicemia or from extension of the inflammation to adjacent organs. 
 The prognosis may be said to depend (1) on the nature and cause of 
 the obstruction, (2) on the size of the cyst, and (3) on the absence or 
 presence of complications. 
 
 Treatment. — In the treatment of a pancreatic cyst the indications 
 are the same as in the treatment of any other kind of cysts, namely— 
 1. Extirpation of the cyst; 2. Evacuation of its contents and oblitera- 
 tion of the cyst. 
 
 Extirpation was attempted in Bozeman's and Rokitansky's cases, in 
 the former instance with complete success ; in the latter the operation 
 was not completed, and the patient died a few days afterward of septic 
 peritonitis. It is proper to state that in both cases the operation was 
 done for the removal of a supposed ovarian cyst, and that a correct 
 diagnosis was made in the first case during the operation, after the 
 
696 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 pedicle was traced to the pancreas and the intact portions of the gland 
 were identified. In the second case the post-mortem examination 
 revealed the true nature and location of the cyst. The brilliant result 
 obtained by Dr. Bozeman is well calculated to stimulate others to fol- 
 low his example. Extirpation of the cyst would guard most effectually 
 against the formation of a permanent pancreatic fistula ; but, on account 
 of the deep location of the pancreas, the shortness or absence of a 
 pedicle, and the many obstacles thrown in the way of the operator by 
 adjacent organs, the procedure becomes one surrounded by innumer- 
 able difficulties, and in the present state of our science it is of doubtful 
 propriety. Simple evacuation of the cyst-contents by means of the 
 aspirator offers two principal objections against its adoption in the 
 treatment of cysts of the pancreas : 1. Escape of cyst-contents into the 
 peritoneal cavity ; 2. Reaccumulation of secretion. 
 
 Reasoning from analogy, we should naturally expect that when 
 pancreatic juice is brought in contact with the peritoneum, it would 
 produce a destructive effect upon it by its digestive properties, or it 
 might even be followed by diffuse peritonitis. In opposition to this 
 assumption, it is affirmed that in experiments on the pancreas it hap- 
 pens quite frequently that pancreatic juice escapes into the abdominal 
 cavity, from the cannula introduced into the pancreatic duct, without 
 any bad results on the animals. Concerning this point Heidenhain 
 says : " The animals do not suffer from this circumstance, as the duct 
 is regenerated in spite of the wounded surface being bathed in the 
 secretion. Nevertheless, it is difficult to explain this. Why do not 
 the wounded and suppurating tissues undergo digestion by the pan- 
 creatic juice? The efficacy of the albumin-ferment is destroyed in 
 some way, probably by being changed into zymogen, the living tissues 
 having on the juice the effect observed by Podolinski on treating the 
 pancreatic juice with pulverized zinc or yeast-ferment. Although small 
 quantities of pancreatic juice may escape into the peritoneal cavity of 
 an animal without any serious consequences, we have no evidence to 
 show that the peritoneal cavity in man is possessed of the same im- 
 munity against such accident, and it would not be prudent to expose 
 a patient to such risk until more light is thrown on this subject by 
 further observation and experiment. At the same time, we must not 
 forget that pure pancreatic juice is found only in small cysts, as the 
 contents of large cysts have undergone various transformations, and 
 are mixed with different accidental products which might prove an 
 additional source of danger in producing peritonitis. In all the cysts 
 where a pancreatic fistula was established the artificial opening con- 
 tinued to discharge the secretion for a variable period of time, and in 
 
RETENTION-CYSTS. 697 
 
 two cases the discharge had not ceased at the time the report was 
 made, and hence reaccumulation would have been inevitable in case the 
 fluid had been removed by aspiration. For these reasons the treatment 
 by aspiration should be limited to cysts of moderate size and where 
 adhesions have formed between the cyst and the anterior walls of the 
 abdomen. In cases presenting these favorable conditions aspiration 
 deserves a trial, and the operation may be repeated as often as required, 
 or until symptoms arise which call for more radical measures. The 
 needle should always be disinfected thoroughly by passing it through 
 the flame of a spirit-lamp and by dipping it in a 5 per cent, solution 
 of carbolic acid. The puncture is made obliquely, so as to prevent the 
 formation of a fistulous opening. The fluid should be withdrawn slowly, 
 and the cyst be emptied as completely as possible. 
 
 After the operation gentle pressure should be made over the cyst 
 by applying a compress and an elastic bandage. The safest and at the 
 same time the most efficient treatment consists in establishing a pan- 
 creatic fistula. The operation which accomplishes this purpose most 
 safely and in the shortest time consists in exposing the cyst by an 
 incision, stitching its walls to the margins of the wound. The same 
 aseptic precautions must be observed before, during, and after the 
 operation as in any other abdominal operation. The stomach being 
 generally pushed forward, upward, and toward the right by the cyst, 
 it is advisable to empty this organ completely as a preliminary measure 
 by abstinence of food and by the use of the siphon irrigator. Except in 
 the writer's case the incision was always made in the linea alba. It 
 seems to the writer that the incision should always be made over the 
 most prominent part of the tumor, and as nearly as possible over the 
 seat of obstruction. In following this rule we select the place where 
 we are most apt to find adhesions, and at the same time we establish 
 the straightest and most direct route to the primary origin of the cyst. 
 An incision through the linea alba or parallel with the costal arch will 
 afford the easiest access with a minimum risk of injury to important 
 parts. The external incision should be at least four inches in length, 
 while the peritoneum should only be opened to the extent of two 
 inches for the purpose of making an exploratory examination, the 
 incision being enlarged as occasion may require. If adhesions are 
 found between the cyst and the omentum and the omentum and the 
 parietal peritoneum, the cyst is punctured with an exploratory needle, 
 and, if the diagnosis is corroborated, the operation is finished by incis- 
 ing and draining the cyst. If no adhesions are found between the 
 omentum and the peritoneum, the former is incised so as to expose the 
 cyst-wall, when either of the following plans may be pursued : The 
 
698 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 parietal peritoneum is stitched to the skin with catgut. The margins 
 of the omental wound are pushed back under the abdominal walls so 
 as to expose the cyst freely, when the wound is packed from the bot- 
 tom with iodoform gauze, and an aseptic dressing is applied and 
 retained for six or eight days, or until adhesions have formed between 
 the cyst and the margins of the wound, which have effectually shut off 
 the peritoneal cavity, when the cyst is incised and drained. 
 
 Suturing of the cyst-wall to the margins of the wound as a prelim- 
 inary operation should never be resorted to, as, on account of thinness 
 of the cyst-walls, there is danger of escape of fluid into the peritoneal 
 cavity from the punctures made by the needle — an occurrence which 
 the procedure was intended to obviate. With proper care, however, 
 the operation can be completed at once. The cyst-wall is grasped with 
 two many-toothed forceps, and is drawn forward so as to bring it in 
 accurate and close contact with the margins of the wound, when the 
 fluid is removed with an aspirator or a trocar with the same care as in 
 emptying an ovarian cyst. As the cyst becomes empty it is pulled 
 through the wound, obviating any further danger of escape of fluid 
 into the peritoneal cavity. When the cyst is nearly empty it is freely 
 incised and sutured to the peritoneal lining of the abdominal wound. 
 The drainage-tube should be fully three-quarters of an inch in diam- 
 eter, and must reach from the bottom of the cyst to the surface of 
 the wound. After emptying the cyst completely by compression and 
 placing the patient on his side, a large Lister dressing is applied for the 
 purpose of guarding against infection and to absorb the secretions. 
 Frequent change of dressing may be required on account of copious 
 escape of pancreatic secretion. Past experience would dictate the advis- 
 ability of protecting the skin against the digestive action of the pancreatic 
 juice by freely applying carbolated oil. The antiseptic dressings should 
 not be abandoned until the peritoneal cavity has become completely 
 closed by firm adhesions and the size of the cyst has been reduced to 
 a fistulous tract. The drainage-tube is shortened from time to time 
 as the depth of the fistulous opening is diminished by obliteration of 
 the cyst from the bottom of the tract. The speedy obliteration of the 
 cyst will depend on the continuance, abatement, or removal of the 
 obstructing cause or upon the condition of the gland-tissue distal to 
 the seat of obstruction. If the stricture in the common duct of the 
 pancreas is complete and of a permanent character, the obstruction 
 will continue, and if healthy gland-tissue remains on the distal side, the 
 fistula will continue to discharge pancreatic juice. If the inflammation 
 which caused the obliteration of the duct subsides, and the passage 
 again becomes permeable, the natural outlet will again be established 
 
RETENTION-CYSTS. 
 
 699 
 
 and the artificial duct will become obliterated. If an impacted calculus 
 has caused the retention, and the fistula continues to discharge, a care- 
 ful examination should be made to detect the calculus, and if found, 
 an effort should be made to remove it through the fistulous opening. 
 If the obstruction has become permanent and the gland-tissue on the 
 distal side has become destroyed either by the cause or causes which 
 produced the obstruction or by the intracystic pressure, that portion of 
 the organ has been deprived of its functional capacity, and, as no pan- 
 creatic juice is secreted, definitive obliteration of the cyst and permanent 
 closure of the fistulous tract will take place in a comparatively short 
 time. 
 
 Fig. 463.— Congenital cystic kidney (after H. Morris). 
 
 Kidney. — Retention-cysts of the kidney occur in the substance of 
 the kidney, constituting the hydrops renum cystiais, or the pelvis 
 of the kidney becomes distended from obstruction anywhere in the 
 urinary passage below — a condition called hydronephrosis. 
 
 Cystic Hydrops of the Kidney. — Retention-cysts of the kidney fre- 
 quently occur as a congenital affection. In the congenital as well as 
 
700 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 in the acquired forms the cyst-formation is due to occlusion of urinifer- 
 ous tubules. According to Erichsen, however, they may also form in 
 connective tissue, in which the fluid is formed in the same manner as 
 in hydrocele. Congenital cysts of the kidney are frequently found on 
 both sides, and so large that the swellings distend the fetal abdomen 
 to its utmost capacity. The kidney is in some cases a huge collection 
 of cysts with little or no kidney-tissue (Fig. 463), and the children are 
 born dead or die soon after birth. At other times the cysts are small 
 and the kidney is contracted and is composed almost exclusively of 
 connective tissue. The obstruction of the uriniferous tubules during 
 intra-uterine life is caused, as in the formation of cysts later in life, 
 by a general nephritis causing blocking of the tubes either by casts 
 or epithelial debris or by hyperplasia of the interstitial connective 
 tissue. A localized connective-tissue hyperplasia extending from the 
 pelvis of the kidney, resulting from nephro-pyelitis fibrosa, pyelo-papil- 
 litis fibrosa ascendens, or a nephritis nrica, from failure of union between 
 
 the renal and collecting tubules, or 
 from rests of the Wolffian or supra- 
 renal bodies, may cause blocking of 
 the tubes. The cysts appear in 
 different parts of the kidney (Fig. 
 464). The spaces, which are lined 
 with cubical or flattened epithelium, 
 appear to be smooth-walled. As the 
 cysts enlarge many of them fuse 
 and form large cavities, so that ulti- 
 mately the kidney acquires a honey- 
 comb appearance. In the adult, cysts 
 of this kind may form from small 
 cysts which originated during intra- 
 uterine life. In other cases they are 
 the result of an interstitial nephritis 
 (Fig. 454). The cysts at first contain 
 urine, or at least urinary salts, which 
 later disappear and are replaced by 
 serum. Children born alive with 
 double cystic disease of the kidney usually die of uremia in a short time. 
 In the adult the same condition is developed in the course of a chronic 
 interstitial nephritis, which generally affects simultaneously both organs, 
 in which case surgical treatment is out of the question. In children 
 with congenital unilateral cystic kidney nephrectomy is indicated if the 
 size of the swelling interferes with important functions. 
 
 Fig. 464.— Congenital cystic kidney, early stage 
 (after Shattuck). 
 
RETENTION-CYSTS. 701 
 
 Hydronephrosis. — The effect of chronic obstruction to the outflow 
 of the urine can be studied profitably in cases of stricture of the 
 urethra or enlargement of the prostate. Dilatation of the urinary 
 passage occurs from the seat of obstruction and ascends progressively 
 the entire length of the urinary apparatus. In prostatic or urethral 
 obstruction the bladder first becomes dilated, the valves guarding the 
 ureteral orifices are rendered incompetent, the ureters dilate, and finally 
 the back pressure results in distention of the pelves of both kidneys, 
 producing a double hydronephrosis. 
 
 Unilateral hydronephrosis is the result of obstruction of the ureter. 
 Abnormal intracystic pressure often results in a localized yielding of 
 the bladder-wall, sacculation, and eventually the formation of a pouch 
 which communicates with the bladder only through a very narrow 
 opening. The presence of a stone in such a pouch frequently eludes 
 detection with the sound, and offers great difficulties in its removal 
 either by the perineal or the suprapubic route. In exceptional cases 
 a diverticulum becomes completely detached from the bladder by 
 obliteration of the communicating opening. Virchow saw such an 
 isolated diverticulum in the perineum. 
 
 In cases of unilateral hydronephrosis with a patent ureter Virchow 
 years ago pointed out a valvular obstruction caused by a congenital 
 or an acquired defect at a point where the ureter dilates to form the 
 pelvis of the kidney. This defect consists of an abnormal obliquity 
 of the ureter at this place. The most frequent causes of obstruction 
 of the ureter are impaction of a calculus, stricture, pressure, and the 
 extension to the ureter of a carcinoma of the uterus. Retroversion 
 of the uterus and benign tumors of the uterus and the ovaries may 
 compress one or both ureters to such an extent as to cause hydro- 
 nephrosis. If the obstruction is located at the osteum urethrale pel- 
 vicum> in the form of an impacted calculus, a stricture, or a valve, 
 the accumulation of urine leads to progressive dilatation of the pelvis 
 of the kidney and to atrophy of the kidney-substance from pressure, 
 so that in the course of time the kidney is converted into a sac com- 
 posed apparently of a fibrous wall, and containing no longer urine, but 
 a serous fluid. If the pelvis of the kidney does not yield to the abnor- 
 mal pressure, pouches form, while other parts of the kidney show to 
 a lesser extent the effects of pressure. If the ureter is occluded or 
 obliterated below the pelvis of the kidney, the part of the ureter above 
 the obstruction dilates simultaneously with the pelvis of the kidney. 
 If the obstruction is not complete, the urine escapes from time to time 
 and the swelling diminishes in size or disappears altogether, to reappear 
 
702 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 with the accumulation of urine, constituting what is called an intermit- 
 ting hydronephrosis. 
 
 Congenital impermeability of the ureter results in congenital hydro- 
 nephrosis, unilateral or bilateral according to whether one or both 
 ureters are defective. 
 
 Hydronephrosis, like all other retention-cysts, is prone to become 
 the seat of secondary pathological conditions by the entrance into the 
 dilated pelvis of the kidney of pyogenic microbes. The suppurative 
 inflammation which then ensues converts the hydronephrosis into 
 pyonephrosis. The suppurative pyelonephritis destroys the atrophic 
 parenchyma of the kidney, so that ultimately nothing remains but the 
 dilated capsule of the kidney filled with pus. Infection most frequently 
 takes place by an ascending suppurative ureteritis, or it may occur by 
 pus-microbes which reach the kidney through the circulation. 
 
 From a diagnostic point of view hydronephrosis is a retroperitoneal 
 cyst which begins in a region occupied by the kidney. If the swelling 
 is large enough to be palpable, fluctuation can usually be felt. In 
 cystic kidney the surface of the organ is usually uneven from the pres- 
 ence of a number of cysts of unequal size. A hydronephrotic kidney 
 presents itself as a smooth swelling. 
 
 The most important point in the differential diagnosis of hydro- 
 nephrosis and of intra-abdominal fluctuating swellings and tumors is 
 to demonstrate the retroperitoneal location of the swelling, which in 
 doubtful cases can be shown satisfactorily by rectal insufflation. In 
 women catheterization of the ureters as described and practised by 
 Kelly will often enable the surgeon to demonstrate not only the exist- 
 ence but also the exact location of the ureteral obstruction. If the 
 swelling can be located positively in the retroperitoneal space, a lumbar 
 exploratory puncture under strict antiseptic precautions is not only 
 permissible but will settle the diagnosis between hydronephrosis and 
 pyonephrosis and malignant tumor of the kidney. A careful chemical 
 and microscopical examination of the urine will often indicate the kidney 
 as the primary seat of the swelling. 
 
 Treatment. — In unilateral hydronephrosis the opposite kidney under- 
 goes compensatory hyperplasia. Experiments and clinical observation 
 have shown that one healthy kidney is sufficient to eliminate the urea, 
 and numerous cases have been recorded in which a hydronephrotic 
 kidney was removed without any immediate or remote ill results. The 
 kidneys are, however, subject to so many accidents and diseases that 
 there is no excuse for sacrificing a kidney unless its parenchyma has 
 been destroyed or the continuity of the urinary passage cannot be 
 restored by some of the operative procedures that have recently been 
 
RETENTION-CYSTS. 703 
 
 devised. The writer, who cannot agree with Morris and Sutton that, 
 in case the opposite kidney is in a healthy condition, the hydronephrotic 
 kidney should be removed, has shown that mechanical obstruction 
 of the ureter in dogs produces progressive hydronephrosis, and has 
 demonstrated, by microscopical examination of the capsule of the cyst, 
 the existence of atrophic kidney-tissue and the capacity of this tissue 
 to regenerate after a nephrotomy. It is different in cases of hydro- 
 nephrosis complicated by suppurative pyelonephritis. In such cases the 
 parenchyma of the kidney, already atrophic from pressure, is quickly 
 destroyed by the suppurative inflammation. In uncomplicated hydro- 
 nephrosis it is the duty of the surgeon to relieve tension and to secure 
 a new outlet for the secretion by a lumbar nephrotomy, and at the 
 same time to search for and remedy the obstruction that has caused 
 the hydronephrosis. Recent advances made in ureteral surgery dic- 
 tate such a conservative course. It is certainly easier to extirpate a 
 hydronephrotic kidney than to remove its primary cause, but this fact 
 is no argument in favor of mutilating surgery. With this additional 
 indication to meet, the kidney and the upper part of the ureter should 
 be exposed by Konig's incision. This incision will expose the pelvis 
 of the kidney and the upper part of the ureter for a thorough examina- 
 tion by sight and touch. If the ureter below the pelvis of the kidney 
 is not dilated, the obstruction must be sought for at the pelvic orifice 
 of the ureter, through an incision into the lowest portion of the dilated 
 pelvis. If an impacted stone is found, it is extracted, and the perme- 
 ability of the ureter is demonstrated by catheterization. If a valve in 
 the form of a projecting spur caused .by a too oblique insertion of the 
 ureter is found, it can be excised and the mucous membrane be sutured 
 with fine catgut ; or if this procedure is impracticable, the ureter may 
 be cut transversely below the pelvis, the proximal end tied, and the 
 distal end implanted into a slit in the dilated pelvis, in which location 
 it may be fixed by a few superficial sutures; the wound in the pelvis 
 may then be closed, and an external temporary urinary fistula estab- 
 lished by an incision through the convex side of the kidney, the fistula 
 being kept open by a tubular drain. If the ureter at this point is com- 
 pletely obliterated, a similar procedure is indicated. If it is narrowed 
 by cicatricial stenosis, a plastic operation such as the one devised by 
 Heineke-Mikulicz for cases of cicatricial stenosis of the pylorus will 
 yield an excellent result, as has been shown by the experience of 
 Fenger. 
 
 Impacted calculi and cicatricial stenosis nearer the bladder are 
 attended by dilatation of the ureter above the obstruction ; the obstruc- 
 tion will therefore be found at the lower end of the dilated ureter. 
 
704 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 The lower end of the ureter can be reached through the sacral route. 
 If the cicatricial stenosis is found at or near the insertion of the ureter 
 into the bladder, transverse section, ligation of the bladder-end, and 
 implantation of the upper end into a slit of the bladder, as advised by 
 Van Hook, will restore the continuity of the urinary canal. In all 
 these operations upon the ureter it is advisable to establish a temporary 
 renal fistula in the lumbar region ; this fistula should be maintained 
 until the patency and efficiency of the ureteral part of the urinary 
 passage have been demonstrated. If a considerable part of the lower 
 portion of the ureter is impermeable, implantation of the upper portion 
 into the rectum — an operation the feasibility of which has been demon- 
 strated by the experiments of Reed and the clinical experience of 
 Chaput and others — should be considered. The writer is firmly con- 
 vinced of the propriety of restricting primary nephrectomy in hydro- 
 nephrosis to cases in which the surgeon can satisfy himself that the 
 opposite kidney is intact, and in which the parenchyma of the affected 
 kidney has been destroyed. In all other cases a nephrotomy should 
 be made, and, if possible, the ureteral obstruction be removed at the 
 same time or subsequently. In the opinion of the writer, it is much 
 better to subject the patient to the slight inconvenience of a permanent 
 renal fistula than to deprive him of an important organ capable of 
 parenchyma-regeneration. The writer has a number of patients who 
 wear a tube of special construction to which is attached a rubber 
 receptacle : the patients are perfectly comfortable, and they prefer this 
 condition rather than subject themselves to a secondary nephrectomy. 
 In a number of such cases it has been observed that while the escape 
 of urine soon after the operation was scanty, the amount of secre- 
 tion gradually increased until after a few months the diseased kidney 
 secreted nearly as much urine as the opposite one — the best possible 
 proof that the atrophic kidney-tissue after the operation resumed its 
 former physiological importance. 
 
 Hydronephrosis caused by obstruction of the ureter from malignant 
 disease does not justify surgical interference. In hydronephrosis pro- 
 duced by pressure upon the uterus the cause of compression should 
 be removed. This includes the removal of benign pelvic tumors, 
 inflammatory adhesions, and the correction of displacement of a patho- 
 logical or a pregnant uterus. 
 
 Testicle. — Cysts of the testicle arising from " rests" have been 
 considered in the section on Cystoma. We shall describe here cysts 
 resulting from obstruction of spermatic tubes. Such cysts are usually 
 thin-walled, spherical or oval cysts, imbedded in and loosely connected 
 with the tissue of the cord. They may occur singly or in a group. 
 
RETENTION-CYSTS. 705 
 
 Their most frequent seat is just above the epididymis, but they may be 
 found in any part of the spermatic cord. Mr. Lloyd and Mr. Liston 
 discovered, independently of each other, spermatozoa in the contents 
 of these cysts. Roth traces spermatic cysts to the retention of fluid 
 from congenital vasa aberrantia. Silcock attributes them to cystic 
 dilatation of tubules. The various forms of seminal cysts have been 
 described fully by Curling. The capsule of the cyst is composed of 
 connective tissue lined with squamous epithelium. Kocher and Rosen- 
 bach demonstrated by fine dissections of specimens the connection of 
 the spermatoceles resulting from retention with the spermatic tubules. 
 Rupture of retention-cysts on the surface of the epididymis and the 
 testicle and rupture of Morgagni's hydatid (Roth) give rise to sperma- 
 tozoa in the fluid of hydrocele. Spermatoceles, which occur in persons 
 after the age of puberty, grow slowly and occasionally attain large size. 
 Paget removed from a cyst of this kind, in a man seventy years old, 
 eighteen ounces of a milky fluid which contained spermatozoa, and 
 Stanley removed twenty-five ounces in a similar case. The cyst from 
 which the fluid was obtained, which furnished the histological elements 
 for Fig. 465, occurred in a man seventy-four years of age, and had 
 
 Fig. 465. — Contents of spermatocele, showing spermatozoa and epithelial cells ; X 350. 
 
 attained the size of a filbert. The patient was suffering at the same 
 time from double epididymitis and hypertrophy of the prostate gland. 
 The swelling is smooth, fluctuates, and in many cases is translucent. 
 
 The treatment consists in tapping with or without the injection of 
 carbolic acid, incision of the cyst, suturing of the cyst-wall to the skin, 
 and drainage as in Volkmann's operation for hydrocele. In the case 
 of small cysts that give rise to no inconvenience operative treatment 
 is contraindicatcd. In cases in which repeated occurrences take place 
 45 
 
yo6 
 
 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 after tapping and injection, excision of the sac is indicated, and the 
 operation yields good results. 
 
 Mammary Gland. — In the mammary gland during lactation reten- 
 tion of milk in the gland-ducts occurs quite frequently in connection 
 with obstruction produced by acute or chronic interstitial mammitis. 
 This form of retention-cyst is called galactocele. If the obstruction of 
 the duct remains permanently, the cyst-contents change. The milk is 
 either transformed into a cheesy mass or is absorbed, being replaced 
 
 Hlf 
 
 Fig. 466. — Circumscribed interstitial mastitis with cyst-formation (after Konig) : a, normal acini; b, 
 transition of normal acini into small cysts; c, dilated duct; d, colostrum-corpuscles. The interstitial con- 
 nective tissue is infiltrated with young cells. 
 
 by a serous fluid which is often stained by the admixture of blood. 
 In the causation of genuine cysts of the mammary gland, usually some 
 form of obstruction leads to dilatation of the lacteal ducts. In some 
 cases the cysts communicate with one another; in others multiple cysts 
 appear simultaneously or in succession independently of one another. 
 Sometimes such cysts attain an enormous size. Mr. Paget quotes a 
 case in which a cyst of this kind contained nine pounds of limpid 
 " serosity " which had developed in three months in a woman thirty 
 years of age. In this case the walls of the cyst were thin and the 
 
RETENTION-CYSTS. 707 
 
 fluid was serous. Degeneration of the cyst-wall retards or arrests 
 growth, rendering the lining membrane which secretes the contents 
 barren. 
 
 Multiple cysts are often produced, as pointed out by Konig, in 
 consequence of chronic interstitial mastitis, which obstructs the milk- 
 ducts (Fig. 466). This form of interstitial mastitis with cyst-production 
 has often been mistaken for carcinoma. 
 
 Chronic interstitial mastitis occurs, according to Konig, as a circum- 
 scribed and diffuse affection. Another variety of retention-cyst occurs 
 in elderly women, frequently as a multiple affection, in consequence of 
 senile involution of the breast. The cysts give rise to no pain, but 
 occasionally they are the starting-points of carcinoma. The cysts are 
 small, and they contain a mucoid substance which causes them to 
 assume a bluish tint when the breast is examined after removal. 
 
 In galactocele complicated by inflammation a free incision relieves 
 the pain and tension and is followed by a speedy obliteration of the 
 cyst. In chronic cases incision followed by cauterization and packing 
 of the wound with iodoform gauze, or excision of the cyst, is indi- 
 cated. Chronic interstitial mastitis with cyst-formation, if circum- 
 scribed, indicates partial excision of the breast. If the disease is diffuse, 
 the entire breast should be removed. Involution-cysts require no 
 surgical treatment, 
 
 Salivary Glands. — A retention-cyst of the ducts of the sublingual 
 and submaxillary salivary glands is called a " ranula." Retention-cysts 
 of Stensen's duct have been seen and described by Bruns, but they are 
 exceedingly rare. Various interpretations have been given as to the 
 origin and nature of the sublingual cysts that were formerly classified 
 under the head of " ranula." Pauli believed that they consisted of a 
 dilated Wharton's duct, in which case he called the swelling a " ptyal- 
 ectasis," or, after rupture of the duct, an accumulation of saliva in the 
 connective tissue, in which case he called the swelling a " ptyalocele." 
 Virchow, for good reasons, objected to the latter mode of origin, as 
 he asserted that the saliva extravasated into the connective tissue would 
 become absorbed. Fleischmann claimed that the salivary ducts could 
 not dilate to the extent seen in cystic swellings under the tongue. 
 He believed that these cysts are hygromata of the base of the genio- 
 glossus muscle. Gurlt and Bernard asserted that the submaxillary 
 gland secreted a mucoid substance analagous to the contents of the 
 cysts so frequently found on the side of the tongue. Ptyalin and 
 rhodankalium, however, have never been discovered in the contents of 
 a ranula. The absence of these two substances in the contents of a 
 ranula is, however, no proof that the cyst is not a dilated duct of a 
 
708 PATHOLOGY AND TREATMENT OF TUMORS. 
 
 salivary gland, as the cyst-contents undergo chemical changes which 
 make it impossible to refer the secretion back to its proper origin by 
 chemical examination. 
 
 Bernard and Weber not only detected the orifice of the duct upon 
 the wall of a retention-cyst of Wharton's duct, but they succeeded in 
 inserting through the orifice a fine probe into the cyst, thus establish- 
 ing beyond all doubt the connection of the cyst with the duct. Neu- 
 mann in a supposed case of ranula excised a part of the cyst-wall, 
 and on examination of sections under the microscope he found the 
 cyst lined with ciliated epithelium. This induced him to regard the 
 foramen cecum as the starting-point of the cyst. Bochdalek showed 
 that the foramen cecum in some cases does not terminate in a blind 
 sac, but extends in the direction of the median glosso-epiglottic liga- 
 ment. The posterior end of this prolongation possesses numerous 
 mucous glands, of which several are situated in the floor of the 
 mouth, on the side of the tongue, and hidden by the genio-glossus 
 muscle. Recklinghausen is of the opinion that most of the cysts 
 which heretofore have been called " ranula " are cysts which originate 
 from Blandin-Nahn's gland in the substance of the tongue. He bases 
 this opinion upon the form and growth of the cysts as well as the cha- 
 racter of their contents. In multilocular ranula remnants of gland- 
 tissue have been found in the cyst- wall. 
 
 From these remarks it will appear that many of the mucous cysts 
 in the floor of the mouth do not always consist of a dilated duct of 
 one of the salivary glands and retained saliva. That retention-cysts of 
 the salivary ducts occur has been shown by the investigations of 
 Bernard and Gurlt. Richet in one case found as the cause of the 
 obstruction a fragment of a grass-blade lodged in the duct, and the 
 duct behind the obstruction was dilated into a cyst. 
 
 Kolliker, Bernard, and Birkett claim that Rivini's duct is as often 
 the seat of retention-cysts as Wharton's duct. The writer, in several 
 cases of dilatation of Wharton's duct to the size of a walnut, has not 
 only discovered its orifice upon the wall of the cyst, but by pressure 
 has been able to empty the cyst through the constricted orifice. In 
 many cases of ranula the outlet of the duct is not completely closed, 
 but is contracted. Stenosis and cicatricial obliteration of Wharton's 
 and Rivini's ducts are caused by inflammation and cicatricial con- 
 traction, producing incomplete or complete obstruction and retention 
 of saliva, which at first constitutes the contents of the cyst, but which 
 undergoes speedy chemical changes. 
 
 A retention-cyst of the ducts of the salivary glands appears clin- 
 ically as a cyst with very thin walls and with mucous contents. The 
 
RETENTION-CYSTS. 709 
 
 cyst is usually somewhat elongated in the long axis of the tongue : 
 it may become so large as to interfere with the free movements of the 
 tongue, and at the same time may appear as a swelling of considerable 
 size in the submaxillary triangle. 
 
 The removal of a ranula by excision is the surest and shortest way 
 to effect a radical cure. The cyst cannot be enucleated, as the cyst- 
 wall is exceedingly delicate and firmly attached. Excision is not 
 applicable in all cases. The second method of treatment is the one 
 usually resorted to ; this method consists in excision of a large part 
 of the cyst-wall, after which the cavity is packed with iodoform gauze 
 to prevent the healing of the incision. The gauze packing should 
 be changed daily until the margins of the wound have healed, thus 
 securing a free and permanent outlet for the duct. 
 
INDEX 
 
 Adenoma, 152 
 
 diagnosis, 175 
 
 etiology, 155 
 
 history and pathology, 153 
 
 in animals, 58 
 
 of digestive tract, 157 
 
 of Fallopian tubes, 161 
 
 of kidney, 175 
 
 of lachrymal gland, 172 
 
 of liver, 173 
 
 of mammary gland, 167 
 
 of nasal cavities, 159 
 
 of ovaries, 161 
 
 of parotid gland, 172 
 
 of prostate gland, 171 
 
 of skin, 157 
 
 of testicle, 172 
 
 of thyroid gland, 162 
 
 of uterus and its appendages, 159 
 
 prognosis, 176 
 
 sebaceum, 157 
 
 sudoriparum, 157 
 
 treatment, 176 
 Akidopeirasty, 98 
 Anastomosis, intestinal, 339 
 Angioma, 448 
 
 anatomical varieties, 452 
 
 complications, 451 
 
 definition, 448 
 
 histogenesis, 449 
 
 histology, 449 
 
 intracranial, 462 
 
 of bones, 461 
 
 of deep connective tissue, 459 
 
 of larynx, 464 
 
 of liver, 462 
 
 of mammary gland, 463 
 
 of muscles, 463 
 
 of skin and mucous membranes, 458 
 
 of tongue, 463 
 
 prognosis, 456 
 
 symptoms and diagnosis, 456 
 
 treatment, 456 
 Angio-sarcoma, 451 
 
 Animals, tumors in, 57 
 Apostoli's uterine electrode, 506 
 Atheroma, deep-seated, 183 
 
 Blepharoplasty, 286 
 
 Blood-corpuscles, immigration of, into paren- 
 chyma of tumor, in 
 Branchial cysts. See Cysts. 
 Bronchocele, 162 
 
 Carcinoma, 203 
 
 cylindrical-celled, 214, 252 
 definition, 203 
 diagnosis, 256 
 etiology, 231 
 
 age, 234 
 
 climate, 236 
 
 diet, 235 
 
 heredity, 232 
 
 mental depression, 236 
 
 microbes, 239 
 
 prolonged irritation and inflammation, 236 
 
 traumatism, 233 
 
 tuberculosis, 236 
 factors in the production of, 86 
 general infection, 225 
 glandular, 215, 253 
 histogenesis, 208 
 histology, 212 
 local diffusion, 2 16 
 malignancy, 215 
 of bladder, 372 
 of cervix uteri, supravaginal amputation for, 
 
 364 
 of external female genital organs, 370 
 of eye, 372 
 of face, 282 
 
 diagnosis, 283 
 
 operative treatment, 286 
 of internal organs, diagnosis, 263 
 of intestines, 335 
 
 enterectomy for, 337 
 
 enterostomy for, 337 
 
 intestinal anastomosis for, 339 
 711 
 
712 
 
 INDEX. 
 
 Carcinoma of intestines, operative treatment 
 of, 337 
 of kidney, 374 
 
 nephrectomy for, 376 
 of lip, 280 
 
 clinical course, 280 
 
 diagnosis, 281 
 
 operative treatment, 283 
 of liver, 345 
 of mammary gland, 303 
 
 acinous variety, 305 
 
 etiology, 307 
 
 prognosis, 315 
 
 symptoms and diagnosis, 308 
 
 treatment, 317 
 
 radical operations, 317 
 of mouth, 289 
 
 radical operations for, 291 
 of nose, operative treatment, 287 
 of oesophagus, 323 
 
 diagnosis of, differential, 324 
 
 gastrostomy for, 325 
 of ovary, 350 
 of parotid gland, 298 
 
 extirpation for, 301 
 of penis, 347 
 
 amputation of penis for, 349 
 of rectum, 339 
 
 extirpation of rectum for, 343 
 
 palliative operations, 342 
 
 symptoms and diagnosis, 341 
 of skin, 275 
 
 degeneration of tumor-tissue, 280 
 
 histological structure, 275 
 
 regional infection, 279 
 of stomach, 326 
 
 gastroenterostomy for, 332 
 
 pylorectomy for, 328 
 
 treatment, 328 
 of testicle, 346 
 of thyroid gland, 300 
 of tongue, 292 
 
 radical operations for, 294 
 of tonsil, 291 
 
 operative treatment of, 291 
 of urethra, 373 
 of uterus, 353 
 
 etiology, 359 
 
 histogenesis and histology, 353 
 
 symptoms and diagnosis, 360 
 
 vaginal hysterectomy for, 366 
 •origin and nature, 204 
 
 Carcinoma, pathology, 242 
 
 prognosis, 264 
 
 regional infection, 220 
 
 secondary, growth of, 222 
 
 ■ local infection of, 223 
 
 squamous-celled, 213, 250 
 
 treatment, 266 
 
 palliative operations, 269 
 radical operations, 271 
 
 ulcerating, difficulty in diagnosis of, 261 
 Carcinoma-cells, degenerative changes in, 246 
 Carcinosis, miliary, 229 
 Caustics in treatment of tumors, 120 
 Cementomes, 446 
 Cervix uteri, supravaginal amputation of, for 
 
 carcinoma, 364 
 Chassaignac's chain ecraseur, 125 
 Cheiloplasty, 286 
 Cholesteatoma, 401 
 Chondroma, 422 
 
 branchiogenes, 432 
 
 definition, 422 
 
 etiology, 426 
 
 histology, 424 
 
 of bone and periosteum, 429 
 
 of cartilage, 428 
 
 of connective tissue, 432 
 
 of joints, 430 
 
 of ovary, 432 
 
 of salivary glands, 431 
 
 of testicle, 432 
 
 origin, 422 
 
 prognosis, 427 
 
 retrogressive metamorphoses, 425 
 
 symptoms and diagnosis, 427 
 
 treatment, 428 
 Clamps, intestinal and stomach, 329 
 Colostomy, inguinal, Maydl's, 342 
 Comedo, 666 
 Cornu cutaneum, 142 
 Cystoma, 178 
 
 diagnosis, 180 
 
 etiology, 180 
 
 of bone, 201 
 
 of broad ligament, 197 
 
 of eye, 199 
 
 of mammary gland, 188 
 
 of ovary, 1 89 
 origin, 194 
 treatment, 197 
 
 of parovarium, 195 
 
 of testicle, 108 
 
INDEX. 
 
 7*3 
 
 Cystoma of thyroid gland, 187 
 of vagina, 198 
 prognosis, 181 
 topography, 181 
 Cysts, allantoic (urachus), 201 
 
 branchial, 623. See also Teratoma. 
 
 anatomy and embryology, 624 
 
 antiseptic drainage in treatment of, 635 
 
 atheromatous, 628 
 
 classification, 626 
 
 diagnosis, 631 
 
 etiology, 630 
 
 extirpation of, 634 
 
 history, 625 
 
 iodine injections in treatment of, 633 
 
 mucous, 628 
 
 prognosis, 631 
 
 serous, 629 
 
 treatment, 632 
 dermoid, 635. See also Teratoma. 
 
 definition, 636 
 
 histology, 637 
 hemato-, of branchial clefts, 629 
 mesoblastic, 186 
 mucous, 185 
 of corpus luteum, 195 
 of jaws, 201 
 
 of vitello-intestinal duct, 199 
 ovarian, 189 
 
 retention-. See Retention-cysts. 
 sebaceous, 666 
 traumatic epithelial, 181 
 
 Deciduoma maligna, 612 
 Dermoid cysts. See Cysts. 
 Desmoid fibroma, 392 
 
 Ecraseur, wire, 126 
 
 Embryo, differentiation of tissue in, 23 
 
 germinal layers of, origin and disposition, 
 
 25 
 
 Embryonic tissue of post-natal origin, trans- 
 formation of, into malignant tumors, 84 
 
 Enkatarrhophy, 182 
 
 Enterectomy, 337 
 
 Enterostomy, 337 
 
 Epulis, sarcomatous, 590 
 
 Exostosis, 56 
 
 Exploratory syringe, value of, as an aid in 
 diagnosis, 101 
 
 Fergusson's percutaneous ligature, 125 
 
 Fibro-chondroma, 424 
 Fibroma, 378 
 
 definition, 379 
 
 etiology, 383 
 
 histogenesis and histology, 379 
 
 of abdominal wall, 391 
 
 of gums, 399 
 
 of mammary gland, 396 
 
 of mucous surfaces, 389 
 
 of nose, 394 
 
 of ovary, 397 
 
 of periosteum and bone, 400 
 
 of serous surfaces, 401 
 
 of skin, 385 
 
 of subcutaneous connective tissue, 390 
 
 of uterus, 397 
 
 of vulva, 398 
 
 prognosis, 384 
 
 retrograde metamorphoses, 382 
 
 symptoms and diagnosis, 383 
 
 treatment, 385 
 Foetus in fcetu, 621 
 Forceps, bowed, 369 
 
 intestinal, 330 
 
 Galactocele, 706 
 
 Gastro-enterostomy, Liicke's operation, 333 
 
 Senn's operation, ^^ 
 
 Wolfler's operation, 332 
 Glioma, 554 
 Gumma of liver, 104 
 
 Harpoon, Warren's, 103 
 Hegar's forceps, 511 
 Hydatids, Morgagni's, 197 
 Hydrokolpos, 671 
 Hydrometra, 671 
 Hydronephrosis, 701 
 Hydrops renum cysticus, 699 
 Hydrosalpinx, 672 
 
 Hysterectomy, complete abdominal, 514 
 
 vaginal, for carcinoma of uterus, 366 
 
 for myofibroma of uterus, 510 
 
 iNCLUsro fcetalis, 621 
 Infection, general. 76 
 
 glandular, sarcoma as a cause of, 51 
 
 local, 75 
 
 meaning of word as applied to tumors, 74 
 
 regional, 75 
 
 carcinoma as a cause of, 51 
 Inflammation, effect of, on tumors, 51 
 
7^4 
 
 INDEX. 
 
 Karyokinesis, 30 
 Karyomitosis, 31 
 Keloid scar, 388 
 
 spontaneous, 386 
 Knaurs, 55 
 
 Kocher's director, 302 
 Koch's syringe, 118 
 Koderick's rosary instrument, 124 
 
 Laparo-hysterectomy or uterine myofibro- 
 ma, 514 
 
 with extraperitoneal treatment of the pedi- 
 cle, 516 
 
 with intra-abdominal treatment of the pedi- 
 cle, 514 
 Laparo-myomectomy, 512 
 Laparotomy for myofibroma of uterus, 510 
 Leiomyoma, 487 
 
 histology and histogenesis, 487 
 Lipoma, 404 
 
 anatomical varieties, 405 
 
 arborescens, 413 
 
 definition, 404 
 
 histology, 404 
 
 in animals, 57 
 
 intermuscular, 413 
 
 of broad ligament, 414 
 
 of eye, 414 
 
 of eyelids, 41 1 
 
 of joints, 413 
 
 of meninges of the brain and spinal cord, 413 
 
 of periosteum, 413 
 
 of scrotum, 414 
 
 of subcutaneous adipose tissue, 408 
 
 of tendon-sheaths, 414 
 
 of vulva, 414 
 
 prognosis, 407 
 
 regressive metamorphoses, 405 
 
 submucous, 412 
 
 subserous, 411 
 
 symptoms and diagnosis, 406 
 
 treatment, 408 
 Lipoxanthoma, 411 
 Liver, carcinoma of, 345 
 Lymphangioma, 465 
 
 anatomical varieties, 465 
 
 definition, 465 
 
 histology and histogenesis, 465 
 
 of lips, 474 
 
 of neck, 475 
 
 of subcutaneous and submucous connective 
 tissue, 477 
 
 Lymphangioma of tongue, 474 
 
 of uterus, 477 
 
 prognosis, 473 
 
 regressive metamorphoses, 471 
 
 symptoms and diagnosis, 472 
 
 treatment, 474 
 Lymphatic glands, enlargement of, 51 
 Lymphoma, 478 
 
 definition, 478 
 
 histology and histogenesis, 480 
 
 retrograde metamorphoses, 480 
 
 symptoms and diagnosis, 481 
 
 treatment, 484 
 Lympho-sarcoma, 580 
 
 Macrochilia, 474 
 Macroglossia, 474 
 Maisonneuve's constrictor, 123 
 Manec's percutaneous ligation of a tumor, 124 
 Melano-sarcoma, 549 
 of skin, 576 
 treatment, 576 
 Metastasis during the growth of a malignant 
 
 tumor, 76 
 Microscope, value of, as an aid in diagnosis, 
 
 103 
 Microtome, freezing, 107 
 Mole, 386 
 Morcellement, 508 
 Myofibroma, regressive metamorphoses, 491 
 
 symptoms and diagnosis, 49 1 
 Myoma, 485 
 definition, 485 
 embryology, 485 
 in animals, 57 
 of alimentary canal, 521 
 of bladder, 522 
 of broad ligament, 519 
 of Fallopian tube, 520 
 of oesophagus, 521 
 of pharynx, 521 
 of rectum, 522 
 of round ligament, 521 
 of small intestines, 521 
 of stomach, 521 
 of uterus, 493 
 etiology, 499 
 
 histology and histogenesis, 496 
 prognosis, 503 
 
 regressive metamorphoses, 497 
 symptoms and diagnosis, 499 
 treatment, 504 
 
INDEX. 
 
 715 
 
 Myoma of uterus, treatment, complete abdom- 
 inal hysterectomy, 514 
 
 curetting, 505 
 
 electrolysis, 506 
 
 ergot, 505 
 
 intraperitoneal enucleation, 512 
 
 laparo-hysterectomy, 514, 516 
 
 laparo-myomectomy, 512 
 
 laparotomy, 510 
 
 salpingo-oophorectomy, 510 
 
 vaginal enucleation, 507 
 hysterectomy, 510 
 myomotomy, 508 
 prognosis, 492 
 
 regressive metamorphoses, 491 
 symptoms and diagnosis, 491 
 treatment, 492 
 Myomotomy, vaginal, 508 
 Myxoma, 415 
 definition, 415 
 etiology, 417 
 histology, 416 
 of glands, 421 
 of intermuscular spaces, 418 
 of middle ear, 420 
 of nerve-sheaths, 420 
 of nose, 419 
 of skin, 418 
 prognosis, 417 
 
 symptoms and diagnosis, 417 
 treatment, 418 
 
 Nephrectomy, 376 
 
 for carcinoma of kidney, 376 
 Neurofibromata, multiple, 532 
 Neuroma, 524 
 
 definition, 524 
 
 embryology, 524 
 
 etiology, 530 
 
 histology and histogenesis, 524 
 
 of cranial nerves, 533 
 
 of lower extremity, 533 
 
 of prepuce, 535 
 
 of spinal nerves, 533 
 
 of upper extremity, 533 
 
 of vulva, 535 
 
 plexiform, 534 
 
 prognosis, 531 
 
 regressive metamorphoses, 530 
 
 symptoms and diagnosis, 530 
 
 treatment, 531 
 Neuromata, Virchow's classification of, 525 
 
 Odontoma, 445 
 
 definition, 445 
 
 Sutton's classification of, 445 
 Odontomes, composite, 447 
 
 compound follicular, 446 
 
 epithelial, 445 
 
 fibrous, 446 
 
 follicular, 445 
 
 in animals, 57 
 
 radicular, 446 
 Onychogryphosis, 150 
 Onychoma, 150 
 Onychomycosis, 150 
 Osteoma, 434 
 
 anatomical varieties, 437 
 
 at seat of a fracture, 443 
 
 definition, 434 
 
 histogenesis, 435 
 
 histology, 435 
 
 in animals, 57 
 
 of brain, 441 
 
 of cranial bones, 438 
 
 of epiphyses of the long bones, 442 
 
 of external meatus, 441 
 
 of eye, 444 
 
 of frontal sinus, 440 
 
 of jaws, 441 
 
 of muscles and tendons, 442 
 
 of orbit, 443 
 
 prognosis, 437 
 
 subungual, 444 
 
 symptoms and diagnosis, 437 
 
 treatment, 437 
 Ovary, glandular cysts of, 193 
 
 hydrops of follicles of, 194 
 
 papillary growths of, 192 
 
 proliferous cysts of, 192 
 
 simple cysts of, origin of, 193 
 
 Pacquelin cautery, 1 19 
 Papilloma, 137 
 
 diagnosis, 149 
 
 fibrous, 144 
 
 hard, 139 
 
 histology and pathology, 137 
 
 of brain, 149 
 
 of digestive tract, 144 
 
 of female organs of generation, 146 
 
 of respiratory tract, 144 
 
 of skin, 141 
 
 of urinary organs, 145 
 
 prognosis, 149 
 
yi6 
 
 INDEX. 
 
 Papilloma, soft, 139 
 
 topography, 141 
 
 treatment, 150 
 Papillomata, transformation of, into malignant 
 
 tumors, 140 
 Parotid gland, extirpation of, 299, 301 
 Pean's forceps, 508 
 Pozzi's enucleator, 507 
 Psammoma, 556 
 Ptyalectasis, 707 
 Ptyalocele, 707 
 
 Ranula, 707 
 
 pancreatica, 685 
 Renal region, topography of, 376 
 Retention-cysts, 657 
 definition, 657 
 etiology, 660 
 histology, 658 
 hydrokolpos, 671 
 hydrometra, 671 
 hydrosalpinx, 672 
 of appendix vermiformis, 674 
 of bile-ducts, 675 
 of kidney, 699 
 
 treatment, 702 
 of mammary glands, 706 
 of mucous membrane, 668 
 of ovary, 665 
 of pancreas, 678 
 
 diagnosis, 689 
 
 etiology, 685 
 
 pathology and morbid anatomy, 684 
 
 prognosis, 694 
 
 treatment, 695 
 of salivary glands, 707 
 of sebaceous glands, 184 
 of shin, 666 
 of testicle, 704 
 
 treatment, 705 
 of thyroid gland, 665 
 of trachea and bronchial tubes, 674 
 prognosis, 664 
 
 symptoms and diagnosis, 661 
 treatment, 664 
 Rhabdomyoma, 486 
 Rhinoplasty, 287-289 
 Rontgen rays in diagnosis of tumors, 102 
 
 Salpingo-oophorectomy for myofibroma of 
 
 uterus, 510 
 Sarcoma, 536 
 
 Sarcoma, alveolar, 552 
 
 beneficial effects of erysipelas in, 573 
 
 capsule of, 562 
 
 definition, 536 
 
 endotheliomatous, 554 
 
 etiology, 566 
 
 fascial, 578 
 
 giant-celled, 546 
 
 histological varieties, 542 
 
 histology and histogenesis, 537 
 
 in animals, 57 
 
 metastasis in, 564 
 
 mixed-cell, 549 
 
 of bladder, 616 
 
 of bones, 582 
 
 giant-celled or myeloid, 583 
 
 round-celled, 584 
 
 spindle-celled, 585 
 
 treatment, 595 
 of brain and its envelopes, 616 
 of cranial bones, 587 
 of eye, 616 
 
 of intestinal canal, 606 
 of jaws, 590 
 of kidney, 607 
 
 diagnosis, 607 
 
 treatment, 608 
 of long bones, 596 
 of lower jaw, 597 
 of lymphatic glands, 580 
 of mammary gland, 602 
 
 excision of, 603 
 of naso-pharynx, 591 
 of nose, 591 
 of omentum, 607 
 of ovary, 612 
 of prostate, 617 
 of salivary glands, 604 
 of skin, 574 
 
 of submucous connective tissue, 576 
 of testicle, 615 
 of thymus gland, 604 
 of tongue, 606 
 of tonsil, 606 
 of upper jaw, 598 
 
 excision of, 599 
 of uterus, 610 
 of vagina, 614 
 of vertebrae, 592 
 
 diagnosis, 592 
 of vulva, 615 
 prognosis, 571 
 
INDEX. 
 
 717 
 
 Sarcoma, regressive metamorphoses, 558 
 
 round-celled, 542 
 
 spindle-celled, 544 
 
 symptoms and diagnosis, 568 
 
 treatment, 571 
 caustics in, 572 
 palliative, 574 
 Sarcoma-cells, morphology of, 541 
 Swellings, infective, 593 
 Syphiloma, 91 
 Syringe, exploratory, Senn's, 100 
 
 Teratoma, 618 
 definition, 618 
 diagnosis, 640 
 of auricle, 650 
 of eye, 647 
 of face, 644 
 of ovary, 651 
 
 clinical aspects, 654 
 histology and histogenesis, 651 
 of palate and pharynx, 645 
 of rectum, 649 
 of scalp and dura mater, 646 
 of scrotum, 655 
 of thorax, 642 
 of tongue, 647 
 of trunk, 641 
 origin, 618 
 prognosis, 641 
 
 regressive metamorphoses, 639 
 treatment, 641 
 
 by antiseptic drainage, 635 
 by extirpation, 634 
 Teratomata, ectogenous, 620 
 
 endogenous, 620 
 Thyroid-dermoids, 649 
 Thyroid gland, extirpation of, 165 
 partial, 166 
 infective swelling of, 163 
 tumors of, differential diagnosis, 164 
 treatment, 165 
 Tongue, amputation of, for carcinoma, 294- 
 
 298 
 Traumatism, influence of, in transformation of 
 
 benign into malignant tumors, 85 
 Tumor-cells, degeneration of, amyloid, 45 
 colloid, 44 
 fatty, 43 
 hyaline, 45 
 mucoid, 44 
 Tumors, accidental ulceration in, 52 
 
 rumors, anatomy of, 34 
 and inflammatory swellings, differences be- 
 tween, 20 
 benign and malignant, clinical aspects of, 
 
 71 
 
 exciting causes effecting a transformation 
 
 into malignant, 80, 8$ 
 biology of, 37 
 blood-vessels of, 35 
 calcification or cretefaction of, 47 
 capsule of, 51 
 
 carcinomatous, location a factor in deter- 
 mining the malignancy of, III 
 caseation of, 46 
 classification of, Cohnheim's, 132 
 
 Senn's, 136 
 
 Virchow's, 131 
 
 Williams's, 133 
 congenital, etiology of, 60 
 connection of, with mother-soil, 97 
 definition, 19 
 diagnosis, 88 
 
 auscultation and percussion in, 102 
 
 clinical history in, 88 
 
 crepitation in, 102 
 
 examination of patient, 91 
 of tumor, 94 
 
 length of time tumor has existed, 89 
 
 location, 89 
 
 pain, 90 
 
 pulsation, 101 
 
 rapidity of growth, 89 
 
 tactile examination, 96 
 
 tenderness, 90, 101 
 effect of local irritation on, 39 
 etiology, 60 
 
 age, 65 
 
 climate, 65 
 
 contagion, 70 
 
 heredity, 61 
 
 inflammation, 69 
 
 irritation, 69 
 
 race, 64 
 
 sex, 67 
 
 social status, 68 
 
 traumatism, 68 
 frequency of recurrence after extirpation, 
 
 78 
 grafting of a malignant upon a benign, 53 
 growth of, 38 
 hemorrhage into, 47 
 histogenesis, 23 
 
7 i8 
 
 INDEX. 
 
 Tumors, history, 17 
 in animals, 57 
 
 adenomata, 58 
 
 cystic tumors, 59 
 
 epithelial tumors, 57 
 
 lipomata, 57 
 
 myomata, 57 
 
 odontomes, 57 
 
 osteomata, 57 
 
 sarcomata, 57 
 
 teratomata, 59 
 inflammation in, 51 
 in plants, 55 
 
 intrinsic tendency to destroy life, 79 
 lymphatic vessels of, 35 
 malignant, 74 
 mobility, 73 
 morphology, 28 
 nerves of, 36 
 operative interference in the treatment of, 
 
 112 
 origin and nature, 17 
 ossification, 47 
 parasitism, 208 
 pathology, 42 
 prognosis, 108 
 pulsating, 39 
 radical operations for, contra-indications to, 
 
 129 
 recurrence of, explanation of, 73 
 relation of, to adjacent tissues, 40 
 relative frequency of, in different organs, 71 
 
 Tumors, resistance and consistence of, 98 
 teratoid, origin of, 618 
 treatment, medical, 113 
 palliative, 129 
 surgical, 115 
 
 by avulsion, 126 
 by cauterization, 119 
 with arsenic, 121 
 with caustic potash, 120 
 with chloride of zinc, 121 
 with chromic acid, 12 1 
 with nitric acid, 121 
 by ecrasement lineaire, 125 
 by extirpation, 126 
 by galvano-caustic wire, 1 24 
 by galvano-puncture, 116 
 by injection of erysipelas toxines, 
 by ligation of blood-vessels, 116 
 by ligature, 123 
 
 by parenchymatous injections, 1 17 
 typical and atypical, 209 
 ulceration of, 52 
 Tumor-tissue, pathological changes in, 43 
 
 Ulcers, spontaneous, 52 
 
 Veins, thrombosis of, 50 
 
 Villous carcinoma of bladder, 372 
 
 Warren's harpoon, 103 
 
 Xanthoma of eyelids, 41 1 
 
 118 
 
CATALOGUE 
 
 OF THE 
 
 MEDICAL PUBLICATIONS 
 
 OF 
 
 W- B. SAUNDERS, 
 
 No. 925 WALNUT STREET, PHILADELPHIA, 
 
 Arranged Alphabetically and Classified under Subjects* 
 
 THE books advertised in this Catalogue as being sold by subscription are usually to be 
 obtained from travelling solicitors, but they will be sent direct from the office of pub- 
 lication (charges of shipment prepaid) upon receipt of the prices given. All the other 
 books advertised are commonly for sale by booksellers in all parts of the United States ; but 
 books will be sent to any address, carriage prepaid, on receipt of the published price. 
 
 Money may be sent at the risk of the publisher in either of the following ways : A post- 
 office money order, an express money order, a bank check, and in a registered letter. Money 
 sent in any other way is at the risk of the sender. 
 
 See pages 30, 3 J, for a List of Contents classified according to subjects* 
 
 LATEST PUBLICATIONS. 
 
 International Text-Book of Surgery* See page 32. 
 
 American Text-Book of Surgery — Third (Revised) Edition* See page 5* 
 
 American Text-Book of Dis* of Eye, Ear* Nose* and Throat* Page 3. 
 
 American Text-Book of Genito-Urinary and Skin Diseases* Page 4. 
 
 Heisler's Embryology* See page 32. 
 
 Nancrede's Principles of Surgery* See page 32. 
 
 Jackson's Diseases of the Eye* See page 32. 
 
 Kyle on the Nose and Throat* See page J5. 
 
 Pryor's Pelvic Inflammations* See pages J9 and 32. 
 
 Abbott's Hygiene of Transmissible Diseases* See page 32. 
 
 Anders' Practice of Medicine— Third (Revised) Edition* See page 6* 
 
 Vierordt's Medical Diagnosis — Fourth (Revised) Edition* See page 29* 
 
 Church and Peterson's Nervous and Mental Diseases* See page 8. 
 
 Da Costa's Surgery — Revised and Enlarged Edition* See page JO. 
 
 Saunders' Medical Hand-Atlases* See page 2. 
 
 Griffith on the Baby — Revised Edition. See page J2. 
 
 Butler's Materia Medica and Therapeutics— Third (Revised) Ed* Page 8. 
 
 De Schweinitz's Diseases of the Eye — Third (Revised) Ed* See page JO. 
 
 Vecki's Sexual Impotence* See page 28. 
 
 Stoney's Materia Medica for Nurses. See page 28. 
 
 McFarland's Pathogenic Bacteria— Revised Edition. See page J7. 
 
 American Pocket Medical Dictionary— Second (Revised) Ed. Page JO. 
 
 Stengel's Text-Book of Pathology. Second Edition* See page 26. 
 
 Hirst's Text-Book of Obstetrics* See page J3. 
 
SAUNDERS' MEDICAL HAND-ATLASES. 
 
 The series of books included under this title consists of authorized translations into 
 English of the world-famous Lehmann Medicinische Handatlanten, which for sci- 
 entific accuracy, pictorial beauty, compactness, and cheapness surpass any similar 
 volumes ever published. Each volume contains from 50 to 100 colored plates, executed 
 by the most skilful German lithographers, besides numerous illustrations in the text. There 
 is a full and appropriate description of each plate, and each book contains a condensed 
 but adequate outline of the subject to which it is devoted. 
 
 One of the most valuable features of these atlases is that they offer a ready and satis- 
 factory substitute for clinical observation. To those unable to attend important clinics 
 these books will be absolutely indispensable. 
 
 In planning this series of books arrangements were made with representative publishers 
 in the chief medical centers of the world for the publication of translations of the atlases 
 into nine different languages, the lithographic plates for ail these editions being made in Ger- 
 many, where work of this kind has been brought to the greatest perfection. The expense of 
 making the plates being shared by the various publishers, the cost to each one was materially 
 reduced. Thus by reason of their universal translation and reproduction, the publish- 
 ers have been enabled to secure for these atlases the best artistic and professional 
 talent, to produce them in the most elegant style, and yet to offer them at a price 
 heretofore unapproached in cheapness. The success of the undertaking is demon- 
 strated by the fact that the volumes have a.ready appeared in nine different languages 
 - — German, English, French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. 
 
 In view of the striking success of these works, Mr. Saunders has contracted with the 
 publisher of the original German edition for one hundred thousand copies of the atlases. 
 In consideration of this enormous undertaking, the publisher has been enabled to prepare 
 and furnish special additional colored plates, making the series even handsomer and more 
 complete than was originally intended. 
 
 As an indication of the practical value of the atlases and of the favor with which they 
 have been received, it should be noted that the Medical Department of the U. S. Army 
 has adopted the "Atlas of Operative Surgery " as its standard, and has ordered the book in 
 large quantities for distribution to the various regiments and army posts. 
 
 The same careful and competent editorial supervision has been secured in the 
 English edition as in the originals, the translations being edited by the leading American 
 specialists in the different subjects. 
 
 NOW READY. 
 
 Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited 
 by Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic; At- 
 tending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations in the text. 
 Cloth, $3.00 net. 
 
 Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peter- 
 son, M.D., Clinical Professor of Mental Diseases, Woman's Medical College, New York; Chiei 
 of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored fig- 
 ures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, $3.50 net. 
 
 Atlas of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited by Charles P. 
 Grayson, M.D., Lecturer on Laryngology and Rhinology in the University of Pennsylvania; 
 Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. 
 With 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net. 
 
 Atlas of Operative Surgery. By Dr. O. Zuckrrkandl, of Vienna. Edited by J. Chalmkrs 
 DaCosta, M.D., Clinical Professor of Surgery, Jetteison Medical College, Philadelphia; Surgeon 
 to the Philadelphia Hospital. With 24 colored plates, and 217 text illustrations. Cloth, $3.00 net. 
 
 Atlas of Syphilis and tne Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited 
 by L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, University and Believue Hospi- 
 tal Medical College, New York. With 71 colored plates, 16 biack-and-white illustrations, and 122 
 pages of text. Cloth, $3.50 net. 
 
 Atlas of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited by G. E. 
 de Schweinitz, M. D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia. 
 With 76 colored illustrations on 40 plates, and 228 pages of text. Cloth, $3.00 net. 
 
 Atlas of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by Henry W. Stelwagon, 
 M. D., Clinical Professor of Dermatology, Jefferson Medical College, Philadelphia. 63 colored plates, 
 39 beautiful half-tone illustrations, and 200 pages of text. Cloth, $3.50 net. 
 
 IN PREPARATION. 
 
 Atlas of Pathological Histology. Atlas of Operative Gynecology. 
 
 Atlas of Orthopedic Surgery. Atlas of Psychiatry. 
 
 Atlas of General Surgery. Atlas of Diseases of the Ear. 
 
THE AMERICAN TEXT-BOOK SERIES. 
 
 AN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS. 
 
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 AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
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 AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI- 
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 AN AMERICAN TEXT=BOOK OF OBSTETRICS. 
 
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 titioner, we commend it because we believe there is no better." — American Journal of the 
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 Illustrated Catalogue of the "American Text-Books " sent free upon application* 
 
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 AN AMERICAN TEXT=BOOK OF PATHOLOGY. 
 
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 Riesman, M.D., Demonstrator of Pathological Histology in the 
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 AN AMERICAN TEXT=BOOK OF PHYSIOLOGY. 
 
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 AN AMERICAN TEXT=BOOK OF SURGERY. Third Edition. 
 
 By 11 Eminent Professors of Surgery. Edited by William W. Keen, 
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 AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
 OF MEDICINE. 
 
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 AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 
 
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 THE AMERICAN POCKET MEDICAL DICTIONARY. 
 
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 ANDERS' PRACTICE OF MEDICINE. Third Revised Edition. 
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 ASHTON'S OBSTETRICS. Fourth Edition, Revised. 
 
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 BALL'S BACTERIOLOGY. Third Edition, Revised. 
 
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Medical Publications of W. B. Saunders. 7 
 
 BASTINS BOTANY. 
 
 Laboratory Exercises in Botany. By Edson S. Bastin, M.A., 
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 work is eminently a practical one. We regard the issuance of this book as an important 
 event in the history of pharmaceutical teaching in this country, and predict for it an unquali- 
 fied success." — Alumni Report to the Philadelphia College of Pharmacy. 
 
 "There is no work like it in the pharmaceutical or botanical literature of this country, 
 and we predict for it a wide circulation." — American Journal of Pharmacy. 
 
 BECK'S SURGICAL ASEPSIS. 
 
 A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to 
 St. Mark's Hospital and the New York German Poliklinik, etc. 306 
 pages; 65 text-illustrations, and 12 full-page plates. Cloth, #1.25 net. 
 
 " An excellent exposition of the ' very latest ' in the treatment of wounds as practised 
 by leading German and American surgeons." — Birmingham (Eng.) Medical Review. , 
 
 "This little volume can be recommended to any who are desirous of learning the details 
 of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet. 
 
 BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
 OPERATIONS. 
 Obstetric Accidents, Emergencies, and Operations. By L. Ch. 
 
 Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis 
 Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. 
 
 " It is clearly and concisely written, and is evidently the work of a teacher and practi- 
 tioner of large experience." — British Medical Journal. 
 
 " A manual so useful to the student or the general practitioner has not been brought to 
 our notice in a long time. The field embraced in the title is covered in a terse, interesting 
 way." — Yale Medical Journal. 
 
 BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
 Essentials of Medical Physics. By Fred J. Brockway, M.D., 
 Assistant Demonstrator of Anatomy in the College of Physicians and 
 Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations. 
 Cloth, $1.00 net ; interleaved for notes, $1.25 net. 
 
 [See Saunders'' Question- Compends, page 21.] 
 
 " The student who is well versed in these pages will certainly prove qualified to com« 
 prehend with ease and pleasure the great majority of questions involving physical principles 
 likely to be met with in his medical studies." — American Practitioner and News. 
 
 " We know of no manual that affords the medical student a better or more concise 
 exposition of physics, and the book may be commended as a most satisfactory presentation 
 of those essentials that are requisite in a course in medicine." — New York Medical Journal. 
 
 " It contains all that one need know on the subject, is well written, and is copiously 
 illustrated." — Medical Record, New York. 
 
 BURR ON NERVOUS DISEASES. 
 
 A Manual of Nervous Diseases. By Charles W. Burr, M.D., 
 Clinical Professor of Nervous Diseases, Medico-Chirurgical College, 
 Philadelphia; Pathologist to the Orthopedic Hospital and Infirmary 
 for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. 
 Jn Preparation. 
 
8 Medical Publications of W. B. Saunders. 
 
 BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
 MACOLOGY. Third Edition, Revised. 
 A Text=Book of Materia Medica, Therapeutics, and Pharma- 
 cology. By George F. Butler, Ph.G., M.D., Professor of Materia 
 Medica and of Clinical Medicine in the College of Physicians and 
 Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, 
 Northwestern University, Woman's Medical School, etc. Octavo, 874 
 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. 
 
 " Taken as a whole, the book may fairly be considered as one of the most satisfactory 
 of any single-volume works on materia medica in the market," — Journal of the American 
 Medical Association. 
 
 CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
 Notes on the Newer Remedies, their Therapeutic Applications 
 and Modes of Administration. By David Cerna, M.D., Ph.D., 
 formerly Demonstrator of and Lecturer on Experimental Therapeutics 
 in the University of Pennsylvania ; Demonstrator of Physiology in the 
 Medical Department of the University of Texas. Rewritten and 
 greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25. 
 
 " The appearance of this new edition of Dr. Cerna's very valuable work shows that it 
 is properly appreciated. The book ought to be in the possession of every practising physi- 
 cian." — New York Medical Journal. 
 
 CHAPIN ON INSANITY. 
 
 A Compendium of Insanity. By John B. Chapin, M.D., LL.D., 
 Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
 cian-Superintendent of the Willard State Hospital, New York ; Hon- 
 orary Member of the Medico-Psychological Society of Great Britain, 
 of the Society of Mental Medicine of Belgium. i2mo, 234 pages, 
 illustrated. Cloth, $1.25 net. 
 
 " The practical parts of Dr. Chapin's book are what constitute its distinctive merit. We 
 desire especially to call attention to the fact that on the subject of therapeutics of insanity 
 the work is exceedingly valuable. It is not a made book, but a genuine condensed thesis, 
 which has all the value of ripe opinion and all the charm of a vigorous and natural style." — 
 Philadelphia Medical Journal. 
 
 CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
 Second Edition, Revised. 
 Medical Jurisprudence and Toxicology. By Henry C. Chapman, 
 M.D., Professor of Institutes of Medicine and Medical Jurisprudence 
 in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
 illustrations and 3 full-page plates in colors. Cloth, $1.50 net. 
 
 "The best book of its class for the undergraduate that we know of." — New York 
 Medical Times. 
 
 CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
 Nervous and Mental Diseases. By Archibald Church, M. D., 
 Professor of Mental Diseases and Medical Jurisprudence in the North- 
 western University Medical School, Chicago ; and Frederick Peter- 
 son, M. D., Clinical Professor of Mental Diseases, Woman's Medical 
 College, N. Y.; Chief of Clinic, Nervous Dept., College of Physi- 
 cians and Surgeons, N. Y. Handsome octavo volume of 843 pages, 
 profusely illustrated. Cloth, $5.00 net; Half Morocco, $6.00 net. 
 
Medical Publications of W. B. Saunders. 9 
 
 CLARKSON'S HISTOLOGY. 
 
 A Text=Book of Histology, Descriptive and Practical. By 
 
 Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
 Physiology in the Owen's College, Manchester; late Demonstrator of 
 Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
 22 engravings in the text, and 174 beautifully colored original illustra- 
 tions. Cloth, strongly bound, $4.00 net. 
 
 " The work must be considered a valuable addition to the list of available text- books, 
 and is to be highly recommended." — New York Medical Journal. 
 
 "This is one of the best works for students we have ever noticed. We predict that the 
 book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 
 
 CLIMATOLOGY. 
 
 Transactions of the Eighth Annual Meeting of the American 
 Climatological Association, held in Washington, September 22-25, 
 1 89 1. Forming a handsome octavo volume of 276 pages, uniform with 
 remainder of series. (A limited quantity only.) Cloth, $1.50. 
 
 COHEN AND ESHNER'S DIAGNOSIS. 
 
 Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
 fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
 phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical 
 Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 
 illustrations. Cloth, $1.50 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 "We can heartily commend the book to all those who contemplate purchasing a 'com- 
 pend.' It is modern and complete, and will give more satisfaction than many other works 
 which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 
 
 CORWIN'S PHYSICAL DIAGNOSIS. Third Edition, Revised. 
 
 Essentials of Physical Diagnosis of the Thorax. By Arthur 
 M. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush 
 Medical College, Chicago ; Attending Physician to Central Free Dis- 
 pensary, Department of Rhinology, Laryngology, and Diseases of the 
 Chest, Chicago. 219 pages, illustrated. Cloth, flexible covers, $1.25 net. 
 
 "It is excellent. The student who shall use it as his guide to the careful study of 
 physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
 working knowledge of the subject." — Philadelphia Polyclinic. 
 
 "A most excellent little work. It brightens the memory of the differential diagnostic 
 signs, and it arranges orderly and in sequence the various objective phenomena to logical 
 solution of a careful diagnosis. "—Journal oj Nervous and Mental Diseases. 
 
 CRAGIN'S GYNAECOLOGY. Fourth Edition, Revised. 
 
 Essentials of Gynaecology. By Edwin B. Cragin, M. D., Lecturer 
 in Obstetrics, College of Physicians and Surgeons, New York. Crown 
 octavo, 200 pages; 62 illustrations. Cloth, $1.00 ; interleaved for notes, 
 $1.25. 
 
 [See Saunders 1 Question- Compends, page 21.] 
 
 "A handy volume, and a distinct improvement on students' compends in general. No 
 author who was not himself a practical gynecologist could have consulted the student's needs 
 so thoroughly as Dr. Cragin has done." — Medical Record, New York. 
 
10 Medical Publications of W. B. Saunders. 
 
 CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 
 
 A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., 
 Professor of Comparative Pathology and Bacteriology, King's College, 
 London. Octavo volume of 700 pages, with 273 engravings and 22 
 original colored plates. Cloth, $6.5.0 net; Half Morocco, $7.50 net. 
 
 " To the student who wishes to obtain a good resume of what has been done in bacteri- 
 ology, or who wishes an accurate account of the various methods of research, the book may 
 be recommended with confidence that he will find there what he requires." — London Lancet. 
 
 Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. 
 Modern Surgery, General and Operative. By John Chalmers 
 DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical 
 College, Philadelphia ; Surgeon to the Philadelphia Hospital, etc. 
 Handsome octavo volume of 900 pages, profusely illustrated. Cloth, 
 $4.00 net; Half Morocco, $5.00 net. 
 
 "We know of no small work on surgery in the English language which so well fulfils 
 the requirements of the modern student." — Medico- Chirttrgical Journal, Bristol, England. 
 
 DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, 
 Revised. 
 Diseases of the Eye. A Handbook of Ophthalmic Practice. 
 
 By G. E. de Schweinitz, M.D., Professor of Ophthalmology in the 
 Jefferson Medical College, Philadelphia, etc. Handsome royal octavo 
 volume of 696 pages, with 256 fine illustrations and 2 chromo-litho- 
 graphic plates. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. 
 
 " A clearly written, comprehensive manual. One which we can commend to students 
 as a reliable text-book, written with an evident knowledge of the wants of those entering 
 upon the study of this special branch of medical science." — British Medical Journal. 
 
 " A work that will meet the requirements not only of the specialist, but of the general 
 practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
 Pepper, M.D., Professor of the Theory and Practice of Medicine and Clinical Medicine , 
 University of Pennsylvania. 
 
 DORLAND'S DICTIONARY. Second Edition, Revised. 
 
 The American Pocket Medical Dictionary. Containing the Pro- 
 nunciation and Definition of all the principal words and phrases, and a 
 large number of useful tables. Edited by W. A. Newman Dorland, 
 M. D., Assistant Demonstrator of Obstetrics, University of Pennsylvania ; 
 Fellow of the American Academy of Medicine. 518 pages ; handsomely 
 bound in full leather, limp, with gilt edges and patent index. Price, 
 #1.00 net; with thumb index, #1.25 net. 
 
 DORLAND'S OBSTETRICS. 
 
 A Manual of Obstetrics. By W. A. Newman Dorland, M.D., 
 Assistant Demonstrator of Obstetrics, University of Pennsylvania; 
 Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. 
 
 " By far the best book on this subject that has ever come to our notice." — American 
 Medical Review. 
 
 " It has rarely been our duty to review a book which has given us more pleasure in its 
 perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, 
 a gold mine of practical, concise thoughts." — American Medico- Surgical Bulletin. 
 
Medical Publications of W. B. Saunders. 11 
 
 FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 
 
 Laboratory Guide for the Bacteriologist. By Langdon Froth- 
 ingham, M.D.V., Assistant in Bacteriology and Veterinary Science, 
 Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. 
 
 " It is a convenient and useful little work, and will more than repay the outlay neces- 
 sary for its purchase in the saving of time which would otherwise be consumed in looking 
 up the various points of technique so clearly and concisely laid down in its pages." — Ameri- 
 can Medico- Surgical Bulletin. 
 
 GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. 
 Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
 fessor of Gynecology in the New York School of Clinical Medicine ; 
 Gynecologist to St. Mark's Hospital and to the German Dispensary, 
 New York City, etc. Handsome octavo volume of 728 pages, illus- 
 trated by 335 engravings and colored plates. Cloth, $4.00 net; 
 Sheep or Half Morocco, $5.00 net. 
 
 " One of the best text-books for students and practitioners which has been published in 
 the English language; it is condensed, clear, and comprehensive. The profound learning 
 and great clinical experience of the distinguished author find expression in this book in a 
 most attractive and instructive form. Young practitioners to whom experienced consultants 
 may not be available will find in this book invaluable counsel and help." — Thad. A. 
 Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. 
 
 GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
 Essentials of Diseases of the Ear. By E. B. Gleason, S.B., 
 M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
 Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
 ment of the Northern Dispensary, Philadelphia. 208 pages, with 
 114 illustrations. Cloth, $1. 00; interleaved for notes, $1.25. 
 [See Saunders'' Question- Compends, page 21.] 
 
 " It is just the book to put into the hands of a student, and cannot fail to give him a 
 useful introduction to ear-affections ; while the style of question and answer which is adopted 
 throughout the book is, we believe, the best method of impressing facts permanently on the 
 mind. " — Liverpool Medico- Chirurgical fournal. 
 
 GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 
 
 Anomalies and Curiosities of Medicine. By George M. Gould, 
 M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
 rare and extraordinary cases and of the most striking instances of 
 abnormality in all branches of Medicine and Surgery, derived from an 
 exhaustive research of medical literature from its origin to the present 
 day, abstracted, classified, annotated, and indexed. Handsome im- 
 perial octavo volume of 968 pages, with 295 engravings in the text, 
 and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net. 
 Sold by Subscription. 
 
 " One of the most valuable contributions ever made to medical literature. It is, so far 
 as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
 the medical profession has this volume value : it will serve as a book of reference for all who 
 are interested in general scientific, sociologic, or medico-legal topics."— Brooklyn Medical 
 Journal. 
 
 "This is certainly a most remarkable and interesting volume. It stands alone among 
 medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
 medical literature. It is a book full of revelations from its first to its last page, and cannot 
 but interest and sometimes almost horrify its readers. " — American Medico- Surgical Bulletin* 
 
12 Medical Publications of W. B. Saunders. 
 
 GRAFSTROM'S MECHANOTHERAPY. 
 
 A Text=Book of Mechanotherapy (Massage and Medical Gym= 
 nasties). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in 
 the Royal Swedish Army ; late House Physician City Hospital, Black- 
 well's Island, New York. i2mo. 139 pages, illustrated. Cloth, $1.00 net. 
 
 GRIFFITH ON THE BABY. Second Edition, Revised. 
 
 The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- 
 cal Professor of Diseases of Children, University of Pennsylvania ; 
 Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404 
 pages, with 67 illustrations in the text, and 5 plates. Cloth, #1.50. 
 
 " The best book for the use of the young mother with which we are acquainted. . . . 
 There are very few general practitioners who could not read the book through with advan- 
 tage." — Archives of Pediatrics. 
 
 "The whole book is characterized by rare good sense, and is evidently written by a 
 master hand. It can be read with benefit not only by mothers but by medical students and 
 by any practitioners who have not had large opportunities for observing children." — Ameri- 
 can Journal of Obstetrics. 
 
 GRIFFITH'S WEIGHT CHART. 
 
 Infant's Weight Chart. Designed by J. P. Crozer Griffith, M.D., 
 Clinical Professor of Diseases of Children in the University of Penn- 
 sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 
 
 A convenient blank for keeping a record of the child's weight during the first two years 
 of life. Printed on each chart is a curve representing the average weight of a healthy infant, 
 so that any deviation from the normal can readily be detected. 
 
 GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 
 
 Autobiography of Samuel D. Gross, M.D., Emeritus Professor of 
 Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
 niscences of His Times and Contemporaries. Edited by his Sons, 
 Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- 
 gery and of Clinical Surgery in the Jefferson Medical College, and 
 A. Hauler Gross, A.M., of the Philadelphia Bar. Preceded by a 
 Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In 
 two handsome volumes, each containing over 400 pages, demy octavo, 
 extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price 
 per volume, $2.50 net. 
 
 " Dr. Gross was perhaps the most eminent exponent of medical science that America 
 has yet produced. His Autobiography, related as it is with a fulness and completeness 
 seldom to be found in such works, is an interesting and valuable book. He comments on 
 many things, especially, of course, on medical men and medical practice, in a very interest- 
 ing way." — The Spectator, London, England. 
 
 HAMPTON'S NURSING. Second Edition, Revised and Enlarged. 
 Nursing : Its Principles and Practice. By Isabel Adams Hamp- 
 ton, Graduate of the New York Training School for Nurses attached 
 to Bellevue Hospital ; late Superintendent of Nurses and Principal of 
 the Training School for Nurses, Johns Hopkins Hospital, Baltimore, 
 Md. 12 mo, 512 pages, illustrated. Cloth, $2.00 net. 
 
 " Seldom have we perused a book upon the subject that has given us so much pleasure 
 as the one before us. We would strongly urge upon the members of our own profession the 
 need of a book like this, for it will enable each of us to become a training school in him- 
 self." — Ontario Medical Journal. 
 
Medical Publications of W. B. Saunders. 13 
 
 HARE'S PHYSIOLOGY. Fourth Edition, Revised. 
 
 Essentials of Physiology. By H. A. Hare, M.D., Professor of 
 Therapeutics and Materia Medica in the Jefferson Medical College of 
 Philadelphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter- 
 leaved for notes, #1.25 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 "The best condensation of physiological knowledge we have yet seen." — Medical 
 Record, New York. 
 
 HARTS DIET IN SICKNESS AND IN HEALTH. 
 
 Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
 Student of the Faculty of Medicine of Paris and of the London School 
 of Medicine for Women ; with an Introduction by Sir Hendry 
 Thompson, F.R.C.S., M.D., London. 220 pages. Cloth, $1.50. 
 
 " We recommend it cordially to the attention of all practitioners ; both to them and to 
 their patients it may be of the greatest service." — New York Medical Journal. 
 
 HAYNES' ANATOMY. 
 
 A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
 Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
 ment of the New York University, etc. 680 pages, illustrated with 42 
 diagrams in the text, and 134 full-page half-tone illustrations from 
 original photographs of the author's dissections. Cloth, $2.50 net. 
 
 " This book is the work of a practical instructor — one who knows by experience the 
 requirements of the average student, and is able to meet these requirements in a very satis- 
 factory way. The book is one that can be commended." — Medical Record, New York. 
 
 HEISLERS EMBRYOLOGY. 
 
 A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
 fessor of Anatomy in the Medico- Chirurgical College, Philadelphia. Oc- 
 tavo volume of 405 pages, handsomely illustrated. Cloth, $2.50 net. 
 
 HIRST'S OBSTETRICS. 
 
 A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., 
 Professor of Obstetrics in the University of Pennsylvania. Handsome 
 octavo volume of 848 pages, with 618 illustrations, and 7 colored 
 plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. 
 
 " The illustrations are numerous and are works of art, many of them appearing for the 
 first time. The arrangement of the subject-matter, the foot-notes, and index are beyond 
 criticism. As a true model of what a modern text-book on obstetrics should be, we feel 
 justified in affirming that Dr. Hirst's book is without a rival." — New York Medical Record. 
 
 HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
 DISEASES. 
 Syphilis and the Venereal Diseases. By James Nevins Hyde, 
 M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
 gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases 
 in Rush Medical College, Chicago, 111. 618 pages, profusely illustrated. 
 Cloth, $2.50 net. 
 
 " We can commend this manual to the student as a help to him in his study of venereal 
 diseases. ' ' — Liverpool Medico- Chirurgical Journal. 
 
 "The best student's manual which has appeared on the subject." — St. Louis Medical 
 and Surgical Journal. 
 
14 Medical Publications of W. B. Saunders. 
 
 JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
 THROAT. Second Edition, Revised. 
 Essentials of Refraction and Diseases of the Eye. By Edward 
 Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
 delphia Polyclinic and College for Graduates in Medicine ; and — 
 Essentials of Diseases of the Nose and Throat. By E. Bald- 
 win Gleason, M.D., Surgeon-in- Charge of the Nose, Throat, and 
 Ear Department of the Northern Dispensary of Philadelphia. Two 
 volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
 $1.00; interleaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " Of great value to the beginner in these branches. The authors are both capable men, 
 and know what a student most needs." — Medical Record, New York. 
 
 KEATING'S DICTIONARY. Second Edition, Revised. 
 
 A New Pronouncing Dictionary of Medicine, with Phonetic 
 Pronunciation, Accentuation, Etymology, etc. By John M. 
 Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
 delphia; Vice-President of the American Pediatric Society; Editor 
 "Cyclopaedia of the Diseases of Children," etc.; and Henry 
 Hamilton, Author of "'A New Translation of Virgil's ^Eneid into 
 English Rhyme," etc.; with the collaboration of J. Chalmers Da- 
 Costa, M.D., and Frederick A. Packard, M.D. With an Appendix 
 containing Tables of Bacilli, Micrococci, Leucomaines, Ptomaines; 
 Drugs and Materials used in Antiseptic Surgery; Poisons and their 
 Antidotes ; Weights and Measures ; Thermometric Scales ; New 
 Official and Unofficial Drugs, etc. One volume of over 800 pages. 
 Prices, with Denison's Patent Ready-Reference Index: Cloth, $5.00 
 net; Sheep or Half Morocco, $6.00 net; Half Russia, $6.50 net. 
 Without Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, 
 $5.00 net. 
 
 " I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
 ing it to my classes." — Henry M. Lyman, M.D., Professor of the Principles and Practice 
 of Medicine, Rush Medical College, Chicago, III. 
 
 " I am convinced that it will be a very valuable adjunct to my study-table, convenient 
 in size and sufficiently full for ordinary use." — C. A. Lindsley, M.D., Professor of the 
 Theory and Practice of Medicine, Medical Dept. Yale University. 
 
 KEATING'S LIFE INSURANCE. 
 
 How to Examine for Life Insurance. By John M. Keating, 
 M. D., Fellow of the College of Physicians of Philadelphia; Vice- 
 President of the American Pediatric Society; Ex- President of the 
 Association of Life Insurance Medical Directors. Royal octavo, 21 j 
 pages ; with two large half-tone illustrations, and a plate prepared by 
 Dr. McClellan from special dissections ; also, numerous other illustra- 
 tions. Cloth, $2.00 net. 
 
 " This is by far the most useful book which has yet appeared on insurance examination, 
 a subject of growing interest and importance. Not the least valuable portion of the volume 
 is Part II., which consists of instructions issued to their examining physicians by twenty-four 
 representative companies of this country. If for these alone, the book should be at the right 
 hand of every physician interested in this special branch of medical science." — The Medical 
 News. 
 
Medical Publications of W. B. Saunders. 15 
 
 KEEN ON THE SURGERY OF TYPHOID FEVER. 
 
 The Surgical Complications and Sequels of Typhoid Fever. 
 
 By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
 gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
 Corresponding Member of the Societe de Chirurgie, Paris ; Honorary 
 Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
 386 pages, illustrated. Cloth, $3.00 net. 
 
 " This is probably the first and only work in the English language that gives the reader 
 a clear view of what typhoid fever really is, and what it does and can do to the human 
 organism. This book should be in the possession of every medical man in America." — 
 American Medico-Surgical Bulletin. 
 
 KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
 An Operation Blank, with Lists of Instruments, etc. Required 
 in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 
 Professor of the Principles of Surgery in Jefferson Medical College, 
 Philadelphia. Price per pad, containing blanks for fifty operations, 
 50 cents net. 
 
 KYLE ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
 Clinical Professor of Laryngology and Rhinology, Jefferson Medical 
 College, Philadelphia ; Consulting Laryngologist, Rhinologist, and 
 Otologist, St. Agnes' Hospital. Handsome octavo volume of about 
 630 pages, with over 150 illustrations and 6 lithographic plates. Price, 
 Cloth, $4.00 net; Half Morocco, $5.00 net. 
 
 LAINE'S TEMPERATURE CHART. 
 
 Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^ 
 inches. A conveniently arranged Chart for recording Temperature, 
 with columns for daily amounts of Urinary and Fecal Excretions, 
 Food, Remarks, etc. On the back of each chart is given in full the 
 method of Brand in the treatment of Typhoid Fever. Price, per pad 
 of 25 charts, 50 cents net. 
 
 " To the busy practitioner this chart will be found of great value in fever cases, and 
 especially for cases of typhoid." — Indian Lancet, Calcutta. 
 
 LOCKWOOD'S PRACTICE OF MEDICINE. 
 
 A Manual of the Practice of Medicine. By George Roe Lock- 
 wood, M.D., Professor of Practice in the Woman's Medical College 
 of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
 the text, and 22 full-page plates. Cloth, $2.50 net. 
 
 " Gives in a most concise manner the points essential to treatment usually enumerated 
 in the most elaborate works." — Massachusetts Medical Journal. 
 
 LONGS SYLLABUS OF GYNECOLOGY. 
 
 A Syllabus of Gynecology, arranged in Conformity with " An 
 American Text=Book of Gynecology." By J. W. Long, M.D., 
 Professor of Diseases of Women and Children, Medical College of 
 Virginia, etc. Cloth, interleaved, $1.00 net. 
 
 "The book is certainly an admirable resume of what every gynecological student and 
 practitioner should know, and will prove of value not only to those who have the ' American 
 Text-Book of Gynecology,' but to others as well."— Brooklyn Medical Journal. 
 
16 Medical Publications of W. B. Saunders. 
 
 MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 
 
 Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. 
 Edin., F.R.C.S., Edin., Professor of the Practice of Surgery and of 
 Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
 Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 
 800 pages, profusely illustrated. Cloth, #5.00 net; Half Morocco, 
 $6.00 net. 
 
 " A thorough and complete work on Surgical diagnosis and treatment, free from pad- 
 ding, full of valuable material, and in accord with the surgical teaching of the day." — The 
 
 Medical Nezvs, New York. 
 
 "The work is brimful of just the kind of practical information that is useful alike to 
 students and practitioners. It is a pleasure to commend the bock because of its intrinsic 
 value to the medical practitioner." — Cincinnati Lancet- Clinic , 
 
 MALLORY AND WRIGHTS PATHOLOGICAL TECHNIQUE. 
 
 Pathological Technique. A Practical Manual for Laboratory Work 
 
 in Pathology, Bacteriology, and Morbid Anatomy, with chapters on 
 Post-Mortem Technique and the Performance of Autopsies. By Frank 
 B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvarn 
 University Medical School, Boston; and James H. Wright, A.M., 
 M.D., Instructor in Pathology, Harvard University Medical School, 
 Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, 
 $2.50 net. 
 
 " I have been looking forward to the publication of this book, and I am glad to say that 
 I find it to be a most useful laboratory and post-mortem guide, full of practical, information, 
 and well up to date." — William H. Welch, Professor of Pathology, Johns Hopkins Uni- 
 versity, Baltimore, Md. 
 
 MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL 
 DISEASES. Second Edition, Revised. 
 Essentials of Minor Surgery, Bandaging, and Venereal 
 Diseases. By Edward Martin, A.M., M.D., Clinical Professor of 
 Genito-Urinary Diseases, University of Pennsylvania, etc. Cr@wn 
 octavo, 166 pages, with 78 illustrations. Cloth, $1.00 ; interleaved for 
 notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 "A very practical and systematic study of the subjects, and shows the author's famil- 
 iarity with the needs of students." — Therapeutic Gazette. 
 
 MARTIN'S SURGERY. Sixth Edition, Revised. 
 
 Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
 cal Landmarks, Minor and Operative Surgery, and a complete de- 
 scription, with illustrations, of the Handkerchief and Roller Bandages. 
 By Edward Martin, A.M., M.D., Clinical Professor of Genito- 
 Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 
 pages, illustrated. With an Appendix containing full directions for the 
 preparation of the materials used in Antiseptic Surgery, etc. Cloth, 
 $1.00; interleaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " Contains all necessary essentials of modern surgery in a comparatively small space. 
 Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter. 
 
 c 
 
Medical Publications of W. B. Saunders. 17 
 
 McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re= 
 vised and Greatly Enlarged. 
 Text=Book upon the Pathogenic Bacteria. By Joseph McFar- 
 land, M. D. , Professor of Pathology and Bacteriology in the Medico- 
 Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, 
 finely illustrated. Cloth, $2.50 net. 
 
 " Dr. McFarland has treated the subject in - ysteraatic manner, and has succeeded in 
 presenting in a concise and readable form the essentials of bacteriology up to date. Alto- 
 gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the 
 students of Trinity College."— H. B. Anderson, M.D., Professor of Pathology and Bac- 
 teriology, Trinity Medical College, Toronto. 
 
 MEIGS ON FEEDING IN INFANCY. 
 
 Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
 in limp cloth, flush edges, 25 cents net. 
 
 "This pamphlet is worth many times over its price to the physician. The author's 
 experiments, and conclusions are original, and have been the means of doing much good." — 
 Medical Bulletin. 
 
 MOORE'S ORTHOPEDIC SURGERY. 
 
 A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
 Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
 University of Minnesota, College of Medicine and Surgery. Octavo 
 volume of 356 pages, handsomely illustrated. Cloth, $2.50 net. 
 
 "A most attractive work. The illustrations and the care with which the book is adapted 
 to the wants of the general practitioner and the student are worthy of great praise." — Chicago 
 Medical Recorder. 
 
 "A very demonstrative work, every illustration of which conveys a lesson. The work is 
 a most excellent and commendable one, which we can certainly endorse with pleasure." — 
 St. Louis Medical and Surgical Journal, 
 
 MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth 
 Edition, Revised. 
 Essentials of Materia Medica, Therapeutics, and Prescription 
 Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
 peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
 of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, 
 $1.00 ; interleaved for notes, $1.25. 
 
 [See Saunders 7 Question- Compends, page 21.] 
 
 " This work, already excellent in the old edition, has been largely improved by revi- 
 sion. " — American Practitioner and News. 
 
 MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
 Third Edition, Revised. 
 Essentials of the Practice of Medicine. By Henry Morris, M.D., 
 late Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
 delphia ; with an Appendix on the Clinical and Microscopic Examina- 
 tion of Urine, by Lawrence Wolff, M.D. , Demonstrator of Chemistry, 
 Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- 
 tial formulae collected and arranged by William M. Powell, M.D. 
 Post-octavo, 488 pages. Cloth, $2.00. 
 
 [See Saunders'' Question- Co?npends, page 21.] 
 
 " The teaching is sound, the presentation graphic ; matter full as can be desired, and 
 style attractive." — American Practitioner and News. 
 
18 Medical Publications of W. B. Saunders. 
 
 MORTEN'S NURSES DICTIONARY. 
 
 Nurse's Dictionary of Medical Terms and Nursing Treat- 
 ment. Containing Definitions of the Principal Medical and Nursing 
 Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- 
 dents, Treatments, Operations, Foods, Appliances, etc. encountered 
 in the ward or in the sick-room. By Honnor Morten, author of 
 "How to Become a Nurse," etc. 161110, 140 pages. Cloth, $1.00. 
 
 " A handy, compact little volume, containing a large amount of general information, all 
 of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. 
 It is certainly of value to those for whose use it is published." — Chicago Clinical Review. 
 
 NANCREDE'S ANATOMY. Sixth Edition, Thoroughly Revised. 
 Essentials of Anatomy, including the Anatomy of the Viscera. 
 By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and 
 of Clinical Surgery in the University of Michigan, Ann Arbor. Crown 
 octavo, 420 pages; 151 illustrations. Based upon Gray's Anatomy. 
 Cloth, $1.00 net; interleaved for notes, $1.25 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at 
 school, it would not be easy to speak of it in terms too favorable. " — American Practitioner. 
 
 NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 
 Essentials of Anatomy and Manual of Practical Dissection. 
 
 By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of 
 Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ; 
 500 pages, with full-page lithographic plates in colors, and nearly 200 
 illustrations. Extra Cloth (or Oilcloth for dissection-room), $2.00 net. 
 
 " It may in many respects be considered an epitome of Gray's popular work on general 
 anatomy, at the same time having some distinguishing characteristics of its own to commend 
 it. The plates are of more than ordinary excellence, and are of especial value to students 
 in their work in the dissecting room." — Journal of the American Medical Association. 
 
 NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. 
 Syllabus of Obstetrical Lectures in the Medical Department 
 of the University of Pennsylvania. By Richard C. Norris, 
 A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. 
 Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. 
 
 " This work is so far superior to others on the same subject that we take pleasure in 
 calling attention briefly to its excellent features. It covers the subject thoroughly, and will 
 prove invaluable both to the student and the practitioner." — Medical Record, New York. 
 
 PENROSE'S DISEASES OF WOMEN. Second Edition, Revised. 
 A Text=Book of Diseases of Women. By Charles B. Penrose, 
 M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- 
 vania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo 
 volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. 
 
 "I shall value very highly the copy of Penrose's 'Diseases of Women' received. 
 I have already recommended it to my class as THE BEST book." — Howard A. Kelly, 
 Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. 
 
 " The book is to be commended without reserve, not only to the student but to the 
 general practitioner who wishes to have the latest and best modes of treatment explained 
 with absolute clearness." — Therapeutic Gazette. 
 
Medical Publications of W. B. Saunders. 19 
 
 POWELL'S DISEASES OF CHILDREN. Second Edition. 
 
 Essentials of Diseases of Children. By William M. Powell, 
 M.D., Attending Physician to the Mercer House for Invalid Women 
 at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of 
 Children in the Hospital of the University of Pennsylvania. Crown 
 octavo, 222 pages. Cloth, $1.00; interleaved for notes, $1.25. 
 
 [See Saunders'' Question- Compends, page 21.] 
 
 "Contains the gist of all the best works in the department to which it relates."— 
 American Practitioner and News. 
 
 PRINGLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. 
 Pictorial Atlas of Skin Diseases and Syphilitic Affections 
 (American Edition). Translation from the French. Edited by 
 J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex 
 Hospital, London. Photo-lithochromes from the famous models in 
 the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- 
 cuts and text. In 12 Parts. Price per Part, $3.00. Complete in 
 one volume, Half Morocco binding, $40.00 net. 
 
 "I strongly recommend this Atlas. The plates are exceedingly well executed, and 
 will be of great value to all studying dermatology." — Stephen Mackenzie, M.D. 
 
 "The introduction of explanatory wood-cuts in the text is a novel and most important 
 feature which greatly furthers the easier understanding of the excellent plates, than which 
 nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
 merit." — New York Medical Journal. 
 
 PRYOR— PELVIC INFLAMMATIONS. 
 
 The Treatment of Pelvic Inflammations through the Vagina. 
 
 By W. R. Pryor, M.D., Professor of Gynecology in New York Poly- 
 clinic. i2mo, 248 pages, handsomely illustrated. Cloth, $2.00 net. 
 
 " This subject, which has recently been so thoroughly canvassed in high gynecological 
 circles, is made available in this volume to the general practitioner and student. Nothing is 
 too minute for mention and nothing is taken for granted ; consequently the book is of the utmost 
 value. The illustrations and the technique are beyond criticism." — Chicago Medical Recorder. 
 
 PYE'S BANDAGING. 
 
 Elementary Bandaging and Surgical Dressing. With Direc- 
 tions concerning the Immediate Treatment of Cases of Emergency. 
 For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late 
 Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 
 illustrations. Cloth, flexible covers, 75 cents net. 
 " The directions are clear and the illustrations are good."— London Lancet. 
 "The author writes well, the diagrams are clear, and the book itself is small and port- 
 able, although the paper and type are good."— British Medical Journal. 
 
 RAYMOND'S PHYSIOLOGY. 
 
 A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., 
 Professor of Physiology and Hygiene and Lecturer on Gynecology in 
 the Long Island College Hospital ; Director of Physiology in the 
 Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the 
 .text, and 4 full-page colored plates. Cloth, $1.25 net. 
 
 ." Extremely well gotten up, and the illustrations have been selected with care The 
 text is fully abreast with modern physiology. "—British Medical Journal. 
 
►AUNDERS' 
 
 Question 
 
 Arranged in Question and 
 Answer Form* 
 
 HTHE MOST COMPLETE AND BEST 
 
 Pn^IDnMnc illustrated series of 
 
 V^UlVlX\ClN.Uo COMPENDS EVER ISSUED. 
 
 Now the Standard Authorities in Medical Literature 
 
 with Students and Practitioners in every City of the United States and Canada. 
 
 o- 
 o- 
 
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 THE REASON WHY. 
 
 They are the advance guard of "Student's Helps" — that DO HELP. They are the 
 leaders in their special line, well and authoritatively written by able men, who, as teachers in 
 the large colleges, know exactly what is wanted by a student preparing for his examinations. 
 The judgment exercised in the selection of authors is fully demonstrated by their professional 
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 them have become Professors and Lecturers in their respective colleges. 
 
 Each book is of convenient size (5x7 inches) , containing on an average 250 pages, 
 profusely illustrated, and elegantly printed in clear, readable type, on fine paper. 
 
 The entire series, numbering twenty-three volumes, has been kept thoroughly revised 
 and enlarged when necessary, many of the books being in their fifth and sixth editions. 
 
 TO SUM UP. 
 
 Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of 
 them approach the "Blue Series of Question Compends;" and the claim is made for the 
 following points of excellence : 
 
 1. Professional distinction and reputation of authors. 
 
 2. Conciseness, clearness, and soundness of treatment. 
 
 3. Quality of illustrations, paper, printing, and binding. 
 
 Any cf these Compends will be mailed on receipt of price (see next page for List). 
 
Saunders' Question-Compend Oeries, 
 
 Price, Cloth, $J.OO per copy, except when otherwise noted. 
 
 "Where the work of preparing students' manuals is to end we cannot say, but the 
 Saunders Series, in our opinion, bears off the palm at present."— New York Medical Record. 
 
 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition, 
 
 revised and enlarged. ($1.00 net.) 
 
 2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, 
 
 revised, with an Appendix on Antiseptic Surgery. 
 
 3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Sixth 
 
 edition, thoroughly revised and enlarged. ($i.oo net.) 
 
 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 
 
 By Lawrence Wolff, M.D. Fifth edition, revised. ($i.oo net.) 
 
 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth 
 
 edition, revised and enlarged. 
 
 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. 
 
 Armand Semple, M.D. 
 
 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 
 
 SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 
 
 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 
 
 M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. 
 Third edition, enlarged by some 300 Essential Formulae, selected from eminent 
 authorities, by Wm. M. Powell, M.D. (Double number, $2.00.) 
 
 10. ESSENTIALS OF GYNAECOLOGY. By Edwin B. Cragin, M.D. Fourth 
 
 edition, revised. 
 
 1 1 . ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, 
 
 M.D. Fourth edition, revised and enlarged. ($1.00 net.) 
 
 12. ESSENTIALS OF MINOR SURGERY, BANDAGiNG, AND VENEREAL 
 
 DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 
 
 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
 
 By C. E. Armand Semple, M.D. 
 
 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 
 
 By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 
 
 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, 
 
 M.D. Second edition. 
 
 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 
 
 M.D. Colored "Vogel Scale." (75 cents.) 
 
 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, 
 
 M.D. ($1.50 net.) 
 
 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 
 
 Second edition, revised and enlarged. 
 
 20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, 
 
 revised. 
 
 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 
 
 Shaw, M. D. Third edition, revised. 
 
 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. 
 
 Second edition, revised. ($1.00 net.) 
 
 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., 
 
 and Edward S. Lawrance, M.D. 
 
 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. 
 
 Second edition, revised and greatly enlarged. 
 
 Pamphlet containing specimen pages, etc. sent free upon application. 
 
Saunders 
 
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 ^T^HAT there exists a need for thoroughly reliable hand-books on the leading branches 
 of Medicine and Surgery is a fact amply demonstrated by the favor with which 
 the SAUNDERS NEW SERIES OF MANUALS have been received by medical 
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 Each volume is concisely and authoritatively written and exhaustive in detail, without 
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 The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior 
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 standard attained by these books. 
 
 Any of these Manuals will be mailed on receipt of price (see next page for List). 
 
Saunders' New Series of Manuals* 
 
 VOLUMES PUBLISHED. 
 
 PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology 
 and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; 
 Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net. 
 
 SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- 
 cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the 
 Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. 
 Octavo, 911 pages, profusely illustrated. Cloth, $4.00 net ; Half Morocco, $5.00 net. 
 
 DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q. 
 
 Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
 delphia. Illustrated. Cloth, $1.25 net. 
 
 SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and 
 to the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net. 
 
 MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
 tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
 delphia. Illustrated. Cloth, $1.50 net. 
 
 SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., 
 Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., 
 Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, 
 Chicago. Profusely illustrated. Cloth, $2.50 net. 
 
 PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of 
 Practice in the Woman's Medical College of the New York Infirmary ; Instructor in 
 Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
 Cloth, $2.50 net. 
 
 MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
 Anatomy and Demonstrator of Anatomy, Medical Department of the New York 
 University, etc. Beautifully illustrated. Cloth, $2.50 net. 
 
 MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
 Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
 pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, $2.50 net. 
 
 DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to 
 Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. 
 Giles, M.D. , B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
 London. Handsomely illustrated. Cloth, $2.50 net. 
 
 VOLUMES IN PREPARATION. 
 
 NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
 Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopaedic 
 Hospital and Infirmary for Nervous Diseases ; Visiting Physician to the St. Joseph 
 Hospital, etc. 
 
 *** There will be published in the same series, at short intervals, carefully-prepared works 
 on various subjects by prominent specialists. 
 
 Pamphlet containing specimen pages, etc. sent free upon application* 
 
24 Medical Publications of W. B. Saunders, 
 
 SAUNDBY'S RENAL AND URINARY DISEASES. 
 
 Lectures on Renal and Urinary Diseases. By Robert Saundby, 
 M.D. Edin., Fellow of the Royal College of Physicians, London, and 
 of the Royal Medico-Chirurgical Society ; Physician to the General 
 Hospital ; Consulting Physician to the Eye Hospital and to the Hos- 
 pital for Diseases of Women ; Professor of Medicine in Mason College, 
 Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
 trations and 4 colored plates. Cloth, $2.50 net. 
 
 " The volume makes a favorable impression at once. The style is clear and succinct. 
 We cannot find any part of the subject in which the views expressed are not carefully thought 
 out and fortified by evidence drawn from the most recent sources. The book may be cordially 
 recommended.' ' — British Medical Journal. 
 
 SAUNDERS' MEDICAL HAND=ATLASES. 
 
 This series of books consists of authorized translations into English of 
 the world-famous Lehmann Medicinische Handatlanten. Each 
 
 volume contains from 50 to 100 colored lithographic plates, besides 
 numerous illustrations in the text. There is a full description of each- 
 plate, and each book contains a condensed but adequate outline of the 
 subject to which it is devoted. For full description of this series, with 
 list of volumes and prices, see page 2. 
 
 " Lehmann Medicinische Handatlanten belong to that class of books that are too good 
 to be appropriated by any one nation." — Journal of Eye, Ear, and Throat Diseases. 
 
 " The appearance of these works marks a new era in illustrated English medical 
 works." — The Canadian Practitioner. 
 
 SAUNDERS' POCKET MEDICAL FORMULARY. Fifth Edition, 
 Revised. 
 
 By William M. Powell, M.D., Attending Physician to the Mercer 
 House for Invalid Women at Atlantic City, N. J. Containing 1800 
 formulae selected from the best-known authorities. With an Appen- 
 dix containing Posological Table, Formulae and Doses for Hypo- 
 dermic Medication, Poisons and their Antidotes, Diameters of the 
 Female Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various 
 Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
 of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
 Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
 somely bound in flexible morocco, with side index, wallet, and flap. 
 $1.75 net. 
 
 " This little book, that can be conveniently carried in the pocket, contains an immense 
 amount of material. It is very useful, and, as the name of the author of each prescription 
 is given, is unusually reliable." — Medical Record, New York. 
 
 SAYRE'S PHARMACY. Second Edition, Revised. 
 
 Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
 M.D., Professor of Pharmacy and Materia Medica in the University of 
 Kansas. Crown octavo, 200 pages. Cloth, $1.00; interleaved for 
 notes, $1.25. 
 
 [See Saunders 1 Question- Compends, page 21.] 
 
 " The topics are treated in a simple, practical manner, and the work forms a very useful 
 Student's manual." — Boston Medical and Surgical Journal. 
 
 . 
 
Medical Publications of W. B. Saunders. 25 
 
 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
 Essentials of Legal Medicine, Toxicology, and Hygiene. By 
 
 C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., 
 Physician to the Northeastern Hospital for Children, Hackney, etc. 
 Crown octavo, 2 1 2 pages ; 130 illustrations. Cloth, $1.00; interleaved 
 for notes, #1.25. 
 
 [See Saunders Question- Compends, page 21.] 
 
 " No general practitioner or student can afford to be without this valuable work. The 
 subjects are dealt with by a masterly hand." — London Hospital Gazette. 
 
 SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 
 
 Essentials of Pathology and Morbid Anatomy. By C. E. 
 
 Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to 
 the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 
 174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. 
 [See Saunders' Question- Compends, page 21.] 
 
 " Should take its place among the standard volumes on the bookshelf of both student 
 and practitioner." — London Hospital Gazette. 
 
 SENN'S GENITOURINARY TUBERCULOSIS. 
 
 Tuberculosis of the Genito=Urinary Organs, Male and Female. 
 
 By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
 Surgery and of Clinical Surgery, Rush Medical College, Chicago. 
 Handsome octavo volume of 320 pages, illustrated. Cloth, $3. 00' net. 
 
 " An important book upon an important subject, and written by a man of mature judg- 
 ment and wide experience. The author has given us an instructive book upon one of the 
 most important subjects of the day." — Clinical Reporter. 
 
 " A work which adds another to the many obligations the profession owes the talented 
 author." — Chicago Medical Recorder. 
 
 SENN'S SYLLABUS OF SURGERY. 
 
 A Syllabus of Lectures on the Practice of Surgery, arranged 
 in conformity with " An American Text=Book of Surgery." By 
 
 Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and 
 of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. 
 
 " This syllabus will be found of service by the teacher as well as the student, the work 
 being superbly done. There is no praise too high for it. No surgeon should be without 
 it." — New York Medical Times. 
 
 SENN'S TUMORS. 
 
 Pathology and Surgical Treatment of Tumors. By N. Senn, 
 
 M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
 Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
 Attending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St. 
 Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 
 engravings, including full-page colored plates. New and Revised Edi- 
 tion in Preparation. 
 
 " The most exhaustive of any recent book in English on this subject. It is well illus- 
 trated, and will doubtless remain as the principal monograph on the subject in our language 
 for some years. The book is handsomely illustrated and printed, and the author has given a 
 notable and lasting contribution to surgery." — Journal of the American Medical Association. 
 
26 Medical Publications of W. B. Saunders. 
 
 SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
 Revised. 
 Essentials of Nervous Diseases and Insanity. By John C. 
 Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous 
 System, Long Island College Hospital Medical School ; Consulting 
 Neurologist to St. Catherine's Hospital and to the Long Island College 
 Hospital. Crown octavo, 186 pages; 48 original illustrations. Cloth, 
 #1.00 ; interleaved for notes, $1.25. 
 
 [See Saunders'' Question- Compends, page 21.] 
 
 "Clearly and intelligently written." — Boston Medical and Surgical Journal. 
 
 "There is a mass of valuable material crowded into this small compass.'" — American 
 Medico- Surgical Bulletin. 
 
 STARR'S DIETS FOR INFANTS AND CHILDREN. 
 
 Diets for Infants and Children in Health and in Disease. By 
 
 Louis Starr, M.D., Editor of "An American Text-Book of the 
 Diseases of Children." 230 blanks (pocket-book size), perforated 
 and neatly bound in flexible morocco. $1.25 net. 
 
 The first series of blanks are prepared for the first seven months of infant life ; each 
 blank indicates the ingredients, but not the quantities, of the food, the latter directions being 
 left for the physician. After the seventh month, modifications being less necessary, the diet 
 lists are printed in full. Formulae for the preparation of diluents and foods- are appended. 
 
 STELW AGON'S DISEASES OF THE SKIN. Fourth Ed., Revised. 
 Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
 M.D., Clinical Professor of Dermatology in the Jefferson Medical 
 College, Philadelphia ; Dermatologist to the Philadelphia Hospital ; 
 Physician to the Skin Department of the Howard Hospital, etc. 
 Crown octavo, 276 pages; 88 illustrations. Cloth, $1.00 net; inter- 
 leaved for notes, $1.25 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 " The best student's manual on skin diseases we have yet seen." — Times and Register. 
 
 STENGEL'S PATHOLOGY. Second Edition. 
 
 A Text=Book of Pathology. By Alfred Stengel, M.D., Professor 
 of Clinical Medicine in the University of Pennsylvania ; Physician to 
 the Philadelphia Hospital ; Physician to the Children's Hospital, etc. 
 Handsome octavo volume of 848 pages, with nearly 400 illustrations, 
 many of them in colors. Cloth, $4.00 net; Half Morocco, $5.00 
 net. 
 
 STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second 
 Edition, Revised. 
 A Manual of Materia Medica and Therapeutics. By A. A. 
 
 Stevens, A.M., M.D., Lecturer on Terminology and Instructor in 
 Physical Diagnosis in the University of Pennsylvania; Professor of 
 Pathology in the Woman's Medical College of Pennsylvania. Post- 
 octavo, 445 pages. Flexible leather, $2.25. 
 "The author has faithfully presented modern therapeutics in a comprehensive work, 
 and, while intended particularly for the use of students, it will be found a reliable guide and 
 sufficiently comprehensive for the physician in practice."— University Medical Magazine. 
 
Medical Publications of W. B. Saunders. 27 
 
 STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. 
 A Manual of the Practice of Medicine. By A. A. Stevens, A. M., 
 M. D., Lecturer on Terminology and Instructor in Physical Diagnosis 
 in the University of Pennsylvania ; Professor of Pathology in the 
 Woman's Medical College of Pennsylvania. Specially intended for 
 students preparing for graduation and hospital examinations. Post- 
 octavo, 519 pages; illustrated. Flexible leather, $2.00 net. 
 
 " The frequency with which new editions of this manual are demanded bespeaks its 
 popularity. It is an excellent condensation of the essentials of medical practice for the 
 student, and maybe found also an excellent reminder for the busy physician." — Buffalo 
 Medical Journal. 
 
 STEWART'S PHYSIOLOGY. Third Edition, Revised. 
 
 A Manual of Physiology, with Practical Exercises. For 
 Students and Practitioners. By G. N. Stewart, M.A., M.D., 
 D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
 of the New Museums, Cambridge University ; Professor of Physiology 
 in the Western Reserve University, Cleveland, Ohio. Octavo volume 
 of 848 pages; 300 illustrations in the text, and 5 colored plates. 
 Cloth, $3.75 net. 
 
 " It will make its way by sheer force of merit, and amply deserves to do so. It is one 
 of the very best English text-books on the subject." — London Lancet. 
 
 "Of the many text-books of physiology published, we do not know of one that so 
 nearly comes up to the ideal as does Prof. Stewart's volume."— British Medical Journal. 
 
 STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 
 
 Essentials of Medical Electricity. By D. D. Stewart, M.D., 
 Demonstrator of Diseases of the Nervous System and Chief of the 
 Neurological Clinic in the Jefferson Medical College; and E. S. 
 Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
 strator of Diseases of the Nervous System in the Jefferson Medical 
 College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
 1 1. 00; interleaved for notes, $1.25. 
 
 [See Saunders 1 Question- Compends, page 21.] 
 
 " Throughout the whole brief space at their command the authors show a discriminating 
 knowledge of their subject." — Medical News. 
 
 STONEY'S NURSING. Second Edition, Revised. 
 
 Practical Points in Nursing. For Nurses in Private Practice. 
 
 By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
 Lawrence, Mass.; late Superintendent of the Training-School for 
 Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
 with 73 engravings in the text, and 8 colored and half-tone plates. 
 Cloth, $1.75 net. 
 
 " There are few books intended for non-profess-ional readers which can be so cordially 
 endorsed by a medical journal as can this one." — Therapeutic Gazette. 
 
 " This is a well-written, eminently practical volume, which covers the entire range of 
 private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
 meet the various emergencies which may arise, and how to prepare everything ordinarily 
 needed in the illness of her patient." — American Journal of Obstetrics and Diseases of 
 Women and Children. 
 
 " It is a work that the physician can place in the hands of his private nurses with the 
 assurance of benefit." — Ohio Medical Journal, 
 
28 Medical Publications of W. B. Saunders. 
 
 STONEY'S MATERIA MEDICA FOR NURSES. 
 
 Materia Medica for Nurses. By Emily A. M. Stoney, Graduate of 
 the Training-School for Nurses, Lawrence, Mass. ; late Superintendent 
 of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 
 Handsome octavo volume of 306 pages. Cloth, $1.50 net. 
 
 The present book differs from other similar works in several features, all of which are 
 intended to render it more practical and generally useful. The general plan of the contents 
 follows the lines laid down in training-schools for nurses, but the book contains much use- 
 ful matter not usually included in works of this character, such as Poison-emergencies, 
 Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms 
 used in Materia Medica, and describing all the latest drugs and remedies, which have been 
 generally neglected by other books of the kind. 
 
 SUTTON AND GILES' DISEASES OF WOMEN. 
 
 Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
 Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, 
 London; and Arthur E. Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin., 
 Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
 somely illustrated. Cloth, #2.50 net. 
 
 "The text has been carefully prepared. Nothing essential has been omitted, and its 
 teachings are those recommended by the leading authorities of the day." — Journal of the 
 American Medical Association. 
 
 THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. 
 
 Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, 
 M.D., Visiting Physician to the Home for Friendless Women and 
 Children and to the Newsboys' Home ; Assistant Visiting Physician 
 to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. 
 
 THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITING. 
 
 Dose=Book and Manual of Prescription=Writing. By E. Q. 
 
 Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical 
 College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. 
 
 "Full of practical suggestions; will take its place in the front rank of works of this 
 sort." — Medical Record, New York. 
 
 VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
 Diseases of the Stomach. By William W. Van Valzah, M.D., 
 Professor of General Medicine and Diseases of the Digestive System 
 and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., 
 Adjunct Professor of General Medicine and Diseases of the Digestive 
 System and the Blood, New York Polyclinic. Octavo volume of 674 
 pages, illustrated. Cloth, $3.50 net. 
 
 " Its chief claim lies in its clearness and general adaptability to the practical needs of 
 the general practitioner or student. In these relations it is probably the best of the recent 
 special works on diseases of the stomach." — Chicago Clinical Review. 
 
 VECKI'S SEXUAL IMPOTENCE. 
 
 The Pathology and Treatment of Sexual Impotence. By Victor 
 G. Vecki, M.D. From the second German edition, revised and en- 
 larged. Demi-octavo, about 300 pages. Cloth, $2.00 net. 
 
 The subject of impotence has seldom been treated in this country in the truly scientific 
 spirit that it deserves. Dr. Vecki's work has long been favorably known, and the German 
 book has received the highest consideration. This edition is more than a mere translation, 
 for, although based on the German edition, it has been entirely rewritten in English. 
 
Medical Publications of W. B. Saunders. 29 
 
 VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. 
 Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
 cine at the University of Heidelberg. Translated, with additions, 
 from the fifth enlarged German edition, with the author's permission, 
 by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume 
 of 603 pages; 194 fine wood-cuts in text, many of them in colors. 
 Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. 
 
 " A treasury of practical information which will be found of daily use to every busy 
 practitioner who will consult it." — C. A. LiNDSLEY, M.D., Professor of the Theory and 
 Practice of Medicine, Yale University. 
 
 " Rarely is a book published with which a reviewer can find so little fault as with the 
 volume before us. Each particular item in the consideration of an organ or apparatus, which 
 is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing 
 seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
 nervous system are especially full and valuable. The reviewer would repeat that the book is 
 one of the best — probably the best — which has fallen into his hands." — University Medical 
 Magazine. 
 
 WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. 
 
 Surgical Pathology and Therapeutics. By John Collins Warren, 
 M.D., LL.D., Professor of Surgery, Medical Department Harvard 
 University; Surgeon to the Massachusetts General Hospital, etc. 
 Handsome octavo volume of 832 pages; 136 relief and lithographic 
 illustrations, 33 of which are printed in colors, and all of which were 
 drawn by William J. Kaula from original specimens. Revised and 
 Enlarged Edition in Preparation. 
 
 "There is the work of Dr. Warren, which I think is the most creditable book on 
 Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that 
 has ever been issued from the American press." — Dr. Roswell Park, in the Harvard 
 Graduate Magazine. 
 
 " The handsomest specimen of bookmaking that has ever been issued from the American 
 medical press." — American Journal of the Medical Sciences. 
 
 "A most striking and very excellent feature of this book is its illustrations. Without 
 exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
 of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
 and detail as almost to give the beholder the impression that he is looking down the barrel 
 of a microscope at a well-mounted section." — Annals of Surgery. 
 
 WOLFF ON EXAMINATION OF URINE. 
 
 Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
 Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, 
 etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
 octavo. Cloth, 75 cents. 
 
 [See Saunders' Question- Comf ends, page 21.] 
 " A very good work of its kind — very well suited to its purpose." — Times and Register. 
 
 WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, Revised. 
 
 Essentials of Medical Chemistry, Organic and Inorganic. 
 
 Containing also Questions on Medical Physics, Chemical Physiology, 
 Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
 Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
 Philadelphia, etc. Crown octavo, 222 pages. Cloth, $1.00 net; inter- 
 leaved for notes, $1.25 net. 
 
 [See Saunders' Question- Comf ends, page 21.] 
 
 "The scope of this work is certainly equal to that of the best course o\ lectures on 
 Medical Chemistry." — Pharmaceutical Era. 
 
CLASSIFIED LIST 
 
 Medical Publications 
 
 OF 
 
 W. B, SAUNDERS, 
 
 925 Walnut Street, Philadelphia. 
 
 ANATOMY, EMBRYOLOGY, 
 HISTOLOGY. 
 
 Clarkson — A Text-Book of Histology, 9 
 Haynes — A Manual of Anatomy, . . . 13 
 Heisler — A Text- Book of Embryology, 13 
 Nancrede — Essentials of Anatomy, . . 18 
 Nancrede — Essentials of Anatomy and 
 
 Manual of Practical Dissection, ... 18 
 Semple — Essentials of Pathology and 
 
 Morbid Anatomy, 25 
 
 BACTERIOLOGY. 
 
 Ball — Essentials of Bacteriology, ... 6 
 Crookshank — A Text- Book of Bacteri- 
 ology, 10 
 
 Frothingham— Laboratory Guide, . . II 
 Mallory and Wright — Pathological 
 
 Technique, 16 
 
 McFarland — Pathogenic Bacteria, . . 17 
 
 CHARTS, DIET-LISTS, ETC. 
 
 Griffith — Infant's Weight Chart, ... 12 
 
 Hart — Diet in Sickness and in Health, . 13 
 
 Keen — Operation Blank, 15 
 
 Laine — Temperature Chart 15 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Starr — Diets for Infants and Children, . 26 
 Thomas — Diet-Lists and Sick-Room 
 
 Dietary, 28 
 
 CHEMISTRY AND PHYSICS. 
 
 Brockway — Essentials of Medical Phys- 
 ics, 7 
 
 Wolff — Essentials of Medical Chemistry, 29 
 
 CHILDREN. 
 
 An American Text-Book of Diseases 
 
 of Children, . . 3 
 
 Griffith — Care of the Baby, 12 
 
 Griffith — Infant's Weight Chart, ... 12 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Powell— Essentials of Dis. of Children, 19 
 
 Starr — Diets for Infants and Children, . 26 
 
 DIAGNOSIS. 
 
 Cohen and Eshner— Essentials of Di- 
 agnosis, . 9 
 
 Corwin — Physical Diagnosis, .... 9 
 
 Macdonald — Surgical Diagnosis and 
 Treatment, 16 
 
 Vierordt — Medical Diagnosis, .... 29 
 
 DICTIONARIES. 
 
 Dorland — Pocket Dictionary, .... 10 
 
 Keating — Pronouncing Dictionary, . . 14 
 
 Morten — Nurse's Dictionary, .... 18 
 
 EYE, EAR, NOSE, AND THROAT. 
 
 An American Text- Book of Diseases 
 
 of the Eye, Ear, Nose, and Throat, . 3 
 De Schweinitz — Diseases of the Eye, . 10 
 Gleason — Essentials of Dis. of the Ear, 1 1 
 Jackson — Manual of Diseases of Eye, . 32 
 Jackson and Gleason — Essentials of 
 
 Diseases of the Eye, Nose, and Throat, 14 
 Kyle — Diseases of the Nose and Throat, 15 
 
 GENITOURINARY. 
 
 An American Text-Book of Genito- 
 urinary and Skin Diseases, 4 
 
 Hyde and Montgomery — Syphilis and 
 the Venereal Diseases, ....... 13 
 
 Martin — Essentials of Minor Surgery, 
 
 Bandaging, and Venereal Diseases, . 16 
 Saundby — Renal and Urinary Diseases, 24 
 Senn — Genito-Urinary Tuberculosis, . 25 
 Vecki — Sexual Impotence, ..... 28 
 
 GYNECOLOGY. 
 
 American Text- Book of Gynecology, 4 
 
 Cragin — Essentials of Gynecology, . . 9 
 
 Garrigues — Diseases of Women, ... 11 
 
 Long — Syllabus of Gynecology, ... 15 
 
 Penrose— Diseases of Women, .... 18 
 
 Pryor — Pelvic Inflammations, .... 32 
 
 Sutton and Giles — Diseases of Women, 28 
 
 MATERIA MEDICA, PHARMACOL- 
 OGY, AND THERAPEUTICS. 
 
 An American Text-Book of Applied 
 
 Therapeutics, 3 
 
 Butler — Text-Book of Materia Medica, 
 
 Therapeutics and Pharmacology, ... 8 
 Cerna — Notes on the Newer Remedies, 8 
 Griffin — Materia Med. and Therapeutics, 12 
 Morris — Essentials of Materia Medica 
 
 and Therapeutics, . .- 17 
 
 Saunders' Pocket Medical Formulary, 24 
 Sayre — Essentials of Pharmacy, ... 24 
 Stevens — Essentials of Materia Medica 
 
 and Therapeutics, 26 
 
 Stoney — Materia Medica for Nurses, . . 28 
 Thornton — Dose- Book and Manual of 
 
 Prescription-Writing, 28 
 
 MEDICAL JURISPRUDENCE AND 
 TOXICOLOGY. 
 
 Chapman — Medical Jurisprudence and 
 Toxicology, ... .... 8 
 
 Semple — Essentials of Legal Medicine, 
 Toxicology, and Hygiene, 25 
 
Medical Publications of W. B. Saunders. 
 
 31 
 
 NERVOUS AND MENTAL 
 DISEASES, ETC. 
 
 Burr — Nervous Diseases, ...... 
 
 Chapin — Compendium of Insanity, . . 
 Church and Peterson— Nervous and 
 
 Mental Diseases, 
 
 Shaw— Essentials of Nervous Diseases 
 
 and Insanity, 
 
 NURSING. 
 
 An American Text-Book of Nursing, 
 Griffith— The Care of the Baby, . . . 
 
 Hampton— Nursing, 
 
 Hart — Diet in Sickness and in Health, 
 Meigs— Feeding in Early Infancy, . . 
 
 Morten— Nurse's Dictionary 
 
 Stoney — Materia Medica for Nurses, . . 
 Stoney — Practical Points in Nursing, . 
 
 OBSTETRICS. 
 
 An American Text-Book of Obstetrics, 
 Ashton— Essentials of Obstetrics, 
 Boisliniere — Obstetric Accidents, 
 Dorland— Manual of Obstetrics, 
 Hirst — Text- Book of Obstetrics, 
 Norris — Syllabus of Obstetrics, . 
 
 26 
 
 29 
 12 
 12 
 13 
 17 
 18 
 28 
 27 
 
 PATHOLOGY. 
 
 An American Text-Book of Pathology, 5 
 Mallory and Wright — Pathological 
 
 Technique, 16 
 
 Semple — Essentials of Pathology and 
 
 Morbid Anatomy, 25 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, 25 
 
 Stengel — Text-Book of Pathology, . . 26 
 Warren — Surgical Pathology and Thera- 
 peutics, 29 
 
 PHYSIOLOGY. 
 
 An American Text-Book of Physi- 
 ology, 5 
 
 Hare — Essentials of Physiology, ... 13 
 Raymond — Manual of Physiology, . . 19 
 Stewart — Manual of Physiology, ... 27 
 
 PRACTICE OF MEDICINE. 
 
 An American Text-Book of the The- 
 ory and Practice of Medicine, .... 5 
 
 An American Year-Book of Medicine 
 and Surgery, 6 
 
 Anders — Text-Book of the Practice of 
 Medicine, 6 
 
 Lockwood — Manual of the Practice of 
 Medicine, 15 
 
 Morris — Essentials of the Practice of 
 Medicine, 17 
 
 Stevens — Manual of the Practice of 
 Medicine, 27 
 
 SKIN AND VENEREAL. 
 
 An American Text-Book of Genito- 
 urinary and Skin Diseases, 3 
 
 Hyde and Montgomery — Syphilis and 
 the Venereal Diseases, 13 
 
 Martin — Essentials of Minor Surgery, 
 Bandaging, and Venereal Diseases, . 16 
 
 Pringle — Pictorial Atlas of Skin Dis- 
 eases and Syphilitic Affections, ... 19 
 
 Stelwagon — Essentials of Diseases of 
 the Skin, 26 
 
 SURGERY. 
 
 An American Text-Book of Surgery, 5 
 An American Year-Book of Medicine 
 
 and Surgery, 6 
 
 Beck — Manual of Surgical Asepsis, . . 7 
 
 DaCosta — Manual of Surgery, .... 10 
 
 International Text-Book of Surgery, . 32 
 
 Keen — Operation Blank, 15 
 
 Keen — The Surgical Complications and 
 
 Sequels of Typhoid Fever, 15 
 
 Macdonald — Surgical Diagnosis and 
 
 Treatment, 16 
 
 Martin — Essentials of Minor Surgery, 
 
 Bandaging, and Venereal Diseases, . 16 
 
 Martin — Essentials of Surgery, .... 16 
 
 Moore — Orthopedic Surgery, 17 
 
 Nancrede — Principles of Surgery, . . 32 
 
 Pye — Bandaging and Surgical Dressing, 19 
 Rowland and Hedley— Archives of 
 
 the Roentgen Ray, 19 
 
 Senn — Genito-Urinary Tuberculosis, . 25 
 
 Senn - Syllabus of Surgery, 25 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, . 25 
 
 Warren — Surgical Pathology and Ther- 
 apeutics, ..... 29 
 
 URINE AND URINARY DISEASES. 
 
 Saundby — Renal and Urinary Diseases, 24 
 Wolff— Essentials of Examination of 
 Urine, 29 
 
 MISCELLANEOUS. 
 
 Abbott — Hygiene of Transmissible Dis- 
 eases, 32 
 
 Bastin — Laboratory Exercises in Bot- 
 any, ..... 7 
 
 Gould and Pyle — Anomalies and Curi- 
 osities of Medicine, 11 
 
 Grafstrom — Massage, ....... 12 
 
 Keating — How to Examine for Life 
 Insurance, ....... „ - . ,- 14 
 
 Rowland and Hedley — Archives of 
 
 the Roentgen Ray, 19 
 
 Saunders' Medical Hand-Atlases, . . 2 
 Saunders' New Series of Manuals, 22, 23 
 Saunders' Pocket Medical Formulary, . 24 
 Saunders' Question-Compends, . . 20, 21 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, .25 
 
 Stewart and Lawrance — Essentials of 
 
 Medical Electricity, 27 
 
 Thornton — Dose-Book and Manual of 
 
 Prescription-Writing, . 2S 
 
 Van Valzah and Nisbet— Diseases of 
 the Stomach, 28 
 
JUST ISSUED. 
 
 THE INTERNATIONAL TEXT=BOOK OF SURGERY. In two volumes. 
 
 By American and British authors. Edited by J. Collins Warren, M. D., LL.D., 
 Professor of Surgery, Harvard Medical School, Boston ; Surgeon to the Massachusetts 
 General Hospital; and A. Pearce Gould, M S., F. R. C. S., Eng., Lecturer on 
 Practical Surgery and Teacher of Operative Surgery, Middlesex Hospital Medical 
 School; Surgeon to the Middlesex Hospital, London, England. Vol. I. — General 
 Surgery. — Handsome octavo volume of 947 pages, with 458 beautiful illustrations in 
 the text and 9 lithographic plates. Vol. II. — Special or Regional Surgery — is now in 
 press, and will be ready Jan. 1, 1900. Prices per volume: Cloth, $5.00 net; Half 
 Morocco, $6.00 net. 
 
 KYLE ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro- 
 fessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia ; Con- 
 sulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital. Octavo volume 
 of 646 pages, with over 150 illustrations and 6 lithographic plates. Prices : Cloth, $4.00 
 net; Half Morocco, $5.00 net. 
 
 PRYOR— PELVIC INFLAMMATIONS. 
 
 The Treatment of Pelvic Inflammations through the Vagina. By W. R. 
 
 Pryor, M. D., Professor of Gynecology in the New York Polyclinic. i2mo volume 
 of 248 pages, handsomely illustrated. Cloth, $2.00 net. 
 
 ABBOTT ON TRANSMISSIBLE DISEASES. 
 
 The Hygiene of Transmissible Diseases : their Causation, Modes of 
 Dissemination, and Methods of Prevention. By . C. Abbott, M. D., Pro 
 fessor of Hygiene in the University of Pennsylvania ; Director of the Laboratory of 
 Hygiene. Octavo volume of 311 pages, containing a numbc of charts and maps, and 
 numerous illustrations. Cloth, $2.00 net. 
 
 HEISLER'S EMBRYOLOGY. 
 
 A Text=Book of Embryology. By John C. Heis er, M. D., Professor of 
 Anatomy in the Medico-Chirurgical College, Philadelphia. Octavo volume of 405 
 pages, with 190 illustrations, 26 in colors. Cloth, $2.50 net. 
 
 JACKSON— DISEASES OF THE EYE. 
 
 A Manual of Diseases of the Eye. By Edward Jacks n, A. M., M. D., some- 
 time Professor of Diseases of the Eye in the Philadelphia Po. clinic and College for 
 Graduates in Medicine. i2mo volume of over 535 pages, witn 178 beautiful illustra- 
 tions, mostly from drawings by the author. 
 
 NANCREDE-PRINCIPLES OF SURGERY. 
 
 Lectures on the Principles of Surgery. By Chas. B. Nai> crede, M.D., LL.D., 
 
 Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. 
 Octavo volume of 398 pages, illustrated. Cloth, $2.50 net. 
 
 IN PREPARATION FOR EARLY PUBLICATION. 
 
 OGDEN— URINARY ANALYSIS. 
 
 A Manual of Urinary Analysis. By J. Bergen Ogd*\ t , M. D., Assistant in 
 Chemistry, Harvard University Medical School. 
 
 STONEY— SURGICAL TECHNIQUE FOR NURSES. 
 
 Surgical Technique for Nurses. By Emily A. M. Stoney, Graduate of Training 
 School for Nurses, Lawrence, Mass.-, late Superintendent 01 Training School for Nurses, 
 Carney Hospital, South Boston, Mass. 
 
 LRBJL78- 
 
LIBRARY OF CONGRESS » 
 
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