C« ■^w''- Jit I THE GIFT OF "^ I, ROSWELL P. FLOWER FOR THE USE OF THE N. Y, STATE VETERINARY CpLLEQE. 3 1924 104 224 526 The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924104224526 TUMOURS INNOCENT AND MALIGNANT PLATE I.—" Fungating " Sebaceous Cyst (Sebaceous Adenoma) on the Scalp of a Woman 83 years of age. (See jMfje 237.) TUMOUES INNOCENT AND MALIGNANT ®Ijcir Clinical JFeaturea ani) appropriate ©reatmettt J. BLAKD SUTTOl^ ASSISTANT SUBGEON TO THE MIDDLESEX HOSPITAL, LONDON niTM TWO. EUNDSBD AND FIFTY ENGRAVINGS AND NINE PLATES PHILADELPHIA LEA BROTHERS & CO PEEFACE. Very early in the practice of my profession I became con- vinced of the great increase in diagnostic power that results from the combination of pathological and clinical knowledge. Imbued with this belief, I foirmed, eight years ago,_ the intention of writing a book on Tumours in which their • clinical and pathological features should be equally considered. In 1885 I began to collect materials, from man and other vertebrates, in order to make myself acquainted with the histological peculiarities of tumours. The great difficulty was to define the boundaries of my subject. In order to do this I determined to eliminate all those conditions, often classed with tumours, which have been demonstrated to depend on micro-organisms. This cleared the ground in a satisfactory manner. Attention was first devoted to cysts, and the results of the investigation were embodied in my Hunterian and Erasnms Wilson Lectures, delivered at the Royal College of Surgeons during the years 1886, '87, '88, '89, '90 and '91 ; they dealt particularly with the group of tumours known as Dermoids, and the genus of cysts which I have ventured to name Tubulo-cysts. During the same period I contributed to the Odontological Society of Great Britain a series of papers to show that many tumours of the jaws, vaguely classed as exostoses, are really derived from iaberrant development of teeth. In describing Cancer a wide departure is made from the beaten track. The terms scirrhus, colloid, and medullary or encephaloid, have dominated the minds of surgeons and hindered progress long enough. The term cancer is employed in a sense equivalent to malignant adenoma, the species being determined by the gland in which the cancer arises. Whenever it seemed desirable to illustrate the nature of a genus of tumours by reference to Comparative Pathology, I have not hesitated to do so. Without this aid, any attempt ■n TUM0UE8. to catch the deeper meaning of many tumours is as difBcult as endeavours to decipher a paHmpsest in which the first characters, written in an unknown tongue, have been im- perfectly removed from the parchment and are allowed to mingle with the second inscription. In describing treatment it would obviously be out of place to give the details of operations in a work of this kind, so I have contented myself by indicating the principles. In selecting the figures every effort has been made to avoid depicting repulsive conditions. To-day surgeons are much more interested in studying the Biology of Tumours than in recording their weight. As the Surgery of Tumours is far safer than in the first half of this century, patients, now thoroughly aware of this, submit to operations at an early date. The more this is recognised, and the more generally the impotence of drugs when employed against tumours is realised, the more successful will the Surgery of Tumours become. I have to thank Mr. T. Carwardine for kindly reading the proof-sheets, Mr. C. Berjeau for his excellent drawings, and Mr. C. Butterworth for many admirable examples of wood- engraving. In a systematic work of this kind it follows that, in order to find descriptions of the various tumours to which an organ is liable, the reader must refer to different sections of the book. To minimise this disadvantage I have made two special indexes — one showing the tumours to which an organ is liable, and the other indicating the distribution of tumours among the organs; hence these constitute a syllabus rather than a mere Index. J. BLAND SUTTON. 48, Queen Anne Street, Cavendish Square, "W. October, 1893. CONTENTS. PAGE Classification ........ 1 CHAPTER I. Group I.— Connective Tissue Tumours . . . . S CHAPTER II. Chondromata (Cartilage Tumours) . . . . .17 CHAPTER III. OSTEOMATA (OSSEOUS TUMOURS) . . . . .23 CHAPTER IV. Odontomata (Tooth Tumours) . . . . . .31 CHAPTER V. Fibromata ......... 49 CHAPTER VI. Myxomata. ....... .59 CHAPTER VII. Gliomata CHAPTER VIII. Sarcomata. ........ 67 CHAPTER IX. Sarcomata {continued) . ...... 78 CHAPTER X. Sarcomata (continiied) ....... 90 CHAPTER XI. Sarcomata {continued) CHAPTER XII. Sarcomata {conthmed) . . .... 104 CHAPTER XIII. Sarcomata {continued) ...... 108 CHAPTER XIV. Sarcomata {concluded) ....... 117 Myomata . . • ■ • CHAPTER XVI. Neuromata CHAPTER XVII, Angeiomata . . . • TUMOURS. CHAPTER XV. PAOE . 1:26 147 158 CHAPTER XVIII. Group IL— Epithelial Tumours— Papillomata . . .167 CHAPTER XIX. Papillomata (concluded). . . • • • • 1'7 CHAPTER XX. Cutaneous Horns . . . . • • .183 CHAPTER XXI. Epithelioma ... .... 191 CHAPTER XXII. Epithelioma [concluded) ....... 207 CHAPTER XXIII. Adenoma and Carcinoma . .... 218 CHAPTER XXIV. Cysts, Adenoma, and Carcinoma op Sebaceous and Mucous Glands. ... . 2.33 CHAPTER XXV. Adenoma and Carcinoma of the Thyroid, Prostate, Parotid, AND Pancreas ....... 240 CHAPTER XXVI. Adenoma and Carcinoma of the Liver, Kidney, Ovary, and Testicle ........ 250 CHAPTER XXVII. Adenoma and Carcinoma of the Stomach, Intestines, and Rectum ... .... 259 CHAPTER XXVIII. Adenoma and Carcinoma of the Uterus and Fallopian Tube 272 CHAPTER XXIX. Group III.— Dermoids ....... 279 CONTENTS. ix CHAPTER XXX. taoe Sequestration Dermoids {continued) . . . . .287 CHAPTER XXXI. Sequestration Dermoids {conchided) . . . . .299 CHAPTER XXXII. Implantation Cvsts . ..... .S04 CHAPTER XXXIII. Tubulo-Dermoids. ....... 308 CHAPTER XXXIV. Tubulo-Dermoids {continued) . .... 318 CHAPTER XXXV. Tubulo-Dermoids {concluded) ... . . 323 CHAPTER XXXVI. Dermoids ......... 330 CHAPTER XXXVII. Dermoids {concluded) . . .... 339 CHAPTER XXXVIII. Peculiarities in the Distribution of Cutaneous Appendages IN Dermoids . . . . . . . .346 CHAPTER XXXIX. Moles . . . • . • '• • ■ 353 CHAPTER XL. The Treatment of Dermoids . . . . . .359 CHAPTER XLI. Teratomata ... .... 363 CHAPTER XLII. Group IV.— Cysts . ... 376 CHAPTER XLIII. Tubulo-Cysts ........ 389 CHAPTER XLIV. Tubulo-Cysts {concluded) ....... 397 CHAPTER XLV. Hydrocele. .....-■• *ll X TUMOURS.. CHAPTER XLVI. page Congenital Cysts (Hydeoceles) of the Neck and Axilla . 419 CHArTER XLVII. Cysts of the Salivary Glands— Ranul^—Panceeatic Cysts— Daceyops ......-• ^^ CHAPTER XLVIII. Pseudo-Cysts ... .... 4,31 CHAPTER XLIX. Neueal Cysts ........ 445 CHAPTER L. Neueal Cysts {concluded) ...... 459 CHAPTER LI. Hydatid Cysts ........ 472 CHAPTER LII. The Zoological Disteibution of Tumoues. . . . 487 CHAPTER LIII. The Cause of Tumoues. . , , . . .492 LIST OF ILLUSTEATIOK'S. Lipoma in the palm of the hand ...... 4 Lipoma of the left axilla ....... 5 Lipoma superficial to the temporal fascia. . ... 6 Diffuse lipoma of the neck ....... 7 Small pendulous appendices epiploicaj, with twisted pedicles, of the ascending colon . . . . . . .9 Lipoma arboiescens of the shoulder ... .10 Enlarged sucking-cushion . . . . . . .12 Emaciated child crying and displaying the sucking-cushions . . 12 Meningeal lipoma simulating a spina bifida in a child eight months old ......... 14 Meningeal lipoma overlying the sac of a spina bifida . . 15 Lad twenty years of age with multiple chondromata . . 18 Condyles and epiphysial line of a rickety femur, with a cartilage island 19 Osteoma of the left frontal sinus (anterior view) . . .24 Osteoma of the left frontal sinus, seen from below . . .24 Exostosis of the femur : its surface was clad with cartilage and sur- mounted by a bursa . . . . . . .26 Symmetrical exostoses of the nasal processes of the maxilte . . 27 Big toe with a sub-ungual exostosis ... .28 Bell's specimen of Chcetodon, with its bony tumours and large occipital crest 29 Epithelial odontome . . ..... 31 Microscopical characters of an epithelial odontome . . .32 Follicular odontome (dentigerous cyst) . . . . .33 Fibrous odontome from a goat . . . . . .33 Cementome from a horse . . . . . . .34 Compound follicular odontome from a Thar (CoyrceyemZaicffl) . . 35 Benticles from the odontome of a Thar . . . . .36 Denticles from Tellander's, from Sims's, and from Mathias's cases . 37 Radicular odontome from human subject. . . .38 Radicular odontome . . . . . . .39 Left lower jaw of a young marmot with a large radicular odontome connected with the incisor . . . . . .39 Lower jaw of an adult Canadian porcupine : a radicular odontome is attached to its lower incisor . . . . . .40 Two figures of a radicular cementome from a man aged twenty-five years . . . . . . • ■ .40 Composite odontome from a young lady aged eighteen . . .41 Composite odontomes . . . . . . 42 & 43 Odontome from the upper jaw . . . . . .43 Composite odontome from the upper jaw . . . . .44 Large odontome, which was spontaneously shed from the antrum . 46 Section of large odontome to show the concentric lamination . . 46 Composite odontome from the upper jaw : the left-hand figure shows the tumour in section ....... 47 Odontome from the upper jaw . . . . . .47 Case of moUuscum fibrosum . . . . . .53 Native of Sierra Leone, aged fifty, witli molluscum fibrosum . - 65 Keloid in the lobule of the pinna, associated with an ear-ring puncture 56 Unusual case of keloid in a coloured woman . . . .57 PAfiE 61 65 66 68 68 69 71 75 80 81 S3" 86 87 88 91 99 100 101 xii TUMOURS. Pedunculated myxoma from the labium of a woman fifty yeara old Bilateral gliomatous enlargement of the pons and crura cerebri Spinal cord, in transverse section, from a case of glioma ■ " Microscopical appearance of a lympho-sarcoma from the mediastinum Small spindle-celled sarcoma from a metacarpal bone . Cells from a spindle-celled sarcoma of the neck of the uterus . Myeloid sarcoma from the acomial end of the clavicle . . Periosteal sarcoma of the ilium invadmg the inferior vena cava Spina ventosa of the fibula . • „ , , ' j „ ' Skeleton of an ossifying periosteal sarcoma of the temur Spindle-celled sarcoma of the fibula ■ ■ Sarcoma arising in tlie follicle of a developing tootli . Deformity produced by a sarcoma of the nasal septum . V™,^<.= Facial region of the skull from the case shown m the preceding figures, seen in sagittal section . ■ • ^, . 1 „ ' „„„ „i Parotid sarcoma implicating the pinna m a woman thirty-hve years ot Microscopical characters of a tumour arising in an accessory adrenal Kenal tumour originating in an accessory adrenal Myo-sarcoma of the testis . . • , ' , * ■* i • i' Portion of a mediastinal lympho-sarcoma, to show the manner in wliicli the tumour extends along the bronchi and pulmonary vessels . Anterior portion of a dace ; each black spot contains a central white dot representing an encysted parasite . _ • . • " Pigmented mole which ulcerated and infected Jhe inguinal lymph glands ; the patient was sixty -five years of age Melano-sarcoma of the uveal tract . _ ■ Secondary nodules of melano-sarcoma in the liver . ^- \, t Forearm of a woman four years after excision of the lower fourth of the ulna and the radius for a myeloid sarcoma of the radius Section of a uterus showing a small myoma Very vascular uterine myoma seen in section . . ' i j Microscopical appearance of the mucous membrane covering a prolaj^sed uterine myoma, showing mutation of columnar ciliated into stratified epithelium as a result of pressure Section of a uterus with multiple myomata Myoma of the broad ligaments Myoma of the Fallopian tube Congenital subcutaneous myoma of the occiput . Neuroma of the infra-orbital nerve invading the antrum . . 148 Neuro-fibroma of the radial nerve at the wrist, from a female nineteen years old ........ 149 Plexiform neuroma from tlie back of a youth nineteen years of age . 152 Arm in which the musculo-spiral nerve was neuromatous . . 153 Tlie arm represented in the preceding figure dissected ; the musculo- spiral nerve and its branches are transformed into a plexiform neuroma . . . . . . . _ . 154 Dissection of a stump of the forearm three yeai's after amputation, to show the bulbs on the ends of nerves .... 155 Dissection of a plexiform angeioma of the forehead . . . 163 Macroglossia in a girl aged eleven years ..... 166 Wart growing from the skin of the cheek and obscuring the eye . 169 Microscopical cliaracters of the wart in the preceding figure . . 170 Wart-horn growing on the pinna ...... 172 Villous tumour of the bladder ...... 173 Pelvis of a kidney with a villous papilloma . . . . 174 Section of a mamma with a dilated duct filled with villous papillomata 176 Microscopical appearance of a typical psammoma . . . 177. Bilateral psanimomata in relation with the lateral recesses of the fourth ventricle ....... 178 Psanimomata in the lp,teral ventricle of a horse's brain . . . 180 105 109 111 113 114 118 128 129 130 1.32 140 142 144 LIST OF ILLJJSTRJTI0N8. Xlll Portion of the spinal cord witli a psammoma Cutaneous horn : the widow Dimanche . Cutaneous horn from the penis Sebaceous horn in a mouse ... Head of an African rhinoceros with a large wart posterior to and in a line with its na.sal horns Head and leg of a thrush with cutaneous horns . Horn formed on the cicatrix of a burn Horns growing from the scar of a burn Epithelioma of the upper lip (earlj^ stage) Epithelioma of the lip, begmning in a fissure "Warty"_variety of epithelioma . Microscopic appearance of the cells in epithelioma : the connective tissue stroma is omitted Epithelioma of the gall bladder Section of an adenoma from a child's rectum Cancer of the breast .... Section from a mammary cancer . Sebaceous glands in the velvet of the antler of a stag Large sebaceous adenoma involving the pinna . Large unilateral bronchocele Bronchocele of unusual size Pulsating tumour of the skull, associated with an enlarged thyroid Microscopical appearance of the tumour of the skull in preceding figure Median prostatic adenoma, sketched from within the bladder . Adenoma of the liver .... Congenital cystic kidney .... Congenital cystic kidney : early stage Adenoma of the kidney .... So-called colloid of the mentum . Cancer of the sigmoid flexure of the colon Cancer of colon (constricting variety) Section of three thoracic vertebrae, with a small dermoid situated over two stunted spinous processes. .... Dermoid in the lumbo-sacral region of a man twenty -two years of age Median aspect of a sheep's digit, showing the interdigital pouch Dermoid situated over the junction of the manubrium and gladiolus of the sternum : there was also a dermoid near the left corner of the hyoid bone ........ Presternal dermoid ........ Sternal dimple . ...... Head of an early human embryo, showing the disposition of the facial fissures. . . • • • . • Mandibular tubercle associated with a malformed auricle Right side of the head of a foetus, showing a large mandibular tubercle and an accessory tragus . . . Pierrot's head, to show the mandibular tubercle .... Median fissure of the lower lip . ■,.,,• . •, . / , ,,■ Congenital fistulse in the lower lip of a child, associated with double hare-lip . . • ■ ■ . • ■,.,,•„• ■ Hare-lip in a frog, associated with a persistent intermandibular fissure Dermoid at the outer angle of the orbit ..... Dermoid at the inner angle of the orbit ..... Dermoid arising in naso-facial sulcus ..... Nasal dermoid m a child . . ■ •,•,■, Pedunculated dermoid tumour from the pharyngeal aspect of the soft palate . . • ,. ■,.,', j ' Dermoid of the scalp connected by a pedicle with the dura mater Head of the man Lake with a large dermoid .... Congenital tumour over the anterior fontanelle Implantation cyst from the tip of the finger . . . . PAGE 181 183 184 185 186 187 188 189 191 192 193 194 216 219 223 224 234 236 241 242 243 244 246 250 253 254 255 261 264 265 280 281 282 283 284 285 287 288 289 290 291 292 293 294 295 296 297 298 299 .300 301 304 TUMOURS. cervical the of the Large implantation cyst of the cornea, following an injury Section ot the cyst in the preceding figure, highly magnified Large lingual dermoid, protruding from the mouth _ . Diagram to show the relation of parts in a case of median fistula ..... Thyroid-dermoid ...... Thyroid-dermoid of the coccygeal region, in section Rectal dermoid in section ..... Rectal dermoid ...... Early mammalian embryo, showing the gill-clefts Diagram to indicate the orifices of persistent branchial fistulpe Pharyngeal diverticulum ..... Head and neck of a young woman, showing branchial fistultc in the neck and a sinus in the helix .... Cervical auricles in a child. .... Head and neck of a goat with cervical auricles . Horned sheep with cervical auricles Head of a pig with cervical auricles (the Bell-pig of Australia) Faun and goat ^vith cervical auricles Two drawings representing the development of the auricle Congenital fistula in the helix .... Dermoid of the auricle and ntevus of the palpebral conjunctiva. Auricle with an accessory trajus .... Mucous membrane from an ovarian dermoid Ovarian dermoid detached from the uterus and hanging from omentum ...... Ovum in its follicle : from a cat .... Magnified section of an ovarian dermoid, to show the large size sebaceous glands ..... Ovarian dermoid with a sebaceous gland, from a woman Ovarian mamma : hair and teeth are also present Head of a sheep with a branchial fistula, cervical auricle, and tooth The germ of an ovarian tooth, from a dermoid . Epithelial pearl ...... Extensive hairy mole upon the face of a boy a year old Extensive hairy mole on the trunk of a man forty-seven years of age, which became the seat of sarcoma, from which the patient quickly died ......... Conjunctival mole : common variety ..... Mole on the caruncle, associated with an eccentric pupil Conjunctival mole associated with coloboma of the eyelid, a mandibular tubercle, and accessory tragus ..... Conjunctival mole in a sheep ...... The twin-sisters Radica and Doodica at the age of three and a half years ••....... Laloo, a Hindoo, with an acardiac parasite attached to his thorax Chick with a supernumerary pair of legs projecting from the ventral aspect of the pelvis •■..... Chick with a supernumerary pair of legs projecting from the dorsal aspect of the pelvis • . . . . Frog {FMua palustris) with a supernumerary hind-leg . Louise I. , daine a qiiatre jambes .... Sacral teratoma with a supernumerary leg Posterior view of J. B. dos Santos at the age of six months Cephalic extremity of a two-headed snake Acardiac foetus •...., Acardiac foetus ••.... Acardiac in Fig. 191 shown in section . ! '. Young toad with a supernumerary hind-limb . ! Section through the tip of the vermiform appendix, to show the abundance of its glands ..... 307 310 314 319 320 321 322 323 324 327 328 330 331 332 333 334 335 336 337 338 340 342 345 346 347 348 349 350 351 353 354 356 356 357 358 363 364 365 365 366 367 368 369 370 371 372 373 374 378 LIST OF ILLUSTRATIONS. xv PAGE Hydronephrosis secondary to a large calculus in the bladder : two fragments of calculus occupying the prostatic portion of the urethra 379 Bilateral hydronephrosis in a new-born child .... 380 Calculus impacted in the urethra of a gelding, producing wide dilata- tion of tlie vesical orifices of the ureters and double hydronephrosis 382 Unilateral (intermitting) hydronephrosis ..... 383 Pyonephrosis of one-half of a horse-shoe kidney .... 384 Concretions from the guttural pouches of horses . . . 388 Congenital pedunculated tumour of the navel .... 389 Diagram of the alimentary canal of the embryo, showing the position of the yolk sac ........ 390 Cyst, probably of the vitello-intestinal duct, attached to the intestine of^an emu ....... 392 Septate ileum ........ 393 Ileum with a persistent vitello-intestinal duct associated with a valve. 394 Imperforate ileum . . . . ■ . . . . 395 Diagram to represent the cyst regions of the ovary . . . 398 Euptured papillomatous (paroophoritic) cysts of the ovary . 399 Cyst of the parovarium, showing its relation to ovary and tube . 402 Anterior portion of a cow's vagina, showing two large cysts developed in the terminal segment of Gartner's duct .... 403 Diagram to show the relation of the mesonephros and its ducts to the adult testicle ........ 404 Hydrocele of the tunica vaginalis, and an encysted hydrocele associated with the^same testis . ..... 405 Testicular adenoma ....... 408 Hydrocele of the tunica vaginalis testis ..... 412 Ovarian hydrocele in a rat ....... 416 Ovarian hydrocele : the interior of the sac is bent with warts . . 417 Congenital cervical cyst extending into the axilla . . . 420 Congenital cervical cyst in a man twenty years of age . . . 421 Congenital cyst of the thorax with noevoid walls. . . . 422 Imperforate pharynx ....... 433 Septate pharynx ........ 434 Pharyngeal diverticulum ....... 435 Tracheal opening and pouch of an emu ..... 436 Bursa under the semi-membranosus tendon communicating with the knee-joint ........ 438 Hydrocephalic skull, from an infant ..... 445 Hydrocephalic skull, showing Wormian bones .... 446 Sagittal section of a hydrocephalic skull from a child, with the brain in situ ......... 447 Drawing from a cast of the head of James Cardinal . . . 449 Head of a lion's whelp in section, showing great dilatation of the cerebral ventricles, due to obstruction of the interventricular passages by a thickened (rickety) tentorium . . . 450 Hydrocele of the fourth ventricle ...... 451 Occipital meningo-encephalocele ...... 4.52 -s. Boy with a cephalhaematoma over the right parietal bone . . 455 Monkey (Cebus monachus) with a huge cephalhematoma . 456 Skull of Cebus monachus, sho-vving the bony walls of the cephal- haematoma and a group of Wormian bones .... 457 Lumbar region of a foetus with spina bifida, variety myelocele . 459 Diagram to represent the microscopic characters of a transverse section of a, myelocele . . . . . ■ . 460 Syringo-myelocele in transverse section ..... 461 Syringo-myeloeele and meningocele in longitudinal section : from the cervical region ...... . 462 Diagram showing meningo-rayelocele in transverse section . . 463 Microscopical appearances of the nerve-tissue from the wall of a menmgo-myelocele showing the central canal . . . 464 xvi TUMOURS. African child with a pedunculated tumour (an occluded spina bifida sac) attached to its buttock . . . . . . • Tumour from the African child [see previous figure), shown in section Hair field on the loin overlying a spina bifida occulta . Hair field overlying a spina bifida occulta ; there is also a long tuft on the cervical region . . , . . ^gipan sporting with a faun [Bacchus and Silenus) Hfur- vertebra ...... Echinococcus colony in the kidney ... Multilocular hydatids of the shaft of the humerus Multitude of minute hydatids on the pelvic peritoneum, probably secondary to the tapping of a cyst in the liver Cyst (implantation) of the palm . . . . • PAGE 465 466 467 468- 469 470 473 474 477- 498 LIST OF PLATES, "Fungating"' Sebaceous Cyst (Sebaceous Adenoma) on the scalp of a woman eighty-three years of age Melanosis of the Skin, secondary to Melano-sarcoma of the Uveal Tract ..... Molluscum Fibrosum combined with tumours on the nerves ....... An unusual form of Wart, growing from the skin of the Pubes ....... Cuirass Cancer. The right breast had been amputated two years. The right arm is in the condition known as ' ' Lymphatic " ffidema . . Inflamed Sebaceous Cyst, situated on the inner margin of the Left Mamma ..... Placenta from a case of Twins, one of which was an Acardiao ...... Right Kidney with Two Ureters, one of which opens into the Bladder at the vesical orifice of the Urethra ; the lower half of the kidney drained by this meter is converted into a pyonephrosis. The upper half drained by the normal ureter is healthy. The left kidney was normal ..... Lower two-thirds of a Femur, with the upper fourths of the Tibia and Fibula. The remnants of the Femur and Tibia are fenestrated osseous shells, in consei^uence of the pressure exercised by multilocular hydatids which began in the Femur, invaded the Knee-joint and involved the Tibia. There is a sequestrum in the Femur measuring 7 '5 cm. by 4 cm. Frontispiece To face page 114 150 170 227 235 374 385 482 TUMOUES INl^OOENT AND MALIGI^ANT: Their Clinical Characters and Appropriate Treatment. CLASSIFICATION. Any thoughtful individual, on commencing the study of tumours, must doubtless have been struck by the confusion which prevails in oncological literature in regard to the use of such terms as classes, groups, species, varieties, etc. This confusion will be more obvious if the student be acquainted even in a moderate degree with Systematic Zoology. Not that the zoologist can in any way claim to have discovered a Jjerfect method of classification, but he certainly uses the terms genus, species, etc., in a consistent manner. In the present work an attempt will be made to classify tumours on similar lines to those employed in Biology. The classification adopted is one which will not, in any serious way, involve the Taxonomy (if it be worth such a name) at present in fashion. It is certain that the efforts of J. Muller (1838) to classify tumours according to their minute structure had a great in- fluence in promoting the study of Oncology. Virchow's labours on the histology of tumours, and especially his success in de- monstrating that all the tissues found in them have a physio- logical prototype, have made it plain that it is impossible, in any useful classification of tumours, to neglect to take into consideration their structural characters. To-day it must be clear to all who study Virchow's great work, "Die Krankhaften Geschwulste" (1863), in the Hght of our present knowledge that he employed the term tumour in a B 2 TUMOURS. too comprehensive manner. It is highly desirable to exckide from tumours those formations known as infective granulo- mata, and there can be no doubt that this group will be largely increased in the near future, as it has been in the recent past, at the expense of sarcomata and, in all probability, of the epitheliomata and carcinomata, as our knowledge of the biology of micro-organisms increases. Tumours may be arranged in four groups : — I. Connective tissue tumours. II. Epithelial tumours. III. Dermoids. IV. Cysts. Each group contains several genera ; each genus has one or more species ; of each species there may be one or more varieties. CHAPTER I GROUP I.— CONNECTIVE TISSUE TUMOURS. The Connective Tissue Group of tumours contains the following genera : — 1. Lipomata (fatty tumours). 2. Chondromata (cartilage tumours), 3. Osteomata (osseous tumours). 4. Odontomata (tooth tumours). 5. Fibromata (fibrous tumours). 6. Myxomata. 7. Gliomata (neuroglia tumours). 8. Sarcomata. 9. Myomata (muscle tumours). 10. Neuromata (tumours on nerves). 11. Angeiomata (tumours composed of blood-vessels). 12. Lymphangeiomata (tumours of lymphatic vessels). LIPOMATA (fatty TUMOURS). A Lipoma is a tumour composed of fat. The various species of this genus, determined mainly by the situations in which they arise, are : I, Subcutaneous ; 2, subserous ; 3, sub- synovial ; 4, submucous ; 5, intermuscular ; 6, intramuscular ; 7, parosteal ; 8, meningeal. I. Subcutaneous Lipomata. — Beneath the skin there exists a layer of fat, which varies in thickness in different parts, but is most abundant over the trunk and trunk ends of the limbs. This subcutaneous fat is a common situation in which to find lipomata. Usually they occur as irregularly lobulated encap- suled tumours, more or less adherent to the skin. Unless they have been irritated, lipomata are movable within their cap- sules. Generally one lipoma is present, but two, ten, twenty, or more may occur concurrently on the same individual. In size they vary widely ; a lipoma iveighing sixteen ounces is a tumour of fair size ; exceptional specimens have been reported to weigh fifty, eighty, and even one himdred pounds. Although subcutaneous lipomata are for the most part confined to the trunk and trunk ends of limbs, they may arise on the distal 4 CONNECTIVE TISSUE TUMOURS. parts of the limbs, such as the hands and feet. Many speci- mens have been observed in the palm of the hand (Fig- 1), a situation in which they are apt to give rise to difficulty in diagnosis, more especially as they simulate compound ganglia of the flexor tendons. The lobes of fat are apt to burrow beneath the palmar fascia, and it is probable that some hpo- mata of the palm originate beneath this fascia, in the lobules Fig. 1.— Lipoma in the palm of the hand. of fat lying between the lumbricales. Fatty tumours are occasionally found on the fingers : Steinheil* has coUected a large number of examples. A lipoma in the sole of the foot IS more comprehensible than one in the palm of the hand yet strange to relate, they are far more frequent in the hand than m the foot ; m both situations they are apt to be congenitaLf Bruns, BeitrSge, bd. vii. 605. t Gay, Trans. Path. Soc, vol. xiv. 243, and Lookwood, ibid., vol. xxxvii. 450. LIPOMATA. S Subcutaneous lipomata are often symmetrical (Fig. 2) and are apt to become pedunculated, especially when growing from the thigh. Pedunculated lipomata are never very large, and when the pedicle is thin it will become twisted by the rotatory movements of the tumour, the growth of which will ia con- sequence be arrested, or at least checked. Fatty tumours are rarely met with upon the head or face, Fig. 2. — Lipoma of the left axilla; a similar tumour occupied the right axilla. but I have on three occasions removed a lipoma from beneath the skin covering the temporal fascia : the largest specimen is depicted in Fig. 3. There is a variety known as the diffuse lipoma ; in typical cases the tumours appear as symmetrical swellings in the neck and on each side of the ligamentum nuchse. The fat has a coarsely granular appearance, due to being bound up in tiny lobules, which causes it to resemble omentum. In the neck these collections of fat are situated on the deep as well as the superficial aspect of the platysma muscle. Similar unencap- suled masses of fat occur in the groin, pubic region, and axillae of those who are unfortimate enough to possess them in the neck (Fig. 4). 6 CONNECTIVE TISSUE TUMOURS. There is a variety of fatty tumour sometimes called, on account of its vascularity, ncBvo-lipoma ; some are of opinion that it is a nsevus which has undergone fatty degeneration. Possibly some of the vascular lipomata met with on the face have this origin. 2, Subserous Lipomata. — The peritoneum, like the skin, rests upon a bed of fat, the thickness of which varies consider- ably. As in the case of subcutaneous lipomata, those which Fig. 3.— Lipoma superficial to the temporal fascia. occur in the subserous tissue may be sessile, pedunculated, or diffuse. Surgeons have long been aware, in operating for ingumal or femoral hetnia, that occasionally they come across a mass of fat, and find difficulty in determining whether it be omental or a local, mcrease of the subserous fat surrounding the hernial sac. It is now clear that in the neighbourhood of the femoral and inguinal canals an overgrowth of the subserous fat may occur and be mistaken for a hernia, and individuals have been recommended to wear, and have actually worn, trusses for fatty tumours of this character. It is also clear that as these LIPOMATA. 7 local overgrowths of fat arise and protrude in the groin, they occasionally draw with them a pouch of peritoneum unasso- ciated with a hernia. These pouches may afterwards lodge a piece of gut, and become true hernial sacs. Thus peritoneal pouches, produced mechanically by subserous Hpomata, may subsequently become hernial sacs ; on the other hand, Hpomata may arise in relation with peritoneal pouches which were Fig. 4.— Diffuse lipoma of the neck. (After Morrant Baker. originally hernial sacs. In some cases a subserous Hpoma of this character will invaginate a peritoneal pouch and form a pedunculated tumour within the hernial sac. Fatty tumours sometimes arise in the scrotum or labium without being connected with hernial pouches.* Lipomata arising in the subperitoneal tissue occasionally appear in the anterior abdominal wall, especially near the um- bilicus ; they are sometimes referred to as " fatty hernise of the * J. Hutchinson, jun., Trans. Path. Soc, vol. xxxvii. 451 and vol; xxxix., gives a good account of hernial lipomata. 8 CONNECTIVE TISSUE TUMOURS. linea alba," and are frequently associated -with peritoneal pouches. These lipomata simulate hernise still further when the traction they exercise on the peritoneum causes pain. Subserous lipomata on the under surface of the diaphra,gm may pass upwards into the mediastinum through the space which exists behind the ensiform cartilage. A few cases are known in which lipomata have grown be- tween the layers of the broad ligament ; * -in one case the tumour was so large as to simulate an ovarian tumour.f Enormous subserous lipomata, in many respects resembling the diffuse tumours of the subcutaneous tissvie, have been described. PickJ recorded a case in which a mass of fat weighing thirty pounds was found posterior to the transverse colon. Meredith§ successfully removed an omental lipoma weighing fifteen pounds and a half, from a woman sixty-two years old ; the operation was undertaken because the tumour was thought to be ovarian. Cooper Forster|| met with a similar tumour, weighing fifty-three pounds, in a woman sixty-three years old. Hernial lipomata are interesting, for they explain the mode in which appendices epiploic£e arise: they are localised pedunculated overgrowths of' subserous fat, and are particu-- larly large and arborescent in the neighbourhood of an old syphilitic stricture of the rectum. In well-nourished individuals the fat of the appendices epiploicae is directly continuous with the fat in the layers of the mesentery ; when wasting occurs the fat between the appendices and the mesentery is liable to atrophy and leave an adipose nodule at the bottom of a peritoneal pouch (Fig. 5). The movements of the intestine and, the traction of the nodule lead to the formation of a pedicle which often becomes twisted ; sometimes the pedicle is so thin that it breaks, and the appendix is set free. Pieces of fat, not infrequently calci- fied, detached in this way, have been found in hernial sacs. Pedunculated lipomata of the colon are hot uncommon in * Parono, Ann. di Ostet. Milam, 1891, xiii. 103, pi. i. t Treves, Trans. Clin. Soc, vol. xxvi. { Trans. Path. Soc, vol. xx. 337. § Trans. Clin. Soc, vol. xx. 206. II Trans. Path. Soc, vol. xix. 246. LIPOMATA. 9 horses and oxen : I have known them weigh two pounds ; they are apt to cause invagination of the bowel. 3. Subsjmovial Lipomata. — Beneath the subserous tissue of large joints, such as the knee, there is a layer of fat of varying thickness. This fat may, as in the case of inguinal lipomata, increase in quantity and, projecting into the joint, form a fatty tumour. A conimon situation for this to occur is beside the patella, at the spot normally occupied by the alar ligaments. Fig. 5.— Small pendulous appendices epiploicae, with twisted pedicles, of the ascending colon. Many specimens are doubtless due to overgrowth of the fat in the alar fringes, but they may arise in other parts of the joint. The best known variety of subsynovial fatty tumour is that to, which Mtiller applied the term "lipoma arborescens." This condition is often, but by no means always, associated with rheumatoid arthritis. A typical specimen from the shoulder-joint is represented in Fig. 6, consisting of small liilger-like processes of fat projecting into the cavity of the joint ; each process is covered by synovial membrane. The lipoma arborescens bears precisely the sanle relation to the - synovial membrane that the appendices epiploicae bear to the peritoneal investment of the colon and sigmoid flexure. 10 GONNEGTIVE TISSUE TUMOURS. 4. Submucous Lipomata.^ — Fat exists in the submucous tissue in many situations and, like tliat in the subcutaneous ' , tissue, is not infrequently the source of lipomata. Thus Virchow* has figured a fatty tumour situated beneath the mucous membrane of the stomach, near the pylorus : it was as big as a nut. They also grow from the jejunum and hang as Fig. 6.— Lipoma arborescens of the shoulder. pedunculated tumours in the gut, and have caused intussus- ception. Laryngeal lipomata are rare.- One of the most remarkable examples was described by Holt.f The patient, a man, died suddenly : hanging from the left aryteno-epiglottic fold and from the side of the epiglottis was a pedunculated tumour, which extended into the oesophagus to a distance of * " Krank. Geschwulste," td. i. 372. t Trans. Path. Soc, vol. xxxii. 243. LWOMATA. 11 22'5 cm. (9"). It consisted of fat covered with mucous membrane. Sydney Jones* removed a lipoma from tlie right aryteno- epiglottic fold of a man forty years old : it was 5 cm. (2") in diameter. The patient could protrude the tumour into his mouth. Bruns removed a Hpoma the size of a hazel nut from the right arytenoid region. Subconjunctival hpomata occasionally occur near the point where the conjunctiva is reflected from the lower lid to the eyeball : they are almost confined to children. Sometimes lipomata arise .from the orbital fat and project the conjunctiva in the neighbourhood of the lachrymal gland and near the insertions of the ocular muscles. 5. Intermuscular Lipomata. — Fatty tumours now and then arise in the connective tissue between muscles : they have been found between the greater and lesser pectorals, between the muscles of the tongue and the intermuscular strata of the anterior abdominal wall. In the last-mentioned situation they have been known to attain prodigious pro- portions.t The most remarkable variety of this species of lipoma arises in connection with the sucking-cushion. This curious ball of fat is situated between the masseter and buccinator muscles, and comes into close relation with the buccal mucous membrane. It is believed to play an important function in connection with sucking, by distributing atmospheric pressure and preventing the buccinators from being forced between the alveolar arches when a vacuum is created in the mouth. They are relatively much larger in infants than in adults. Ranks % also points out that in emaciated children the cushions are only slightly diminished in size even when there is scarcely any subcutaneous fat. (Figs. 7 and 8.) The sucking-cushions sometimes enlarge in adults, and simulate more serious species of tumours, and it is curious that in some of the recorded cases the enlargement of the cushion has been associated with the impaction of a salivary * Trans. Path. Soc, vol. v. 123. f Sir Astley Cooper, Medico-Chir. Trans., vol. xi. 440. Eve, Trana. Path. Soc, vol. xxxix. 295. Abdel-Fattah Fehmy, Srit. Med. Journal, 1893, vol. i. 459. J Virchow's " Arohiv,'' bd. xcvii. 527. 12 GONNEOTIVE TISSUE TUMOURS. Fig. 7. — Enlarged suckiDg-cushion. {After Ranks.) calculus in the duct of the parotid gland.* The association of an impacted salivary calculus and an enlarged sucking-cushion , Fig. 8.— Emaciated child crj'ing and displaying the sucking-cushions. {Afler Sanke.') * Berger, Gaz. des HSpitaux, Nov. 15, 1883; and Owen, Lancet, 1890 vol. ii. 71. ' LIPOMATA. 13 is interesting in relation with an observation of Norman Moore, who found a large collection of fat around a ureter at the site of an impacted calculus. (Museum, Royal College of Surgeons, 196a.) 6. Intramuscular Lipomata. — Many examples of fatty tumours occurring in the midst of muscles have been reported, and are of interest from the trouble they cause in diagnosis. They have been found in the deltoid, biceps humeri, com- plexus, and rectus abdominis ; in the muscular tissue of the heart, and in the middle of a submucous myoma of the uterus.* 7. Farosteal Lipomata. — This term has been applied to fatty tumours arising from the periosteum of bone. They are usually congenital, and nearly always contain tracts of striated inuscle fibre. Some of these tumours are clinical puzzles. Dr. F. Taylorf reported a case in which a fatty tumour grew frotn the anterior surface of the bodies of the cervical vertebrae ; it projected the posterior wall of the pharynx, and simulated a post-pharyngeai abscess. The patient was a girl four years old. I have removed parosteal lipomata from the dorsal surface of the infra-spinous fossa of the scapula, the body of the pubes, and the frontal bone immediately above the right superciliary ridge. The appended table contains references to descriptions and accessible examples of parosteal lipomata. PAROSTEAL LIPOMATA. Seat. Femur . Tibia and Fibula Ischium Spiue of Ilium Clavicle . Scapula . Necls of Radius Coccyx . Frontal . Eepobter. D'Arcy Power Butlin . T. Smith Walsham Gould . T. W. Nunn T. Smith T. Smith Sydney Jones Repekence. Trans. Val/i. Sue, xxxix. 270. Trans. Fath. Soc, xxviii. 221. Trans. Path. Soc, xvii. 286. Trans. Path. Soc, xxxi. 310. Museum, Middlesex Hospital. Museum, Middlesex Hospital. Trans. Path. Soc, xix. 344. Trans. Path. Soc, xxi. 334. Trans. Path. Soc, xxxii. 243. • T. Smith, Trans. Path. Soc, vol. xii. 148. See also Lebert, "Traite d'Anatomie Pathologique," plate xvi., fig. 11, t. i. p. 128. t Trans. Path. Soc, vol. xxviii. 216. 14 CONNECTIVE TISSUE TUMOUES: 8. Meningeal Lipomata. — Fatty tumours occur within the spinal dura mater, as well as external to this membrane. When growing within the sheath they surround the cord. Gowers,* Recklinghausen,! and ObreJ have recorded examples. In the cases described by the first two observers the tumours Fig. 9.— Meningeal lipoma simulating a spina bifida in a child eight months old. (After Tcmoin.^) contained striped muscle tissue. The occurrence of an intra- dural lipoma is not surprising, as the loose connective tissue between the cord and dura mater contains fat. Fatty tumours- are not uncommon in the middle Mne of the * Trans. Path. Soc, vol. xxvii. 19. t Virchow's "Archiv," bd. ov. 243. J Trans. Path. Soc, \-ol. iii. 248. ^ Arch. JProvineialcs de Chirurgie, 1892, p. 179. LIPOMATA. 15 back, especially in the lumbo-sacral region, overlying the sac of a spina bifida. (Figs. 9 and 10.) Clinical Features. — Although lipomata occur more fre- quently than any other genus of connective tissue tumours, and may, in most instances, be diagnosed with absolute cer- tainty, yet under some conditions they are very puzzling, and give rise to much difference of opinion. The subcutaneous species is rarely the source of doubtful diagnosis, unless Pig. la— Meningeal lipoma overlying the sac of a spina bifida. (Museum, Royal College of Surgeons.) situated in the pahn of the hand, sole of the foot, or on the scalp. The intimate relation between the tumour and the over- lying skin, the absence of definite boundaries and its dough- like consistence, are usually sufficiently trustworthy guides. When a lipoma is connected with the periosteum of a long bone it will sometimes simulate a sarcoma ; when embedded in a muscle the most divergent opinions are often expressed in regard to the nature of the tumour. 16 CONNECTIVE TISSUE TUMOURS. Keference has already been made to those large lipomata which arise in the subperitoneal tissue and the way they mimic the signs of ovarian tumours. Lipomata in the neigh- bourhood of hernial openings have often been confounded with hernise. Especial attention must be drawn to supposed fatty tumours situated in the middle line of the back : in most cases these are abnormal masses of fat overlying the sacs of spinse bifidse. Incautious surgeons, in operating upon such tumours, have unexpectedly opened the dura mater. Treatment. — Solitary subcutaneous lipomata should, as a general rule, be removed. When very many tumours are present (ten or twenty) it is not customary to interfere with them, for when multiple they rarely attain uncomfortable or dangerous proportions. It occasionally happens with multiple, (and also with solitary) lipomata, that one or other becomes irritated with some part of the dress, such as petticoat bands, braces, etc., or in some particular employment followed by the individual. Such tumours should invariably be removed. The removal of a subcutaneous lipoma is one of the simplest proceedings in surgery, but the extirpation of a large subperitoneal fatty tumour is often attended with difficulty and grave danger.* Diffuse lipomata do not admit of removal. It was for- merly stated that liquor potassse, taken internally, caused them to diminish in size and even disappear. So far as my observations have extended, the administration of this drug is useless in preventingthe growth or reducing the size of these tumours. * Homans, International J. Med. Set., April, 1891 ; and Spencer Wells, "Ovarian and Uterine Tumours," 1882. 17 CHAPTER II. CHONDROMATA (CARTILAGE TUMOURS). Chondromata (encliondromata) are tumours composed of hyaline cartilage. This genus contains three species: — 1, chondromata ; 2, ecchondroses ; 3, loose cartilages in joints. 1. Chondromata. — Cartilage tumours in their typical con- dition occur in long bones, and, as a rule, grow in relation with the epiphysial cartilages, hence they are most frequently observed in children and young adults. Often a chondroma is solitary, but very frequently many exist, especially on the long bones of the hand. A remarkable case is de- picted in Fig. 11 ; this patient was under observation at the Tubingen Clinic twenty-five years. He died at the age of forty-five. Most of the long bones of the limbs were occupied with cartilage tumours. Some of them were very large.* -Kast and Recklinghausenf have described a similar case, and I have a photograph of a lad who used to be exhibited for gain at fairs in various parts of England, with cartilage tumours on his hands, feet, and legs as numerous as in Steudel's unfortunate patient. Chondromata are always encapsuled, and form deep hollows in the bones from which they grow ; they are pamless, grow slowly, and are firm to the touch. Frequently they undergo mucoid softening, then the softened patches give rise to fluctuation. This often serves to distinguish them from osteomata, with which they are liable to be confounded cHnically. Cartilage tumours are prone to ossify. The frequency of chondromata in those who were rickety in early life may be due, as Virchow pointed out, to the existence of untransformed pieces of cartilages acting the part of tumour-germs. Such remnants of unossified cartilage (cartilage islands) are not difficult of demonstration in rickety bones. (Fig. 12.) It is a curious circumstance that the tissue of a chondroma * Bruns, Beitrage, bd. viii. 503. t Vii'ohow's " Archiv," bd. cxviii. s. i. 18 CONNECTIVE TISSUE TUMOURS resembles, histologically, the bluish translucent epiphysial cartilage characteristic of progressive rickets. 2. Ecchondroses may be defined as small local overgrowths of cartilages. They are best studied in three situations — viz.. Fig, 11. — Lad twenty years of age with multiple chondromata. (After Steudel.) along the edges of articular cartilages, the laryngeal cartilages, and the triangular cartilage of the nose. Ecchondroses of articular cartilage are especially common in the knee joint, and occur in connection with the condition known as rheumatoid arthritis. They are frequent in the joints of persons past the meridian of life, and they piesent OEONDBOMATA. 19 themselves as small projecting prominences along the margins of the articular cartilage. Often the edge of the cartilage is produced into a raised prominent Hp, the regularity of which is broken here and there by a sessile or pedunculated nodule. When these nodules are examined many of them present on their outer surface a convex outline, but on the inner aspect — that looking towards the joint — they are concave, the concavity being produced by friction during the movements of the joint, or by pressure when the parts are at rest. Occa- sionally erosion of the ecchondrosis may extend so deeply that by some extra movement of the joint the pedicle is broken, and the detached nodule either falls as a loose body into the Fig. 12. - Conilyles and epiphysial line of a rickety femur, witlj a cartilage island. joint-cavity, or it may be retained in position by its attachments to the fibrous structures of the articulation. Laryngeal ecchondroses are by no means common ; they grow from the thyroid, cricoid, and occasionally the arytenoid cartilages. Paul Bruns* collected fourteen cases of laryngeal chondromata; of these, eight sprang from the cricoid, four from the thyroid, one from the arytenoid, and one from the epiglottis. Most of the ecchondroses of the cricoid cartilage sprang from the broad posterior plate. In many of the cases the inner and outer surfaces of the cricoid were involved, so that the tumour encroached upon the cavity of the larynx. Ecchondroses vary greatly in size ; some are scarcely larger than a pea, others may be as big as walnuts. Morell * JBeitrage sit Kl'm.-Chir., td. iii. 347. 20 CONNECTIVE TISSUE TUMOURS. Mackenzie* has described an example growing from the cricoid which attained the size of a bantam's egg ; in this instance the tumour extended downwards in front of the trachea. Small ecchondroses growing from the inner surfaces of the laryngeal cartilages are more dangerous than the larger examples springing from their outer surfaces. Ecchondroses, v,rhen pro- jecting mto the larynx, are covered with its mucous mem- brane ; they may be smooth or tuberculated, round or conical. In exceptional cases the overlying mucous membrane has been found ulcerated. Chondromata, when they project into the larjmx, produce stridor, difficulty in breathing, and sometimes interfere with the movements of the vocal cords. When the tumours only involve the outer surfaces of the laryngeal carti- lages, they do not as a rule produce any inconvenience unless they are exceptionally large. Small outgrowths from the triangular cartilage of the nose are by no means uncommon ; they never attain a large size, and are always sessile. It is difficult to imagine that ecchondroses of the nasal cartilage could be a source of much inconvenience, but some surgeons, who are enthusiastic in treating diseases of the nasal passages, view them with dis- favour. 3. Loose Cartilages. — Bodies of various kinds axe found loose in the cavities of large joints, but those to be considered under the head of chondromata, in addition to detached ecchondroses, are pieces of hyaline cartilage found hanging in the jouat by narrow pedicles, or occupying depressions in the bone, from which they are occasionally dislodged. Structurally they are composed of hyaline cartilage, and assume various forms. Some appear as flat discs, others are ovoid; they may be perfectly smooth, or present an irregular worm-eaten appearance, and the majority are impregnated with calcareous particles. It is a remarkable fact that in many instances in which a loose cartilage has been found in one joint, a body identical in size and shape has been found in the corresponding joint of the opposite hmb.f Loose cartilages may be single or * Trans. Path. Soc, vol. xxi. 58. t Bowlby, Trans. Path. Soc, vol. xxxix. 281 ; Glutton, ibid., vol. xxxix. 284 ; American Journal of Med. Sci., vol. i.- 303 ; Weiohselbaum, Virohow's " Archiv " Ivii. 127. GHONBROMATA. 21 multiple : several hundred may exist in one joint, and vary in size from a rape-seed to an almond. _ The origin of these cartilages is interesting. In large joints, such as the hip, knee, or shoulder, it is easy to demon- strate, in the recesses of the joint near the spot where the syriovial membrane becomes continuous with the margin of the articular cartilage, villous-like processes of the synovial mem- brane projecting into the joint. Under certain conditions, especially that known as rheumatoid arthritis, these villi become greatly enlarged and increase in number until the whole synovial membrane may be so covered with them as to become quite velvety in appearance. Structurally, these synovial villi consist of a redupUcation of the serous mem- brane, and contain tufts of capillaries. As they enlarge, some of them iindergo chondrification, and this change may take place so extensively that a villous process is entirely con- verted into hyaline cartilage, which becomes the matrix for a deposit of lime salts. As these nodules of cartilage are merely sustained by narrow pedicles, the nodules may be de- tached either by their mere weight, undue movement of the joint, or from axial rotation, and tumbling into the joint give rise to all the inconveniences characteristic of a loose body. Specimens occasionally come to hand in which cartilaginous bodies of this description may be found sessile among the fringes, or hanging on good pedicles, or with stalks so thin that they appear to be on the eve of detachment. Occasionally these overgrown synovial villi, instead of chon- drifying, are converted into oval bodies, which, on microscopic examination, present a central cavity surrounded by a lami- nated structureless substance. To the naked eye many of these oval bodies resemble cartilage, and it is only on microscopi- cal examination that it is possible to distinguish between them ; many are infiltrated with calcareous granules. These oval bodies are present in some cases in great number. On one occasion Mr. Benthf sent me 1,532 which he removed from the shoulder joint of a girl. Loose bodies of this character occur not only in joints, but in compound ganglia and in bursse. In concluding this account of cartilage tumours it is very necessary to point out that every tumour containing cartilage 22 CONNECTIVE TISSUE TUMOUBS. is not necessarily a chondroma. In describing sarcomata it will be pointed out that the spindle-celled species is very apt to contain cartilage, particularly when arising in the testis, parotid gland, or periosteum. Much ingenious speculation has been exercised to account for the presence of cartilage in sarcomata arising in such structures, but it appears to be an extremely easy task for connective tissue to form hyaline cartilage. Treatment. — The operative treatment of chondromata has been greatly simplified since surgeons have appreciated the fact that these tumours, when growing in relation with bones, are distinctly encapsuled. Hence, when it is necessary to interfere with a chondroma, even in cases where several tumours are present, it has become customary to incise the capsule and shell out the cartilage. In most instances this simple method is successful. Exceptionally, however, cases come under observation which demand more serious measures. When the cartilage tumours are very numerous on the bones of the hand, the fingers are so crippled and useless that amputation becomes necessary. In the patient represented in Fig. 11 the weight of the tumours caused so much fatigue that it was deemed advisable to amputate the hand. For- tunately, such severe treatment is very rarely needed. In the case of loose bodies in joints it is the usual practice, when the pieces of cartilage are in the habit of getting between the opposed surfaces of the joints, to open the synovial cavity, and remove the loose body or bodies. When this manceuvre is conducted with proper care it is highly successful When the loose body is lodged in a sacculus, it is in a measure isolated from the general cavity of the joint, and does not call for interference. The smaller bodies, which, like mice, slip in and out of the recesses of a complex joint, are more likely to give trouble than those larger pieces of cartilage, sometimes as big as chestnuts, which the patients can grasp with their fingers, and shp in and out of the great cul-de-sac above the pateUa almost as readily as a marble may be manipulated under a tablecloth. Bodies of this sort rarely call for interference. 23 CHAPTER HI. OSTEOMATA (OSSEOUS TUMOURS). It has been customary to describe almost all kinds of tumours composed of bone, or bone-like tissue, under the name of exos- toses. A critical examination of these tumours indicates that they belong to at least two genera, osteomata and odontomata. The term exostosis should be limited to irregular bony out- growths to which the term tumour is not in any sense applicable. Osteomata may be defined as ossifying chondromata, for they are found near the epiphysial lines of long bones, and when they arise in connection with flat bones it is generally in the vicinity of a tract of cartilage. Every growing osteoma has a cap of hyaline cartilage, which stands in the same relation to the growth of the tumour as an epiphysial line to the increase in length of a long bone. The genus osteoma contains two species : — 1, the compact or ivory osteoma ; 2, the cancellous osteoma. 1. Compact Osteomata. — These are structurally identical with the tissue forming the shaft of a long bone. They may occur on any part of the skeleton, but are more frequent in the frontal sinus, external auditory meatus, and mastoid process than elsewhere. The general characters of an osteoma of the frontal sinus may be gathered from the specimen (Figs. 13 and 14) pre- served in the museum of the Royal College of Surgeons, London ; it is figured in Baillie's "Morbid Anatomy," fas. x., pi. L, fig. 2. Unfortunately, no history of the case is forth- coming. Many of these tumours extend into the orbit, and others sometimes make their way through the posterior part of the orbital roof into the cranial cavity. Osteomata of this kind arise occasionally in the frontal sinuses of oxen, and form huge irregular lobulated masses, sometimes weighing as much as sixteen pounds, and as dense as ivory. Similar tumours grow from the petrosal and en- croach upon the cranial cavity; some of these have been reported in veterinary Hterature as ossified brains ! 24 CONNECTIVE TISSUE TUMOURS. In many instances very large tumours have been removed from the maxillos and described as exostoses ; some of these were huge odon tomes. (See next Chap.) Fig. 13.— Osteoma of the left frontal sinus (anterior view). Osteomata at the margins of the external auditory meatus have been especially studied because they are apt to obstruct Fig. 14. — Osteoma of the left frontal sinus, seen from below. {Museum, Royal College of Surge(ms.) the meatus and cause deafness ; when both meatuses are affected — and this is not rare — absolute deafness may result. It is a curious fact that osteomata at the margins of the auditory meatus have been observed in many different races of men. OSTEOMATA. 25 Professor Sir William Turner* has drawn attention to observa- tions of Seligmann, Welcker, Barnard Davis, and added some of his OAvn, concerning the presence of such exostoses in certain deformed skuUs described as Titicaca's, Huanaka's, and Aymara's. Also in skulls from the Marquesas Islands, Sandwich Islands, Chatham Island, and New Zealand.! It is not surprising that osteomata shovild arise from the walls of the external auditory meatus when we remember the number of centres by which the periotic cartilage is transformed into bone, and the various ossific elements that come into relation with each other at this meatus. 2. Cancellous Osteomata. — These tumours in structure re- semble the cancellous tissue of bone, and are soft in comparison with the preceding species. They usually possess a thick covering of hyaline cartilage, and when growing at the distal end of the radius, or tibia, present a series of deep channels for the passage of tendons. Occasionally an osteoma is pedunculated ; more frequently it has a broad base. Osteo- mata, whether sessile or stalked, usually grow slowly, but in the course of years they sometimes attain large proportions. They are innocent tumours, but occasionally imperil life by mechanically interfering, with the function of vital organs. KeidJ described a case in which an osteoma grew from the posterior surface of the odontoid process and projected into the neural canal to the extent of 8 mm. and compressed the spinal cord with fatal effect. Although in themselves painless, osteomata often induce pain by pressing on nerve trunks in their vicinity. Exostoses. — The various bony outgrowths classed as exostoses fall into three groups : — 1. Ossification of tendons at their attachments. .2. The sub-ungual exostosis. 3. Calcification of inflammatory exudations. 1. Exostoses formed by Ossification of Tendons at their Attachments. The long bones of a child at birth are smooth in outline and almost cylindrical in shape ; the periosteum is relatively • Journal of Anat. and Fhysiology, vol. xiii., p. 200. t Zoology of the " Challenger Expedition," pt. xxix., p. 117. J min. Med. Journal, 184-3, p. 194. 26 CONNECTIVE TISSUE TUMOURS. thick, and gives attachment to the muscles. On examining the long bones of an adult muscular man their shafts are found to be irregular, and present many asperities, such as the linea aspera, gluteal ridges, oblique lines, and the like. These ridges and lines, in the majority of instances, are the ossified insertions of muscles, and occasionally they are so pronounced , as to be appreciable through the soft structures, and are then described clinically as exostoses. The two naost frequent Fig. 15.-Exostosis of the femur: its surface was clad with carti'lage and surmounted by a bursa. (^AJter Orlow.*) examples of this form of exostosis are the adductor tubercle of the femur and the tubercle on the first rib at the insertion ot the scalenus anticus. Probably the most common exostosis IS that which occurs in the tendon of insertion of the adductor raagnus : it usually assumes the form of a broad Ifedge of bone ; exceptionally it is stalked, and in rare cases surmounted by a bursa (Fig. 15); the walls of such bursse are now and then turmshed with villi, and even loose bodies have been found m them. Care must be taken not to confound a supracondyloid " Zeitsehrift fiir Chir., bd. xxxi. 293. 08TE0MATA. -2.1 process of the humerus, and the occasional third trochanter ot the femur, with exostoses. . A bursa will form on exostos^'or osteomata if their sur- faces be exposed to pressure, or to friction from the movement of tendons and muscles. Localised outgrowths are very common on the facial bones, especially the nasal processes of the maxillae, where they may be unilateral or bilateral. (Fig. 16.) The cause of these exos- toses is obscure. Small irregular osseous prominences are fairly frequent along the alveolar borders of- the maxillaj and mandible. Fig. 16.— Symmetrical exostoses of the nasal processes of the maxillsp. (,AJteT Hutchinson.*) Exostoses of the maxillae similar to those in Fig. 16 have been observed in natives of the West Coast of Africa. In- teresting particulars relating to these cases are furnished by Macalister.t and more recently by Lamprey.J of the Army Medical Staff. Macalister discusses the condition in relation to the supposed existence of horned men in Africa. 2. The Sub-ungual Exostosis is a troublesome outgrowth from the ungual phalanx of the big toe ; it makes its way through the bed of the nail, and peers out between the nail and the skin at the tip of the toe, nearer the inner than the outer side ; * " Illustrations of Clin. Surgery," vol. i., p. 2. + Proc. R. Irish Academy, 2nd Series, vol. iii., 1883. t Brit. Med. Journal, 1887, vol. ii., 1273. 28 CONNECTIVE TISSUE TUMOURS. its appearance is so cliaracteristic that it only requires to be once seen to be appreciated readily. (Fig. 17.) The sub-iingual exostosis is never very large : as a rule, it is no bigger than a cherry-stone ; exceptionally it may be double this size, but larger examples are excessively rare. The soft tissue overlying the exostosis is apt to ulcerate. As seen pro- jecting beneath the nail it is of a dull red colour. When the soft tissues investing it are removed, the tumour appears as a low prominence of cancellous bone jutting from the' dorsal surface of the terminal phalanx. These outgrowths are prob- ably due to the pressure of ill-fitting boots, and should be ranked among inflammatory productions. 3. Exostoses due to calcification of infiaviTnatory exudations scarcely re- quire consideration in this work: there is reason to believe that some of the cases described as multiple exostoses were really examples of the strange and rare disease known as "myositis ossi- ficans." Bony tumours are of fairly frequent • ''sub-uii^iSfexostos^.* occurrence in all vertebrata. Paul Ger- vais* has published descriptions of many interestmg specimens from fish. Perhaps the most striking example is furnished by the skeleton of the fish Ghcetodon, in which some of the bones are furnished with rounded bony tumours. The museum of the Eoyal CoUege of Surgeons con- tains many loose bones with tumours, as well as the skeleton of the original fish sent by WilHam Bellf to John Hunter. (Pig. 18.) Single bones of Ghcetodon are not uncommon in osteological collections ; Cuvier explained ttis by stating that they are brought home by travellers who have eaten this fish. On section it will be found that the outline of the ray can be clearly defined running through the midst of the tumour. For fuller details relating to Ghmtodon, consult the subjoined reference. J Treatment. — When osseous tumours grow in situations * Journal de Zoologie, 1875, vol. iv. t Phil. Trans., 1793. J Trans. Path. Soc, vol. xxxix. 472. OSTEOMATA. 29 where they do not inYolve important structures, the rule is not to interfere with them. When they press upon nerves and occupy accessible situations, and especially when pedunculated, they may be removed with chisel and mallet, or with stout forceps. 30 CONNECTIVE TISSUE TUMOURS. Cratiial osteomata are as a rule formidable objects; when growing from the roof of an orbit, or frontal bone, they not infrequently extend as deeply into the cranial cavity as they project beyond it* Osteomata obstructing the external auditory meatus, and producing deafness, have been on many occasions successfully perforated by means of steel drills. Osseous tumours, especially when sessUe and of the ivorj'- variety, sometimes require the most persevering efforts of the surgeon, aided by the best surgical cutlery. When exostoses are seated near joints and the synovial membrane is likely to be opened in the operation, they should not be removed unless they produce grave interference. It should always be remembered that in removing osteomata and exos- toses, the cancellous tissue of the bone from which they grow is opened. Sub-ungual exostoses are best treated by removing the nail, then exposing the base of the bony projection and detaching it from the phalanx with cutting forceps. * Spencer Watson reported ii case on which Fergussou operated which illus- trates this fact. Trans. Path. Soc, vol. zix. 310. 31 CHAPTER IV. ODONTOMATA (TOOTH TUMOURS). An Odontome is a tumour composed of dental tissues in varying proportions and different degrees of development., arising from teetli-germs, or teeth still La the process of growth. The species of this genus are determined according to the part of the tooth-germ concerned in their formation. 1. Epithelial odontome : from the enamel-organ. 2. Follicular odontome From the tooth- foUicle. 3. Fibrous odontome 4. Cementome 5. Compound follicular odontome. 6. Radicular odontome : from the papilla. 7. Composite odontome : from the whole germ. 1. Epithelial Odontomes. — These tumours occur, as a rule, in the mandible, but they have been observed in the maxilla Fig. 19.— Epithelial odontome. (Nat. siie.) They have a fairly firm capsule, and in section display a cono-eries of cysts of various shapes and sizes ; but the loculi rarely exceed 2 cm. in diameter. The cysts are separated by thin fibrous septa, sometimes ossified. The cavities contain mucoid fluid of a brownish colour. The growing portions of the tumour have a reddish tint not unlike a myeloid sarcoma (Fig. 19). Histologically, an epithelial odontome consists of branching and anastomosing cohimns of epithelium, portions of which 32 CONNECTIVE TISSUE TUMOUBS. form alveoli. (Fig. 20.) The cells, occupying the alveoU vary ; the outer layer may be columnar, whilst the central cells degenerate and give rise to tissue resembhng the stratum intermedium of an enamel-organ. Odontomes of this species are most frequent about the twentieth year, but they may occur at any age. The tumours have been investigated by Eve (who gave them the name of multilocular cystic epithelial tumour) and by Falkson and Bryck. They probably arise from persistent portions of the epithelium of enamel-organs. 2. Follicular Odontomes. — This species comprises those Pig. 20. — Microscopical characters of an epithelial odontomo, swellings often called dentigerous cysts, a term which has come to be used very loosely. Follicular odontomes arise commonly in connection with teeth of the permanent set, and especially with the molars. Sometimes these tumours attain large dimensions, and produce great deformity. The tumour consists of a wall of a varying thickness, which represents an expanded tooth-foUicle ; in some cases it is thia and crepitant, in others it may be 1 cm. thick. The cavity of the cyst usually contains viscid fluid and the crown or the root of an imperfectly developed tooth ; occasionally the tooth is loose in the follicle, sometimes inverted, and often its root is truncated (Fig. 21) ; exceptionally the tooth is absent. The walls of the cyst always contain calcific or osseous matter ; the amount varies considerably. Follicular odontomes rarely suppurate. These tumours are not unknown iu other mammals : I ODONTOMATA. 33 have seen them in lambs, pigs, and porcupines. C. Tomes has suggested that these cysts are probably due to the excessive formation around a retained tooth, between it and the wall of the fol- licle, cif a fluid which is normally present after the complete develop- ment of a tooth. 3. Fibrous Odontomes. — In a developing tooth, a portion of the connective tissue in which it is em- bedded, is found to be denser and more vascular than the rest ; it also presents a fibrillar arrange- ment. This condensed tissue is known as the tooth-sac, and when fully developed presents an outer firm wall and an inner looser layer of tissue. At the root of the tooth the follicle-wall blends with the dentine papilla, and is indistinguishable from it Before the tooth cuts the gum it is completely enclosed within this capsule. Under certain Fig. 21. — Follicular odortoirie (denti- gerous cyst). Tlie tooth lias a trun- cated root. (Nat. size.) Fig. 22. — Fibrous odontonie from a goat. (Nat, size.) conditions this capsule becomes greatly increased in thick- ness, and so thoroughly encysts the tooth that it is never erupted (Fig. 22). Such thickened capsules are mistaken for fibrous tumours, especially if the tooth be small and ill- developed. Under the microscope they present a laminated appearance, with strata of calcareous matter. To these, the term fibrous odontomes may be applied. They are more common in ruminants than in other mammals, and are especially frequent 34 CONNECTIVE TISSUE TUMOUBS. in goats. As a rule they are multiple, four being by no means an unusual number. They occur in marsupials, bears, and lions, as well as in the human subject. There is good reason for the belief that rickets is respon- sible for some of these thickened capsules. That the tooth- sac should thicken in rickety children need not surprise us when we remember that this remarkable disease kffects most particularly those membranes engaged in the production of bone. Such thickenings of the follicles occur in rickety children, as the following description of a specimen, preserved in the museum of the Royal College of Surgeons, testifies. It runs thus in the catalogue : " Sections of two myeloid tumours developed symmetrically in the angles of the lower jaw. Their surfiaces are covered by the external layer of compact tissue of the bone which they have expanded and thinned." These tumours were removed by Mr. Heath from a boy seven and a half years old, with rickety legs, but he was well nourished when the tumours were removed ; they were Fig. 23.— Cementome from a horse. (HcU/ not. sise.) observed when he was two and a half years old. After a care- ful examination of these tumours I have no hesitation in declaring them to be thickened tooth -follicles fibrous odontomes. 4 Oementomes.— When the capsule of a tooth becomes enlarged, as in the specimens just considered, and these ODONTOMATA. 35 thick capsules ossify, the tooth will become embedded in a mass of cementum. To this form of odontome the name cementoma may be applied. Odontomes of this character occur most frequently in horses, and sometimes attain a large size. Broca* has described and figured specimens from horses, Mr. Charles Tomes f has described one which weighed ten Fig. 24.— Compound follicular odontome from a Thar (Caprajemlaica). n, Sarerior maxillary division of the fifth nerve, {kat. size.) ounces, and I have given an account of another which weighed twenty-five ounces. The main portion of this odon- tome is sketched in Fig. 23. When divided, three teeth could be made out, embedded in cementum. The periphery of the tumour was cautiously decalcified in hydrochloric acid, and sections were prepared for the microscope. The structure of the decalcified mass was very instructive, for the periphery of the tumour exhibited the laminated disposition seen in fibrous odontomes. The largest cementome from a horse known to me is pre- served in the museum of the Koyal Veterinary (^^ollege, London ; it weighs seventy ounces, and though excessively dense, is nevertheless very vascular. Its chief structural * "Traite des Tumeurs," t. ii., p. 350, 1869. t Trans. Odont. Soo. Great Britain, 1872, p. 103. 36 CONNECTIVE TISSUE TUMOURS. peculiarity is the presence, in enormous numbers, of large, richly branched lacunse.* 5. Compound Follicular Odontomes. — If the thickened capsule ossifies sporadically instead of en masse a curious con- dition is brought about, for the tumour will then contain a number of small teeth or denticles consisting of cementum, or dentine, or even ill-shaped teeth composed of three dental elements, cementum, dentine, and enamel. The number of teeth and denticles in such tumours varies greatly, and may reach a total of three or four hundred. The odontome sketched in Fig. 24 was of this nature. I obtained it from a Thar or Himalayan goat, which had one in each upper jaw. The interior of each tumour was occupied with teeth, denticles, and fragments of cementum of varying size, numbering in all three hundred. This odontome is preserved in the museum of the Royal (/ollege of Surgeons. The shape and size of the Fig. 25.— Denticles from the odontome of a Thar. (Nat. swe.) deiiticles may be inferred from those sketched in Fig. 25. These fragments were firmly embedded in the fibrous walls of the tumour, whilst those which were free in the sac had become loosened by suppuration. Tumours of this character have been described in the human subject by several observers. Amongst the most note; worthy are the following : — Tellander, of Stockholm, met with a case in a woman aged twenty-seven years. The right upper first molar, bicuspids, and canine of the permanent set had not erupted, but the spot where these teeth should have been was occupied by a hard, painless enlargement, which the patient, had noticed since the age of twelve years. Subsequently this swelling was found to * Trans. Odont. Soc. Great Britain, 1891, p. 215. ODONTOMATA. 37 contain minute teeth. There were nine single teeth, each one perfect in itself, having a conical root with a conical crown tipped with enamel ; also six masses built up of adherent single teeth. The denticles presented the usual characters of super- numerary teeth. About a year afterwards a tooth was found making its appearance in the spot from which the host of Fig. 26. — A, .Denticles from Tellaiider's case. Total number, twenty-eight, ij, ,, from Sims's case. Total number, forty. 0, ,, from Matlnas's case. Total number, fifteen. teeth was removed. A few of the teeth are represented in Fig. 26. A similar case has been recorded by Sir John Tomes, the details of which were communicated to him by Mr. Mathias,* whilst on medical service in India. A Hindoo, aged twenty, had a large number of ill-formed teeth united. Further search was instituted, until at last fifteen masses of supernumerary teeth and bone were removed. The soft parts rapidly healed the deformity disappeared, and the only peculiarity noticeable was the absence of the central and lateral incisors. The canines * Trans. Odont. Soo. Great Britain, vol. iii. , p. 365. 38 CONNECTIVE TISSUE TUMOURS. occupied their usual position. A few of the fragments are ' shown in Fig. 26, c. A third example of this remarkable condition has been re- corded by Professor Windle and Mr. Humphreys.* The case occurred in the practice of Mr. Sims at the Dental Hospital, Birmingham. The tumour was found in the mouth of a boy aged ten years; neither the deciduous nor permanent right lateral incisor or canine had erupted. The space thus unoccu- pied was filled by a tumour with dense unyielding walls. On Fig. 27.— Eadieular odontome from human snb.ject. a represents the natural size of the specimen. (After Salter.) opening this tumour forty small denticles of curious and , irregular forms were removed (Fig. 26, b). Albert t and HildebrandJ have observed similar cases, and Logan § reported an example from the maxilla of a horse containing four hundred denticles. 6. Radicular Odontomes.— This term is applied to odon- * Journal of Anat. and Physiology, vol. xxi. 1887. t Illustrated' Med. Journal, Aug. 10, 1889. X "Zeitsch. fiir Chir.," M. xxxi. 282. § Jaumalof Camp. Med. and Surgery, New York, 1887. OBONTOMATA. 39 tomes which arise after the crown of the tooth has been com- pleted, and while the roots are in the process of formation. As the crown of the tooth, when once formed, is unalterable, it naturally follows that should the root develop an odontome enamel cannot enter into its composition ; the tumour would consist of dentine and eementum in varying proportions, these two tissues being the result of the activity of the papilla. As a typical radicular odontome, we may choose the well- known specimen described by Salter, and represented in Fig. 27. In this specimen the tumour is clearly connected with , the roots. The outer layer of the odontome is composed of eementum ; within this is a layer of dentine, deficient in the lower part of the tumour, and inside this is a nucleus of calcified pulp. Mr. Hare, of Limerick, removed from the upper jaw of a man aged forty-one the odontome sketched in Fig. 28. This specimen was originally de- scribed by Sir John Tomes,* but it was examined and re- described by Mr. Charles Tomos-t The mass is in- vested by eementum ; inside this casing is a shell of den- tine ; the tubules radiate out- wards and are disposed with some regularity : this dentine was deficient at the distal end of the tumour ; its interior was filled with an ill-defined osseous material Eadicular odontomes are rare in man, but frequent in other mammals, and are often multiple. Rodents are especi- ally liable to them, due in a large measure to the fact that their teeth grow from persis- tent pulps. A young marmot had four odontomes, one attached to each incisor in the upper and lower jaw. One of them is sketched in situ (Fig. 29) * Trans. Odont. Soc. Great Britain, 1^63. f Trans. Odont. Soc. Great Britain, 1872. Fig. 28. — Badicnlar odontome. {Nat. size.) (After John Tomes.) Fig. '29.— Left lower jaw of a young marmot with a large radicular odontome connected with the incisor. (iVa«. size.) 40 CONNECTIVE- TISSUE TUMOURS. and of natural size. It consisted mainly pf cementum. A similar tumour from a Canadian porcupine is shown in Fig. 30. It consisted mainly of dentine. The tumour was lodged in a Fig. 30.— Lower jaw of an adult Canadian porcupine. A radicular odohtome is attached to its lower incisor. {Nat. size.) large pus-containing cavity, and the surrounding hone was bare and dead. I have recorded a similar specimen in an agouti. In all these cases death was probably due to the profuse suppuration set up by the odontomes, the pus, being drawn into the air-passages, setting up septic pneumonia. Kadicular odontomes have been obtained from elephants, arising in connection with the roots of the tusks ; indeed, the largest odontomes on record were obtained from elephants. The museum of the Eoyal College of Surgeons contains several excellent specimens. Structurally they consist almost entirely of osteo-dentine. A radicular odontome described by Windle Fig. 31.— Two drawings of a radicular cementome, from a man aged twenty-five years. (Nat. size.) and Humphreys is represented in Fig. 31. It was obtained from a man twenty-five years of age. This odontome was situated in the lower jaw, on the right side, in the neighbourhood of the second molar tooth. After more than four months' excruciating pain, accompanied with profuse suppuration, life being several times despaired of, the odontome, seven months after its presence was first noticed. OBONTOMATA. 41 became liberated and fell into tbe mouth. The crown is fairly well formed, the labial surface being perfect, the lingual some- what tuberculated. The roots are fused into a shapeless mass. The under surface is irregular, and at one point presents an ^ixcavation. It is much to be regretted that it was impossible to obtain sections of this interesting tumour. 7. Composite Odontomes. — This is a convenient term to apply to those hard tooth tumours which bear little or no resemblance in shape to teeth, but occur in the jaws, and consist of a disordered conglomeration of enamel, dentine, and cementum. Such odontomes may be considered as arising from an abnormal growth of all the elements of a too t^ -germ — enamel-organ, papilla, and follicle. Not only is this class of odontomes composite in that the tumours comprised in it originate from all the elements of a tooth-germ, but they are composite in another sense. In the majority of cases the tumours are composed of two or more tooth-germs indiscriminately fused. But they differ from the cementomata containing two or more teeth, in the fact that the various parts of the teeth composing the mass are in- distinguishably mixed, whereas the individual teeth implicated in a cementoma can be clearly defined. Up to the present time I have found no such odontomes in the lower mammals, all the recorded cases having occurred in man. A typical odontome of this group is the one described by Mr. Heath* as occurring in the lower jaw of a young lady, Fig. 82.— Coiniiosite odontome from a young lady aged eighteen. (Nat. size.) {After Heath,.) aged eighteen. The clinical history in this case is very in- structive, and the reader is referred to the original account of it (Fig. 32.) • Clinical Sooietj-'s Transiictions, vol. xv. 10. 42 OONSEGTIVE TISSUE TUMOUBS. The specimen is further valuable on account of the exhaustive and careful histological examination made by Mr. Charles Tomes, who found it composed of enamel, dentine, and osteo-dentine. Forget's classical case belongs to this species. The patient was twenty years old, but the disease had been noticed since the age of five years. Behind the first bicuspid no teeth were seen, but the jaw as far back as the ramus was the seat of a smooth, unyielding tumour. The parts represented in the figure were removed during life. (Fig. 33.) On micro- scopical examination the tumour consisted mainly of dentine, the surface of which was in places covered with enamel Fig. 33.— Composite odontome. (Nat. size.) (After Forget.) dipping into the crevices, at the bottom of which cementum was found. The Transactions of the Pathological Society, London, though a mine of wealth in most kinds of tumours, contain only one description of an odontome ; it is described by. Mr. Kushton Parker.* The specimen originated in connection with the second left lower molar of a lady aged nineteen years. An effort was made to extract the tooth, but it broke, leaving the tumour behind. Subsequently an attempt made to extract the mass failed, a few fragments only being detached ; about two years later it issued spontaneously from * Trans. Path. Soc, vol. xxxii. 240. ODONTOMATA. 43 the alveolus. The odontome, which weighs 136 grams, is represented in Fig. 34, taken from a drawing kindly furnished me by Mr. Rushton Parker. In the same category may be placed the odontome dislodged by Professor Annandale* from the lower jaw of a girl aged seventeen. It weighed 300 grains, and consisted of dentine and osteo- dentine capped by enamel. Nine months before the patient was seen by Mr. Annandale, an abscess formed over the top of the swelling, from which the odontome was ultimately dis- lodged ; the abscess left a chronic sinus from which small quantities of pus issued up to the time of the operation. No molar teeth were erupted in the right lower jaw, their position being occupied by the odontome. The cavity left by the Fig. 34. — Odontome. {Nat. size.) (Mr. Rushton Parker's case.) rig. SS.^^Odontome from the upper jaw. ^Nat. size.) (Af. Michon's case.) dislodgment of the tumour was Hned with a smooth, velvety membrane. It is supposed that odontomes are more frequent in the lower than the upper jaw, but there is good ground for the *Edin. Med. and Surg. Journal, 1873, p. 599. ii CONNECTIVD TISSUE TUMOUBS. belief that many such tumours have been described as exostoses of the antrum. Thus M. Michon removed from the antrum of a Frenchman, aged nineteen years, ht the H6pital de la Piti6 (without an ans^thetic), the large odontome repre- sented in Fig. 35. The operation, which may be described as a " surgical struggle," lasted upwards of an hour 'and a quarter. The tumour is described as an exostosis, but fortunately M. Michon's account is accompanied by some excellent figures which show clearly enough that the tumour is an odontome. The cut surface exhibited a lamiuated disposition. Microscopically it was composed of tissue presenting many parallel tubules having the appearance of exaggerated dentinal tubes. It is the largest odontome but one from man of which we have any record ; its weight is 1,080 grains.* A tumour almost parallel with that of M. MicKon has been described by Dr. T. Duka,| by whom it was removed from a Mahomedan woman, aged twenty-six years, at Monghyr, Fig. 3C.—Comi)osite odontome from __ _. ■, W. sfee.) (Dr. Dvha's case.) Bengal. The woman had for six years, suffered from a muco- purulent discharge from the right nostril, and was now anxious for relief The case was regarded as one of necrosis, but after a " surgical struggle " lasting nearly an hour without * Mem. de la Societe de la Chir., Paris, 1850. f Trans. Path. Soc, vol. xvii. 256. ODONTOMATA. 45 chloroform, the tumour represented in Fig. 36 was withdrawn from^ the antrum. It had no connection with the surround- ing tissues. ^ The tumour, which was regarded as an exostosis, was sub- mitted to a committee of the Pathological Society. In its report this committee states that the bone tissue differs in character from that ordinarily seen in exostoses. An examina- tion of the tumour, which is preserved in St. George's Hospital museum, and an inspection of the figures illustrating the above-mentioned report, show clea,rly enough that it is a com- posite odontome. Dr. Duka, in his account of the case, states that Dr. AUen Webb was of opinion that the nucleus was formed by a tooth-follicle escaping into the antrum of Highmore. This was a guess, but one not far short of the • truth. The largest odontome known to have grown in the human antrum, and which for many years has been regarded as an exostosis, is preserved in the museum of Guy's Hospital. It has an extraordinary clinical history which was recorded bv Hilton.* (Fig. 37.) The patient, a man aged thirty-six years, had a large osseous tumour occupying the antrum. The pressure of this tumour had caused the front wall of the antrum, with the in- tegument and soft tissues covering it, to slough. The trouble was first noticed thirteen years before ; as the cheek enlarged the eyeball became displaced and finally burst. For a long time the surface of the tvimour was exposed, the suppuration being copious, and occasionally pieces of bone irregular in shape came away ; at last, to the man's astonishment, the bony mass dropped out, leaving an enormous hole in his face. The general appearance of this tumour may be inferred from the accompanying sketch. It weighed nearly fifteen ounces, and measured 27'5 cm. (11") in its greatest circumference. I have had an opportunity of investigating this tumour ; it is remark- ably hard, presents on section an ivory-like surface and, on close scrutiny, a number of closely-arranged concentric laminae. (Fig. 38.) Sections ground thin anc' examined under the microscope show large numbers of lacunae and canaliculi arranged in a' very regular manner. ' I could not detect * Guy's Hospital Reports, vol. i., p. 493, 1836. 46 CONNECTIVE TISSUE. TUMOURS. dentine, and it is impossible, without niutilating the specimen, to be sure that no teeth are embedded in it. As this tumour had no bony connections, occupied the Fig. 37. — Large odontorne which was spontaneously slied from the antnim; weight, nearly fifteen ounces. Hilton*s case. (From the Miiseum of Guy's Hospital.) antrum, and in the structure of its peripheral parts is so closely identical with odontomes which occur in horses, there need be no hesitation in believing that this particular tumour Fig. 3S.— Section of the turaouv represented in Fig. 87 to show the concentric lamination. ODONTOMATA. , 47 originated in one or more enlarged tooth-follicles, and is in fact an odontome. Mr. Jordan Lloyd* has published an excellent account of an odontome of this class which he removed from the right upper jaw of a young man. As so often happens, the case was regarded as one of necrosis, but when removed from its bed was recognised as an odontome. The tumour (Fig. 39) weighed Fig. -Composite odontome from the upper jaw. (Nat. size..) The left-hand figure shows the tumour in section. (Mr. Jordan Lloyd's case.) 279 graiiis ; it is composed of osteo-dentine, with cementum here and there. Opaline, pearly patches are studded irregu- larly around the edge of the cut surface. The mass occupied the space of the second, and probably the third, right upper molars ; it could be felt to be slightly loose before attempts were made to remove it. After its extraction a deep, round, smooth, velvet-like cavity remained, and the exposed part, with its crater-like hollow and surrounding ridge, bore a certain resemblance to a molar tooth crown. The odontome represented in Fig. 40 was removed by Mr. S. Brock from a lad aged nine- teen years ; it was situated in front of the right upper bicuspid, displacing the lateral incisor and canine so as to occupy their position in the dental arch. As will be seen in the figure, it appears to consist merely of a crown and neck, but the crown bristles with cusps ; as many as nine distinct enamel-covered eminences can be detected. Odontomes resemble teeth in this way — for a time during their development they remain hidden below the mucous membrane, and give little or no evidence of their existence. To this succeeds an eruptive stage, and the * lancet, 1888, vol. i., p. 64. Fig. 40.— Odontome Jrom the upper jaw. (It is slight- ly enlarged in the sketch.) 48 CONNECTIVE TISSUE TUMOURS. suppuration, with the constitutional disturbance dependeilt thereon, draws attention to them. This remarkable odontome had not only cut the gum but had taken a position in the dental series, and is further interesting in that it consists, of a conglomeration of denticles, for 1 have urged that those remarkable cases in which denticles have from time to time been erupted from a tumour connected with the jaw should be classed as odontomes. It is easy to imagine that if the cusps of this odontome remained distinct, and each had been sepa- rately erupted, they would have been called supernumerary teeth. Indeed, many of the cusps can be easily detached from the main mass. Thus this strange specimen serves to bridge the gap between compound follicular and composite odontomes. Treatment. — A study of the literature relating to odon- tomes is very instructive, for it serves to show that patients have in many instances been submitted to operations need- lessly severe and dangerous. It is a curious fact that up to ' this date there is no instance on record in which an odontome, other than a follicular cyst, has been diagnosed be- fore operation. In some cases the trouble has been regarded as due to necrosed bone, or unerupted teeth ; in a few the tumours were regarded as exostoses, whilst several fibrous odontomes have been described as myeloid sarcomata. In the case of a tumour of the jaw, the nature of which is doubtful, particularly in a young adult, it is incumbent on the surgeon to satisfy himself before proceeding to excise a portion of the mandible or maxilla that the tumour is not an odontome, for this kind of tumour only requires enucleation. In the case of a follicular odontome it is usually sufficient to ekcise a por- tion of its wall, scrape out the cavity, remove the tooth if one be present, stuff the sac, and allow it to close by the process of granulation. 49 CHAPTER V. FIBROMATA, Fibromata, or tumours bomposed of fibrous tissue, were formerly supposed to be very common, but careful histological research has shown that tumours consisting almost entirely of fibrous tissue are somewhat rare. For instance, it was the fashion to describe as fibromata those tumours of the uterus now known as myomata and fibro-myomata ; traces of this belief linger still, for some yet write of them as " uterine fibroids." Many tumours now recognised as spindle-celled sarcomata were, a few years ago, named " recurring fibroid tumours." The difficulty of distinguishing between a myoma, a slowly growing spindle-celled sarcoma, and a pure fibroma is well known to skilled histologists ; when a tumour com- posed of slender fusiform cells occurs in such an organ as the ovary, where myomata, fibromata, and sarcomata also occur, the distinction on histological grounds alone is often impossible. In slow-growing fibromata there is not much difficulty, but in softer forms it often becomes a matter of importance to de- cide between a fibroma and a spindle-celled sarcoma. It is a matter of less moment to decide between a myoma and a fibroma, as both are innocent tumours, and it is probable that some uterine tumours begin as myomata and degenerate into fibrous tissue. Typical fibromata are generally dense tumours consisting of wavy bundles of fibrous tissue. The bundles are composed of long, slender, fusiform cells closely packed together. The tissue of the tumours; often arranged in whorls, is permeated by bloodvessels. Fibromata occur in the following situations : — The ovary, uterus, intestine, the gum (epulis), as laryngeal polypi, on the sheath of nerves (neuromata) and in the subcutaneous tissues as " painful subcutaneous tubercles " ; and in the condition termed moUuscum fibrosum. There is a spurious form of tumour known as keloid which, E 50 r . GONNKGTIVE TISSUE TUMOURS. stands in the same relation to a fibroma that an exostosis bears to an osteoma. T'he chief species of fibromata are : — 1, Simple fibromata ; 2, molluscum fibrosum ; 3, neuro-fibromata. In this section simple fibromata, epulis, and moUnscnm fibrosum will be considered. Neuro-fibromata will be described with neuromata. 1. Simple Fibromata'. — A most interesting and certainly a very frequent variety of fibroma is the small nodules so often met with in the subcutaneous tissues of the trunk, and especially the limbs, described and named by Wood* the Painful Subcutaneous Tubercle in the foUowmg words : — " This disease consists in the formation of a tubercle of peculiar nature in the subcutaneous cellular substance. This tubercle is met with in different parts of the body, but most frequently in the extremities. It is extremely small, generally of the size and form of a flattened garden pea, iand ul none of the cases of which I have been able to procure a distinct account, larger than a coffee-bean. It is of firm consistence, and is apparently quite circumscribed, being situated loosely in the cellular substance, immediately under the iategtiments,- : which retain their natural colour and appearance. In the greater proportion of cases there is no visible appearance of disease whatever, and it is only when the surgeon applies his finger to aparticular spot pointed out by the- patient that he becomes sensible of the existence of the tubercle. In some few cases, however, although small, it is so superficially seated as to form a visible prominence. "As in all the cases with which I am acquainted, the tubercle had attained nearly its full growth before its presence was detected. I am unable to say whether it is originally of slow or rapid formation ; but having acquired a certain size, it remains nearly stationary, undergoing hardly any perceptible increase of bulk, even in the course of a great many years ; nor does it ever show any tendency to affect either the skin or surrounding cellular substance. " Trifling as the diseased part is, in point of size and appear- ance, it becomes the cause of very severe and even excruciating * Edin. Med. and Surg. Journal, 1812, p. 283. FIBROMATA: 51 pain. So strongly is this pain represented by the patients that we might be apt to imagine their statement exaggerated, did we not find them all concurring in the same repre- sentation. " The pain is extremely acute in the tubercle, and extends from it to a considerable distance along the neighbouring parts ; it is not constant, but occurs in paroxysms. In general, at the commencement of the paroxysm, the pain is slight, but gradually increases until it becomes excruciatingly severe, and it goes oti' in the same gradual manner, leaving the parts in the neighbourhood of the tubercle, for some time after- wards, sore to the touch, as if they had been bruised. The paroxysms vary in duration from ten minutes to upwards of two hours ; but they seem to increase, both in frequency and severity, in proportion to the length of time the disease has existed. " Some of the patients have occasional intervals of ease for days or even weeks ; in others the paroxysms occur several times in the course of one day. They generally come on spon- taneously, but in some of the cases they were sometimes in- duced by the friction of the clothes along the surface of the tubercle. They frequently attack the patient when asleep, in which case he is suddenly awoke by the severity of the pain. " The degree of pain produced by touching the tubercle is different in different cases. Acute pain is produced at all times by the tubercle being accidentally struck against any hard substance. " It is a singular circumstance that in all the cases which have -come to my knowledge, with perhaps one exception, this species of tubercle occurred in females. It does not appear to be confined to any particular age, but is frequently met with at an early period of life, and I have known it to remain nearly unchanged for upwards of eighteen years." Although these small painful tumours have been abun- dantly studied since Wood wrote his description of them, no advance has been made in our knowledge of them. It has been fully demonstrated that they are found four or five times more frequently in females than in males. From the extreme ,pain produced by these tubercles many have imagined that they must contain nerve-fibrils ; but even with the elaborate 52 CONNECTIVE TISSUE TUMOUBS. methods of modem histology no one has succeeded in deinon- strating their existence. The removal of these Httle bodies at once arrests the paroxysms of pain. Ovarian J?'i6romato.— Tumours, sometimes of large size, composed of fibrous tissue have, in a few rare instances, been demonstrated 'n the ovary. They may be regarded as patho- logical ctiriosities. Uterine Fibromata. — Fibrous tissue often forms a very large proportion of many uterine myoraata, and it has already been mentioned that some uterine tumours, apparently con- sisting of pure fibrous tissue, were probably in their early stages myomata or fibro-myomata. Intestinal Fibromata.— From what is known, in the light of modern histology, of the nature of tumours springing from the walls of the intestine, it seems a fair inference that many specimens reported in older hterature as " fibrous tumours " were in reality myomata. Laryngeal Fibromata. — Small polypoid outgrowths have in a few instances been removed from the mucous membrane of the larynx ; on, microscopical examination they were found to consist of pure fibrous tissue. Epulis. — This is a term which formerly had a wide signi- ficance. It was applied to almost any tumour growing upon the gums ; but when the microscope was employed to assist in the classification of tumours it was found that sorne epulides were sarcomatous, others fibrous, a few myxomatous, and so on. As a consequence the term came to have merely a topographical significance. It will be wise to restrict the term to tumours composed of fibrous tissue arising from the gums, or from the periodontal membrane. These tumours either arise in connection with the root of a decayed tooth, or from the retained root of a carious tooth hidden by the gums. An epulis of this character is made up of fibrous tissue covered externally with the gingival mucous membrane ; it may be pedunculated or sessile, and occasionally two may be present.' When freely excised and the stump, or carious tooth, with which the epulis is invariably associated removed, it rarely ever returns. Althougji an epuhs is seldom larger than a walnut, it may attain a size equal to the closed fist. Such a tumour will exercise great pressure upon the dental arches, FIBROMATA. 03 distort the cheek, alter the shape of the maxilla and mandible, encroach upon the palate, and even protrude between the lips.' 2. MoUuscum Fibrosum.— This extraordinary condition of the skin and subcutaneous tissue has been described under such names as Fibro-cellular Tumour, Dermatolysis, and Paehy- Fig. 41. — Case of iiioUuscum fibrosum. (After MotL) dermatocele. The chief features of the disease consist of an overgrowth of the skin and subcutaneous tissue, which will aifect a small area like the scalp, or may involve a large extent of skin on the trunk and limbs, causing it to hang in pendulous folds. Sometimes moUuscum fibrosum assumes the form of discrete nodules scattered over the skin ; these nodules vary in size, the extremes being represented by a pea and a walnut. 54 CONNECTIVE TISSUE TUMOURS. This variety of the disease is sometimes associated with similar nodules (neuromata)' scattered upon the sheath of nerves in various parts of the body. (Plate III.) Exceptionally the pendulous and nodular lesions occur in the same individual. The histology of the nodules and the pendulous flaps is similar ; the condition appears to be due to an overgrowth of the fibrous tissue of the skin and subcutaneous tissue. Con- cerning the cause of this overgrowth nothing is known ; the disease is not confined to any clime or race, for it has been observed in North America, the British Isles, Germany, and in natives of the West Coast of Africa. The most remarkable series of cases of this nature is re- corded by Valentine Mott* under the name of Pachydermato- cele. One ease will serve as a type. The patient,' a single lady forty-five years of age, when she pame under Mott's care had a large tumour of a copper colour, soft and elastic to the touch, and forming five folds or convolutions, as represented in Fig. 41. This mass was attached to the skin 'directly under the lobule of the ear, to the side of the neck, the thorax, and abdomen as low as the umbilicus ; it extended down the arm to the insertion of the deltoid. The mother of the patient stated that the tumour had been' noticed soon after birth. The woman was anxious to have the mass removed. During the operation many arteries required ligatures, and some were of considerable size ; two very large veins were seen, which Mott describes as the largest superficial veins he had ever seen; they terminated in the subclavian. The patient recovered, notwithstanding two attacks of ery- sipelas during convalescence. Five years later the patient was in perfect health, and there had been no recurrence of the tumour. Unfortunately no careful account of the his- tology of the tumour is forthcoming beyond the statement that " the specimen appears to consist of a hypertrophy of the skin and of the subcutaneous cellular tissue." Lampreyt recorded a case of dermatolysis which he observed in a negro in a street of Sierra Leone. He was successful in obtaining a photograph. (Fig. 42.) ' A large mass of skin hangs in folds from the back and left 'side * Medico- Chi r. Trans., vol. xxxvii., p. 155. t Jirit. Med. Journal, 1892, vol. i., p. 173. FIBROMATA. 55 of the head, and falls over the left shoulder and back. In addition to the scalp tumour there are numerous nodules on the skin of the trunk, legs, arms, and face, varying in size from a peppercorn to a bLUiard-ball, some of which had Fig. 42.- -Native of Sierra Leone, aged fifty, witli niollusciuii fibro.sum. (After Lamprey.) ulcerated. The man stated that he was born with lumps on his skin. As the case resembled, in some respects, elephantiasis, the blood was obtained at seven p.m. from one of the tumours, and carefully examiaed for filarise, but with negative results. For other cases of this disease the following references may 56 GONNEGTIVE TISSUE TUMOURS. be consulted.* Tho disease appears to be equally common in women and men. The frontispiece to Band I. of Virchow's "Die KrankJiaften Geschwiilste" represents a case of dermato- lysis associated with a multitude of cutaneous nodules in a woman forty-seven years old, under the title of " fibrosum moUuscum multiplex." Keloid. — This term is applied to formations of dense fibrous tissue which arise in cicatrices of the skin. A keloid rig. 43.— Keloid in the lobnle of Hie pinna, associated witli an ear-ring pnnctare. projects above the surface of the skin sometimes to the extent of a centimetre ; its surface is quite smooth, and may be white or shining, or pink from the number of dilated vessels coursing over it. Sometimes the tumour has a regular outline, but, as a rule, it sends out spuriike processes into the adjacent skin ; structurally it is identical with cicatricial tissue. Though originating in scars, keloid is not always Hmited by the scar in which it arises, but it rarely transgresses to any great extent , * Flower, Zmicet, 1860 ; Treves, Trans. Path. See., vol. x-xxvi. 494 • Wright Trans. Path. Soc, xvi. 269 ; PoUock, Trans. Path. Soc, xxvi. 219. FIBROMATA. 57 upon the healthy skin. When a keloid is excised; in the ma- jority of cases it returns as the wound heals, and very generally the scars of the stitch-holes become the seats of keloid also. The conditions which favour the production of keloid are unknown ; it occurs fairly frequently in the scars left by burns, .':•: ■'ii'ii S Fig. 41. — Unusual case of keloid in a coloured woman. {After Taylor. } but it will ensue on almost any kind of injury to the skin. It has been observed in the scars left by small-pox, by vaccination, primary and secondary ; in acne scars and the scars of leech- bites ; it has been frequently observed in cicatrices the result of surgical operations, and in the coarse stripes left by the severe use of the lash. It has been frequently observed in the lobule of the pinna in the puhctures made for ear-rings, in white and 5S CONNECTIVE TISSUE TUMOURS. especially in black races of mankind (Fig. 43), and it also occurs in the scars left by syphilitic lesions. Keloid has been observed before the tenth year of life, but this is uncommon ; it is most frequently met with in adults, and becomes very rare in old age. The tumour, when it makes its appearance, slowly pro- gresses up to a certain point, remains stationary for an indefi- nite period, in some cases lasting for ten, twenty, or even thirty years, then slowly disappearing. It is said that involution of keloid occurs quicker in the young than in those advanced in life. In describing keloid it is customary to distinguish a true or spontaneous keloid and a false keloid. The true variety was supposed to arise indepeildently of a scar, but clinical observation has shown that it often arises in scars left by such slight iojuries, that it is very reasonable to beheve that the sup- posed spontaneous keloid arose in scars whose existence had been forgotten. Taylor* has described a very extreme example of keloid ; which came under his observation in a coloured ' woman twenty-three years of age. (Fig. 44.) When ten years old this patient suffered many hardships, and was the drudge ot the family ; she was required to go into the woods for fuel, and, having no clothes above the waist, was frequently torn in linear stripes by the bushes and briars. In the scars resulting from these injuries the keloid masses shown in the figure de- veloped. The growth on the pinna formed around a hole made for an ear-ring. This tumour has been three times removed, and has re-formed after each operation. * New York Med. Journal, Jan. 7, iS93. 59 CHAPTER YI. MYXOMATA. A myxoma is a tumour composed of mucous tissue identical with, that which surrounds the vessels of the umbilical cord. This genus contains three species : — (1) Nasal and aural polypi ; (2) Cutaneous myxomata ; (3) Neuro-myxomata. Myxomatous tissue is often the result of degenerative changes in cartilage, muscle, sarcomatous and fibrous tissues. Some writers hold the opinion that giving a myxoma the rank even of a species is not justifiable. 1. Nasal Polypus. — This species is the purest form of myxoma ; it grows from the mucous membrane covering the turbinal bones, and occasionally from the mucous lining of the frontal sinuses, and rarely from the mucousmembrane of the antrum. Nasal polypi — for they usually occur in multiples — hang in the nasal fossse as soft gelatinous tumours of a greyish- yellow colour. Each polypus may consist of a single lobule attached to the mucous membrane of a turbinal bone by a narrow pedimcle. Not infrequently a polypus may be racemose, a number of lobules being attached by a common stalk. The number of polypi varies greatly ; exceptionally only one is present ; often six or more will be found. They may be confined to one nasal fossa ; more often both fossse contain polypi. When, they are very numerous and not inter- fered with, the nasal passages are expanded, and the polypi are visible at the anterior nares, or project through the pos- terior nares, and block up the naso-pharynx, forming pendulous masses behind the soft palate. Sometimes a polypus will extend solow as to reach the level of the aryteno-epiglottic folds. In the rare instances of myxomata occupying the frontal sinus, they cause a peculiar bulging at the inner angle of the orbit like that produced by distension of this sinus with fluid. A nasal myxoma has an external capsule of mucous 60 OONNEGTIVE TI88VE TUMOURS. membrane covered with epithelium, which may be of the colunmar (ciliated) or stratified variety. Sometimes two varieties wiE be detected on the same tumour. Stratified epithelium is common on the exposed parts of a polypus. The bulk of the tumour is composed of myxomatous tissue traversed by numerous blood-vessels. On microscopical examination it resembles very cedematous connective tissue ; the cells possess long slender processes which interlace with ■ those of adjacent cells. Nasal myxomata are rare before puberty, and, though most frequently met with in young adults, are by no means rare in individuals of middle age. Aural Polypus.— SmaU myxomata grow from the mucous membrane of the tympanum, and constitute one variety of aural polypus ; when large enough to block up the tympanic cavity or occlude the external auditory meatus, they produce deafness. At birth the tympanum is filled with delicate foetal connective tissue and the ear-bones are em- bedded in it. As pulmonary respiration becomes established this tissue slowly disappears, and air from the pharynx gradually gains access to the tympanum by way of the Eustachian tube. Jacobson* has suggested that aural -myxomata may in some instances arise from vestiges of this connective tissue.- 2. Cutaneous Myxomata. — These occur either as sessile or pedunculated tumours. They are by no means common. Some of the most typical cases that have come under my observation presented themselves as sessile tumours in the loin, but not extending beyond the deep fascia. When divided, the surface of a pure myxoma resembles a mass of transparent trembling jelly ; a viscid fluid, sometimes of a pale straw colour, drains from it. Pedunculated myxomata are most frequent in the neigh- bourhood of the perineum and labia. In young individuals they possess a regular, usually oval, outline. Later in hfe," as the fluid parts absorb, they assume the lobulated appearance shown in Fig. 45. Sessile myxomata are very prone to recur after removal ; in some instances it is very probable that they are sarcomata * Guy's Hospital Reports, 1882, vol. xli. p. 217. MYXOMATA. 61 whicli have undergone myxomatous degeneration. Such a tumour is sometimes called sarcoma inyxomatodes. The pedunculated variety approximates in structure very closely to the pendulous cutaneous folds characteristic of moUuscum iibrosum. 3. Neuro-Myxomata are described with neuromata in chap. xvi. Myxomatous Disease of the Chorion. — It is usual in works on tumours to describe this interesting condition (the hydatid Fig. 45.— Pedunculated myxoma from the labium of a woman fifty years old : it had existed many years. mole of midwifery) ; but as it does not in any strictness belong to tumours, it will not be considered further in this treatise. Treatment.— My'xomata, like tumours in general, should be removed whenever their position and relations to surround- ing structures permit. In the case of nasal polypi this plan of treatment is invariably adopted, and there are several methods of eifectmg their removal, such as snaring them with small wire snares, or detaching them with a galvano-cautery, 62 GONNEGTIVE TISSUE TUMOURS. ' or avulsion witli forceps. Wlien the polypi are confined to the lowest and middle turbinals they are easily and completely, torn away, but when they spring from the highest turbinal or occupy the ethmoid cells and frontal sinus, it is a difficult matter to eradicate them thoroughly. Pedunculated myxomata, of the kind represented in Fig. 45, are easily removed ; they never recur. 63 CHAPTER VII. GLIOMATA A glioma is a tumour composed of delicate connective tissue identical with the variety known as neuroglia. This geniis consists of a single species — glioma — which bears the same relation to the central nervous system that a plexiforni neuroma hears to the peripheral nerves. Gliomata occur only in the central nervous system. A tissue very similar to neuroglia forms the sustentacular frame- work of the retina. This is frequently the seat of sarcomata, which are often termed retinal gliomata. (See page "87.) ' ^Gliomata of the Brain. — In the brain a glioma occurs as a tumour imperfectly demarcated from the surrounding tissue. It may appear as a translucent swelling of the consistence of vitreous humour, or it majr be as iirm as the tissue of the pons. As a rule, a ghoma is of the same firmness as the cerebral cortex. StructuraUy, gliomata consist of cells, contaming one or more nuclei, furnished with delicate ramifying processes, mixed with fibrous tissue. The proportion of cells to the fibrous tissue varies greatly ; sometimes one set of ele- ments preponderates, sometimes the other. These tumours are often very vascular, the vessels being irregularly dilated and occasionally sacculated. The number of blood- vessels in some specimens is so great that the tumours are described as angeiomata or angeio-sarcomata. As a rule, gliomata are solitary, and they do not give rise to secondary deposits. In certain situations they rather resemble diffuse overgrowths than tumours. Virchow pointed out that when a glioma is situated near the surface of the cortex it will appear like a colossal convolution. Should it grow . in the tissue of an optic thalamus it would cause the thalamus to bulge into the third ventricle as though over- grown, and a glioma of the occipital lobe will project into the descending cornu like an additional thalamus. The best illustration of this indefiniteness so characteristic of a glioma 64 CONNECTIVE TISSUE TUMOJJJIS. comes out very strikingly when the pons is occupied by this form of tumour. Ghomata occasionally occur in the pons, and form tumours of considerable size. Sometimes they are confined to one side, and extend into the adjacent cerebellar crura. In a case de- scribed by Cayley * which occurred in a child two years of age, a glioma as large as a walnut occupied the right half of the pons and extended along the superior cerebellar peduncle of that side, reachuag as far forward as the corpora quadrigemina. The gliomatous mass formed a prominence on the correspond- ing half of the floor of the fourth ventricle, and obstructed the Sylvian aqueduct. In some cases both sides of the pons are involved, and the overgrowth of neuroglia extends forwards into the cerebral crura and the cerebellar peduncles, and involves the corpora quadrigemina. In a few it extends downwards into the medulla, and may even involve the cervical portion of the cord, as in a specimen described by Whipham.f Sometimes the gliomatous tissue is so abundant as to pro- duce an enlargement of the pons and cerebral peduncles, as represented in Fig. 46. The appearance of such brains is very peculiar ; the basilar artery and its branches appear as though sunk in deep furrows, which cause the parts to resemble " a soft package tightly corded" (Dickinson). Such cases are rare, and in nearly aU instances the patients have been under twelve years of age. Thus the case recorded by Percy KiddJ occurred in a girl six and a-half years old. Gee's§ patient was a boy of nine years. In two cases described by Angel Money, || one was a boy of eleven years, and the other a girl of six and a-half years. GoodhartH has described a specimen from a boy aged nine years; Schulz** has observed one in a man of thirty- two years. The relations of a glioma to the surrounding tissues are best seen in recent specimens. On examination soon after * Trans. Path. Soc, vol. xvi., p. 23. t Trans. Path. Soc, vol. xxxii., p. 8. J kSt. Earth. Hosp. Rep., vol. xiii., p. 272. § St. Barth. Hosp. Eep,, vol. xidi., p. 285. II Med.-Chir. Trans., vol. Ixvi., p. 283. 1 Trans. Path Soc, vol. xxxvii., p. 14. *' Neurologisches Centralblatt, 1883, s. 5. This paper contains several references. GLIOMATA. 65 death the diseased parts are abnormally large, and on section exhibit a characteristic pale blue colour; in thin sections the tissue has a delicate translucent ' appearance. The tumour itself is very soft, and imparts to the fingers a sensation hke fluctuation. When the parts are immersed in alcohol the tissue becomes firm, opaque, and white; under these conditions Fig. 46. —Bilateral gliouiatous enlargement of the pons anil crura cerebri. {Angel Money.) it is particularly difficult to determine the limits of the tumour. Gliomata of the Spinal Cord. — A glioma in the spinal cord is a very rare tumour, and, judging from the scanty records, it ■v^ould appear that a glioma in the brain is tv/enty times more frequent than in the cord. The tumour is imperfectly demar- cated from the nervous tissue, and often causes a general enlargement of the cord, producing an effect upon it like the gliomatous disease of the pons, crura, and medulla F 66 CONNECTIVE TISSUE TUMOURS. depicted in Fig. 46. Reisinger* collected and epitomised tho' records of nineteen cases of glioma of the spinal cord, and adds a full description of a case which he observed ; the report is accompanied by an account of the morbid anatomy of the parts by Prof Marchand. The disease may attack any part of the cord, but is most frequent in the cervical enlargement. In a few instances the tumour was seated in the lumbar region. It appears most fre- quently between the seventeenth and thirtieth years, but it has been observed as late as fifty. Sharkeyf has published an interesting account of a spinal glioma which occurred in a man fifty years old, and he uses it to demonstrate the clinical fact that when a tumour arises within - Grey matter, ^-j^q cord, as gliomata always do, -Tumour. it disturbs its functions from- - Grey matter, the Commencement ; but, as the nerve substance appears to Fig. 47.— Spinal cord, in transverse section, v„ plnotip nnd tn nllnw a orinrl froin a case of glioma. Tl)e expanded "'' BidbUO, dUU. tO aiiOW a gOOQ nerve tis.sue forms a rim, or capsule, Aaa] r\f rrrarllial atTPt/iViinfT iin'f>i around tlie tumour (After Sharkey.) ^^^dl OI graClUai StrCtCUmg^ Wltn- out serious interference with its functions, a tumour may continue to grow for a long time- before it produces striking pathological phenomena (Fig. 47). When a tumour grows in the spinal canal outside the cord it may produce but few symptoms until it presses the cord against the resisting walls of the canal ; after this has taken place the course of the disease is naturally very rapid, as the cord is quickly flattened by the constantly increasing demands for growing-space which are made by the tumour. The peculiar relation of the gliomatous tissue to the nerve ' tissue of the cord precludes any surgical interference. * Virchow's "Archiv," xcviii. 369. + Gulstonian Lectures, 1B86. 67 CHAPTER VIII. SARCOMATA. The histological characters of sarcomata are those of immature connective tissue, in which cells preponderate over the inter- cellular substance. Clinically, sarcomata are distinguished from the preceding genera of tumours in that they rarely pos- sess capsules, infiltrate the surrounding tissues and are prone to disseminate ; their infiltrating propensities render complete removal a matter of difficulty, hence sarcomata are liable to recur. Such characters constitute malignancy. Sarcomata are arranged in species according to the shape and disposition of the cells. 1. Round-celled' sarcoma. 2. Lympho-sarcoma. 3. Spiudle-celled sarcoma. 4. Myeloid sarcoma. 5. Alveolar sarcoma. 6. Melano-sarcoma. The round and spindle-celled species present varieties which will be particularised when each species is separately considered. , 1. Bound-celled Sarcomata. — This species is of very simple construction, and consists of round cells with very little inter- cellular substance. The cells contain a large round vesicular nucleus and a small proportion of protoplasm ; the nuclei are always conspicuous objects in stamed sections. Blood-vessels are abundant, often appearing as mere channels between the cells. Lymphatics are absent. Round-celled sarcomata grow very rapidly, infiltrate surrounding tissues, recur quickly after removal, and give rise to secondary deposits especially in the lungs. There is a variety, known as the large round-celled sarcoma, in which the cells are of unequal size ; some of them contain two or more nuclei; a few are multinuclear, and resemble myeloid cells. The round-celled sarcoma is the most generalised tumour 68 CONNECTIVE TISSUE TUMOURS. that affects the human body; it may occur in any tissue, bone, brain, muscle, spinal cord, ovary, or testis, and even in the delicate sustentacular framework of the retina. It attacks the body at all periods of life, from the fcetus in utero and the Fig. 4S.— Microscopical appearance of a lymplio-sarcoma from the mediastinum. child just born up to the extreme limits of age. Among vertebrate animals it is almost ubiquitous. 2. Lympho-Sarcomata consist of cells identical with those, of round-celled sarcomata, but the cells are contained in. Fig. 49.— Small spindle-celled sarcoma from a metacarpal bone. delicate meshes : the tissue resembles that of lymphatic glands (Fig. 48), hence the origin of the term lympho-sarcoma. These tumours must not be confounded with simple (irritative) enlargement of lymphatic glands, 'nor with the general over- growth of lymph-adenoid tissue associated with leuktemia or lymphadenoma (Hodgkin's disease). 3. Spindle-celled Sarcomata.— The cells of the species SAliOOMATA. 69 classed under this head vary considerably in size, but they agree in the circumstance that they are oat-shaped (Fig. 49) or fusiform. The cells have a tendency to run in bundles, which take different directions, so that in sections of the growth seen under the microscope some cells will be cut in the direction of their length and others at right angles. This must be borne in mind, or an incorrect opinion will be formed as to the nature of the tumour. Fig. 50 Cells from a spindle-celleil sarcoma of the neck of the uteru?. Some of the cells present a cross-striation. {After Pernice.) The following facts will afford some idea as to the degree of variation in size of the cells of spindle-celled sarcomata. In some of the tumours the cells are so thin and slender, and contain so little protoplasm that they seem to consist only of a nucleus and cell processes. It is difficult to distinguish such cells from those of moderately firm fibrous tissue. In other specimens the cells are large, beautifully fusiform, and rich in protoplasm. Such cells give rise to considerable difficulty to the morbid anatomist, and he often feels in- competent to decide between them and those of young 70 CONNECTIVE TISSUE TUMOUBS. unstriped muscle-fibre. The complexity of such tumours is further increased by the fact that occasionally these long spindle-cells are transversely striated like voluntary muscle fibre. (Fig. 50.) This variety of sarcoma is Imown as myo-sarcoma (rhabdomyoma). Another peculiarity of spindle-celled sarcomata is the frequent presence of tracts of immature hyaline cartilage ; indeed in many instances this tissue constitutes so large a proportion of the tumours that they are described as chondro- mata ; the cartilage is sometimes calcified and even ossified. It may seem strange to associate tumours containing striped cells and cartilage with sarcomata, but the correctness of the classification is demonstrated by the fact that such tumours are apt to recur after removal, and in some of the cases in which the primary and recurrent tumours have been carefully examined, the primary tumour has contained cartilage, or muscle, whilst the recurrent mass has shown no evidence of these tissues, but has conformed to the structure of a pure spindle-celled or a round-celled sarcoma. In order, there- fore, to indicate the nature of such composite sarcomata they will be referred to as myo-sarcomata (rhabdomyomata) and chondro-sarcomata. Spindle-celled sarcomata often contain round and even multinuclear cells. In slow-growing spindle-celled sarcomata the cells some- times become converted into fibrous tissue ; such tumours are often termed fibro-sarcomata or fibrifying sarcomata. 4. Myeloid Sarcomata.— This species is composed of tissue histologically resembling the red marrow of young bone. Myeloid sarcomata usually occur in the long bones and are of a deep red or maroon colour, and, when fresh, the cut surface looks like a piece of liver. The tissue contains large numbers of multinuclear cells embedded in a matrix of spindle or round cells. Many central tumours of bone contain multi- nuclear cells, but it is only when these large cells are present in such quantity as to make up a large part of the tumours that they should be classed as myeloid sarcomata. (Fig. 61.) 5. Alveolar Sarcomata. — This is a peculiar species of tumour in which the cells, contrary to the rule of sarcomata, generally assume an alveolar arrangement which mimics very strongly the disposition of cells characteristic of cancer. In SARCOMATA. 71 carefully prepared sections such tumours rarely cause diffi- culty because the cells are usually , of large size, and even when^ they resemble epithehum it is possible to distinguish a delicate reticulum between the individual cells, a condition never found in cancer. Alveolar sarcomata have occasionally been described as growing in connection with bone, but their common situation is the skin, especially in relation with those congenital defects Fig. 51. — Myeloid sarcoma from the acromial end of the clavicle. known as hairy and pigmented moles. The peculiarities of this species will be more fully considered in the chapter devoted to melano-sarcomata. 6. Melano-sarcomata. — Structurally this species may be composed of round or spindle cells, and they may some- times be arranged in alveoli ; the distinguishing feature is the presence in the cells and in the intercellular substance of a Variable quantity of black pigment. The Blood-Supply of Sarcomata. — The vascularity of sarcomata varies greatly ; in all, the circulation is mainly capillary. In the small round-celled sarcomata the vessels are so numerous as to cause a distinct pulsation and a bruit. 72 CONNECTIVE TISSUE TUMOURS. whilst in the slow-growing spindle-celled varieties — especially those undergoing chondrification — the vessels are not numerous, and the tumours on section are of a white colour. It has already been pointed out, in describing the .minute structure of sarcomata, that the walls of the vessels are very thin, and are often so attenuated as to resemble channels between the cells. This explains the frequency of haemorrhage within the soft and rapidly growing varieties. Repeated extravasations of blood will sometimes convert these tumours into cysts containing blood intermixed with sarcomatous cells. Tumours transformed in this way were formerly described as malignant blood-cysts. Although the vessels in a sarcoma are, in the main, capillaries, nevertheless the arteries supplying the tumour may be very large and numerous. When a sarcoma grows from the distal end of the femur and attains a large size, arteries supplying it from neighbouring muscular, periosteal, and articular trunks become important branches, and in such circumstances an incision into the tumour wiU be attended with alarming haemorrhage. When attempts are made to dissect out such a tumour from the limb instead of adopting more radical measures, such as amputation, these enlarged vessels must not be forgotten, or they will intrude themselves upon the surgeon in a very unmistakable manner. Arteries which, under ordinary conditions, are almost inappreciable, will, when nourishing a sarcoma, attain the dimensions of the radial or even larger trunks. Dissemination. — Sarcomata are liable to reproduce them- selves in distant organs, a phenomenon frequently referred to as metastasis. This dissemination takes place mainly through the veins because, as has already been mentioned, sarcomata are devoid of lymphatics. The most common organ in which to find secondary sarcomata is the lung, unless the primary growth is situated in the territory of the portal circulation, then they will be found in the liver. In very mahgnant sarcomata, especially the small round-celled species, secondary deposits may form in any organ of the body. Secondary nodules are always identical in structure with the primary tumour. The Infiltrating Properties of Sarcomata. — The tendency SARCOMATA. 73 to extensively infiltrate the planes of connective tissue adjacent to the tumour is not pecuHar to sarcomata, for it is observed in carcinomata. This property, so far as sarcomata are concerned, comes out in a marked manner in the case of the voluntary muscles. Sarcomata occur in voluntary muscles under three con- ditions : — 1, Primary tumours ; 2, Infiltrations from adjacent tumours ; 3, secondary deposits. Primary sarcomata of muscles are very rare; they may be of the round-celled or spindle-celled species. For a time at least the tumour is limited by the sheath of the affected muscle. At first the disease appears localised to a particular spot of the muscle, but it gradually extends until the whole belly of the muscle is involved, and becomes transformed into an indurated mass. On section the muscle-tissue appears replaced by hard, tough material of a pale grey colour. When sections are examined under the microscope the appearance is very striking, for each fasciculus is isolated from its neighbour by collections of cells (usually round cells) characteristic of the sarcoma. Primary sarcomata have been observed in the following muscles : — Pectoralis major, rectus abdominis, peroneus longus, gracilis, tensor vaginae femoris, adductor brevis, sartorius, tibialis anticus, and the triceps. Infiltration of muscles by sarcomata is by no means rare. For instance, when a retinal sarcoma protrudes through the posterior part of the sclerotic and invades the orbit, it some- times makes its way into the sheaths of the recti and converts them into masses resembling yellow wax; on section the various fascicuH will be found isolated by the cells of the sarcoma. Periosteal sarcomata often invade muscles, and this is easUy comprehended when the intimate relations of muscles to periosteum are remembered. Thus in Fig. 55 a sarcoma springs from the fibula and involves the origin of the flexor longus hallucis and the peroneal muscles. In a similar way I have seen the adductor muscles invaded bj' a periosteal sar- coma springing from the upper third of the shaft of the femur, and it doubtless occurs in most cases in which sarcomata spring from bone near the origin or insertion of muscles. 74 CONNECTIVE TISSUE TUMOURS, Secondary deposits of sarcomata in muscles are occasionally seen wtere there is wide dissemination of the disease ; in such cases scarcely an organ escapes, and nodules may even occur in the heart. Care must be exercised not to confound a syphilitic gumma in a muscle with a sarcoma. The Burrowing Tendencies of Sarcomata. — AH tumours in their growth tend to follow the lines of least resistance, and thus enter into nooks and crannies in the most unexpected- manner. Every surgeon knows how a sarcoma of the maxilla will send processes into the spheno-maxillary fossa and creep through the foramen rotundum, to appear in the cranial cavity. Sarcomata springing from the heads of the ribs or processes of the vertebrae have been known to extend through interverte- bral foramina and compress the cord, giving rise to fatal para-' plegia. In one case the tumour has been removed, and ,the patient recovered motion and sensation.* This burrowing tendency comes out very strongly in the case of lympho-sarcomata growing in the mediastinum. {See page 104.) It is also remarkable what slender barriers will serve as checks to sarcomata. For example, it is no uncommon condition to find one of these tumours springing from the periosteum near a joint extend in aU directions and envelop the synovial membrane, yet be prevented by it from invading the joint. The Relation of Sarcomata to Veins. — It has long been recognised that when sarcomata become disseminated the secondary tumours occur in situations which indicate that the ■ distribution has been effected by means of the veins. Attention has already been drawn to the tendency which seems inherent in most species of sarcomata to burrow ; this tendency comes out in a striking way when studied in connection with veins. Perhaps the simplest form occurs in the eyeball. When a melanoma arises in the uveal tract, especially when the tumour is in close relation with the choroid, it remains for a period re- stricted to the interior of the globe, until it produces such changes in the intra-ocular tension that the cornea sloughs and the growth protrudes externally. In many of these specimens,- if the sclerotic be carefully examined in the situations where * Davies-CoUey, Trans. Clin. Soo., vol. Sxv. 163. SABGOMATA. 75 the venae vorticosae pierce it, small nodules of the tumour will be detected projecting through these openings, having made their way out by burrowing in the sheaths, and, in some cases, actually travelling along the lumina of the veins. Inferior vena cava. Intra venous procfiss of the sarcoma. Glands infected by sarcoma. -A sarcoma springing from the ilinni. Fig. 52. — Periosteal sarcoma of the ilium invading the inferior vena cava. {Museum, St. Bartholomew's Hospital.) The relations of sarcomata to veins come out strongly when these tumours affect bones. In some examples of periosteal sarcomata the medulla is invaded by processes of the tumour making their way along the veins traversing the Haversian canals. The converse of this is also true, for a central sar- coma will sometimes implicate thfe periosteum by way of the Haversian canals. It is well established that most examples of central sar- 76 , OONNEGTIVE TISSUE TUMOURS. comata occur near the joint ends of bones, and yet it is excep- tional to find the joints invaded. Whenjoint invasion happens, it occurs late in the course of the disease, and then, in most cases, the tumour creeps in through the synovial membrane. This comparative immunity of joints is usually, attributed to the articular cartilage acting as neutral tissue; but it appears rather to be due to the fact that the cartilage, unlike the com- pact tissue of bone, is not traversed by a multitude of narrow venous channels. Extraordinary examples of the invasion of veins 'bj sarcomata occur in the abdomen. In cases of renal sarcomata processes of tumour will find their way into the renal veui, and thus gain the inferior vena cava. Periosteal sarcomata of the pelvic surface of the ilium are very liable to infiltrate the iliac veins and extend into the vena cava. (Fig. 52). This specimen illustrates very well the general relation of an intravenous outrunner from a sarcoma; the process lies freely in the lumen of the vein, its apex is smooth, and rounded, and there are no lateral adhesions save in the situations where the main mass of the tumour infiltrates the wall of the vein. The portion of the sarcoma situated within the vein is, as would be expected, structurally identical with the main mass of the tumour, and has its own blood-vessels, which are continuous with those of the sarcoma. Such a large invasion of a venous trunk as is represented in Fig. 52 is unusual, but it is by no means rare to find a small portion of a sarcoma projecting into the lumen of a vein to the extent, perhaps, of 2, 3, or 4 cm. When processes from a sarcoma project into a vein, the circulating blood is apt to detach large fragments, and these become dangerous emboli. Thus Osier* has recorded an example of renal sarcoma with intravenous processes in which so large a piece was detached, carried forward, and arrested at the right auriculo^ventricular orifice that it speedily killed the patient, a child three years old. The mere presence of a sarcomatous outrunner in a vein does not necessarily imply dissemination of the sarcoma, for very large intravenous processes may exist, and the lungs be free from any gross lesion of a sarcomatous nature. On the * Joiirn. Anat. and Phys., vol. xiv., p. 230. SARCOMATA. 77 Other hand, a very small invasion may lead to extensive infec- tion of the lungs, especially if the protruding surface of the tumour be eroded by the blood current. Dr. Pitt* has described a case in which a man with sarcoma of the thyroid gland died suddenly. At the post-mortem examination the cavities on the right side of the heart con- 'tained fragments of growth embedded in clot; on dissection it was ascertained that the sarcoma had ulcerated into the internal jugular vein. When a vein is invaded by a sarcoma, and discharges of emboli frequently occur, they easily traverse, when small, the right auricle and ventricle, but are too large to pass through the pulmonary capillaries; hence the small vessels in the lungs act as filters, and these arrested particles become secondary foci, and may attain the size of cob-nuts. It is possible that sarcomata may originate in the walls of a vein and extend along its lumen. Griffithsf has recorded a case of this kind in connection with the internal jugular vein. Secondary Changes. — Sarcomata are very prone to degene- rative changes; for instance, haemorrhage is very apt to take place in those which grow quickly, producing spurious cysts. The tissues of the tumour are apt to liquefy, and myxomatous changes are very common. Calcification occurs in those which grow slowly, especially if connected with bone. When sarco- mata grow rapidly and involve the skiu, ulceration is very prone to occur, and leads to profuse and oft-repeated haemor- rhages, which not only exhaust the patient, but in many cases induce death. Occasionally considerable portions of a sarcoma will necrose; this is more apt to occur in very large tumours. In such cases a large spurious cyst forms in the sarcoma, and on cutting into it the fluid escapes, with large irregular pieces of the tumour, which are generally of a greyish-white colour. When necrosis occurs extensively in a large sarcoma it will sometimes check its course in a very marked manner. * Ti-ans. rath. Soc, vol. xxxviii. 398. See Paget's claasical case, Med.-Chir. Trans., vol. xxxviil., 247. t Trans. Path. Soc, vol. sxxis. 311. 78 CHAPTER IX. SAKCOMATA (continued). As connective tissue occurs in every organ of the body, so sarcomata are anatomically ubiquitous; but tbey occur in some situations more commonly than others. They frequently grow from the subcutaneous tissue and fascia, intermuscular septa, periosteum and marrow of bone, the testis, ovary, and salivary glands ; occasionally they grow in the brain, spinal cord, and sheaths of nerves. They are rare as primary tumours of the liver or lung, spleen, ahmentary canal or uterus ; sarcomata grow from the retina and uveal tract, and are fairly frequent in connection with congenital defects of the skin. In order to indicate the peculiarities of sarcomata it win be necessar}'^ to consider them in relation with the affected organs, and this will allow their clinical features to bo systematically dealt with. Sarcomata of Bone.— When arising from the periosteum these tumours are spoken of as periosteal or peripheral sarco- mata ; those which grow from the interior of the bone arc termed central sarcomata. 1. Central Sarcomata may arise in the middle of the shaft of a long bone, but more frequently they originate in the cancellous tissue near the joint-ends of the bone. Sarcomata arising in the diaphysis belong, as a rule, to the round-celled species. Those which grow at the extremities are generally spindle-celled, and contain ^a variable quantity of myeloid cells ; cartilage is sometimes present. They occur at any age, but are most frequent between ten and forty, and are more common in the long bones of the lower than m the corresponding bones of the upper limb. When a tumour occupies the centre of the diaphysis its growth causes expansion of the osseous boundaries, and pro- duces a rounded or spindle-shaped swelling, and the bone may become so thin that, upon some slight exertion, it breaks. In cases where the tumour affects the extremity of the bone it will, in young subjects, infiltrate the epiphysis, but it rarely SARCOMATA. 79 transgresses the articular cartilage; hence the contiguous joint is^rarely invaded by a central sarcoma. Central sarcomata rarely affect the adjacent lymph- glands. In exceptional cases, especially with small round- celled sarcomata, the cells will make their way along the Haversian canals and form a tumour beneath the periosteum. Central sarcomata lead to enlargement of the surrounding bone ; hence when the soft tissues are removed by maceration a large bulb-like, osseous mass is left. These specimens are common in pathological museums. (Fig. 53.) In some cases this osseous capsule is so thin that the tissue of the tumour makes its way through, and as it is very vascular a strong rhythmical pulsation (accompanied by a bruit) is perceptible over the protruding portion. Myeloid sarcomata are always central tumours, and, hke the spindle- and round-celled species, cause expansion of the bone. These tumours have a characteristic maroon colour • they rarely exceed a fist in size, grow with extreme slowness, and are the least malignant of all the species of sarcomata. 2. Periosteal Sarcomata. — These are often referred to as parosteal, or peripheral sarcomata. They may be round-celled or spindle-celled (never myeloid), and are liable to the various metamorphoses and degenerations affecting sarcomata generally, but are more liable to calcification and ossification than central tumours. They occur earlier in hfe than those of the preceding class, and are frequently associated with antecedent injury. They do not, as a rule, invade joints, but now and then portions of them are conveyed into the adjacent articulation along the ligaments. When growing from the periosteum near the middle of the shaft, a sarcoma may be restricted to a portion of its circumference or entirely surround it, producing a fusiform swelling. In such specimens the shaft of the bone traverses the tumour and may, beyond a slight amount of erosion, be unaffected by it. In such a case, however, the medulla may be infected by the cells making their way along the Haversian canals. Periosteal like central sarcomata have a greater pre- dilection for the joint-ends of the bone than for the central portion of its shaft. In size periosteal sarcomata vary greatly ; sometimes they 80 CONNECTIVE TISSUE TUMOUIiS. are of the dimensions of an orange, and they have been recorded measuring 1 m. (40") in circumference^ they do not, as a rule, lead to fracture of the bone from slight Fia. sa-Spina ventosa of the fibula. (Muscim, Middlesex Hospital.) > causes, as is the case with central tumours. Many of them, become more or less ossified; the ossific tracts may assume the form of spicules, as in Fig. 54, or the tumour IS traversed by an osseous mesh, the spaces being filled SABGOMATA. 81 with sarcomatous tissue. In some iastanees the affected bone is greatly thickened in the parts related to the tumour. The extensive ossification associated with periosteal sarcomata is Fig. 54.— Skeleton of an ossifying periosteal sarcoma of the femur. not a matter for surprise when we remember that bone-makmg is the essential function of periosteum. The crystal-like spicules so frequently found in these tumours doubtless represent ossifications of the fibrous trabecule which normally connect the periosteum with the compact tissue of the bone. 82 CONNECTIVE TISSUE TUMOURS. As tlie periosteum is raised from the bone ISy the growing tumour these trabeculse elongate and afterwards ' ossify into spicules. After this general survey of sarcomata affecting bone it will be useful to briefly consider the liabiUty of the various bones to these tumours. Of all bones the femur is the one^most liable to sarcomata, central as well as peripheral ; the tumours are most frequently associated with its lower third, and invariably run a rapidly fatal course, especially those which spring from the periosteum. The duration of life rarely exceeds eighteen months ; often it is very much less. They are most frequent between the age of fifteen and forty years. Sarcomata are fairly common in the tibia ; they prefer the upper to the lower end, and do not run such a rapid course as those of the femur, and appear somewhat later. The fibula is not often attacked; the upper end of the bone is the favourite situation, but periosteal sarcomata may spring from any part of its shaft. (Fig. 55.) Sarcomata of the shaft of the humiBrus are very deadly tumours, and occur at all ages, from infancy to extreme old age. They generally involve the whole of the diaphysis, and form large, soft, rapidly-growing, carrotTshaped masses. Central tumours of the humerus usually attack the upper end. The radius and ulna are occasionally the seat of sarcomata; the periosteal tumours grow from the middle of the shafts, whilst the central varieties exhibit a partiality for the lower "extremities. Sarcomata of the clavicle, sternuTn, the bones of the hands and feet, and the ribs are excessively rare. Sarcomata of the ribs usually spring from the neck or head of the bone, and are liable to send processes through the intervertebral foramina and compress the cord. The scapula and hip bone are sometimes attacked by sar- comata. In the case of the scapula the tumour usually springs from the body of the bone; exceptionally, the seat of origin has been the coracoid process. Of the various parts of the hip bone the ilium is most often attacked. The skull bones are by no means uncommon situations for sarcomata, but they are attacked much later in life than the long bones. SARCOMATA. 83 Of the various bones ot the skull, two call for especial mention — viz., the maxilla and mandible. Sarcomata of the Jaws. — Although it is customary to speak of tumours connected with the maxilla or mandible Accessory nodule of sarcoma. luterosseous membrane. Sarconia. Flexor loiigus hallucis. Pevoneus longus. _ Detached portion of the flexor longus hallucis. Fig. 66.-Spindle-celled sarcoma of the fibula. (M,«««^ MiUlesex Hospital.) clinically as tumours of the jaws, it would be erroneous to describe them indiscriminately as tumours of bone. In each jaw there are, in addition to the bone and its periosteum, two structures to consider-mucous membrane and teeth In the case of the maxilla, the antrum must be 84 CONNECTIVE TISSUE TUMOURS. considered ; in addition, the maxilla is liable to be invaded by sarcomata arising in the naso-pharynx, orbit, and nasal fossa.' Sarcomata of the jaws may a^ise from the periosteum or the muco-periosteum ; in either case they are of the round-celled or spindle-celled species. When springing from the gums sar- comata are often spoken of as malignant epulides. The term epulis has only a topographical significance. Sarcomata arising in the follicles of teeth are often confounded with central tumours. Periosteal sarcomata originate in any part of the maxilla, but they rarely arise from its facial surface, and, though fairly frequent on the gums, are very rare in connection with the mucous membrane of the palatine process. The muco- periosteum of the antrum is a common situation for these tumours, and as they grow lead to thinning and expansion of the walls of this chamber. This enlargement of the body of the maxilla causes it to encroach on the nasal fossa and obstruct respiration ; often the tumour pushes up the orbital plate and displaces the eyeball (proptosis) and in a certain pro- portion of cases the alveolar border is depressed. The nasal duct is frequently implicated, and when completely obstructed epiphora is the consequence. Clinically, a sarcoma originating within the antrum behaves like a central tumour in a long bone, and by degrees processes of the tumomr make their way through the thin walls and implicate the skin of the cheek, or, projecting into the nasal fossa, ulcerate, and give rise to frequently recurring hsemorrhage. When the tumour makes its way through the posterior Tvall of the antrum it wUl enter the zygomatic and spheno-maxillary fossae, and creep thence into the temporal fossa, or make its way through the spheno- maxillary fissure and ramify in the orbit, or steal through the sphenoidal fissure or foramen rotundum into the middle fossa of the cranium. Sarcomata growing from the gxims project usually into the space between the teeth and the cheeks ; such tumours, when large, stretch the cheeks and often produce great displacement of the teeth on the affected side, and marked alterations in the conformation of the alveolar borders of the jaws. When the tumour is unusually large it will protrude beyond the lips. Periosteal sarcomata of the jaws are very rare before the SARCOMATA. 85 age of fifteen years, but they occasionally happen in very young children. The usual period of life at which they grow is between the twentieth and sixtieth years. Periosteal sarcomata are less frequent on the mandible than the maxilla ; they, may grow from any part of it, and sometimes attain a large size. The spindle-celled species is very apt to contain cartilage, and this tissue may be very abundant. Sarcomata springing from the outer surface of the ramus are apt to be mistaken for parotid tumours. Myeloid Sarcomata are very rare in the maxilla, and, as a rule, arise in connection with the nasal process; although they grow slowly, such tumours sometimes attain a large size. In the mandible they spring usually from the body of the bone. To judge from the descriptions current in text-books, it would be imagined that myeloid sarcomata are fairly frequent in the alveolar borders of the jaws ; this error is due to the circumstance that sufficient attention has not been devoted to sarcomata arising in connection with developing teeth. When specimens preserved in museums as examples of myeloid sarcomata of jaws are critically examined they wiU be found to fall into three categories : — 1, Fibrous odontomes ; 2, sarcomata originating in the follicles of teeth ; 3, myeloid sarcomata. Fibrous odontomes have already been considered, and the 'presence of the few multinucleated cells they contain ex- plained. (Page 34.) Sarcomata arising in the follicles of teeth are composed of small round, and spindle cells, with a few multinuclear cells interspersed. In their early stages these tumours are distinctly encapsuled, but as they increase in size and involve the gums, the exposed surfaces ulcerate, and give rise to haemorrhage. When ulceration occurs, the neighbouring lymph glands are apt to become infected. Sarcoma of a tooth follicle only occurs in children, and is particularly apt to involve the germ of the first permanent inola/r. (Fig. 56.) When suspected cases are critically exammed, myeloid sar- comata of the jaws, as in other parts of the skeleton, will be found somewhat unusual tumours. They are rarely met with 86 CONNECTIVE TI8SUE TUMOURS. after the twenty-fifth year, and in the jaws, as elsewhere, are the least malignant species of sarcomata. It has been mentioned that the maxilla is very apt to become involved by sarcomata springing from adjacent parts, and this is a very important clinical fact to bear in mind. This invasion may take place from two sources ; in particular, the naso-pharynx and nasal fossa. Spindle-celled sarcomata occasionally arise in that portion of the pharyngeal mucous membrane which covers the under surface of the body of the sphenoid and forms the roof of the naso-pharynx. It is not uncommon for such tumours to Mandibular nerve. Developing tooth. Sarcoma. Fig. 66.— Sarcoma arising in the follicle of a developing tooth. (The dotted lines indicate the amount of the mandible removed at the operation.) extend into and plug one or both nasal fossae, processes of the tumour appearing at the nostril; or they may extend down- wards into the pharynx and impede deglutition. Sometimes the base of the skull is perforated by the tumour, and the patient dies of meningitis. Naso-pharyngeal sarcomata give rise to agonising pain and intense frontal headache. Whilst the pain wears out the patient, strength is further exhausted by frequently recurring and often profuse epistaxis. Excep- tionally, a piece of the tumour will slough and become im- pacted in the larynx; suffocation has followed this accident. Naso-pharyngeal sarcomata are chiefly met with in patients between the age of fifteen and twenty. Sarcomata arising in the nasal fossa and invading the antrum are not very common. One of the most remarkable cases illustrating this has been recorded by Moore.* In this * Trans. Path. Soc, vol. xix. 332. 8ARG0MATA. 87 instance a mixed-celled sarcoma arose in connection with the nasal septum and spread laterally into each antrum As it in- creased m size the space between the orbits widened, and at the same time the face projected forwards, producing the dreadful deformity depicted in Fig. 57. One of the most extraordinary features m this unusual case was the entire absence of pain or cerebral disturbance ; the sense of smell was lost and the sight of the right eye unpaired. Moore attempted the formidable Fig. 57. — Deformity produced by a Rarcoma of the nasal septum. {Maoris cfue.) task of removing this tumour, but the patient died during its progress, in consequence of some interference with respiration. An examination of the parts showed that the tumour was surrounded by a thick osseous capsule, its wall being continuous with that portion of the nasal septum formed by the mes- ethmoid (Fig. 58) ; as the tumour increased in size it invaded each antrum, but its bony capsule remained separate from the maxillae. Sarcomata of the Retina. — These tumours are often called gliomata; formerly they were known as medullary cancer, encephaloid tumours, or fungus ha3matodes. A retinal sarcoma, in structure, mimics the cells composing the granular layer of the retina. It occurs exclusively in children. Exceptionally the tumour may be noticed at birth; 88 CONNECTIVE TISSUE TUMOURS. more commonly it makes its appearance during the first four years of life ; it is very rare after the seventh year, and is almost unknown after the age of twelve. In a certam propor- tion of cases (twenty per cent.)* both retinsB are affected, either simultaneously or after a .brief mterval. This is always an indication that the tumour is highly malignant. In the early stages there is, as a rule, no pain or symptom denoting the presence of a tumour ; gradually the pupil dilates, and a pecu- Fig. 68.— Facial region of the skull from the case shown in the preceding figure, seen in sagittal , section. The sarcoma is restricted to the nasal septum. (Mmeum, Middlesex Hospital.) liar reflex is noticed at the fundus (this is often termed cat's- eye), and, on testing, the eye will be foimd quite blind. As soon as the existence of a glioma is discovered by the surgeon, the eye is, as a rule, promptly excised. In cases where treatment of this kind is refused or deferred, the following changes occur. The tumour, continuing to increase, pushes forward the intra- ocular structures and induces great pain as the result of the increased intra-ocular pressure it produces, until the cornea yields and the tumour bursts forth, and, growing very rapidly, soon makes its way between the eyelids, which become swollen * Lawford and Collins, Eoy. Lond. Ophth. Hosp. Eep., vol. xiii., p. 1. SARCOMATA. 89 and everted, and then, in consequence of exposure, assumes a dusky red fleshy appearance, whilst from its surface a sanious fluid exudes which may form crusts on the surface of the tumour. Should the parts become excoriated or handled, they bleed freely. A fungating tumour of this kind wiU sometimes attain a very large size before it destroys the child's life. After excision of an eye for retinal sarcoma the disease is very prone to recur, and the recurrent tumour may attain very large proportions before it destroys life. There is a specimen in the museuna of the Middlesex Hospital which well illus- trates the malignant characters of some retinal sarcomata. The patient, a girl two years of age, had a tumour in each eye. In December, 1883, Mr. G. Lawson * excised the right eye ; in January, 1884, the left was removed on account of the pain caused by the tumour. A month later the sarcoma recurred in the left orbit, and grew so rapidly that in August there was a large tumour extending over the left half of the child's face like a huge cauliflower. She died eight months after the re- moval of the right eye. Secondary deposits were found in the right deltoid, on the dura mater, and a mass as large as an orange was connected with the optic commissure and occupied the sella turcica. The disease in this case was exceptional in the rapidity of its growth, the large size to which the recurrent tumour attained, and the presence of secondary deposits, which are the exception 3:ather than the rule. When an eye is excised for retinal sarcoma, and especially when the operation has been long delayed, the growth may have burst through the sclerotic and invaded the orbital tissues ; in a larger proportion of cases it has infiltrated the optic nerve, and it is in this structure that the disease reappears. The frequency with which sarcoma returns in the stump of the optic nerve is, m all probability, due to the intimate lymphatic relations of this nerve with the intra-ocular lymph spaces. * Trans. Path. Soc, vol. xxxvi., 418. 90 CHAPTER X. SARCOMATA (continued). Sarcomata of Secreting Glands.— In describing spindle-celled sarcomata it was mentioned that it is no imcommon condi- tion to find tracts of hyaline cartilage, usually of an immature type, in the substance of the tumour. When the cartilage is fairly abundant, the tumour is usually described as a chon- drifying sarcoma. In addition to bone, tumours of this character occur in the parotid, submaxillary, and lachrymal glands ; in the testis and in the mamma. In the case of the salivary glands and the testis the cartilage often constitutes the main mass of the tumour, which is, under such conditions, erroneously described as a chondroma. 1. Parotid Sarcomata. — These appear as oval, smooth, and elastic swellings in the parotid immediately in front of or behind the angle of the mandible ; increasing in size, they become tuberous and may implicate the tragus. Left to them- selves, they burrow deeply among the tissues of the neck, dip beneath the sterno-mastoid, and acquire attachments to the carotid sheath ; sometimes they creep upwards and adhere to the under surface of the petrosal, and pushing towards the middle line, so bulge the pharyngeal wall inwards as to impede • deglutition. Rapidly growing tumours tend to involve the skin and ulcerate; in very large tumours semi-fluctuating spaces form in consequence of degenerate (mucoid) thanges. The facial nerve is usually involved in large parotid tumours; the small specimens which burrow behind the ramus of the mandible often implicate the nerve as it issues from the stylo-mastoid foramen. Structurally, these tumours exhibit extraordinary variety. Some consist entirely of hyaline cartilage arranged in lobules bound together by loose connective tissue. The cells of the cartilage rarely possess capsules, and are often stellate, as in immature cartilage. Such grow with extreme slowness, and rarely exceed a bantam's egg in size, and may require ten or even twelve years to attain such proportions. The large, rapidly growing tumours consist of spindle cells SARCOMATA. 91 in which tract's and islets of hyaline cartilage are interspersed. When chondral tissue is abundant, it is very prone to mucoid changes, and soft, fluctuating spaces are formed. The con- nective tissue is very liable to undergo myxomatous change, and, as if to render these tumours more complex, portions of the secreting tissue of the gland are imprisoned in them. It is not unusual in sections from a parotid sarcoma to meet with spindle cells, cartilage, myxomatous tissue, glandular Fig. 59.— Parotid sarcoma implicating the pinna in a woman thirty-five years ot age. acini, and fibrous tissue in an area 2 cm. square. Exceptionally striped spindle cells are seen. Parotid tumours of such com- ' plex structure grow rapidly and attain a large size, and often infiltrate the surrounding tissue and skin. Some of them infect the adjacent lymph glands and give rise to secondary deposits in the lungs. Chondrifying sarcomata of the parotid are most frequently met with between the fifteenth and thirty-fifth years, but they have been observed as late as the seventy-fourth year, ibey present very characteristic features. (Fig. 59.) In their early stages they are easily removed, but many of the rapidly 92 CONNUOTIVE TISSUE TUMOURS. growing forms so quickly infiltrate the tissues that their complete extirpation is not always possible. When left to themselves they cause death in a variety of ways. Thus they may press upon the pharynx and lead to fatal dysphagia, or ulceration may open some large vessel in the neck and produce fatal haemorrhage ; secondary nodules sometimes form in the lungs and induce fatal broncho-pneumonia. 2. Chondrifying Sarcomata of the Submaxillary Gland. — These tumours are far less frequent in the submaxillary than in the parotid gland. They are distinctly encapsuled and, as a rule, shell out easily. They grow slowly and occur in the young as well as in adults, but they do not appear to attain so large a size as in the case of the parotid. Butlin* has described a typical case, and gives references to a few other examples. As in the case of parotid sarcomata, gland- ular tissue is often associated with the cartilage. 3. Chondrifying Sarcomata of the Lachrymal Gland. — Tumours containing cartilage are very rare in this gland. Butlinf has described an example removed by Vernon from the orbit of a man twenty-eight years of age. The tumour had been growing nine years ; it was easily shelled out of a tough capsule, and measured 6 by 4 cm. Seven years later the man was free from recurrence. 4. Sarcomata of the Pancreas. — Connective -tissue tumours of the pancreas are very rare. I have not succeeded in finding a specimen or description of a chondrifying sarcoma of the pancreas. Sarcomata of the Testicle.— This gland is somewhat prone to sarcomata ; the two varieties, round-celled and spindle- celled, occur in about equal proportion. Lympho-sarcomata occur occasionally. Butlin| has pointed out' that the disease is most frequent at two periods of hfe : the first period begins at birth and ends with the tenth year ; the second period is irom the thirtieth to the fortieth years. It is not rare to find both testes affected in cases of round- * Trans. Path. Soc, vol. xxviii. 228. {iSee also Lano, Trans. Clin. Soo., vol. xxiv., 17). t Trans. Path.. Soc, vol. xxvi., ISl. J " Sarcoma and Carcinoma," London. SARCOMATA. 93 celled sarcomata, and in this respect there is an interesting analogy between this species of sarcoma in the testis, ovary, and retina. Spindle-celled sarcoma of the testis only attacks one testicle; in about one-half the cases the tumours contain hyaline cartilage, and in some the amount of cartilage is so large that they have been described as " enchondromata " of the testis. Occasionally the cartilage assumes the form of tubes or cylinders disposed like the tubules of the testis. One of the best examples is the classical case described by Sir James Paget.* The secondary deposits associated with chondrifying testicular sarcomata contain cartilage, and in a few instances this tissue is more abundant in the secondary nodules than in the primary tumour. Spindle cells with transverse striation occasionally occur. Spindle-celled sarcomata of the testis in their structure and life history are parallel with parotid sarcomata, and, like these tumours, are occasionally composed almost entirely of cartilage. Butlin has described a case in which castration was performed in 1875 on a man, twenty-one years of age, for a small tumour of the testis which had been growing four years. It was composed of hyaline cartilage with a capsule of fibrous tissue, and septa of the same tissue traversed the cartilage. The man was in good health in 1879. Lympho-sarcomata of the testis are often included in the round-celled species; this is unfortunate, as the lympho- sarcomata are even more malignant than the round-celled tumours, and disseminate much more rapidly. It is also well established that they not infrequently attack both testes either simultaneously or after a brief interval. The clinical recognition of sarcoma of the testis is not by any means a simple matter; it is often impossible to dis- tinguish between a hsematocele and a solid tumour. The points on which it is best to rely are the weight of the tumour and absence of inflampaation, syphilis, and translucency. Some sarcomata are intensely hard, others are soft and almost fluctuate ; most of them are painless, but a few are the seat of continual pain. * Med. CLir. Trans., vol. xxxviii. 247. 94 CONNECTIVE TISSUE TUMOURS. Ovarian Sarcomata. — The ovary is occasionally the seat of sarcoma ; the round- and spindle-celled species occur in about equal proportion. Both ovaries are synultaneously affected in about twenty per cent, of the cases ; in this respect sarcomata of the ovaries resemble those of the testis and retina. The similarity of ovarian and retinal sarcomata is further illustrated by the fact that they are most frequent' in young children. For instance, in seventy recorded cases of ovarian cysts and tumours removed from girls under fifteen years of age, twelve were examples of sarcomata. In com- prehensive ovariotomy lists solid tumours make up five per cent, of the cases, and this includes fibromata and myomata, as well as sarcomata, occurring at all periods of life. A careful study of cases shows that sarcomata of the ovaries are four times more frequent in girls under fifteen years of age than in adult women. At whatever period of life they appear, ovarian sarcomata* grow rapidly, and are invariably associated with free fluid in the peritoneum ; in the later stages of the disease fluid accumulations may occur in one or both pleural cavities. Ovarian sarcoma in the young and in adults runs a rapidly fatal course. Sarcomata of the Mammary Gland. — The mamma is occasionally the seat of a sarcoma, and when we take into con- sideration the large amount of conn3Ctive tissue which it often contains, it is somewhat surprising that these tumours are not more frequent. As is the case with sarcomata growing in the parotid gland, these tumours, originating in the connective tissue of the breast, usually entangle the ducts and acini in their immediate neighbourhood; such incorporated glandular structures occasionally give rise to cystic spaces, which, when viewed in section under the microscope, exhibit a regular lining of epithelium. Such tumours are often called " adeno- sarcomata." This is a misuse of the term sarcoma, and it has unfortunately been extended so as to include many adenomata of the breast, especially if they should happen to grow rapidly or attain a large size. The breast is liable to round- and spindle-celled sarcomata. The round-celled species rapidly infiltrate the organ and invade adjacent structures, giving rise to brawny indurated ' SARCOMATA. 95 tumours. They recur very quickly after removal, and grow with fearful rapidity in women who are suckling. Spindle-celled sarcomata grow slowly, and in the few reported cases the tumour had attained the proportion of an orange before removal. In the breast, as in the case of the salivary glands and testis, such tumours occasionally contain ' tracts of hyaline cartilage* and even well-formed bone.f * Bowlby, Trans. Path. Soc, vol. xxxiii. 306. •f Battle, Trans. Path. Soc, vol. xxxvii. 473. CHAPTER XI. SARCOMATA (continued). Myo-sarcomata (rhabdomyomata). — It is a remarkable fact, considering the large amount of striped muscle tissue existing in the body, that tumours composed of or containing, this tissue do not arise in connection with the voluntary muscles, but make' their appearance in such unexpected situations as the kidney, testis, neck of the uterus, parotid gland, and in parosteal hpomata, organs and tissues which, under normal conditions, do not contain muscle cells of the striped variety. Before discussing the probable origin of striped muscle cells in anomalous situations, it will be necessary to consider the characters of the tumours in which they occur, for more extended observations have brought to light many facts wliich serve materially to modify the earher speculations on this question. 1. Renal Sarcomata. — The foUowiag species of sarcomata occur in the kidnej^:— (1) Spindle-celled sarcoma and its variety, myo-sarcoma ; (2) Round-celled sarcoma ; (3) Tumours composed of adrenal tissue. The most remarkable feature concerning renal sarcomata is that in a very large proportion of cases they are congenital, or are noticed within a few months of birth. Congenital Renal Sarcomata exhibit the following characters. These tumours grow very rapidly and attain large dimensions in the course of a few months ; they are, as a rule, painless. Death, which usually occurs before the end of the third year, is, in most cases, due to mechanical causes ; the large size of the tumour causes it to push up the diaphragm, encroach upon the thoracic cavity, and impede respiration. In about haK the cases both kidneys are affected ; w^hen only a portion of the gland is involved the tumour is isolated from the renal tissue by a capsule. On section the sarcoma presents a yellowish- white colour, dotted here and there with groups of small cavities due to secondary changes. The basis of the tumour is connective tissue containing cells of various SARCOMATA. 97 shapes and sizes ; some are round or oat-shaped, and others are spindles. In many specimens a large proportion of the tumour is composed of fasciculi, which present the cross striation so characteristic of the fibres of voluntary muscle ; when these cells are isolated they appear as elongated spindles furnished with a large nucleus and transversely striated ; in some of them there is also an oblique striation. The cells are without a sarcolemma. The second variety of renal sarcoma has been called " congenital adeno-sarcoma " (a very misleading name) because it contains groups of tubules lined with regular cubical epithelium, so that on section they convey an appearance hke that afforded by a number of renal tubules in transverse section. An examination of several examples of these tumours and a careful study of the descriptions published by others, make it appear that when the striped cells are very abundant the epithelial-hned tubules arc, as a rule, absent, and when the tubules are numerous it may be necessary to examine many sections before the striated cells are detected. In the two conditions the round, oat-shaped, and spindle cells are equally abundant. It has been suggested by Paul that, as the most typical myo-sarcomata are more sharply delimited from the kidney than the other varieties, the tubular elements may be derived from the kidney ; my own inquiries do not support this view. Kenal myo-sarcomata are well suppUed with blood-vessels, and do not, as a rule, give rise to secondary deposits. Ribbert, in an interesting paper, has collected the scattered literature relating to these tumours, and enriched it by some new observations. He refers to two cases described in "Dissertations at Bonn, 1891," m which tumours containing striated spindles occupied the pelvis of the kidney. One case was obtained from an adult man, the other from a child eight years and a half old. Renal sarcomata of the round- and spindle-celled species occur in adults ; they are less common than in inftmts, and difier from them in two important points : — (1) It is rare for both kidneys to be affected. (2) Striated cells are very rarely present. They may occur at any age, but an examination of a large 98 , CONNECTIVE TISSUE TUM0UE8. number of records indicates that the period between the fifth and thirtieth years of life is singularly free from renal sarco- mata. They seem to occur equally in. men and women. The effects which they produce are similar to those of sarcomata in other organs. Occasionally a process of the tumour will make its way into the pelvis of the kidney and traveldown the ureter in the same manner that sarcomatous out-runners make their way along the lumina of veins whenever they manage to penetrate the walls of these vessels. (See page 74.) When the ureter is thus invaded small fragments of the, tumour are detached and conveyed by the urine into the bladder, to be expelled during micturition. This fact is worth remembering, as it is sometimes of assistance in diagnosis. It is necessary to mention that a ureter may be involved in a sarcoma arising in. its neighbourhood ; the waUs become infiltrated, and then a process of the tumour may project into its lumen. Exceptionally, a process from a sarcoma of the bladder will enter the vesical orifice of the ureter and travel along it for a considerable distance. Much uncertainty must exist in drawing conclusions from old records of renal sarcomata, because it is now clear that many tumours of the kidney in adults, which have been described as sarcomata, were, in many instances, composed of tissue similar, if not identical, in structure with that which forms the zona fasciculata of the adrenal (suprarenal capsule). (Fig. 60.) It is quite certain that some specimens regarded as sarcomata of the kidney turn out on critical investigation to be tumours of the adrenals ; it will therefore be necessary to consider tumours of the adrenal as a sequel to renal sarcomata. Adrenal Tumours. — There are two varieties of tumour which come under this heading : — (1) Tumours of the adrenal. (2) Tumours of accessory adrenals. There is sufficient evidence forthcoming to demonstrate that an adrenal may become transformed into a large tumour in the same way that the thyroid gland becomes a goitre ; indeed, the analogy is so striking that Yirchow, years ago, proposed for such enlarged adrenals the term " struma supra- renalis." The museum of the Royal College of Surgeons contains two good specimens of enlarged adrenals, one of which ■ . SABOOMATA. 99 weighed eleven pounds * They were removed from patients aged lilty-three and thirty-six years respectively. Similar tumours (adrenal goitres) also occur in other mammals. In 1885 I detected in a marmot (Gyywmys ludo- Blood-vessels Blood-vessels. n0^~^..mWmy®®-¥%®:Si-^!i^^S^S^ Fibrous tU Capsule, W^ S.~--^^~: tissue sale. '■^'■'•^^W:W^ ■ Hyaline de- w>wr->rt)f generation of a 1 ^^^^^3SK4*i3^^^''"^^^^''^"^"*~=^'£=^^^ ^°^^''' Fig. 60. — Microscopical characters of a tumour arising in an accessory adrenal. {Gmwitz.) vicianus) an example associated with numerous secondary nodules in the liver and one in the spleen, f It is well known that accessory adrenals are fairly common, and have, in many instances, been detected embedded in the cortex of the kidney beneath its capsule. These bodies con- tain a quantity of fat, and this fact has led many writers to describe them as " renal lipomata." When sections of these supposed fatty tumours are submitted to ether and the fat dissolved from them, their structural identity with an adrenal is obvious enough. Ordinarily, these accessory adrenals are no larger than a cherry-stone, but now and then they become large and dangerous tumours, and by pressure induce J* Thornton, Trans. Path. Soo., vol. xxxiv. 141, and Trans. Clin. Soc. vol. xxiii. 150. ~ f Journal of Anat. and Phys., vol. xix., p. 458, pi. xxiii., fig. 7. 100 CONNECTIVE TISSUE TUMOURS. destruction of the kidney. An excellent example is repre- sented in Fig. 61, which was removed from a man lorty-three years of age. Many secondary nodules were observed, durmg Tlie tummir Ureter. Kidney. Fig. 61. — Renal tumour originating in an accessory adrenal. {After Henry Morris*) the operation, in the liver. There was also a fixed hard nodule in the left temporal region. Mr. Morrist in his account of this interesting case, draws attention to the analogy of this kind of tumour with the rare form of goitre which is accompanied by secondary deposits in the bone and viscera, these deposits being structural repro- ductions of the thyroid gland. {See page 243.) Clinical Features. — In describing the various kinds of renal sarcomata, incidental references have been made to most of their clinical pecuHarities. Sarcomata of the kidneys in infants are so well known that their chnical recognition is a very simple matter. As a rule, the diagnosis of solid renal tumours is not a matter of difficulty, but at present there is no way of dis- tinguishing between a renal sarcoma and a tumour arising in * Grawitz, Virohow'a " Arehiv," xciii., 39. ■f Brit. Med. Journal, 1893, vol. i., p. 2. SARCOMATA. 101 an accessory adrenal. It is also difficult to decide between a solid renal tumour and one arising in an adrenal. Clinical ob- servation may soon render this probable, for it has been noticed in at least two cases (Thornton) that in tumours of the adrenal there is an absence of hsematuria, whereas in all cases of solid tumours of the kidney in adults, whether sarcomata or arising in accessory adrenals lodged in its cortex, from time to time the urine will be found to contain blood, — sometimes mere traces, but occasionally it will be abundant. Sarcoma of the kidney in children and in adults runs a rapidly fatal course. In children the duration of life, after the tumour has attained such a size as to be obvious clinically, is rarely longer than six months. In adults life is seldom pro- longed beyond eighteen months. The malignancy of renal sajcomata is displayed in the tables on pages 120 and 121. 2. Myo-sarcomata of the Testis. — Tumours composed mainly of spindle cells exhibiting cross striation have several times been found in connection with the testis. One of the earliest and most carefully described cases is that of Neumann* Spermatic cord. Epididymis. Testis. Tunica vaginalis. Poition of tumour within the tunica vaginalis. .The tumour. Fig. G2.— Myo-sarcoma of the testis. (After Neumami.) (Fig 62) in which a myoma was situated at the lower pole of the testis of a child three and a half years old. Ribbertt refers to three specimens ; of these two were * Virchow's "Archiv," M. ciii. 497. i t v t „f + llTZ'l " Archiv," M. cxxx. 249. This paper contains a complete hst of references. 102 CONNECTIVE TISSUE TUMOURS. removed from children aged thirteen and fourteen years respectively ; the age of the third patient is not stated. 3. Myo-sarcomata of the Uterus and Vagina.— Tumours containing striped muscle fibre have been found in connection with the body of the uterus, neck of the uterus, and vagina. One of the most remarkable as well as one of the best described cases is recorded by Pemice.* In this instance a racemose tumour grew from the cervix uteri of a woman. This tumour, when examined microscopically, was found to contain a large number of spindle-shaped cells, which were nucleated, and ex- hibited a transverse striation such as exists in myo-sarcomata. (Fig. 50.) In the basal parts of this tumour gland-like spaces lined with cylindrical or with cubical epithelium were found. After removal the tumour quickly recurred; it was removed a second time, but reappeared, rapidly infiltrated the uterus, forming a large mass ; death speedily ensued. When the recurrent tumours were microscoped no striated spindles were found, and the growth had all the characters of a spindle-ceUed sarcoma. 4. Myo-sarcoma of the Parotid Gland. — Pruddenf has described a tumour situated near the angle of the mandible of a boy seven years old. The tumour contained, in addition to round and spindle ceUs, numerous striated spindles and tubules lined with cubical epithelium. Its resemblance to a renal myo-sarcoma was thus very close. 5. Myo-sarcomata of Periosteum. — ZenkerJ and Bayer have each met with an example in the orbit ; Targett § found one on the scapula of a child six months old ; and Marchand {| describes one which grew from the ischial tuberosity of a boy four years of age. It is also singular that congenital lipomata growing from periosteum contain striped muscle' fibre. These have already been described (page 13). There has been much speculation as to the mode of origin of myo-sarcomata. When our knowledge of them was limited to those which occurred in the kidney, the notion that they * Virchow's "Archiv," bd. cxiii. 46. t ^m. Jour. Med. Sci., 1SS3. J Virchow's " Archiv," hd. cxx. § Trans. Path. Soc, vol. xliii, 157. II Virchow's " Archiv," bd. u. p. 42. SABCOMATA. 103 arose in detached portions of the mesoblastic somites, as suggested by Cohnheim, found favour with many; striped cells in tumours of the testis were explained as arising from the muscular tissue of the gubernaculum. Increased observa- tions show that these notions are untenable. It is much more reasonable to regard the presence of striated cells in sarcomata as due to the similar changes in the tissue that give rise to hyaline cartilage. Muscle belongs to the connective tissues, and is derived from the same tissue as that which furnishes cartilage and fat. . It is also of interest in relation to the fre- quency with which chondro-sarcomata arise from periosteum, that myo-sarcomata also spring from this membrane. 104 CHAPTER XII, SARCOMATA {continued). Lympho-sarcoma. — This species is, by many writers, regarded as a variety of the round-celled sarcoma. As lympho- sarcomata exhibit a very characteristic structure, and occur, as a rule, in very definite situations, and have somewhat special clinical features, it is desirable to separate them from the round-celled species. These tumours occur in the superior mediastinum, in the subpleural and subperitoneal connective tissue, at the base of the tongue, in the larynx, in the tonsil, and in the testis. In considering these tumours, the overgrowth of lymphoid tissue in lymph glands will not be dealt with ; an enlarged lymph gland, a big Uver, a leuksemic spleen, or a parenchy- matous goitre, are not tumours in the sense in which the term is employed in this book. 1. Thoracic Lympho-sarcomata. — The most frequent situation for a lympho-sarcoma is the posterior mediastinum ; it probably starts in connection with a lymphatic gland, and, growing rapidly, quickly envelops the trachea and bronchi, the aorta and other large vessels, the oesophagus, and large nerve trunks. The tumour extends along the branches of the bronchi and invades the interlobular connective tissue at the roots of the lungs. When the tumour starts in the superior mediastinum it descends along the big vessels and invests the pericardium. It may even creep along the sheaths of the vessels to the heart and infiltrate its substance : this is rare. Processes of the tumour may find their way along the sheaths of the big vessels and appear in the posterior triangles of the neck. The relation of a mediastinal Ijrmpho-sarcoma to the adjacent structures is interesting. For instance, the large arterial trunks, though embedded in the tumour, are not as a rule damaged by it; the thin-walled veins are early compressed, and interference with the venous circulation is a marked feature. In some of the cases infiltration of the walls of the veins takes place, and processes of the tumour project into their channels. SARCOMATA. 105 The bronchi are very liable to be damaged by a lympho- sarcoma, for the tumour moulds itself around these tubes, and by pressure causes them to be narrowed ; apart from this effect, the tissues proper of the tubes become eroded as well as atrophied. These changes not only induce difficulty in respiration by restricting the admission of air, but the com- pression of the vessels accompanying the bronchi leads to changes in the nutrition of the pulmonary tissue, which end in pneumonia, gangrene, and death. The important nerves traversing the mediastinum, the vagus and phrenic nerves especially, are often involved in the Fig. 63.-Portion of a mediastinal ly™r^-»J»'"»v\>lt7a^y veTls'"" '''''°"'' tumour extends along the bronchi and pulmonary vessels. tumour, but their sheaths are rarely invaded bythe cells; in some instances the left recurrent laryngeal nerve is compressed sufficiently to produce severe laryngeal spasms and even paralysis of the muscles supplied by it. 106 CONNECTIVE TISSUE TUMOURS. The cesophagus becomes compressed by an intrathoracic lympho-sarcoma, but dysphagia is not so prominent a symptom as in many cases of intrathoracic aneurysm. It is a somewhat repaarkable feature of lympho-sarcomata that they extend to, and enclose, neighbouring lymph glands without affecting them. For instance, it is nftt unusual, in a section of a large mediastinal lympho-sarcoma, to find bronchial lymph glands, fully charged with pigment, exposed on the cut surface of the tumour and embedded in its substance. (Fig. 63.) 2. Abdominal Lympho-sarcomata occasionally arise in the connective-tissue planes posterior to the peritoneum ; in this situation the tumour involves the abdominal aorta, and is con- ducted to the kidney by the renal vessels. A lympho-sarcoma sometimes arises in the perirenal tissue and forms large lobu- lated masses enveloping the kidney. My own observations indicate that abdominal lympho-sarcomata are more common in children than adults. Lympho-sarcomata sometimes arise in the connective tissue between the pelvic peritoneum and the pelvic fascia, and form large lobulated niasses, which are apt to involve the rectum. In such cases large secondary deposits are formed in the liver. 3. Lingual and Laryngeal Lympho-sarcomata. — Between the mouth and the true pha,rynx there exists a some- what remarkable ring of l3rmphoid tissue which is worth some consideration. The lateral portions of this ring are indicated by the tonsils ; the superior segment is formed by the collection of adenoid tissue on the posterior wall of the pharynx near the roof, known as the pharyngeal tonsU, and the inferior segment consists of a collection of this tissue on the posterior third of the tongue, sometimes referred to as the lingual tonsil; extensions from it run downwards into the mucous membrane of the larynx. This circle of lymphoid tissue is the source of lingual and laryngeal lympho-sarcomata. Lingual Lympho-sarcomata. — One of the best observed cases is recorded by Hutchinson.* The patient was a man twenty-two years of age. The tumour, which had been grow- ing half the patient's life, at last attained such a size as to interfere with respiration and deglutition. The tongue and * Med.-Chir. Trans., Iviii. 311. SARCOMATA. 107 tumour were removed. The mucous membrane covering it was nodulated like a mulberry. Two years later there was a recurrence, and the patient died quickly, partly from pressure and partly from exhaustion. Laryngeal Lympho-sarcomata are very rare tumours, and usually take the form of outgrowths from the laryngeal mucous membrane.* Bealef recorded fuUy a case associated with secondary nodules in the eyelid and cerebral membranes. 4. Testicular lympho-sarcomata are well-known tumours, and their occurrence in this organ cannot easUy be explained. Many of these tumours are described as small round-ceUed sarcomata. The chief facts to relate concerning them is that they occur in lads and young adults, often affect first one and then the other testicle after a variable interval, dis- seminate very rapidly, and speedily cause death. An instructive case of lympho-sarcoma affecting one testicle and subsequently its fellow is described by Hutchin- son.t It is well worth perusal ; the patient was seventy years of age. * "Wolfenden and Martin, " Studies in Path. Anat.," 1888, p. 26. t laneet, 1887, toI. ii. 749. j Trans. Path. Soc, vol. xl., 193. 108 CHAPTER XIII. SARCOMATA (continued). Melanosis and Melano-sarcoma.— In the majority of mammals there are certain epithelial and fibrous tissues which normally contain pigment. Among pigmented tissues the skin and epithelial layer of the retina hold the first place. In skin the pigment is chiefly contained in the deeper layers of the rete mucosum; hence hair that is derived from the cells of this layer is pigmented also. In many mammals other tissues contain pigment, such as the mucous membrane of the roof of the mouth of the dog, and the blue colouration of the vaginal mucous membrane of the vervet monkey. In man the amount of pigment in the skin varies greatly, so that we may pass gradually from individuals whose sldns are intensely black to others who have no trace of cutaneous pigment. It is a noteworthy fact that animals' with no pigment in the skin also lack pigment in the uveal tract of the eye- ball. A familiar example of this is the white rabbit with pink eyes. Such a condition is termed albinism, and colour- less animals, or albinos, occur among all classes of animals, vertebrate and invertebrate. Excessive development of black pigment in the skin is known as melanism; this is much rarer than albinism. Abnormal distribution of pigment is common ; in man it gives rise to the condition termed leucoderma when it affects the skin, and unequal distribution of pigment in the retina is known as retinitis pigmentosa. Irregular patches of black in the skins of horses cause them to be described as piebald, and when disseminated in small dots and irregular tracts they are said to be grey. In the white races of men the pigment granules are a,lmost entirely confined to the cells of the rete mucosum, but when the pigmentation is very marked it will be found dis- tributed in the other tissues of the skin. The pigment, or melanin as it is called, lies within the cells either in the. form of black or brown granules, or they may be uniformly SARCOMATA. 109 stained by it. As to the source of the pigment nothing is known. Melanosis is sometimes produced by parasites. This variety of melanism is rarely seen in man, but is fairly frequent in other animals. An example is depicted in Fig. 64. Pigmentation in this form is not uncommon in the lungs of mammals, but it must not be confounded with the Fig. 64.— Anterior portion of a dace ; eacli black spot contains a central white dot representing an encysted parasite. irregular, black patches so common in the lungs of those who dwell in densely populated and smoky towns. Small liodules surrounded by a zone of intensely black pigment' are not tmcommon in the skins of dogs; the central nodules usually contain an encysted parasite. Pathological pigmentation in its most serious forms is found in connection with tumours arising in the skin or withm the eyeball. Melanotic tumours occur in two genera :— 1. Melano-sarcoma. 2. Melano-carcinoma. 1. Melano-sarcomata— It was formerly the custom to describe all varieties of melanotic tumours as cancers. Later, when the histological distinctions between sarcoma and cancer were more accurately defined, it was found that the majority oi tumours containing black pigment were structurally sarcomata. Kecent careful researches, of which some details will be given afterwards, establish beyond any doubt that some melanomata are cancers. 110 CONNECTIVE TISSUE TUMOURS. In these tumours, whether sarcom J) J) J) »> )> Trans. Fath. Hoc, Vol. xxxvii. 295. Unpublished. Edin. Med. Journ., Oct. 1886, p. 351. Med. Times aiidGaz., l882,Vo\.u.6'8. Brit. Med. Journ., 1881, Vol. ii. 741. Mcd.-Clnr. Trans., Vol. Ixvi. 305. In this Table there are 14 operations, with 6 recoveries and 8 deaths. Of those who recovered, all were dead from recurrence within the year. in one table and sarcomata of adults in another. Many of the tumours in adults were recorded as examples of " encephaloid," a term which has no meaning for the pathologist, and for the surgeon has probably the same significance as sarcoma. It is necessary to mention that Ris* has reported a case in which Kronlein of Zurich excised a kidney from a woman fifty-six years of age for a tumour, described by Klebs as an adeno-sarcoma ; the patient was alive and well live years after the operation. Nephrectomy for renal sarcoma in children is absolutely unavailing, and is fast falling into disfavour. The excision of a sarcomatous kidney in adults is occasionally a measure of necessity, on account of the great pain and distress it induces. It is curious that renal sarcomata cause no pam when they occur in young children. It is as yet impossible to speak definitely in regard to thj results of excision of adrenal tumours until more of these cases have been accurately studied. At present there is good reason to believe that they are less malignant than rena] sarcomata. * Bruns, Beitrdge, bd. vii., 140. 122 CONNECTIVE TISSUE TUMOUBS. The Results of the Operative Treatment of Sarcomata. — A comprehensive study of this question indicates that the results of operations for sarcomata are influenced by the situation as well as by the nature of the tumours. It is a somewhat remarkable fact that the two most deadly situations in which sarcomata grow are the periosteum of the femur and the maxilla. In the majority of cases in which amputation is performed for round- or spindle-celled sarcomata of the femur, the patients die within a year of the operation. Many of them succumb at the end of three months, the fatal result being due in most patients to secondary deposits in the lungs. In the case of the maxilla, life is rarely prolonged beyond a year ; the patients in a few instances die from rapid and extensive recurrence, or from broncho-pneumonia, rarely from dissemination. In other bones far better results are obtained, and where limbs have been cut off' for sarcoma of the tibia, fibula, radius, or ulna, life has been prolonged for several years, even in young individuals. Central tumours of bone are much more favourable than the periosteal, and this holds good when allowance is made for the fact that myeloid sarcomata have been included in the statistical lists from which the conclusions were drawn. Mye- loid sarcomata give the best results, and references have already been made (p. 118) to cases that have been reported. The results of ovariotomy for sarcoma are not very en- couraging. Thornton* published records of ten cases in which the patients submitted to operation. Of these, three died from the effects of the operation ; of the seven which recovered, one remained in good health and had a child two years later One died a few months after the operation from recurrence in the pelvis. Another had recurrence eighteen months later. The remaining four died within a year of the operation from dissemination of the growth. A careful analysis of the statis- tical tables of other surgeons gives almost identical results. The above facts indicate the greater risk of ovariotomy for sarcoma than other genera of ovarian tumours. This is even * Med. Times and Gaz., 1883, vol. i., 383. SARCOMATA. 123 more forcibly illustrated by the following facts. A searcli through periodical literature enabled me to collect seventy cases in which ovariotomy had been performed in girls under fifteen years of age, with the following results : — Dermoids, 29, with 25 recoveries. Cysts, 29, „ 27 Sarcomata, 12, „ 5 „ The cases of sarcomata are subjoined in tabular form. OPERATIONS FOR OVARIAN" SARCOMATA IN CHILDREN. Eepokteb. A&E. Result. Eeferekce. Chenowcth 8 yrs. D. Am. Jonrnal of Ohstet., Vol. xv. 625. Cameron . 31 „ r>. Glasgow Med. Journal, 18S9, p. 37. Malins 9 „ D. Lancet, 1890, Vol. i. 1174. Wagner 10 „ R. Arch, fur Klin. Chir., Bd. xxx. 504. Croom 11 .. R. Ubstet. Trans., Ed., Vol. xiv. 93. Wagner 13 „ D. Arch, fur Klin. Chir., Bd. xxx. 304. Smith 14 „ D. Lancet, 1874, Vol. ii. 501. Tsander 15 „ R. Vrach, No. 48, 1890, 1087. Thornton 15 „ D. Med. Times and Gaz., 1883, Vol. i., p. 211. Von Szabo 15 „ D. Arch.fiir Gyn., Bd. xxxii. 193. Kelly . 12 „ R. Keating's Cyclopasdia, Vol. iii. 739. Groom . 7 „ R. Ed. Med. EPITHELIOMA. 197 The extirpation of an epithelioma in its early stages is oft- times a very trivial proceeding ; when allowed to extend, its complete removal will often demand a very extensive, diffi- cult, and frequently a dangerous operation, and often is an impossible task. It is difficult to formulate rules for the operative treatment of epithelioma and to decide what is, and what is not jtistifiable surgery. Every surgeon must be guided by in-' dividual experience. It is exceedingly difficult to express collectively the effects of operation in eradicating this disease. The facts broadly stated stand thus : — In a small proportion of cases the operation is of doubtful utility, and in a few instances hfe is sacrificed in consequence of the interference. On the other hand, a large number of patients de- rive the greatest comfort, and their lives are certainly prolonged in consequence of operation. In a small number of instances an actual cure is brought about. When an epithelioma is removed and there is no recur- rence for five years, the individual may be regarded as cured. The results and relative dangers of operations for epithelioma will be given in connection with the various organs in the ensuing pages. It will be useful to reiterate here that of the three clinical varieties of epithelioma the burrowing form is not only the most malignant, but gives the worst results after operation. The warty variety is not only the least malignant, but affords the best results when excised. It may be taken as an axiom that in cases where opera- tions are performed for epithelioma, and as far as could be judged, the incisions were carried wide of the diseased tissues, a quick recurrence of the disease, either in, or near, the cicatrix, or the subsequent enlargement of the lymph glands, may be taken as an indication of a high degree of malignancy, and, as a rule, of the uselessness of further operative interference. EPITHELIOMA OF LIPS, TONGUE, MOUTH, AND JAWS. Epithelionta of the Lips. — In this situation it is most common between the thirty-fifth and sixtieth years ; it has been recorded as early as the twenty-fifth year and as late 198 EPITHELIAL TUMOURS. as 102* Epithelioma is nearly one hundred times more frequent on the lower lip of men than women; in men itis fifty times more common on the lower than the upper hp. When the disease begins on the nether lip near^ the angle of the mouth it may involve the upper hp ; this is rare, but primary epithelioma of the upper lip is very rare. It is a curious fact that epithelioma is more frequent on the upper •lip in women than in men. The mode in which the disease attacks the lips is shown in Figs. 101, 102 and 103. Epithelioma of the lip, when left to run its course, soon infects the tymph glands in the submaxillary region. Occa- sionally epitheHoma will attack the right side of the lower lip but infect the lymph glands in the left submaxillary region and vice versa. No anatomical explanation of this anomaly is forthcoming. The tissues of the hp are gradually destroyed, and the mucous membrane covering the mandible is impli- cated and the bone itself eroded. In the later stages the glands in the neck form huge masses, which gradually implicate the overlying skin, causing it to ulcerate, and at last the ulcer ia the neck and the primary ulcer on the lip join, and as the underlying tissues slough a horrible chasm is formed in the neck, on the floor of which large vessels may be seen pulsating. Death is due to asthenia from repeated haemorrhage, or from a profuse hemorrhage, septic pneumonia, or oedema of the glottis. The averasre duration of life in untreated cases is twelve months. Treatment. — Epithelioma of the lip in the early stages is easily removed by the V-shaped method, or some one or other of its many modifications. When the submaxillary or submental lymph glands are enlarged they shoiild be dissected out. When the disease has been allowed to extend until it involves the underlying bon6 and extensively infiltrates the cheek and neck, operative interference can rarely be undertaken with much prospect of doing good. After the excision of an epithelioma of the lip, recurrence may take place along the edge of the scar, or in the submaxillary lymph glands, and as these enlarge the periglandular tissue also becomes infiltrated with epitheliomatous material, which * Jalland, Jirit. Med. Jotmial, 1891, vol. i., p. 1019. EPITHELIOMA. 199 renders the removal of the diseased tissue a difficult and often impossible task. There is a form of recurrence of epithe- lioma of the lip which begins near the angle of the mandible, and spreads up each side of the body of this bone in such a way as to resemble a periosteal sarcoma. The early removal of an epithelioma of the lip is more likely to be followed by good results than in any other part of the body. Occasionally the operation is followed by quick recurrence, even when the primary lesion was very small ; but in a large proportion of cases recurrence is delayed two, three, or more years, and in a few cases a cure is brought about. Operations for epithelioma of the lip should have practically no mortality. Epithelioma of the Tongue. — In this situation epithelioma is most frequent after the age of forty years, but it has been recorded in patients as young as twenty-five, and in individuals of seventy-five years ; it is three times commoner in men than women. This predilection of epithelioma for the tongues of men is usually attributed to the habit of smoliing. Epithelioma usually makes its appearance on one side ot the tongue, usually near its tip ; in a fair proportion of cases it begins on the dorsum, but always distinctly to one side of the middle line, and the beginning of the disease is always at some spot in the anterior two- thirds of the tongue. In a fair proportion of cases (twenty per cent.) epithelioma of the tongue is preceded by changes known as leukoplakia and ichthyosis : they are frequently referred to as pre- cancerous conditions. Ichthyotic patches upon the tongue do not necessarily ■ become epitheliomatous in every individual, and when epithe- homa attacks an ichthyotic tongue it does not always begin in the ichthyotic patch; indeed, epithelioma is sometimes seen on one side of the tongue and ichthyosis on the other. Evon after excision of an epitheliomatous tongue the stump may become ichthyotic and the disease not recur in it. Epithelioma when it attacks the tongue usually destroys life quickly ; the lymph glands in the neck are soon infected, and as a rule, the disease runs its course in about a year. The average duration of hfe varies from six to twenty-four months. 200 EPITHELIAL TUMOURS. Death ensues in a large proportion of cases from exhaus- tion, the result of pain, distress of mind, and difficulty in taking food ; in a few it occurs from septic pneunaonia, the r.esult of inhaling the fcEtid discharges from the mouth; a few die early from hsemorrhage when the ulceration opens up the lingual, or the carotid artery. Death is occasionally due to asphyxia. This may arise from two causes ; the epithelioma may extend to the base of the tongue and- infiltrate the epi- glottis and its folds, producing oedema of the glottis, or, a mass of enlarged glands in the neck may press upon the trachea and cause suffocation. In addition to the tongue and lips, epithelioma may begin in the mucous membrane of the cheek, the gums, soft palate, the tonsils, and pharynx. In the case of the cheek epithelioma is sometimes preceded by a patch of leukoplakia, as in the case of the tongue. The disease often starts close to the angle of the mouth, and extends backwards into the cheek ; or it begins in the fold of mucous membrane between the gum and the cheek, and occasionally it starts in the centre of the cheek, often on a level with the meeting-place of the crowns of the upper and lower molar teeth. Epithelioma may begin in any part of the gum, but it appears more frequently in the mucous membrane covering the lower than in that covering the upper alveolar processes. The disease often starts near the stump of a carious tooth, and quickly infiltrates the adjacent mucous membrane; thus, whilst it is eroding the bone, it is creeping along the mucous mein- brane towards the cheek on one side and the tongue on the other. It is astonishing how epithelioma erodes such a firm and compact bone as the mandible. Similar effects may be observed when the disease attacks the gums in relation with the maxilla ; as the alveolar process is destroyed the cavity of the antrum is exposed, and a foul ulcerating chasm formed. One of the facts connected with epithelioma of the mucous membrane of the mouth — and it matters little whether the disease begins on the tongue, cheek, hard or soft palate, or gums — is the extraordinary size which the infected lymph glands in the neck sometimes attain, whilst the ulcer scarcely exceeds 1 cm. in diameter. This is worth bearing in mind. EPITHELIOMA. ' 201 because an enlargement of the cervical lymph glands in individuals past middle age should always induce the surgeon to examine the various recesses of the mouth and fauces for small, inconspicuous epitheliomatous ulcers, and with every care they sometimes escape detection during life. It is neces- sary to emphasise this, because a good deal has been written about " branchiogenous cancer," or, as it is sometimes called, "malignant cyst" of the neck. The tumour is most com- monly observed after the age of fifty, and is deeply seated in the neck, usually near the fork of the carotid ; it grows with great rapidity, and in many cases softens in the centre and gives rise to fluctuation. The overlying skin becomes brawny and red, and the resemblance to an abscess is so striking that, in several cases, I have known a knife to be used under this impression. Gradually the implicated skin sloughs, and then an epitheliomatous chasm forms in the neclt. Microscopically the tissue of these tumours is characteristic of epithelioma. Some writers are of opinion that these are primary epitheliomata arising in remnants of branchial clefts. My belief is that, in most of .the cases, these gland masses are secondary to epithe- liomata originating in recesses of the pharynx or naso-pharynx, and the theory that they arise in remnants of branchial clefts is pure fiction. They run a rapidly fatal course : the average duration of life is about six months. These tumours resent interference, and in the few cases where patients have survived operation quick recurrence has been the rule. Treatment. — The results of the operative treatment of epi- thelioma of the tongue stand in striking contrast to those which follow operations for this disease when affecting the lower lip. The manner of removing an epitheliomatous tongue is modified according to the situation and extent of the disease. The excision of the anterior portion of the tongue, or the right or left anterior fourth of the organ when the disease is localised to one side, is an operation devoid of risk or difficulty. When the disease deeply invades the tongue, involves the floor of the mouth, or extends so far backwards that, in order to get beyond the limits of the disease, the surgeon interferes with the pillar of the fauces, then the operation is often hazardous. The chief difficulty is connected with haemorrhage, and in order to obviate it a variety of methods have been advocated for the 202 EPITHELIAL TUMOUES. excision of the tongiie. Tlius some prefer to slowly cnisli through the tissues with the wire or wire-rope of an ecraseur: others use a galvano-cautery ; many deliberately cut through, the tissues with scissors and seize the divided lingual arteries with forceps. It is a good plan (and one which has in my own practice been very successful) to tie both lingual arteries through incisions in the neck ; the tongue can then be cut out with scissors without any risk of haemorrhage. In this way infected submaxillary lymph glands, if any exist, can be dis- sected out through the same incisions, and it is sometunes convenient to remove the submaxillary salivary glands. The advantage of preUminary ligature of the lingual arteries is two- fold ; not only is it a guarantee against haemorrhage, but it so hmits the blood supply of the part that it reduces sloughing and fcEtor to a minimum and retards recurrence. The removal of the salivary glands relieves the patient of the profuse sahvation which is such a source of discomfort. When the disease is very extensive it is necessary to acquire space for manipulation by slitting the cheek. When the man- dible is involved the diseased part must be excised with the tongue, and in exceptional cases it is necessary to obtain a free removal of the floor of the mouth by means of incisions between the symphysis and the hyoid bone. Mr. Buthn, in his work on the "Surgery of the Tongue," mentions a score of methods that have been employed in dealing with epithelioma of this organ. It is an important point in operating upon the tongue to avoid the entrance of blood into the trachea, as it is then drawn, during inspiration, into the lungs and gives rise to septic pneumonia. Should blood in considerable quantity get into the trachea it niay cause suffocation. To avoid these complications it is useful, in extensive operations on the tongue, to perform laryngotomy and administer the anaesthetic through a laryngotomy tube, and in order to prevent blood from getting into the trachea, the pharynx is plugged with a sponge. The mortality of operations for the removal of epitheUo- matous tongues is not less than ten per cent.; the chief causes of death are haemorrhage, septic pneumonia, and asthenia. Although after excision of an epithelioma of the tongue, recurrence in the stump or cervical lymph glands within a EPITHELIOMA. 203 year of the operation is the rule, nevertheless it is in some cases delayed for five and even seven years. It is also useful to bear in mind that, in some cases, Avhere the disease is ad- vanced and too extensive to admit of removal, the pain may be relieved by division of the lingual nerve, and a few patients are rendered comfortable by ligature of the lingual and facial arteries. It- has been already mentioned that epithelioma occurring in the gums -will afterwards invade the mandible or maxilla, according to its situation. Although in the majority of in- stances in which the maxilla is implicated in an epithelioma, the disease begins in the gingival mucous membrane, there is a small number of cases in which patients past middle hfe complain of pain in the jaw for which no adequate cause can be assigned. Gradually a slight fulness is observed in the infra-orbital region, with perhaps, oedema of the eyelid; the skin becomes brawny, and at last an epitheliomatous ulcer appears in the skin of the cheek, and the antrum is then found to be filled with a tumour. When such a case is submitted to operation and the skin of the cheek reflected, the extensive in- roads the disease has been silently making on the surrounding parts is truly extraordinary. The greater part of the maxilla will be found destroyed, and outrunners from the growth will be found in the orbit and among the pterygoid muscles. The skin of the cheek is usually so infiltrated that it must be re- moved. The successful treatment of such cases demands much boldness on the part of the operator, as he will find it necessary to sacrifice the eye and the orbital contents, the palatine aspect of the maxilla, and a portion of the skin covering the cheek ; as a result, a large yawning cavern is left. Life is rarely pro- longed, but the patients are spared much pain and discomfort. This is the variety which Reclus* called " Epithelioma t^r^- ' brant," and is usually rendered in English as " Boring epithe- lioma." It is certainly an excessively malignant and extremely insidious variety of epithehoma. EPITHELIOMA. OF THE (ESOPHAGUS. This disease is four times more frequent in males than in females, and is most common between the fortieth and * Progres Medical, 1876, t. iv., p. 795. 204 EPITHELIAL TUMOURS. sixtieth years. It has been observed as early as the thirtieth year, and my oldest case was eighty-four. Certain parts of the oesophagus are more liable to be attacked than others; the usual situations are: 1, at the level of the cricoid cartilage ; 2, where it is crossed by the left bronchus ; 3, at its termination. Nothing is known of the early stages of oesophageal epithe- lioma, as it produces few symptoms until neighbouring struc- tures, such as the larynx, trachea, pleura, etc., are implicated. The disease runs a very rapid course; most cases terminate fatally within a year from the time the patient comes under observation. Death occurs in a variety of ways: inanition and exhaustion are the results of obstruction to the passage of food; pleurisy and septic pneumonia, due to perforation of the pleura and trachea. A fistula between the trachea and oesophagus is the rule in this disease. Mediastinal abscess, which may perforate the pleurae or pericardium, sometimes forms, and ulceration has been known to broach the aorta. When epithelioma begins at the commencement of the oesophagus, . the recurrent laryngeal nerves are apt to become entangled and cause paralysis of the laryngeal muscles. When the disease occupies the middle and lower parts of the oesophagus, the IjTuph glands of the mediastinum and lumbar region enlarge. When the upper third of the tube is implicated the mediastinal glands and those at the root of the neck are involved. It does not necessarily follow that the glands nearest the seat of disease are those most enlarged, for it occasionally happens that the neighbouring glands are apparently iinafl'ected, whilst those at some little distance are charged with epithehomatous material. For instance, in a case in which a man died from a large epithehoma of the middle third of the oesophagus, the mediastinal glands were slightly bigger than usual ; but in the neck, immediately above the clavicle, there was one hard gland, the size of a bean, just beneath the skin. The enlargement of this gland was regarded, in the presence of other signs, as an indication of the malignant nature of the oesophageal stricture. Dissemination is rare in epithelioma of the oesophagus. Treatment. — The pecuhar relations of the oesophagus render it impossible to carry out with any prospect of success EPITHELIOMA. 205 excision of an epithelioma. The inabiHty to swallow food and the almost inevitable fate, death from starvation, has induced surgeons to perform gastrostomy. The results of this opera- tion for oesophageal epithelioma are not encouraging. EPITHELIOMA OF THE LARYNX. When this disease originates in the mucous membrane of the ventricles, vocal cords, or ventricular bands it is said to be intrinsic. When epithelioma arises in the aryteno-epiglottic folds, or the mucous membrane covering the arytenoids or the inter-arytenoid folds, it is said to be extrinsic. • In addition, the larynx may be implicated in extensive epi- thelioma of the tongue, fauces, or upper part of the oesophagus. Intrinsic epithelioma of the larynx usually commences in one of the ventricles, and is almost invariably of the warty variety; it is particularly rich in ceU-nests, and these are exceptionally hornjr. The papillomatous character of intrinsic laryngeal epithelioma must be borne in mind, or it may lead to grave errors in diagnosis. The laryngeal wart is essentially a disease of children and young adults, whereas epithelioma is an affection of adults, especially men who have passed the ^ meridian of hfe. A wart-hke growth in the larynx of an individual over forty years of life should be viewed with suspicion. As a rule, ulceration and infection of lymph glands occur early in the coiirse of the disease. Laryngeal epithelioma is usually rapid in its progress ; death occurs in from twelve to eighteen months, and is rarely prolonged beyond two years. The fatal result is due to asthenia, which' is intensified by the difficulty these patients experience in swallowing, and pneumonia. Actual suffocation is obviated early in the course of the disease by tracheotomy. Extrinsic epithehoma of the larynx appears to be a far more formidable affection than the intrinsic form. It not only extends more rapidly and infects the lymph glands at a very early period, but implicates the surrounding parts far more extensively than the intrinsic variety ; the duration of life is therefore shorter. Dissemination is extremely rare in laryngeal epithelioma. Treatment. — It is of great importance to recognise early the nature of this grave disease of the larynx ; as a rule, there 206 EPITHELIAL TUMOUBS. is little difficulty in appreciating the extrinsic variety, but the papillomatous nature of intrinsic epithelioma of the larynx makes the diagnosis somewhat dubious in the early stages. Thus it is customary when there is an element of doubt as to the nature of a laryngeal growth in an adult, to remove a fragment by means of laryngeal forceps and submit it to microscopical examination. Acting on the principles that prevail in the treatment of epithelioma in other parts of the body, surgeons have in recent years (following the lead of Billroth, 1873) attempted to cure epithelioma of the larynx by excision. Unfortunately there is very little to urge in favour of complete extirpation of the larynx for intrinsic epithelioma ; it has been abandoned by most surgeons in the extrinsic form of the disease, and even for the intrinsic form laryngectomy is fast falling into disfavour. The operation has an excessively high mortahty, a very large proportion of the patients succumb to septic pneumonia, and the few that recover are often in a miserable and pitiable condition. Excision of a lateral half of the larynx for intrinsic epi- thelioma is a much more successful operation, and this is also true of the operation known as thyrotomy, in which the thyroid cartilage is divided in the median hue and the diseased soft tissues are dissected out or destroyed by a galvano-cautery. Although partial excision of the larynx is a fairly satis- factory operation, the opinion is gaining ground among surgeons that the needs of the patient are in most cases best satisfied by a simple tracheotomy. EPITHELIOMA OP THE PINNA. This is a very unusual situation for epithehoma. Some carefuUy described cases will be found in the records of the Pathological Society, London. The disease may begin in any part of this appendage. So far it has been mainly observed in individuals advanced in years, and attacks men and women equally. After destroying the pinna it attacl^s the bony wall of the skuU. Its disastrous effects are well illustrated in a case described by Hulke.* * Trans. Path. Soo., vol. xxvi. 187. {See also Bowlby, Hid., vol. xxxv. 330, and R. WiUiams, xxxv. 331.) 207 CHAPTER XXII. EPITHELIOMA {concluded). EPITHELIOMA OF THE GENITO-URINARY ORGANS. Epithelioma of the Scrotum or Chimney -Sweep's Cancer appears on the scrotum in the form of a wart or warts ; they are often spoken of as soot-warts, for they not only occur on the scrotum of the chimney-sweep, but are met with in men who are brought much in contact with soot. In many cases the scrotal wart is harmless, but in a certain proportion of cases it grows slowly, or if they are multiple, one of them becomes more prominent than its feUows and ulcerates. The ulceration, at first limited to the wart, extends to the surrounding skin and forms an epithelio- matous ulcer, which will extensively involve the skia of the scrotum, and spread thence to the skin around the anus and pubes, and even to the thigh. In some cases the ulceration, instead of spreading widely, involves the tissues deeply, so that the tunica vaginalis is exposed and sometimes implicated in the disease ; but this is rare. The inguinal glands become infected and attain a large size, then slowly involve the skin, break down, and ulcerate ; this process often leads to the formation of deep excavations in the groin, and it not iixfrequently happens that the femoral, or external iliac" artery, or both will be seen exposed and pulsating on the floor of one of these deep pits. It is not uncommon in such cases for the ulceration to open up one of these large vessels, and violent fatal haemorrhage is the result. It has been stated by several writers that in chimney- sweeps epithelioma may begin in the inguinal glands. There can be little doubt that such views arise in imperfect observation. In some of these cases the lesion on the scrotum assumes the form of a small hemispherical pimple no larger than a split pea, so small indeed that I have known them to escape very vigilant eyes ; and yet such a small lesion will 208 EPITHELIAL TUMOURS. cause the inguinal glands to grow into a mass as big as two fists. Two such" cases have come under my own notice. A very remarkable feature connected with epithelioma in EngUsh chimney-sweeps is, that they are not more prone to it in other parts of their bodies than those persons who follow other occupations ; yet the scrotum, which in other individuals is the part least disposed to epithehoma, is in sweeps so veiy hable to become the seat of this disease. No answer to this problem is at present forthcoming ; neither has anyone suc- ceeded in assigning a reason why it is so very much more frequent in English chimney-sweeps than in sweeps of other nations.* There is good reason to believe that tar and paraffin are liable to produce an affection of the scrotum, similar to the epithelioma of chimney-sweeps. Such cases are, however, very rare. The literature has been summarised by Butlin.t Treatment. — This consists in the free removal of the disease whenever it is practicable ; the very best results follow the excision of a soot- wart in its earliest stages. When the disease is permitted to extend deeply into the tissues of the scrotum so that it is necessary to excise one or both testicles with the scrotum, and perhaps a portion of the neighbouring skin, it is not probable that lasting benefit will follow the operation. In cases where soot-warts have been early and thoroughly removed there is good ground for the behef that a cure is sometimes brought about. Epithelioma of the Penis and Urethra. — Epithehoma may attack the prepuce or the epithelial investment of the glans. The disease is excessively rare before the age of thirty years, and appears to be most common between the ages of fifty and seventy. There is reason to believe that phimosis, congenital and acquired, is a condition that favours the development of epithelioma of the penis. It is certainly true that phimosis, by leading to the retention of smegma, is indirectly a cause of penile warts not only in men but other mammals, especially horses and bulls. Mention has already been made of the fact that penile warts are particularly prone to be transformed into wart horns, and cases hav5 been recorded in which men * Butlin, Brit. Med. Journal, 1892, vol. i. 1341. t JBrit. Med. Journal, 1892, vol. ii. p. 68. EPITHELIOMA. 209 have had a wart horn on the penis for several years, and at length the base has ulcerated and epithelioma developed. Gould* has described a good example of this, which is further pecuHar in that the wart and ulceration appeared to start in a scar left by circumcision. It must be remembered that epithe- lioma may begin as an ulcer on the penis, but the warty variety is by far the most frequent. When the disease begins as an ulcer it is very liable to be mistaken for some manifestation of primary or tertiary syphilis. Epithelioma in whatever form it commences gradually involves and as surely destroys the penis, imphcates the scrotum, and infects the inguinal lymph glands on each side ; in many cases the lumbar glands also become infected. Secondary deposits seem to be rare. The duration of life in this disease is very uncertain. As a rule, its course is short — six months to a year ; but in many cases it is much longer. When the urethra is involved this passage is liable to become narrowed, and not infrequently urinary fistulse add to the patient's misery. Epithelioma of the Urethra. — Judging from the scanty records obtainable, primary cancer of the urethra is very rare. It is possible that the disease is more frequent than we imagine, as it is an affection very likely to be mistaken for perineal abscess. The disease in all the recorded cases commenced in that section of the tube which is in relation with the bulb. In the reported cases where the details are given with sufficient care, and the nature of the tumour is confirmed by microscopical examination, the features of the disease are as follows : — The patients were men between the ages of fifty and seventy-three ; they had all suffered from gonorrhoea in youth, but urethral stricture did not follow as a sequence. The trouble began by the formation of a hard mass in the perineum in relation with the bulb and corpora cavernosa. This mass led to interference with micturition, and attempts to pass a catheter provoked intense pain and free haemorrhage from the urethra. The obstruction increased until the urethra became impermeable to instruments, the overlying skin was involved, and fistulse formed in the perineum. In most of * Trans. Path. Soc, xxxviii. 355. 210 EPITHELIAL TUMOURS. the cases perineal section was performed, and the cut surface of the tumour had a greyish- white appearance, and the tissue was extremely brittle. This tissue presented under the micro- scope the characters typical of squamous-celled epithelioma with abundant cell-nests. As a rule, the lymph glands are not enlarged, and secondary deposits are rare.* Treatment.— Epithelioma of the penis is treated by partial or complete removal of this organ according to the extent of the disease. Partial removal of the penis, whether by knife, cautery, or ecraseur (of the three methods that in which the knife is employed is the best) is a simple proceeding, and entails but little risk so long as the cut end of the urethra is stitched to the skin. When the disease is so extensive as to. demand complete removal of the penis, the operation which gives best results consists in excising not only the corpus spongiosum and corpora cavernosa, but the penile crura as well by detaching them from the pubic arch. The urethra is brought otit and attached to the incision in the perineum. The published results of this complete operation are very good, and my experience of it has been in every way satis- factory. The ultimate results of amputation of the penis are more favourable after partial than after complete removal of organ, simply because the disease is not so advanced when partial amputation is sufficient. In regard to epithehoma of the urethra, sufficient evidence is nbt yet accessible to enable a decision to be formed as to the most appropriate treatment. Epithelioma of the Bladder. — Epithelioma occasionally attacks the vesical mucous membrane, and it does not appear to exhibit a predilection for any particular part of it. From what is known of the habits of this disease elsewhere, it would be anticipated that in a certain proportion of cases it would begin at the orifices of the ureters. This is actually the case ; but it must not be assumed that when the ureteral orifices are found involved in the late stages of the disease that the epithelioma originated at these orifices. Epithehoma of the bladder seems to be more common in women than in men. The signs of its presence are hsematuria, * J. Griffiths, Trans. Path. Soc, vol. xl. 177 ; Marcus Beck, " International Clinics," vol. ii. 256 ; and Witsenhausen, Bruns, Beitrage, bd. vii. 571. EPITHELIOMA. 211 painful micturition, and cystitis. Sucli signs are, of course, equivocal, and it is usual to demonstrate its existence by means of the cystoscope, or a cystotomy in men, and dilatation of the urethra in women. It is very unusual before the age of forty. Death results from renal complications, exhaustion from repeated bleeding, bodily suffering, and frequent micturition. Epithelioma of the Female Genitalia.— The female genital organs liable to epithelioma are the labia major a and minora, the clitoris, vagina, and that portion of the cervix of the uterus which projects into the vagina. Collectively, epithelioma of these parts is by no means in- 'frequent; when each part is individually considered, epithelioma is somewhat rare. This disease is more frequent in the labia than in all the parts of the genital passage taken together. The Labia Majora and Minora. — Epithehoma may begin in any part of the labia ; its course, relation to lymph glands, and modes by which it causes death are very similar to epithe- lioma of the scrotum. It iis a curious fact that two cases of' cancer of the labium have come under my notice in patients who were wives of chimney-sweeps. The Clitoris. — Epithelioma of this organ is very rare indeed. In the only case that has come under my notice the disease began at the extremity of the chtoris ; the lymph glands in each inguinal region were enlarged. Vagina. — Epithelioma may make its appearance in any part of the mucous membrane lining this canal, but it is much more liable to begin at the junction of the vagina with the vulva, and on that portion which is reflected over the uterine cervix. In many cases in which the yulval extremity of the vagina is invaded by epithelioma the disease begins at, or in close proximity to the urethral orifice and extends into the vagina. In such cases, the inguinal lymph glands are infected very early, and the ulceration destroys the vesico-vaginal septum and perforates the posterior wall of the bladder. When the posterior wall of the vagina is the seat of epi- thehomathe recto-vaginal septum becomes infiltrated; ulcera- tion ensues, and leads to the formation of a recto-vagina, fistula. It is very remarkable that in its early stages epithelioma produces such slight inconvenience that the patients rarely 212 EPITHELIAL TUMOURS. seek advice until the disease has long passed beyond the hounds of operative interference. This is especially the case when it attacks the vaginal portion of the cervix uteri, and it is on this account that so few opportunities arise for studying its early stages. The epitheUal investment of the uterine cervix derived from the vagina is continuous, at the margin of the os uteri, with the columnar cells lining the cervical canal. The layer of squamous epithelium covering the vaginal surface of the cervix has been compared to " a tailor's thimble which fits on the lower end of the cervix proper " ( Wilhams). Epithelioma may begin at any point from the os uteri to the vaginal vault. In the earliest stages at which it comes under observation the disease assumes the form of a circular ulcer with raised and everted edges, as is seen in many epithehomata of the lips ; sometimes it erodes deeply from the beginning ; and excep- tionally it forms luxuriant cauliflower excrescences. Thus in its naked-eye characters, as well as in its minute structure, epithe- lioma of the vaginal portion of the uterine neck does not differ from this form of tumour in other regions of the body. Gradu- ally the disease extends from the cervix to the vaginal wall; it rarely extends into the cervical canal, but it quickly involves the connective tissue of one or both broad ligaments. Gradually the structures implicated by the disease ulcerate and necrose. When these destructive changes involve the anterior vaginal wall the bladder is apt to be perforated, and a urinary fistula adds to the misery of the patient. In a similar way, when the disease invades the posterior wall of the vagina the rectum may be perforated. In some cases, in the later stages, when the upper segment of the vagina is destroyed, the bladder and rectum may both communicate with a foul ulcerating chasm. Epithelioma of the cervix is unusual before the age of thirty, and is most common between thirty-five and fifty-five. Treatment. — When epithelioma attacks the labia and its nature is recognised before it has had time to spread very extensively, the affected tissues must be freely removed with knife and cautery. Should the inguinal lymph glands be enlarged, they must be dissected out. In the rare instances in which the clitoris is attacked with EPITHELIOMA. 213 epithelioma it is the usual practice to dissect out this append- age with its crura. In the case of the vagina the patients very rarely submit themselves to observation at a sufficiently early stage of the disease to allow a satisfactory operation to be per- formed. When epithelioma spreads to the recto-vaginal, or the vesico-vaginal septum, the removal of the disease will lead to the formation of a fistula between rectum and vagina, or between bladder and vagina, and thus anticipate, in a measure, those distressing complications which are almost sure to be produced in the course of the disease. When epithelioma attacks the vaginal portion of the uterine cervix and is seen early, prompt removal of the cervix will do much to delay the progress of the disease. Operations of this kind have a limited application, because they can only be carried out when the disease is very restricted, on account of the close proximity of the bladder to the anterior surface of the cervix. Recurrence usually begins at the cut edge of the vaginal mucous membrane and spreads into the vaginal fornices. Removal of a limited epithelioma from the cervix is attended with very little risk to hfe. EPITHELIOMA OF THE ANUS is about equal in frequency to this disease in the scrotum and labia. It is more frequent in women than in men, and " rarely begins before the fortieth year. In about half the cases the inguinal glands are affected on one or both sides. Wlien seen in the early stages and its nature recognised, epithehoma of the anus admits of free and complete removal, and the results of such interference are admir- able. In cases where the disease runs its course life is rarely prolonged beyond twelve months ; whereas in cases where the growth is satisfactorily removed life has been prolonged several years (five to eight). In cases where the disease cannot be extirpated, the patients are sometimes made more comfortable by diverting the course of the fasces. , EPITHELIOMA OF SCARS. Surgeons have long been aware that scars left by burns are Hable to become the seat of epithehoma, especially when situated on the Hmbs. Scars upon the legs are more prone to 214 EPITEELIAL TUM0UB8. this disease than those on the arms. When epithelioma attacks a scar the change usually begms near the junction of the skin and cicatricial tissue ; in some caseg the disease extends along this margin and encroaches but little upon the skin on one side, or the scar on the other ; more commonly the whole cicatrix is quickly involved, and a large ulcerating surface with raised rampart-hke edges results. Histologically, this variety of epithelioma is identical with that which occurs ori the lips ; it involves adjacent tissues and the underlying bone, infects the neighbouring lymph glands, and recurs locally after removal. When a limb is the seat of epithelioma, and amputation is performed, the disease is apt to recur in the stump. Scar epithelioma is usually less malignant than the same disease in the lips, tongue, anus, or scrotum. Many chronic ulcers occurring in connection with scars in adults are often clinically described as epitheliomata. In collecting evidence relating to this question no case should be classed as a scar- epithelioma unless the diagnosis is confirmed by a carefvl ' histological examination. Lupus scars are also liable to epithelioma. Bayha* has published some good observations, in which he points out that this sequel of lupus is most prone to occur between the fortieth and the sixtieth years ; it has, however, been observed in a patient of fourteen years. Epithelioma of lupus scars has been * most frequently seen on the face, and in a very large proportion of cases it affects the skin near the malar bone. Treatment. — When epithelioma attacks scars situated on the limbs it is the usual practice to perform amputation and the results are satisfactory. When the disease occurs in scars seated on the face, free removal with the knife and sharp spoon, accompanied by thorough destruction of the impHcated tissue by means of the cautery, gives the best resiilts. EPITHELIOMA OF THE CONJUNCTIVA. ' It is very rarely that epithelioma attacks the conjunctiva ; when it occurs in this mucous membrane the disease makes *Bruns, Beitriige.hd. iii. , s. 1 ; and Berry, Trans. Path. Soc, vol xlii. p. 308. EPITHELIOMA. 215 its appearance as a pimple, or phlyctenule, at the corneo- sclerotic margin on the outer side of the eyeball. The majority of cases of epithelioma of the conjunctiva occur after the fiftieth year, but it has been reported in a patient twenty-seven years of age, in whom it supervened upon an injury ; the man received a scratch upon the conjunctiva from a branch of a tree, and a few months later a small tumour arose between the caruncle and the comeo-sclerotic margin * In the early stages epithelioma restricts itself to the conjunctiva, but infiltrates the whole thickness of this mem- brane ; even in the later stages it shows little tendency to implicate the cornea or sclerotic, but invades the eyeball at the point of junction of the cornea and sclerotic. Two examples of conjunctival epithehoma that came under my own observation occurred in the cicatrices left by injuries caused by hme. In one case the eye had been useless many years. The tumour rarely exceeds a nut in size, but before it attains the dimensions of a pea it ulcerates and assumes the appearance characteristic of an epithehomatous ulcer elsewhere. When the tumour is excised, quick recurrence is the rule. When it infects lymph glands it is the pre-auricular set which enlarge, and afterwards those in the submaxillary region. Treatment. — As the disease usually recurs very quickly when the conjunctiva alone is excised, it appears advisable to remove the disease thoroughly by excising the eyeball with the conjunctiva. When the eye is useless in consequence of an old injury, such as a lime-burn, there should be no hesitation in sacrificing the globe. If the pre-auricular and submaxillary lymph glands are enlarged, they should be enucleated at the same time as the globe. EPITHELIOMA OF THE GALL BLADDER. There is a fair number of cases recorded in medical literature under the name of cancer of the gaU bladder, but it is an unfortunate circumstance that very few of the specimens have been submitted to careful microscopical examination. Of the few that have been thus investigated * Lagrange, " De I'epithelioma de la conjunctive bulbaire." Soc. Franijaise d'Ophtalmologie, 1892, p. 71. 216 EPITHELIAL TUMOURS. the tumours seem to be epitheliomata rather than cancers; hence it will be convenient, until more careful reports are forthcoming, to deal with "cancer" of the gall bladder m this chapter. ' . r\-.^ The disease presents itself as a uniform thickenmg ot the walls of the gall bladder, which causes it to assume a pyritorm Fig. 105. — Epithelioma of the gall bladder. (Museum, Middlesex Hospital.) shape and project from the under surface of the liver. In some few cases the tumour has attained the dimensions of a large fist. In the early stages the disease is confined to the gall bladder, but later it invades the liver, and sometimes the duodenum and stomach. When the tumour is bisected it presents the characters displayed in Fig. 106. In the middle of the tumour there is usually a chamber containing biliary calculi, representing the original cavity of the gall bladder. EPITHELIOMA. 217 It is an interesting fact that calculi are found in more than three-fourths of the cases. Dissemination is rare. When it occurs, the secondary nodules are found in the liver. In several cases the peri- toneum has been infected, its surface being dotted with an innumerable number of minute miliary knots. A case of this kind came under my own notice ; there was hydroperitoneum. The lymph glands in the hilum of the liver are often infected. The 'chief chnical features of " cancer " of the gall bladder may be thus summarised : — ^ The disease is most frequent between the fortieth and sixtieth years. Jaundice is the exception, and probably occurs in less than one-third of the cases. The chief signs are the presence of a hard but tender tumour in the region of the gall bladder accompanied by epigastric pain.* * Musser has collected the chief cases in the Boston Med. and Surg. Journal, DficemlDer 16, 1889 ; and Norman Moore, " Visceral New-Growths," p. 39. 218 CHAPTER XXIII. ADENOMA AND CAKCINOMA, An adenoma may be defined as a tumour constructed , upon the type of, and growing in connection with a secreting gland, but differs from it in being impotent to produce the secretion peculiar to the gland it mimics. (Fig. 106.) Adenomata occur as encapsuled tumours in such glands as the mamma, parotid, thyroid, and liver ; in the mucous membrane of the rectum, intestine, and uterus they are pedunculated. A single adenoma may be present, but not infrequently two or more exist in the same gland. In the case of the intestine a score or more may co-exist in the same individual. In size they vary greatly; some are no larger, than peas, whereas in certain situations — e.g., the mamma — an adenoma will occasionally attain the dimensions of a man's head, and in the case of the ovary an adenoma weighing forty pounds is no rarity ; in such the acini are usually distend^ed vdth fluid. The effects of adenomata depend mainly upon the situations in which they grow. The following statements axe true for all : — When completely removed there is no fear of recurrence ; they do not infect neighbouring lymph glands, nor give rise to secondary deposits. When an adenoma causes death, it is in consequence of mechanical complications, depending on the situation and size of the tumour. The dangers to be apprehended from adenomata will be mentioned with each species. Although the distinguishing structural peculiarity of an adenoma is the presence of epithehum disposed as in a secreting gland, the connective tissue (stroma) entering into its com- position must also be taken into account. In many adenomata the epithehal element is the most conspicuous ; in others the connective tissue is out of all proportion to the epithelium,' and occasionally preponderates to such a degree that the tumour from some writers receives the misleading name of " adeno-sarcoma." When the epithelium-Uned spaces are ADENOMA AND CARCINOMA. 219 distended with fluid the tumour is spoken of as a cystic adenoma (adenocele). The chief species of adenomata are : Mammary. Renal. Sebaceous. Ovarian. Thyroid. Testicular. Pituitary. Gastric. Prostatic. Intestinal. , Parotid. Fallopian. Hepatic. Uterine. Carcinomata are tumours that always grow from pre- existing gland tissue and mimic the parent gland, but they ■ Fig. 106. — Section of an adenoma from a child's rectum. (Highly magnified.) differ from adenomata in the fact that the structural mimicry is incomplete ; the epithelial cells, instead of exhibiting the regular disposition so constant in those tumours, are, in the cancers, collected in the acini and ducts in irregular clusters, or fill them so completely as to give rise to the appearance of 220 EPITHELIAL TUMOURS. sections of columns of epithelial cells when seen under the microscope. (Fig. 108.) As in the case of adenomata, there are species of carcino- mata depending upon the relation of the epithelium to the stroma of the tumour. Each of these will be considered when the various species are described. Carcinomata arise in every secreting gland that gives rise to an adenoma ; but they are very common in some glands and exceedingly r^re in others ; indeed, those glands which are the most frequently affected with adenoma are the most liable to carcinoma, with the exception of the ovary. The chief species of carcinoma 'are ■.■^— Mammary. Kenal. Sebaceous. Ovarian. Thyroid. Testicular. Prostatic. Gastric. Parotid. Intestinal. Pancreatic, Fallopian. Hepatic. Uterine. Cancers are not encapsuled, but infiltrate surrouncdng tissues and pass beyond the glands in which they originate ; they are very prone to involve the superficial tissues, ulcerate, and quickly infect the lymph glands in their neighbourhood. A marked feature of carcinomata is their great tendency to undergo degenerate changes and necrosis. The rapidity with which the lymph glands are infected is due to the abundance of lymphatics in most species of cancer. Dissemination. — Cancers are exceptionally prone to become disseminated ; the secondary growths may make their appearance in any organ or tissue, and not infrequently in the bones. The cancer germs that give rise to these secondary nodules are transported by lymph and blood-vessels, and when these minute emboli are lodged in suitable situations they nmltiply, giving rise to a growth which, in its histological features, exactly resembles the parent tumour. So faithful is this reproduction that the nature of the primary tumour can often be correctly inferred from a microscopic examination of a secondary nodule. The amount of dissemination varies greatly. In some cases secondary deposits will be found only in the liver, whilst in ADHNOMA AND CAEGINOMA. 221 another and apparently identical case, in so far as the structure of the tumour is concerned, secondary knots occur in almost every organ of the body, including the skeleton. Secondary deposits of cancers are not always so small as merely to merit the name of knots, but form occasionally tumours of some magnitude, and may even excel in size the primary tumour. MAMMARY ADENOMA AND CARCINOMA. Adenomata. — There are two varieties of mammary ade- noma: — 1, Fibro-adenoma ; 2, Cystic adenoma (adenocele). 1. Fibro-adenomata 'Occur as spherical or oval tumours, furnished with distinct capsules, lodged in the superficial parts of mamma; ; exceptionally they may be situated deeply in the breast substance. As a rule, they are firm and elastic to the touch, and sHp about under the examining finger. It is not rare to find a fibro-adenoma in each mamma, but it is unusual to find more than one tumour in the same gland. When occupying a superficial position they will, even when small, project the skin so as to cause an irregularity in the contour of the breast; very exceptionally they may be pedunculated. Although the majority of mammary adenomata do not exceed the dimensions of a walnut or a Tangerine orange, some are as big as cocoa-nuts. Structurally they consist of fibrous tissue in which glandular acini are embedded ; the tumour itself is isolated from the surrounding gland tissue by a thick capsule. 2. Cystic Adenomata. — These tumours often attain a very large size, and specimens now and then come under observa- tion weighing ten or twelve pounds. Like fibro-adenomata . they are encapsuled, and have a fibrous stroma with glandular acini embedded therein; but the acini are dilated so as to form epithelium-lined cavities, from the walls of which papilloma- tous processes project and form what are known as intracystic growths. The size and number of the cavities and the amount of intracystic growth vary greatly in different cases. This variety of adenoma grows slowly, and produces very little disturbance of the health ; by pressure it induces atrophy of the true gland tissue, which in some cases becomes reduced to exceedingly small proportions. Adenomata occur at any age from puberty to the fiftieth 222 EPITHELIAL TUMOURS. year— that is, during the period of sexual activity. Fibro- adenomata are most common between the ages of twenty and thirty, whereas the cystic adenomata are most common after the thirtieth year. The small fibro-adenomata are frequently sources of pain and inconvenience, especially during menstrua- tion. Most patients experience pain and discomfort when the tumour is handled. Both varieties of mammary adenomata occasionally occur in young men. Cystic adenomata are rarely a source of pain, but they may become inconvenient when very large. In a case under the care of Stanley the patient had had a tumour of the breast twelve years. It gradually became pendulous, and when she sat the breast rested in her lap. At last the integument sloughed; the breast was then removed by cutting through the pedicle. It is not uncommon to find in the breasts of unmarried women between the twenty-fifth and the thirty-fifth years, small rounded bodies that are extremely painftil when pressed. These often convey to the finger an impression similar to that imparted by a small fibroma. They are most common around the periphery of the areola, but they occur in aU parts of the breast. When dissected out they have a corymbose appearance, and are composed of tiny cysts continuous with the mammary tissue. They are often a source of distress to nervous women ; otherwise they are of no importance. Carcinomata. — There are two varieties of mammary cancer — namely, acinous cancer and duct cancer. 1. Acinous Carcinoma. — This variety presents much histo- logical diversity, which has led to great confusion in surgical writings. In the most typical form it occurs as a solitary hard, tumour (so hard as to obtain the name of scirrhous cancer) situated at the base of the nipple ; but it may occur at any part of the gland, even at its periphery. When the tumour is near the areola it will often induce retraction of the nipple ; when situated in other parts of the breast it will lead to dimpling and puckering of the overlying skin. On section such a tumour has the appearance and consist- ence of an unripe pear ; microscopically, it will be found to con- sist of columns of epithelial cells, disposed like the lobules of the gland, embedded in dense fibrous tissue. The tumour has EPITHELIOMA. 223 no capsule, and fades away indefinitely into the surrounding tissues. When the parts beyond the tumour are examined, isolated collections of cells will often be detected. ¥i« 107 -Cancer of the breast ; the dotted line indicates the extent to which the "■ • nipple and areola have retracted. In other cases the tumour will be only moderately firm, and on section exhibit a succulent appearance. When micro- scopically examined it presents alveolar spaces hned with epithelium, here and there raised into irregularly-shaped heaps Such cases are difiicult to, distinguish from adenomata ; but when the sections are attentively examined, parts will be found in which the alveoH are completely filled with irregularly-shaped epithelial cells. In many examples of mammary cancer the tumour, when bisected, appears to the naked eye merely hke a tract of , 224 EPITHELIAL TUMOURS. cicatricial tissue, and feels as hard as cartilage ; when examined microscopically it will be found to consist of strands of fibrous tissue enclosing here and there a few epithelial cells. This variety is sometimes spoken of as "withering" or contractmg scirrhus ; it runs a much slower course than the precedmg kinds, and gradually, by its contraction, causes the gland to shrivel, so that at length the patient presents an appear- ance as if the breast had been removed. Some of these cases have been known to last ten and even fifteen years. t .. --"^ t • « + * ft Wv Fig. 103.— Section finm a mammary cancer. {Highly magnified.) Clinical Features. — Acinous cancer of the breast never develops before puberty, and is very rare before the age 6i thirty ; it is most common between forty and fifty ; after fifty it gradually becomes less frequent, and is rare after seventy. I have seen it in a woman ninety years of age. This variety of breast cancer occurs in the single as well as the married ; in the sterile as well as in those who have had many children ; in women who have nursed their offspring and in those who have never given suck. It also attacks the male ADENOMA AND CARCINOMA. 225 breast. Mammary cancer is one hundred times more frequent in women than in men. It usually attracts attention as a circumscribed hard lump in the mamma ; it never forms a large ■ tumour — indeed a mammary cancer rarely exceeds the dimensions of a fist. The rate of growth may be slow, often extremely slow, especially in old individuals. When cancer appears during lactation it progresses with frightful rapidity. As the tumour increases in size it infiltrates surrounding tissues, becomes adherent to the fascia of the pectoral muscle, , and even infiltrates the muscle ; at the same time it implicates the subcutaneous tissue. These infiltrated tissues shrink and cause the cancerous breast to become smaller, often much smaller, than its fellow. This fact is illustrated by Fig. 107. The general shrinking of the breast is an important factor in diagnosis, and must not be confounded with retraction of the nipple, which is of no diagnostic import, as it occurs under a variety of conditions. Lymph gland infection occurs early in cancer, and is an important clinical sign. The glands of the axilla which run parallel with the free border of the greater pectoral are first affected, but the infection quickly extends to and involves the whole set, and in later stages, the glands lying in the posterior triangle of the neck immediately above the clavicle enlarge. It by no means follows that because a tumour of the breast is unassociated with large lymph glands the tumour is not a cancer. By the time the glands are sensibly enlarged the tumour has made its way towards the surface, and at last the skin involved in the growth ulcerates. The advent of ulcera- tion is heralded by a purplish or bluish appearance of the skin, which sometimes resembles a recent cicatrix with veins radiating from it, or the surrounding skin may be dotted with small knots of the size of a split pea or even larger. After the skin breaks, the ulcer tends to spread, and soon assumes the typical appearance of a cancerous ulcer ; its edges are raised and rampart-like, and surround an irregular depression, the floor of which is formed of firm granulations, discharging a foul ichorous or blood-stained fluid.* • T. "W. Nunn. in his wmk, " On Cancer of the Breast," Lcmdon, 1SS2, gives some admirable and life-like illustrations of the various stages of maminaiy cancer. 226 EPITHELIAL TUMOURS. Paw.— There is no symptom more variable in mammary cancer than pain. A large proportion of patients experience no painful sensations whatever, and are absolutely ignorant of the presence of any disease in the breast until their attention is arrested by some irregularity in its outline, or some marked difference in the comparative size of the two breasts, or it is accidentally observed by a friend. In others the pain is so severe that the patients suffer torture so intense that only the imagination can suggest parallels. In some the pain is localised, but in others it radiates from the tumour to the surroundmg parts. Pathology has totally failed to furnish an explanation why, in two patients of about the same age, temperament, and character, each having a tumour in the breast in corresponding situations, and in structure identical, one should suffer anguish too terrible to describe, and the other be absolutely free from pain, and often devoid even of any feeling of discomfort. Concurrently with, but more frequently subsequent to, infection of the lymph glands secondary deposits occur in the viscera, especially the liver and lung ; but any organ may be the seat of deposit. When the liver is attacked it enlarges, and there may be hydroperitoneum, rarely jaundice ; deposits in the kings and pleurae set up pneumonia and pleurisy. When effusions occur in the pleurae, peritoneum, or pericardium, as a result of cancerous infection, the fluid is often blood-stained. Secondary deposits in the brain give rise to mental aliena- tion and coma. Deposits in the bones cause " spontaneous " fracture, and when the vertebral column is imphcated para- plegia preceded by acute suffering is the usual consequence. Enlarged glands and secondary deposits may so involve large vessels and lymphatic trunks in the axiUa as to produce solid oedema of the arm. It must also be remembered that in the late stages of the disease the tissues covering the thorax may be infiltrated, and this local extension may implicate the ribs and directly infect the pleura. One of the rarer effects of secondary deposits is when they break out in a great number of small knots over the skin on the front of the chest and both breasts, and induce such PLATE v.— Cuirass Cancer. The Right Breast had been amputated two years. The Right Arm is in the condition Icnown as "Lymphatic" CEdema. ADEJSrOMA AND OARGINOMA. 227 induration of the skin that it becomes so rigid as to resemble a firm leather shield, a condition which has earned for it the name of "cancer en cuirasse." In this extreme condition the skin is so firm and hard that it is impossible to wrinkle it. (Plate V.) This peculiar condition is probably due to cancerous invasion of the cutaneous lymphatics. As the cancer extends locally and ulcerates, and more especially when there is evidence of secondary deposits, the patient's health begins rapidly to decline and the tissues to waste. It is, however, astonishing how women with breasts infiltrated with cancer, or eroded by large and foul ulcers, will sometimes be able to get about and busy themselves with household matters ; and this state of things will continue for many months, perhaps until the supervention of pleurisy, pneumonia, or some comphcation due to the dissemination of the cancer incapacitates them and extinguishes life. Lymphatic (Edema. — This occasional complication of mammary cancer must be considered on account of the in- convenience and distress it produces. It is a condition which cannot be mistaken. The cedema usually becomes manifest in the skin about the shoulder, and gradually extends to the skin of the arm, and in due course involves the forearm and hand ; the skin covering the scapula is also implicated. The limb in typical cases has a swollen appearance as though anasarcous, but when the skin is pressed, instead of pitting on pressure it will be found firm, brawny, and unyielding. The limb grows extremely heavy, and the patient finds it necessary to support it in a sling ; exceptionally the weight of the Umb prevents the patient from talking walking exercise, and usually produces a moderate degree of lateral curvature of the spine. The connective tissue may be so infiltrated with lymph that the skin becomes so tense as to prevent movement at the wrist, elbow, and shoulder; under such conditions the arm resembles a cast rather than a living hmb, and is absolutely useless. When the tissues of such a limb are examined immediately after death, it will be noticed that the increase in size is duo to infiltration of the subcutaneous tissue with lymph, which causes the cut surface to resemble in colour and in texture the pulp of a succulent orange, and large quantities of lymph 228 ' EPITHELIAL TUMOURS. flow from tlie incisions. The muscles are smaller than natural and infiltrated with fat. In the character of the fluid which exudes from the limb, and the firmness of the infiltrated connective tissue, it resembles the oedema characteristic of myxoedema. In the condition we are considering, the obstruction to the lymphatic circulation of the upper limb is due to the pressure of lymph glands infiltrated with cancer, or to secondary nodules lying in the course of the main lymphatic channels at the apex of the axilla. Exceptionally it comphcates the rare form of cancerous dissemination known as cuirass cancer. Lymphatic cedema of the upper limb may supervene in, patients with cancerous breasts who have never been sub- mitted to operation, in those in which the axillary lymph glands were removed when the breasts were amputated, and in those whose axillas were not interfered with. Many more cases have come under ray notice in the right -than in the left arm. Paiu is experienced in the limb by most of the patients, and it is often very severe. This is due not to the oedema, but to the enlarged glands or cancerous nodules pressing on the cords of the brachial plexus or their branches. 2. Duct Carcinoma. — Towards the approach of the meno- pause the breast enters into a resting stage ; its glandular structures atrophy, and nothing but ducts remains. Breasts in this condition often present on their deep surfaces large numbers of cysts varying in size from a mustard seed to a cherry. These are often called involution cysts, and are filled with mucoid fluid which causes them to assume a bluish tint when the breast is examined after its removal from the body. The cysts are most abundant on the deep surface of the gland. Cystic breasts of this kind are most frequently met with between the fortj'-fifth and fifty-fifth years. In sterile women they occur somewhat earlier, and as a rule, both breasts are affected. When cystic disease of this kind is more advanced in one breast than the other, it is apt to be mistaken for diffuse cancer. It is quite exceptional for this variety of cystic disease to give rise to pain. Cystic mammary glands of this character require attentive study because the walls of the dilated ductus are occasionally the starting-points of cancer ADENOMA AND CAECINOMA. , 229 [n rare instances villous processes, or papillomata. sprout from ;he walls of such C3'^sts, particularly when the cysts represent iilated lacteal sinuses. When cancer arises in dilated mammary ducts it is now customary to speak of it as duct cancer. This variety occurs most frequently in the terminal ducts and especially in the impullse (lacteal sinuses), usually as a single tumour ; occasion- ally several isolated nodules are present in the same gland. The tumour is in some cases no larger than a walnut, but may be as big as a child's fist. When situated near the skin it assumes a deep red or even purple colour. Seen in section, the cancer will be found provided with a distinct capsule (the dilated duct), whilst the mass within projects as a soft red outgrowth from the cyst-wall; some- times this is so large as completely to occupy the cavity. When this intracystic growth is examined microscopically it will be found to consist of glandular spaces, lined with regular columnar or subcolumnar epithelium. Sometimes the intra- cystic mass takes the form of villous processes, like those sometimes met with in the bladder. Such are termed duct papillomata of the mamma. (Fig. 89). Clinical Features. — Duct papilloma and duct cancer ap- pear most frequently between the age of thirty-five and sixty-five. The tumour is always softer than in the common, or acinous, variety. When seated near the skin it assumes a dark-red or even purple tint, and has even been mistaken for a melanoma. The nipple is not retracted, but may be in- verted. This is, however, a sign of no value. In a very large proportion of cases there is an abundant discharge of blood- stained fluid from the nipple. The tumour grows very slowly, rarely implicates the lymph glands, and exhibits very little tendency to recur or to become disseminated. It is the least malignant variety of manunary cancer. Literature.— T\x& best reported cases of duct cancer wdl be found in the Trans. Path. Soc, vols, xxxvii, xxxvui., xxxix., xl., and xli. See also Bowlby, St. Earth. Hosp. Rep., vol. xxiv., 263. Treatment.— The removal of a fibro-adenoma ot the mamma is such a simple proceeding and so devoid of risk that it is the mode of treatment ahnost exclusively employed 230 EPITHELIAL TUMOURS. against these tumours. Even large cystic adenomata (^deno- celes) weighing eight or ten pounds may be removed^ with marvellously Httle risk to the patients, and recovery is in- variably rapid and complete. The treatment which, with our present knowledge, offers the best prospect to individuals affected with mammary cancer is early and complete removal of the whole of the diseased gland and pectoral fascia. Careful observations show clearly enough that those patients do best who have the cancerous mammae extirpated at the earliest possible date after the tumour is perceived. There is a consensus of opinion among surgeons who have , had the largest experience in cancer that, when a patient comes under observation with a nodule in the mamma which it is reasonable to regard as cancerous, it is the duty of the medical attendant to advise the removal of the breast. It is, however, a remarkable fact that mammary tumours, innocent and malignant, have been subject to observation for centuries, yet there is no organ in the body in which tumours ' give rise to more doubt or difficulty in diagnosis than in the mamma. This is so generally recognised that it is the duty ot every surgeon, before amputating a breast, to make an incision' into the swelling in order to assure himself that he is really dealing with a malignant tumour and not a simple cyst, abscess, or localised inflammation. The chief difficulty the surgeon finds in recommending appropriate treatment for cancer of the breast, arises from the circumstance that patients so often conceal the fact that they have a tumour until com- pelled to seek advice on account of pain, discomfort, or actual misery induced by the ulceration and sloughing of the cancer. There is, of course, a small proportion of females who absolutely refuse to submit to operation in the early hopeful stages, and wait until the skin becomes involved before they realise their unfortunate condition. When the tumour has been allowed to nm its course and infect the axillary lymph glands or ulcerate, the chance of doing good by operation ia seriously diminished. The prospects of a patient with cancer of the breast, when submitted to operation may be indicated in the following manner : — AJDHNOMA AND CABOmOMA. 231 1. The cancer is limited to the breast, does not implicate the skin or pectoral muscle, and has not induced ap- preciable enlargement of the axillary lymph glands. Such a case gives good results, immediate and remote. The risks of the operation are very small (one per cent.), and as there is no interference with the axilla, the patient retains free use of the arm. Recurrence and dissemination may be indefinitely delayed. 2. The cancer implicates the skin, but has not yet ulcerated ; moderate enlargement of lymph glands. Immediate extirpation of the breast, cutting wide of the imphcated area of skin, dissecting away the pectoral fascia, and removal of the axillary lymph glands is the proper course. Many of these patients enjoy a long immunity from recurrence, but their expectancy of life is less than in the preceding class. The immediate risk to life is much greater in consequence of the interference with the armpit. 3. The cancer has ulcerated, but the extent of skin impli- cated is small ; there is no adhesion of the tumour to the chest wall. The axillary lymph glands are enlarged. In such a case many surgeons excise the breast and remove the axillary lymph glands, not with much hope of prolonging life, but in order to rid the patient of what will become foul, offensive, and a source of mental anguish. Although it is extremely difficult to indicate even approxi- maite rules as to the advisability or otherwise, of operating in certain conditions of mammary cancer, there are cases in which it can be definitely laid down that operations are useless. For instance : — 1. When the supraclavicular lymph glands are infected. whether the cancer has ulcerated or not : such extensive infection of lymph glands indicates a high degree of malignancy. 2. When a large area of skin is imphcated, and particularly in cases where it is brawny or beset with small nodules. (Cuirass cancer.) 3. In the withering or atrophic form of cancer. 4. In no case where there is reason to believe that dis- semination has occurred. 5. When both breasts are implicated. 232 EPITHELIAL TUMOUBS. Of all the circumstances that modify the mortality of operations for removal of the mammary gland, none influence it so much as opening the axilla. This proceeding trans- forms a simple and safe operation into one often fraught with danger. So important is this that I will emphasise again my opmions in regard to the lymph glands : — 1. The axilla should not be opened unless there is really good reason to believe that its lymph glands are infected. 2. When the lymph glands are obviously enlarged they should be removed with the primary tumour. 3. When the supraclavicular lymph glands are obviously infected, operation is useless. Not only does the removal of these lymph glands increase the risk of the operation and impair the subsequent utility of the limb, but in operating in the arm-pit the axillaiy vein has in jnany instances been torn or punctured. Such extensive proceedings as excision of large portions of the pectoral muscles, and division of the clavicle to facilitate the removal of outnmning portions of the tumours are hopeless enterprises. Recurrence. — In a certain proportion of cases recurrence of the cancer may be expected. It is important to ascertain on what this depends, as it is usually regarded as an indication that the disease was not removed at the time of operation. The skin incisions may have been made too near the tumour, or fragments of the glandular tissue may have been detached and left behind in the process of reflecting the skin ; or out- runners on the deep surface of the breast may have been cut across and small pieces remained hidden in the recesses of the wound. All these have been advanced to explain the recurrence. The reappearance of the disease may take the form of one or more smaU nodules in, or near, the cicatrix ; sometimes actually in a stitch-hole. It may manifest itself as a brawny infiltration of the skin on each side of the cicatrix, and exceptionally recurrence appears as a general outburst of small shotty nodules in the skin over one or both mammary regions. When the recurrence is locaUsed, especially in the form of one or two nodules, or even as a tumour the size of an egg, it should be promptly removed, so long as there is no sign of dissemination. 233 CHAPTER XXIV. CYSTS, ADENOMA AND CARCINOMA OF SEBACEOUS AND MUCOUS GLANDS. The consideration of tumours connected with sebaceous glands naturally follows upon that of tumours of the mammary gland, because the latter is regarded as being a highly specialised sebaceous gland or group of glands. It win also be necessary to deal with tumours arising in connection with the cluster of specialised sebaceous glands at the base of the glans penis known as Tyson's glands, for they are the source of a rare species of penUe cancer. Tumours conflBeted with sebaceous glands are : — 1, Sebaceous cysts or wens ; 2, sebaceous adenomata ; 3, cancer of Tyson's glands. 1. Sebaceous Cysts (Wens). — The sebum resulting from the activity of a sebaceous gland escapes as it is formed on to the free surface. Should the orifice of the foUicle become occluded, the secretion is retained, and the glandvilar acini, becoming distended, give rise to an appreciable swelling known as a sebaceous cyst. This is the usual description of the mode by which these cysts arise ; but even a superficial examination of a number of sebaceous cysts will serve to show that in many there is no obvious obstruction — indeed, the duct may be widely open and the sebum exuding, so that obstruction of the duct is not an explanation that will cover all cases. It has long been known that the sebaceous follicles often contain one or more examples of the demodex folliculorum. It is usually stated that these arachnids are harmless; but judging from the grave lesions one species of demodex produces in the external auditory meatus of the dog, it is quite open to question if their presence is merely an epiphenomenon. These cysts occur in all situations where sebaceous glands abound; an exceptionally common place is the scalp. The cyst may be single ; sometimes many are present — indeed six- teen or more may be counted on one scalp. In size they vary greatly ; many are as large as walnuts ; others are of the size of peas ; they are rarely bigger than Tangerine oranges. 234 EPITHELIAL TUMOURS. In most situations sebaceous cysts are readily recognised, as they are distinctly circumscribed and adhere to the skm. On the surface of sebaceous cysts occurrmg m any part ot the trunk and head, save the scalp, close scrutiny will reveal either a black dot or a smaU dimple. This is the orifice of the folhcle, and on picking off the black spot and squeezing the cyst, sebum wiU exude, and thus furnish positive evidence of the nature of the cyst. It is a curious fact that m wens of the A. i \ V k Fig. 109. — Sebaceous glands in the velvet of the antler of a stag (cermis elaphus). scalp the orifice is rarely seen, except those which occur along the junction of the skin of the forehead with the hairy scalp. A sebaceous cyst, unless it has been inflamed, is easily shelled out of its matrix. It then presents a capsule and con- tents. The capsule may be exceedingly thin and phant, the inner surface presenting an epithehal lining; or it may be laminated, thick, and hard.. The contents of the cyst may be pultaceous material, consisting of shed epithelial scales, fat and cholesterine ; or laminae of firm yellowish- white inaterial arranged like the tissue of a bulb. These laminse represent the epithelium of the lining wall that has been shed in successive layers. In rare instances the contents of sebaceous cysts calcify. Sebaceous cysts are sometimes mistaken clinically for dermoids, and vice versd. Sebaceous cysts occur not only in the scalp, but also in the PLATE VI.— Inflamed Sebaceous Cyst, situated on the Inner Margin of the Left Mamma. ADENOMA AND CARCINOMA. 235 skin covering any part of the trunk. They are excessively rare on the limbs. These cysts are not uncommon in the skin of the penis and scrotum, as well as in that of the labia majora and minora. Among other curious situations may be mentioned the interior of ovarian dermoids and in the " velvet " covering the growing antlers of deer. The " velvet " of a growing antler is covered with fine downy hair furnished with large sebaceous glands. (Fig. 109.) Sebaceous cysts, apart from the inconvenience their presence often causes, and their unsightliness when growing in exposed situations become sources of discomfort when their contents decompose, or the cyst inflames. Apart from this, they are liable to secondary changes, whereby they form pecuharly foul and fungating ulcers, and in others develop horns. Each of these changes will be considered. Decomposition of the Contents. — It has already been men- tioned that tha contents of a sebaceous cyst sometimes ooze from the orifice of the follicle. In some instances such cysts give rise to an extremely offensive odour. This is due to de- composition of the cyst-contents in consequence of admission of air, and as the substance within the cyst contains a large proportion of fat and epithelium, the odour evolved is not' difficult of explanation. Decomposition of the cyst-contents occurs independently of inflammation of the cyst, and is alrnost confined to sebaceous cysts occurring on the trunk. Inflammation of the Cyst. — When sebaceous cysts grow in situations where they are exposed to injury, as, for instance, on the side of the head, where they may be injured by the hat, or on parts of the body where they are liable to be rubbed by the clothes, they are apt to inflame and suppurate. An in- flamed sebaceous cyst has a characteristic colour, and re- sembles the deep red of a ripe plum. (Plate VI.) Such inflammation may subside and recur. These recurrent attacks of inflammation cause firm adhesion between the capsule and surroimding structures, which renders their removal somewhat tedious. When they suppurate the cyst thins, and at last bursts, unless this result is anticipated by the timely use of a scalpel. The suppuration often leads to their cure; but frag- ments of capsule may be retained and lead to the formation of fistulse. In some instances the cyst bursts, the pus escapes, 236 EPITHELIAL TUMOURS. and the point of rupture heals, the cyst-wall being retained. When this is the case the cyst refills with sebaceous matter. Thus in dealing with these cysts surgically it is an important thing to remove thoroughly every particle of the cyst-wall. Horns. — Mention has already been made of the fact that sebaceous cysts are occasionally the source of horns, sometimes of very large size. In their general appearance and structure they are indistinguishable from wart-horns. (See chap, xx.) 2. Sebaceous Adenomata. — It has been so customary to Fig. 110. — Large sebaceous adonoiua involving the pinna. regard aU tumours arising in connection with sebaceous glands as wens or sebaceous cysts, that it is quite an exceptional event for them to be submitted to microscopical examination. It has already been pointed out that there are two varieties of sebaceous cysts, one in which the cyst contains sebum and epithelial debris, and another in which the contents are arranged in thick laminae. In addition to these, tumours occasionally occur in the skin and furnish the usual clinical signs of wens ; * v^hen removed and examined microscopically they are found to be composed of lobules which structurally * Shiittocik, Trans. Path. Soc, vol. xxxiii. 290. M.UEISVMA AJSl) UALWINOMA. 237 resemble the exuberant masses upon the nose that used to be called Hpomata, but are now known to be due to that over- growth of the krge sebaceous glands that occupy the skin in this situation. These tumours are sebaceous adenomata, and they are liable to ulcerate and exceptionally to calcify* The largest sebaceous adenoma that has occurred in my own practice began in the skin over the mastoid process and involved the pinna. (Fig. 110.) f There can be little'doubt that a few of the supposed wens on the scalp are adenomata, especially those which fungate. These supposed fungating wens should be carefully studied ; they are particularly apt to be mistaken for epitheliomata. Such tumours consist of more or less circular masses of red vascular tissue with definite edges, raised a centimetre or more above the level of the surrounding skin, and strikingly resemble ulcerating epitheliomata — a resemblance that is rendered more complete when the adjacent lyrnph glands are enlarged. The discharge from such tumours is always very foetid. There is usually no difSculty in recognising the nature of these masses when they occur on the scalp, as they are not infrequently associated Avith wens. {Frontispiece.) These ap- pearances are usually described as the result of inflammation and subsequent rupture of a sebaceous cyst. This is probably the correct explanation in some cases, but in others the tumour is made up of adenomatous tissue, which makes it certain that, in a few instances at least, tlie supposed fungating cyst is an- ulcerating iobaceous adenoma. 3. Carcinoma. — The common variety of sebaceous glands is not the source of any species of cancer. There is, however a rare species of cancer constructed on the type of the specialised sebaceous glands named after Tyson. I once had an opportunity of studying such a tumour in a man fifty years of age ; it sprang from the penis and was confined to the corona glandis and adjacent parts of the penis. The lymph glands in each groin were infected. I amputated the penis and enucleated the enlarged lymph glands. The patient died nine months Ip.ter with the signs of secondary deposits in the abdominal viscera, but no dissection was * * Eve, Trnns. Path. Soc, vol. xxxiii. 335. t Trans. Clin. Sou., vol. xxi. 172. 238 ETITnELIAL TUMOURS. permitted. Sections were prepared from the tumour in such a way as to include the glans penis, its corona, and the tumour ; in this way the relation of the cancer to Tyson's glands was clearly demonstrated. Treatment. — A sebaceous cyst is easily removed ; when _. the skin covering one is incised and the capsule exposed,,J the cyst usually shells out quite easily. When the cyst has been inflamed and is firmly adherent to the skin, some little dissection will be necessary to eflfect its removal. A suppurating cyst can in many instances be dissected ' out. Often, however, the wall is so thin that the cyst is best treated as an abscess — that is, by free incision. Before the importance of extreme cleanliness was appre- | ciated by surgeons the removal of sebaceous cysts was often ^; J followed by septic inflammation. An excellent notion of the fears which surgeons entertained in regard to secondary com- plications after the removal of wens is furnished by the case of George IV., who had a sebaceous cyst on the top of his head. This formed the subject of a serious consultation attended by Cline, Astley Cooper, Brodie, and others. Eventually Cooper, with Cline's assistance, removed the wen, and his anxiety lest erysipelas should supervene seems scarcely com- pensated by the baronetcy which the king bestowed upon him as a reward for the successful issue of the operation.* Mucous Glands. — These structures, like sebaceous glands, sometimes become transformed into cysts, but they rarely exceed the dimensions of a nut ; usually they appear as small transparent bodies the size of small peas. They are fairly frequent in the buccal mucous membrane ; they also occur in the mucous membrane lining the trachea and bronchi. {See tracheal diverticula). The mucous glands of the bronchi are of interest in con- nection with reported cases of supposed primary cancer of the lung. For instance, Dr. Finlayt described the case of a man * " Life of Sir Astley Cooper," vol. ii., chap. ix. Brodie refers to this case in his " Autobiography," thus :— " Eventually the operation was performed by Sir Astley Cooper in the presence of Sir Everard Home, Mr. Cline, Sir William Knighton, the King's physicians, Sir Henry Halford, Sir Matthew Tiernoy, and myself ; making a very large assembly for so small a matter." t Jled.-Chir. Trans., vol. Ix. 313. thirty-seven years old who died from puhnonary disease. The, left lung contained a tumour and the right one numerous secondary nodules; some of the mediastinal lymph glands were enlarged and the liver contained secondary nodules. These tumours exhibited the characteristic histological featiires of cancer. Coats* reported a case which he investigated in a youth seventeen years old who died from a tumour of the right lung. There were secondary nodules in the left lung, the brain, the femora, some of the ribs, vertebriE, left ilium, and the liver. Many of the secondary knots were small cysts lined with cylindrical epithelium. Langhans,t who appears to have studied tumours of this kind very carefully, is of opinion that the cancer in such cases originates in the mucous glands of the bronchi. The Glands of Bartholin and Cowper. — It is well known that Bartholin's glands in the female are very liable to become cystic ; they are also very apt to inflame and suppurate. These glands are occasionally the source of carcinoma. Schweizer J has reported a case, and collected the literature. Oowper's Glands are the homologue in the male of Bartholin's glands in the female. They are liable to inflame, and occasionally become cystic. There is reason to believe that the gland may become cancerous. The most recent contribution to this subject is that by Witsenhausen.il Treatment. — Inflamed Bartholin glands are sources of much inconvenience and often distress, which mere incision only serves to aggravate. Tlis appropriate treatment conaists in dissecting out every trace of the gland. * Trana. Tatli. Soc, vol. xxxi.x. 326. ■j- Virchow's " Archiv," vol. liii. 479. J Aich. fiir Gyn. bd. xliv. 322. II Bruns, BeitrSr/e, bd. vii. 5S2. 240 CHAPTER XXV. ADENOMA AND CARCINOMA OF THE THYROID, PROSTATE, PAROTID AND PANCREAS. THE THYROID GLAND. Adenomata. — Two varieties of adenoma are met with in the thyroid gland; by most writers they are described as adeno- matous goitre and cystic goitre or bronchocele, to distinguish them from the general enlargement of the entire gland known as " parenchymatous " goitre. A thyroid adenoma is an encap- suled tumour of the thyroid gland containing vesicles of the same character as those which make up the normal gland. The size of these adenomata varies greatly ; many are no larger than cherries, whilst others are bigger than fowls' eggs. When both lobes contain an adenoma the gland wUl maintain its normal shape ; when one lobe only is involved, the gland be- comes unsymmetrical ; exceptionally an adenoma wiU develop in the isthmus. As these tumours increase in size the vesicles coalesce, then the septa gradually disappear, and a thyroid cyst or bronchocele is formed. Bronchoceles sometimes attain very large dimensions. (Fig. 111.) Their capsules are formed of dense fibrous tissue, which may contain calcareous plates ; in some old specimens the capsules are converted into calcareous shells. SinaU bronchoceles contain a thick peripheral stratum of glandular tissue ; their central cavities contain colloid material or a thinner fluid of a reddish colour, due to haemor- rhage ; not infrequently the fluid is largely charged with cholesterme. In very large bronchoceles all traces of gland tissue disappear ; nothing remains but a tough, more or less calcified cyst-wall. Aug. Reverdin* recorded a case m which an old man of sixty-two years had a cystic adenoma of the thyroid 60 cm. in circumference. On puncturing it a large number of bodies, white in colour and crenate like mulberries, escaped with a large quantity of brown fluid. Reverdin stated that the composition of these bodies was like coagulated fibrin. * Journal de la Suisse Romande ' 18S3. ADENOMA AND CARCINOMA. 241 ^ It is important to bear in mind that adenomata of the thy- roid gland, large or small, shell out quite easily. For example, the exceedingly large bronchocele depicted in Fig. 112 was successfully enucleated by P. Bruns.* The patient was fifty- eight years old, and the cyst was so large as nearly to reach the navel. The weight of the tumour produced lordosis in the cervical, and kyphosis in the thoracic regions of the spine. The tumour measured in its horizontal circumference 61 cm., and Fig. 111. — Large unilateral bronchocele. {J/ler Berry,) in a sagittal direction 70 cm. It was single-chambered, and ihe walls were in parts calcified. The tumour was so heavy ;hat the woman was in the habit of resting it upon the table ivhen she sat down. Adenomata and bronchoceles occasionally arise in accessory ihyroids. Although it would be appropriate to consider them lere, it has been found more convenient to discuss them in ■elation with dermoids in chapter xxxiii. Carcinomata. — Cancer of the thyroid gland is an ex- iremely rare affection in England. In the majority of cases it * Bruris, Beitrage, bd. vii. 650. 242 ■EPITSELIAL TUMOURS. produces uniform enlargement of the organ ; the gland, how- ever, does not attain large dimensions. The cancerous portion disintegrates, and a cavity with shreddy walls, containing dirty semi-fluid material, is usually found in one or other of the lobes. The walls of the cavity may be calcified. The solid parts of Fig. 112 — Bi-oncliocele of unusual size. (P. Brum.) the cancerous gland exhibit under the microscope alveoU filled with epitheUal cells. In many of the specimens the whole of the normal tissue of the gland is replaced by new growth, (.'ancer of the thyroid gland usually occurs between the ages of forty and sixty. The adjacent lymph glands are early Involved. Death fre- ,.,: quently happens from early implication of the mferior laryngeal i nerves, which leads to spasmodic attacks of dyspnoea. i'^ Dissemination in the ordinary form of cancer of the thyroid - ADENOMA AND CABCINOMA. 243 gland is very rare, but there is a form of pulsatile tumour of bone associated with, if not secondary to, enlargement of this gland. Several remarkable cases have been investigated clinically and pathologically in which pulsatile tumours have appeared "- the bones of the skull vault, at the sternal end of the in clavicle, in the femur, atlas, axis, and other vertebrse. These Fig. I13.^-Pulsating tumour of the skull, associated with an enlarp;ed thyroid. (From a photograph in the Museum of the Middlesex Hospit satisfactory as the operation known as trachelorraphy. Carcinoma. — A study of the pathological tendencies of uterine cancer is of the first importance as a prelude to its treatment, because it would certainly be inferred from experience acquired in the treatment of mammary cancer that if it be desirable to remove a cancerous uterine cervix, the interests of the patient would be best served by the entire removal of the uterus. Dr. Williamsf has clearly pointed out that the tendency of cancer of the cervix, in its early stages, is to infiltrate the parametric tissue rather than to extend upwards and invade the body of the uterus. Cases are occasionally observed in which the disease even in its early stages involves the body of the uterus, but these are exceptional. The great difficulty in the operative treatment of uterine cancer lies in the circumstance that the disease is so insidious, and m. the majority of patients, has involved the tissues so extensively before the cases come under observation, that an operation for the adequate removal of the disease is attended with so much immediate danger, while the probability of pro- longing life is so very remote that few surgeons are disposed to urge such measures upon their patients. The important question to decide m. the treatment of cancer involvmg the cervical canal is this: — When the disease is recognised early, and whilst still limited to the cervix, is it * Trans. Path. Soc, vol. xxxix. 208, and vol. xl. 221. f " Cancer of the Uterus." 278 EPITHELIAL TUMOURS. sufficient to amputate the cervix only, or should the whole uterus be extirpated f Dr. J. Williams is very emphatic ia the opinion that, in such cases the removal of the cervix is sufficient, and- a study , '^ of the arguments he adduces would appear to establish this. The view has been severely criticised by a few obstetric physicians who maintain that the whole uterus should be - extirpated. Published statistics relating to this matter indicate that when it is possible to remove the disease completely by limit- ing the operation to the cervix it is the safer measure, and offers a good prospect to the patient, the risk to life, so far as the operation is concerned, being reduced to a minimum. The rules for the treatment of uterine cancer may be formulated thus : — 1. Amputation of the vaginal segment is sufficient when the cancer is limited to the lower portion of the cervix. 2. When the cancer has extended to the upper segment h of the cervical canal it wUl be necessary to perform supra-vaginal amputation of the cervix. In primary cancer of the body of the uterus the whole ' organ should be removed through the vagina. When the cancerous ulceration has eodended beyond the uterine tissues operative interference is worse than useless. 279 CHAPTER XXIX. GROUP III. -DERMOIDS. Dermoids are tumours furnished with skin or mucous membrane occurring in situations where these structures are not found under normal conditions. They only possess tissues which naturally belong to skin or mucous membrane. Dermoids may be arranged in four genera : — I. Sequestration dermoids. II. Tubulo-dermoids. III. Ovarian dermoids. IV. Dermoid patches. Each genus contains at least two species that occur in definite situations and present structural peculiarities. The simplest dermoids belong to the first genus, the most complex are found in the ovary. SEQUESTRATION DERMOIDS. Dermoids belonging to this genus arise in detached or sequestrated portions of surface epithelium, chiefly in situa- tions where, during embryonic life, coalescence takes place between skin-covered surfaces. Dermoids of the Trunk. — These occur strictly in the regions where the lateral halves of the body coalesce.' This line of union, commencing immediately below the occipital pro- tuberance, extends along the middle of the back to the coccyx; it then passes through the perineum (scrotum and penis in the male) and upwards through the umbilicus, thorax, neck and chin, to terminate at the margin of the lower lip. Dermoids are rare along the dorsal part of this line, and when they do occur are apt to be mistaken for spina bifida cysts. In at least one instance a dermoid has been detected in association with spina bifida occulta. The parts are shown in section in Fig. 123. The patient was a child two years old ; the skin covering the defective spines presented the hair-field usual in these cases. In the tissues immediately over the stunted spines there was a dermoid containing the usiial pultaceous material and hairs. The specimen was dissected by 280 DERMOIDS. Mr. Gilbert Barling, who kindly afforded me an opportunity of examining it. Theoretically, dermoids should occur with tolerable frequency along the mid-dorsal line. In a case described by Dr. Wild* (which I had an opportunity of examining), a large dermoid projected from the lumbo-sacral region of a man aged twenty-two years. It was congenital, and had been regarded as a spina bifida cyst. The swelling had. never caused the man inconvenience until a few days before his admission into hospital, when it became inflamed and then burst, discharging a quantity of foul-smelling sebaceous ma- terial mixed with hairs. The cavity was freely opened and cleared of decomposing ma- terial. The skin lining the Ulterior of the dermoid was beset with pores of large size, corresponding to the orifices of sweat glands ; when the patient perspired, drops of sweat could be seen oozing from these pores. This skin also contained' nerves, for the man could localise the prick of a pin on the interior of the dermoid, as easily as one made upon, the skin surrounding the tumour. When the tumour was removed, the spinous processes under- lying it were found to be unusually short and surrounded by fat. (Fig. 124.) Faulty coalescence of the cutaneous covering of the back ' often occurs over the lower sacral vertebrae, and gives rise to small congenital sinuses known as " post-anal dimples." These recesses are lined with skin furnished with hairs, sebaceous and sweat glands. Sometimes they measure 10 mm. in de.pth. As a rule, they are single and often accompany lumbo-sacral spina bifida. Though most commonly seen over the coccy- geal, or the last two sacral vertebrae, I have seen them as high as the fourth lumbar vertebra, and always exactly in the middle line. * Trans. Path. Soc, vol. x\., p. 386. ;. 123.— Section of three thoracic vertebrse with a small dei'inoid situated over two stunted spinous processes. SEQUESTRATION' DERMOIDS. 281 These post-anal dimples are interesting, for — as will be shown afterwards — in many situations where sequestration dermoids occur, similar cutaneous recesses are also seen. An examination of such a, sinus serves to show that if its external orifice became occluded, without the deeper parts becoming obliterated, we should have the germ of a dermoid, for the numerous glands in the walls would be active, and their Fig. 124.— Dermoid in the lambo-sacral region of a man twenty-two years of age. secretion, with the shed epithelial scales and hairs, would soon cause it to enlarge and assume such proportions as to be clinically recognised as a tumour. A good physiological type of such dermoids is furnished by the interdigital pouch of the sheep. This pouch — as shown in Fig. 125 — lies between the digits, and all the dis- section required to expose it is to separate the digits with a sharp knife, keeping close to the phalanges of one or other side. In adult sheep it is always full of shed wool and grit. Sometimes its orifice is occluded and it becomes a retention cyst ; suppuration follows, much to the sheep's discomfort. 282 DERMOIDS. The walls of this pouch are full of very large glands. In order to get satisfactory sections it is necessary to obtain the digits from a still-born lamb, for as soon as lambs nm about grit gets into the pouch and spoils the edge of the knife. Dermoids of the Scrotum.— There are many good rea,sons for believing that the majority of dermoids reported as arising in the testicles were really scrotal in origin. This was clearly the case in a specimen described by Bilton PoRard* as a dermoid of the testicle. The dermoid was situated on the left side of the scrotum, between the testi- cles, and adhered to the back of the left one outside the tunica vaginalis. It contained putty- like material in which there were a few grey hairs. The cyst was lined with stratified epithelium; papillae and seba- ceous glands were detected. It is usually stated in text- books that dermoids of the testis are common. This is very improbable, for very few cases are to be found in surgi-- cal literature, and the details in most cases are insufficient to enable me to determine whether the dermoids were scrotal or testicular. For evidence as to the rarity of testicular dermoids Mr. D'Arcy Power's t paper should be consulted. In records of future cases it wUl be necessary to pay particular attention to the relation the dermoids bear to the testicle, tunica vaginalis, and scrotum. Dermoids have been found in the inguinal canals of men closely associated with the spermatic cord, and it may be easily imagined that in such situations they run the risk of being confounded with hernise. Such specimens are excessively rare, and as I have not' had an opportunity of * Trans. Path. Soc, vol. xxxvii., p. 3-12. t Trans. Path. Soc, vol. xxxviii., p. 242. Fig. 125. — Median aspect of a sheep's digits showing the inteMigital pouch. SEQUESTRATION DERMOIDS. 283 investigating one, I am unable to offer an explanation of their mode of origin. Dermoids of the Thorax.— Judging from the few available records, dermoids of the thorax are very uncommon. They occur in two situations — viz., on the anterior aspect of the sternum and in the thoracic cavity. Dermoids on the front of the sternum are situated in the middle line near the junction Pig. 126. — Dermoid situated over the jimntion of the manubrium and gladiolus of the sternum ; there was also a dermoid near the left cornu of the hyoid bone. The boy was nineteen years of age. [After Bramann.*) of the manubrium with the gladiolus. (Figs. 126 and 127.) Cahen's f patient was a child eight months old. The mother stated that at birth the tumour was ho larger than a pea, but had slowly increased in size. It was extirpated, and found to contain sebaceous material ; the wall of the cyst was lined with * Langenbeck's " Archiv," bd. xl. t Zeitsclirift fiir Chir., bd. xxxi. 370. 284 DERMOIDS. stratified epithelium, and it contained sweat-glands. Qutton* described a specimen which he removed from a female thirty- nine years of age. The tumour contained eleven ounces of pultaceous material. The wall of the cyst was lined with skin, and one hair was found growing from it. No glands were detected. When the patient was six weeks old the tumour was as big as a pea ; at the age of nineteen it had attained Fig. 127.— Prestemal dermoid. {After CaTien.) the dimensions of an egg, and continued slowly to increase in size. When the patient came under Glutton's care the tumour hung pendulous between the breasts. The history of the case clearly indicated that the dermoid had been from the first situated over the middle of the sternum. Intrathoracic dermoids seem to be equally rare. Hale White f met with one as large as a Tangerine orange, attached to the anterior and right surface of the pericardium, and by a few adhesions to the right lung. The cyst contained sebaceous matter and hair. * Trans. Path. Soc, vol. xxxviii. 393. t Trans. Path. Soc, vol. xli. 283. SEQUESTRATION DESMOIDS. 285 Albers* described and figured a dermoid of the thorax that ocdurred in a woman twenty-eight years old. , At the age of fifteen it was noticed she brought up hairs on coughing. At her death a large cyst, furnished with pilose skin and fleshy protuberances, was found in connection with the left lung. A case fully reported in regard to clinical details by Dr. Douglas Powell and Mr. Godleet was observed in a lady Fig. 128.— Sternal dimple. {After W. W. Ord.) twenty-nine years of age. She presented signs of empyema, and whilst under operative treatment it was ascertained that a large dermoid occupied the right pleura and extended to the summit of the lung. The interior of the dermoid contained hair and fleshy protuberances as in Albers' case. The patient died four years after the cyst had been opened, but no post- mortem examination could be obtained. In this case the cyst communicated with a bronchus, because the patient remembered that she had coughed up hair. * Atlas der Path. Auat., 1846, tat. xxxiv.; und Erlautenmg, o. 342. t Med.-Chir. Trans., vol. Ixxii. 317, 286 ■ , BEEM0IB8. At first glance it would seem difficult to account for tlie presence of a large dermoid within the thorax, and it has been thought that, as dermoids are not uncommon at the episternal notch, a cyst in this situation had burrowed downwards into the superior mediastinum and encroached upon the pleura. A review of the mode of development of the sternum throws much clear light on the subject. The two lateral halves of the sternum are, in the early embryo, widely separated from each other ; gradually they coalesce in the middle line. Every anatomist is aware that this median coalescence is extremely liable to be faulty, and conditions occur like those which, hap- pening in connection with the medullary folds, produce spina bifida. In this line of coalescence, so far as sternal dermoids are concerned, we may get skin-lined recesses resembling the coccygeal dimples (Fig. 128). These sternal recesses, or dimples, occur near the junction of the manubrium with the gladiolus, and may be more than a centimetre deep. Should a piece of skin become sequestrated during coalescence of the' thoracic walls, it may, during the development of the sternum, be dislocated forwards to the outer surface, or backwards towards the mediastinum, conditions in every way parallel to the variations in the position of cranial dermoids. So long as a dermoid on the deep surface of the sternum remains small it will cause no trouble, but it is easy to understand that a large tumour, as in Glutton's patient, would, if projecting into the thorax, encroach on the pleura ; even then it would not produce much disturbance so long as air did not gain access to it ; but if by pressure the wall of the cyst becomes so thin as to allow air to enter its cavity, or an actual communi- cation forms between the cyst and a bronchus or the air- sacs of the lung, then suppuration, with aU its disastrous consequences would ensue. 287 CHAPTER XXX. SEQUESTRATION DERMOIDS (continued). Facial Dermoids.— Dermoids occur on the face 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. To these, for the sake of convenience in description, may be added dermoids of the palate. In order to appreciate the origin of dermoids in these situations it is necessary to bear in mind the relation of the facial fissures in the embryo, which in the adult are represented by the orbits, lachrj'mal ducts, mouth, and certain furrows in the lips and cheek. In the early embryo the central portion of the face is represented by an opening from which five fissures radiate. The upper pair (Fig. 1 29) 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 ultimately 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 together in the middle line to form the central piece, or philtrum, of the upper lip. The elongation of the fronto-nasal process necessarily lengthens the orbito- nasal fissures. Eventually the sides of the fronto-nasal plate coalesce superficially 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 permanently indicated in the adult by the naso-facial sulcus or groove, and indicated still more deeply Pig. 129.— Head of an early liumai) ejnliryo, showing the disposition of the fa- cial fissures. (After His.) 288 DESMOIDS. by the lachrvmal 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. The above account indicates iu a general way the relation of these fissures to each other ; but it wiU be necessary in con- sidering dermoids arising in them to mention certain details connected with each. But here it may be mentioned that the Fii,^ 130. Mandibular tubercle associated with a malformed auricle. defects associated with any of them are of three kinds:— 1, the fissure may persist; 2, it may close imperfectly and leave a recess or puckering of the skin ; 3, portions of the surface epithelium may be sequestrated and give rise to dermoids. These conditions may be illustrated by the mandibular fissure. In the embryo this fissure or cleft is relatively more extensive than the opening of the mouth ivhich in the adult ultimately represents it. In fishes the whole of the mandibular fissure persists as the gape ; but in mammals the dorsal portions of the clefts are obliterated by the imion of their margins, leaving the central portion as the mouth. Persistence of the whole length of the fissure is a rare defect, and known as macrostoma. Excessive closure of the fissure produces microstoma. Imperfect union of those sections that normally SEQUESTRATION BEliMOIDS. 289 coalesce gives rise to slighter imperfections, of which some examples will now be described. Occasionally we find on one or both cheeks of children, at a spot varying from 2 to 4 cm. behind the angle of the mouth, a small nodule rarely exceeding a rape-seed in size. Some- times there is a depression or sinus in the cheek surmounted Fig, 131.— Right side of tlie head of a foetus, showing a large mandibular tubercle and an accessory tragus. by the nodule. In a fair proportion of cases the buccal mucous membrane presents a shallow recess, sometimes a sinus, and occasionally a white cicatrix at a spot exactly correspond- ing to the nodule on the cutaneous surface of the cheek. These mandibular tubercles and recesses are frequently associated with malformations of the corresponding auricles. (l"'ig. 130.) Mr. CoweU described a case in which a mandibular tubercle was associated with a puckered recess in the mucous mem- brane of the cheek, two cutaneous tubercles on the tragus 290 DERMOIDS. of the corresponding auricle, and a coloboma, of the upper eyelid. (Fig. 179.) The largest specimen which has yet come under my observation occurred in a stiU-born foetus. Pro- jecting from the right cheek, 2 cm. behind the angle of the mouth, was a nodule the size of a rape-seed, and immediately behind this a pedunculated body 8 mm. long. On the cor- responding pinna there was an accessory tragus. (Fig. 131.) Histologically the tubercle on the cheek consisted of dense ''^■*s:n>-^!5^^ Fig. 132.— Pierrot's head, to show the mandibular tubercle. connective tissue traversed by blood-vessels and covered with skill beset with lanugo, and richly supplied with sweat glands and sebaceous glands of large size. Thus' it was structurally a small dermoid tumour. The left cheek and pinna were normal. The foetus had a large spina bifida sac (meningo- myelocele) in the lumbar region. In connection with these tubercles it will be interesting to mention that Mr. Noble Smith drew my attention to a bronze bust in the Art Gallery, Birmingham, labelled "Bust of Ccecilius Jucundus, a -money lender. Bronze. The original found in Pompeii, and now in the National Musewm, Naples." Behind the angle of the mouth on the left cheek there is a weU-marked mandibular tubercle. SEQUESTRATION- DEBMOIBS. 291 It may here be pointed out tliat in many mammals, especially dogs, small cutaneous nodules furnished with vibrissse may often be detected in a line with the angle of the mouth. These nodules occupy positions identical" with Fig. 133.— Median fissure of the lower lip. (IVolJier.) the mandibular tubercles when they occur on the cheeks of children. (Fig. 132.) There is very little relationship between pathology and poetry, but that very philosophical pathologist, Dr. Samuel Wilks, in reference to my observation that the usual position of the mandibular tubercle and recess corresponds with that of the dimple in the baby's cheek, drew my attention to the following passage in his Harveian Oration, 1870. "From any point of view we take, and upon whatever subject we fix our gaze, we come to the conclusion that the greatest discovery ever made by man about himself, and 292 DERMOIDS. of the earth of which he forms a part, is the doctrine of evolution." " The softest dimple in a Ijaby's smile Springs from the whole of past eternity, Tasked all the sum of things to bring it there." Wilks observed to me howHttle the poet (Miss Bevington) divined that there is a material basis for these three pretty and significant lines Similar defects are met with in the intermandibular JTBALQPNia SC Fig. 134.— Congenital fistulse in the lower lip of a child, associated with double hare-lip. ' {AJier Madelnng.) fissure. Thus, when the mandibular processes fail to coalesce, the result will be a median cleft in the lower lip extending to or even beyond the chin. (Fig. 133.) Median clefts of this kind are excessively rare. Occasionally such a defect is associated with a dermoid* or a pair of small nodules in the skin. In terriers such nodules are almost constantly present between the symphysis and the body of the hyoid bone. In children with double hare-lip two sinuses are sometimes seen in the mucous membrane of the lower lip. Their orifices are indicated by small but prominent papiUse. The sinuses are large enough to admit a probe, and they are in some cases 2 cm. deep. Mucoid fluid exudes from these recesses, it is furnished by mucous glands which beset the membrane * Launelongue, " Kystes Congenitaux," 188G, p. 46. • SEQUESTRATION DEEMQIDS. 293 lining their walls. Several examples of this condition have been recorded, and a good specimen observed and described by Madelung is represented in Fig. 134. In this case the child was the subject of double hare-lip and cleft palate. The two conditions seem to be frequently associated. Madelung's patient died four days after operation; the lower lip was examined microscopically, and some excellent drawings illus- trating the relations of the glands to the sinuses accompany the paper.* Arbuthnot Lanef reported a case of this nature in a lad thirteen years of age with double hare-lip. I have little doubt that these sinuses are due to faulty Fi<'. 135. -Have-lip in a frog, associated with a persistent intermandibular fi-ssurc. The foi-eliuibs are webbed. closure of the intermandibular fissure; this view of their ori Dermoids in the lower section of the orbito-nasal fissure are very rare. When present they occupy the naso-facial sulcus, as in Fig. 138. Nasal Dermoids. — It is necessary to point out that all dermoids arising in connection with the nose are not associated Fig. 137. — Dermoid at the inuer angle of the orljit. with the orbito-nasal fissure. For instance, in the case of the child in Fig. 139, there is a small dermoid exactly in the middle line at the root of the nose. This part of the face is not traversed by a fissure in the embryo. Nasal dermoids, unassociated with the orbito-nasal fissure, appear either as complete cysts, or as small congenital sinuses in the skin of the nose. Sometimes such sinuses are merely shallow recesses in the skin ; in other cases tufts of hair project from their orifices. The mode by which such dermoids arise is in all respects identical with that which gives rise to dermoids on the scalp. In the skull of the early embryo, the naso-frontal plate, which ultimately forms the nose, consists of a lamina of hyaline 296 DEimOIDS. cartilage covered externally by skin and internally by mucous membrane. After the third month sections made through the nasal capsule, immediately anterior to the ethmoid, show that the skin is being dissociated from the underlying cartilage by bony tissue which eventually becomes the nasal bones. Fig. 138. - Dermoid arising in naso-fncial sulcus. {After Bramann.*) Ultimately the cartilage disappears as a result of the pressure exercised by these bones. It is reasonable to believe that in the gradual separation of the skin from the cartilage of the fronto- nasal plate by the intrusion of the nasal bones, small portions of skin or epithelium become sequestrated and eventually develop into dermoids. This explanation is more fully set forth in the chapter on dermoids of the scalp and dura mater. It is necessary to mention that dermoids at the root of the * Langenbeck's " Archiv," bd. xl., 101. SEQUESTRATION BEBMOIDS. 297 nose often have such extremely thin walls as to be trans- lucent like a hydrocele of the tunica vaginalis testis. Such dermoids contain a fluid like oil. Palatine Dermoids.— In the early embryo the nasal and buccal cavities form a common chamber. Gradually the Fig. 139. — Nasal dermoid in a child. palatine processes of the maxillas and palate bones converge to the middle line and form the hard palate. For a period, however, the palate is traversed by a fissure, which eventually closes from before backward. Occasionally this union never takes place, and the deformity, cleft palate, is the result. Small bodies known as '' epithelial pearls " are sometimes met with in the middle line of the palate ; they are not uncommon in the mouths of children at birth, hanging by short, thin pedicles. They are composed of concentric masses of epi- thelial cells.* The mode by which these pearls arise is discussed in chapter xxxviii. * Lotoucq, "Arch, de Biologie," vol. ii. 400. 298 BEBMOIDS. Dermoids sometimes arise in the palate ; they take the form of tumours, inasmuch as the skin covers the outside of the mass instead of hning a cavity ; the tumour is usually composed of connective tissue containing striped muscle tissue and cartilage. The dermoid may project either from the buccal or pharyngeal aspect of the soft palate. It is occasion- ally difficult to determine when the tumour projects into the pharynx, whether it grows from the soft palate or roof of the pharynx.* Lamblt reported a case in which a pharyngeal dermoid in a child became detached and was swallowed. Next day it v/as voided by the anus. Adenomata of the Palate. — A somewhat rare species of tumour is occasionally met with in the palate which may provisionally form an appendix to palatine dermoids. The uumours in question are often referred 10 under the name of palatine adeno- mata. They are usually oval ia shape, and vary in size from a cob-nut to a hen's egg ; the latter size is excep- tional. The tumours are more fre- quent in the soft (Fig. 140) than the hard palate, and as a rule are distinctly encapsuled ; even when pendulous the tumour has a capsule. In structure palatine adenomata are very complex ; some possess glandular tissue with ill-formed ducts and acini, and in their histological features mimic cancer, whilst the stroma in which these gland-like bodies are embedded imitates sarcomatous tissue. Epithelial pearls are often abundant and may contain horn. Myxomatous tissue is sometimes present, and HutchinsoniJ: has published the details of a palatine adenoma which contained lymphoid follicles. Palatine adenomata occur at puberty or between the thirtieth and fiftieth years. § They are innocent tumours. * Hale White, Trans. Path. Soc, vol. xxxii. 201. t A'irchow's "Archiv," bd. cxi. 176. J Trans. Path. Soc, vol. xxxvii. 490. § Stephen Paget, Trans. Path. Soc, vol. xxxviii. 348. Fig. 140 Pedunculated dermoid tumnui- fi-om the iiliaryiigeal aspect of tlie soft palate. (Arnold.) 299 CHAPTER XXXI. SEQUESTRATION DERMOIDS (concluded). Dermoids of the Scalp and Dura Mater.— The common situations for dermoids of the scalp are over the anterior fontanelle and occipital protuberance. In these situations they may be confounded with sebaceous cysts or with menin- goceles. Dermoids of the scalp often have a thin pedunculated Fig. 141.— Dermoid of the scalp connected by a pedicle willi tlie dura mater, {Museum, Middlesex Hospital.) attachment to the dura mater, the pedicle traverses a hole in the underlying bone, unless the cyst is over a fontanelle. The specimen represented in Fig. 141 was long preserved in the museum as an example of a sebaceous cyst or wen ; its connection with the dura mater induced me to examine it, and I ascertained that the cyst contained skin and hair. The term " wen " used to be applied indifferently to sebaceous cysts and dermoids of the scalp. Sir Astley Cooper,* in his well-known essay on " Encysted Tumours," even included orbital dermoids among wens. In describing them, he writes : — " The largest size I have known them acquire has been that of a common- sized cocoa-nut, and this grew upon the head of a man named * "Surgical Essays," vol. ii., p. 213, 1818. 300 DESMOIDS. Lake, who kept tlie house called the ' Six Bells ' at Dartford. It sprang from the vertex, and gave him a most grotesque appearance, for when his hat was put on it was placed upon the tumour and scarcely reached his head. The cyst is in the Fig. 142.— Hcatl of tlie man I.ako with a large dormoid. (From a cast in the Museum, St. Thomas's Hospital.) collection at St. Thomas's Hospital, also an excellent cast of his head taken just prior to the operation." A^ drawing of the cast is given in Fig. 142. I have examined the cyst in the museum and find that it is a typical dermoid. This is far the largest dermoid of the scalp with which I am acquainted. The cyst contained a number of round balls, some having a diameter of 1 cm. These con- sisted of epithelial cells mixed with fat. Some of the balls have been preserved. Sibthorpe* described a specimen which he removed from * £rU. Med. Journal, 1888, vol. i.,p. 350. SEQUESTRATION DESMOIDS. 301 the scalp of a young Hindu. The tumour had been present since birth. When excised it was of the shape and size of a cocoa-nut. It contained short hairs, grease, and fat cells. When dermoids 'are situated over the anterior fontanelle they may easily be inistaken for meningoceles. Arnott* published the details of an instructive case of dermoid situated over the anterior fontanelle in an infant a few days old. The tumour exactly resembled a meningocele, " rising and falling with regular pulsation, and swelling when the child coughed " ; the resemblance was so strong that it Pig. 143.— Congenital tumour over the anterior fontanelle. {After HutcMmon.) was regarded as a meningocele. A few weeks later the child died from broncho-pneumonia, and the cyst was found to bo a dermoid. The specimen is preserved in the museum of St. Thomas's Hospital. Giraldest records a case even more remarkable than this. A child, three months old, had an ovoid tumour, of the size of a pigeon's egg, over the anterior fontanelle. The tumour was covered with fine white hair, and did not pulsate with respira- tion. It was thought to be a meningocele, and in order to estabhsh a diagnosis it was punctured with a fine trocar, and fluid resembling that found in meningoceles was withdrawn. Notwithstanding numerous subsequent punctures, the tumour maintained its original volume. Some months later it was removed, Giraldes being still under the impression that it was a meningocele ; but it was found to be a typical dermoid. * Trnns. Path. Soc, vol. xxv., p. 228. t " Maladies Chir. des Enfants," p. 342. 302 DERMOIDS. The clinical characters of such tumours occurring at the anterior ibntanollo may be illustrated by the case reported by Hutchinson (Fig. 143).* As the tumour distinctly filled when the child cried, it was not interfered with. At the date when the case was published the patient was a fine young man of eighteen, and the cyst had not shown any tendency to increase since birth. Dermoids in the neighbourhood of the occipital protuber- ance may lie on the inner aspect of the occipital bone and are nearly always in relation with the tentorium cerebelli. Examples have been described by Turner,t Ogle,t Pearson Irvine,§ and Lannelongue.|| They occurred in children, and in Ogle's case there was defective development of the squamous portion of the occipital bone. In Lannelongue's patient, a girl seven years old, the dermoid had attained the size of an orange ; it produced marked symptoms, such as paralysis, amaurosis and coma, ending in death. Although at first sight a dermoid connected with the dura mater and projecting into the brain seems to violate all embryological rules, nevertheless, when we view this membrane from a morphological standpoint, the strangeness vanishes and a satisfactory explanation is forthcoming. Morphologically considered, the bony framework of the skull is an additional element to the primitive cranium which is represented by the dura mater, and as I have elsewhere^ endeavoured to show, the term extracranial should strictly apply to all tissues outside the dura mater. In surgical practice we find it convenient to regard the bones as the boundary of the skull, but morphologically this is inaccurate; the skull-bones must be regarded as secondarj'- cranial ele- ments. Early in embryonic life the dura mater and skin are in contact ; gradually the base and portions of the side-Avalls of the membranous cranium chondrify, thus separating the skin from the dura mater. In the vault of the skull, bone * " Illustrations of Clinical Surgery," vol. ii., plate xlvi. t St. Earth. Hosp. Eep., vol. ii. 62. + Brit, and Fm: Med.-Chir. Review, 1865. § Trans. Path. Soc, vol. xxx. 195. II "Affections Congenitales," 1S91, p. 49. IT Journal of Anat. and Fhyswhgy, vol. xxii., p. 28 : "A Critical Study in Cranial Morphology." SEQUESTRATION BERMOIBS. 303 develops between the dura ma.ter and its cutaneous cap, but the skin and dura mater remain in contact along the various sutures even for a year or more after birth. This relation of the dura mater and skin persists longest in the region of the anterior fontanelle and the neighbourhood of the torcular. Should the skin be imperfectly separated, or a portion remain persistently adherent to the dura mater, it would act precisely as a tumour germ and give rise to a dermoid cyst. Such a tumour may retain its original attachment to the dura mater, and its pedicle become surrounded by bone : the dermoid would lie outside the bone, but be lodged in a depression on its surface, with an aperture transmitting its pedicle. On the ■ other hand, the tumour may become separated from the skin by bone ; it would then project on the inner surface, or between the layers of the dura mater. If this view of the origin of dermoids of the scalp be admitted, we must then slightly modify our teaching, and say that the depressions in which dermoids of the cranium are lodged arise as imperfections in the developmental process, and are not due to absorption induced by the pressure they exert ; further, the fibrous connection of such dermoids with the underlying dura mater is primary, not accidental. The relation of dermoids to the tentorium requires further consideration. A study of the development of the tentorium cerebelli will demonstrate that it is composed of two folds of dura mater, and it arises as an infolding or crease in this membrane, caused by the rapid backward extension of the developing cerebrum. The opposed surfaces of the tentorial lamellae, like the outer surface of the dura mater in relation with the cerebrum, were originally in contact with the sl^;in, and as the posterior margins of the bay or recess formed by the crease" in the dura mater come together, a portion of the skin may become nipped or even sequestrated between the layers of the tentorium ; this preserving its vitality, and in some cases its cutaneous connections, may ultimately give rise to an intracranial dermoid. 304 CHAPTER XXXII. IMPLANTATION CYSTS. These small tumours should form a group by themselves and not be included among dermoids ; but their consideration in connection with sequestration dermoids is imperative, as they furnish valuable (almost experimental) evidence of the reality of the theory that this genus of dermoids arises from " rests," the results of faulty coalescence. Implantation cysts are caused by the accidental transplantation of portions of skin, surface epithelium, or hair bulbs into the underlying connective tissue. The transplanted tissue acts, in many instances, as a graft and ultimately forms a small tumour. Cysts of this character have been described as sebaceous cysts, dermal cj'sts and dermoids. They occur most commonly on the fingers, and especially on the fingers of women who live by sewing shoe-makers, carpenters, and the like. Fig. 144.— Implanta- t-> i -ii j<. i ■ /. t tion cyst from the rolaiiion* has Written an account of digital til.' of the fin'''sr. ® dermoids, and gives M. Muron the credit of first recognising the character of such cysts (1868). He says the tumours are more frequent on the palmar than the dorsal aspect of the digits, but he fails to associate them with ante- cedent injury, though he distinctly points out that they occur mainly on the hands of workpeople and soldiers.t A digital dermoid in the subcutaneous tissue of the finger- tip is represented in Fig. 144. The specimen was placed at my disposal by Mr. Shattock, who described its micro- scopical characters thus : " It appeared as if a piece of the skin covering the pulp of the finger had been inverted." There was no clear history of old mechanical injury, but the patient was a farrier. Implantation cysts occur in other parts of the bodv. Treves X described a case Avhich occurred in a woman twenty- * " Die. Enuy. des Sci. Med.," 18S4, in an admirable article, " Doigt." t The Trans. Path. Soc, vol. xxxv. onwards, contain careful descriptions of several oases by Barker, Bowlby, Poland, and others. J Lmicet, 1889, vol. i., p. G82. IMPLANTATION CYSTS. 305 nine years of age. The tumour was situated over tlie external 'occipital protuberance, and measured 7 cm. in its long axis. It was cystic, the walls being lined internally with skin furnished with hair 5 to 8 cm. long. The cavity also con- tained sebaceous material and mucus. The patient affirmed that the tumour appeared eight years previously after a laceration of the scalp, the scar of which was visible at the time the tumour was removed; it was situated some httle way from the cyst. These cases are of interest, for they serve to throw light on some cysts, containing hair and wool, preserved in the museum of the Royal CoUege of Surgeons. Two of the cysts are from sheep, and contain wool embedded in fatty matter. Unfortunately, the catalogue aftbrds no information as to the region of the body whence they were removed. The third and fourth specimens were removed from the shoulder of a cow that had' six legs. The cysts contain light hair, fatty and calcareous matter. These four specimens are Hunterian. The fifth specimen was removed from beneath the integuments of the shoulder of an ox. It contained slender black hairs, resembling those on the skin of the animal, mixed with fat. I once obtained a good example of an implantation cyst from the axilla of an ox. The cyst was as large as a bihiard ball, and in structure resembled a piece of inverted skin. Fortunately, these cj'sts can be explained on the same lines as dermoid cysts of the fingers in man. The sticks used by cattle-drovers are armed at the end with a sharp iron spike, 2-5 cm. (1") long, with which they "prod" the beasts, often, very severely. It may be assumed that punctures produced with such an instrument may lead to the deposition of dermal grafts beneath the skin, which may give rise to dermoids in the same way as punctured wounds in the skin of men and women. Punctured wounds in sheep and oxen may also be caused by projecting nails, iron spikes, tenter- hooks, and the like. The opinion that dermoids may arise in the subcutaneous tissues by implantation, receives the strongest possible con- firmation from what we know of similar cysts of the iris and cornea associated with mechanical injury. Iritic Cysts. — Cysts of the iris are of comparative rarity, 306 DERMOIDS. generally appearing as transparent vesicles situated on its anterior surface. As a rule, they are sessile, but occasionally possess a pedicle. The contents may be opaque, but^ in exceptional cases they have been filled with sebaceous material, such as fills the cavities of dermoids, Mr. Hulke* has collected some valuable facts in relation to such cysts, and states that in fifteen out of nineteen cases, as well as in two reported by himself, there was distinct history of antecedent mechanical injury. He suggested that some of these cysts originated from portions of Descemet> membrane, which may have been torn from the cornea and implanted on the iris. Mr. Power mentioned to me the case Pig. 145.— Large implantation cyst of the cornea, following an injury. (After T. Collins.) of a sailor who wounded his cornea with a knife ; afterwards a small cyst was found on the iris, with an eyelash sprouting from its middle. On this head we have the accumulated experi- mental observations of Dooremaal, Goldzieher, Schweninger, Zahn, and Masse, who introduced various kinds of tissue, such as cartilage, hairs, and conjunctiva, into the anterror chambers of rabbits' eyes. In some instances the transplanted tissues grew; in others they were absorbed or extruded from the globe. Corneal Cysts. — In addition to the evidence furnished by implantation cysts of the iris we know that similar cysts Occur in the cornea. Treacher Collins has investigated this matter, and has published some valuable researches in which he has succeeded in demonstrating that after gunshot injuries of the eyeball, blows from tip-cats, and incisions made for the extraction of cataracts, cysts, usually of small size, are liable * " On Cases of Cysts of the Iris," R. Lend. Ophth. Hosp. Kep., vol. vi., 1869; also Hosch, "Ex. Studion iiber Iriscysten," Virchow's "Arcliiv," td. Kcix., 8. 449. IMPLANTATION CTSTS. 307 to form in the cornea near the seat of injury, m some of the specimens, as for instance the eye sketched in Fig. 145, the cyst may be very large and conspicuous ; when examined microscopically, their inner walls are found lined with layers of cells identical with those covering the anterior surface of the conjunctiva. (Fig. 146.) The structure of these t --^s^. Fig. 146. — Section of the cyst in the preceding figure, highly magnified. It shows the laminated epithelium. (After Treacher CoUiiis.) cysts, taken in conjunction with the antecedent injuries, thoroughly supports the view that they arise from conjunctival epithelium transplanted into the deep tissues of the cornea. The most careful investigation into the origin and structure of corneal cysts has been undertaken by Treacher Collins,* whose communications deserve the most attentive study from all interested in this subject. * Royal London Ophth. Hosp. Reports, vol. xii. 308 CHAPTER XXXIII TUBULO-DERMOIDS. There exist in the human embryo certain canals and passages, many of which normally disappear before birth. Among these obsolete canals there are three that require especial consideration in connection with dermoids — Vvz,., the thyro-lingual duct, the post-anal gut, and the branchial clefts. The remainder will be considered in connection with cysts. The Thyro-glossal Duct. — The thyroid gland of man consists of two lobes united by a narrower portion or isthmus. His maintains that the three parts of this gland arise separately. The lateral lobes originate independently of the isthmus ; the latter is derived from a median tubular outgrowth from the ventral Avall of the embryonic pharynx known as the thyro- glossal duct. This duct bifurcates at its lower end and gives rise to the thyroid isthmus, which fuses with the lateral thyroid rudiments, and assists in forming the lobes of the gland. Originally the duct extends as far upwards (forwards in the embryo) as the dorsum of the tongue, but as the body of the hyoid bone develops, the duct becomes divided into an upper segment, the lingual duct, and a lower portion, the thyroid duct. In the ordinary course of development these ducts disappear, but in some cases they persist and attain a fair size, and in others give rise to pathological conditions of great interest. There are at least three abnormalities which appear to be associated with vagaries of the thyro-glossal duct, viz. (1) lingual dermoids, (2) median cervical fistulse, (3) accessory thyroids. It will be convenient to begin with dermoids in the tongue. Lingual Dermoids have been frequently mistaken for sebaceous cysts, and until recently were regarded by most surgical writers as rarities. Since Barker* published his excellent paper on the subject, many cases have been observed and recorded. Barker analysed sixteen cases, and showed that * Trans. Cliu. Soc, vol. xvi., p. 215. TUBULO-DERMOIDS. 309 tHey may be situated between tbe genio-lijo-glossus and mylo-hyoid musoles, or occupy a central position between the genio-byo-glossi muscles. The lateral group is discussed in the section devoted to dermoids arising in branchial clefts; those occupying the centre of the tongue concern us now. Central dermoids of the tongue are rarely sufficiently large to attract attention in infants. Eichet, however, removed one from a child, a few days old, in I'Hopital St. Louis. Most of the cases have occurred in young adults, and in many instances have been regarded as ranulse. As a rule, they cause the floor of the mouth to bulge on each side of the frsenum, and when unusually large, a prominence is noticed under the chin. In at least two cases the swelling has been mistaken for an abscess. The dermoid can be removed, when small, through the floor of the mouth, and when large by dissection through a median incision extending from the chin to the body of the hyoid. The cyst- wall must be completely dissected out. A man, aged twenty-four years, came under my care with a lingual dermoid that had been previously mistaken for a ranula ; during nine years he had been submitted to seven operations without success. On dissecting out the cyst I found it firmly adherent to the body of the hyoid bone, and extending between the genio-hyo-glossi to ■ the foramen csecum. The walls of lingual dermoids are composed of fibrous tissue, lined internally with squamous epithelium beset with hair, and sometimes glands. In one case reported by Stephen Paget* there was a deposit of pigment in the cyst-walL The contents of these cysts are epithelial cells, hair, sebum, and cholesterine. Should the cyst burst, then it would suppurate " and become very disagreeable. Dermoids lying in the middle line of the tongue arise in the lingual duct. This, when fully developed, extends from the foramen caecum to the posterior surface of the body of the hyoid: the foramen csecum marks the termuiation of this duct on the dorsum of the tongue; occasionally it is so large that a narrow probe may be passed along it. * Trans. Path. Soc, vol. xxxvii., p. 225. 310 DERMOIDS. The duct lies exactly between the genio-hyo-giossi muscles, and is not infrequently replaced by a solid fibrous cord. It is easy to understand that if a persistent duct should have its upper end obstructed or obliterated, the continual shedding of the epithelium which lines it and the aacumulation of Fig. 147. — Large lingual dermoid, protruding from the mouth. (Gray.) sebum from the glands would convert it into a cyst, which in due course would assume such a size as to come within the range of clinical observation. Stich a tumour would project into the floor of the mouth and, when unusually large, form a swelling above the body of the hyoid bone. In some rare instances they project from the mouth, as in the negro whose- case was reported by Barker.* This man was under the care of Dr. Wellington Gray, in Bombay. (Fig. 147.) The tumour protruded from the man's mouth, and was as large as a medium-sized cocoa-nut. It completely filled the space between the jaws, the upper incisor teeth projected horizontally forwards, whilst those of the lower jaw were not only loosened but their direction was reversed. The tumour * Trans. Clin. Soc, vol. xxiv., p. 68. TUBULO-BEBMOIDS. 311 caused a swelling in the neck as low as the thyroid cartilage. The patient's voice was an indistinct miunble, and only- fluid food could be taken. The tumour was successfully removed : it contained forty ounces of pultaceous matter, consisting of epithelium, fat, and cholesterine. The walls were lined with epithelium. Such large cysts are excessively rare. Stephen Paget* described a very large cyst which he successfully removed from a child four years old, in whom it was congenital. Its anatomical relations were like those of a dermoid arising in the lingual duct. It contained fluid of a yellow colour, and was so large as to project from the child's mouth and almost touch the sternum. In addition to the common variety of dermoid, the tongue is occasionally occupied by tumours which in structure re- semble the thyroid gland. They occur in the neighbour- hood of the foramen caecum, between the genio-hyo-glossi muscles. Bernays has given a careful description of such a tumour, which he removed from the tongue of a girl seven- teen years of age. In the account of the case Bernaysf clearly associates the tumour with the lingual duct. ButlinJ has recorded two cases that came under his notice : one in a female thirty-two years of age, and the other — also a female — twenty-seven years old. The tumours were situated at the base of the tongue, where they formed prominent swellings just in front of the epiglottis, and caused very httle inconvenience. A curious effect of' the partial removal of these tumours is noted by Butlin. The interference excited growth and for a time caused the remnants to increase in size ; gradually growth ceased, the tumour remained passive, and then dwindled to half its bulk. This happened in the two cases under Butlin's care and in a case recorded by Rushton Parker. Wolf § has described an example which occurred in a girl of eighteen years. He removed the tumour from the substance of the base of the tongue. As its microscopical characters * Trans. Path. Soc, vol. xliii. 57. •j- St. Louis Medical and SurfficalJour7ial, vol. Iv. 201. t Trans. Clin. Soc, vol. xxiii. 118. § Langenteck's " Archiv," bd. xxxix. 224. See aho Warren, Intel-national Journal of Med. Science, October, 1892, vol. civ. p. 377. 312 BERMOIBS. SO strongly resembled thyroid gland, Wolf regarded it as an accessory thyroid body (accessorishe schilddruse). We have now to deal with abnormalities arising in con- nection with the thyroid section of the thyro-lingual duct. It will be convenient to begin with the consideration of median cervical fistulse. These openings occur singly, and open at some point in the middle line of the neck between the hyoid bone and the top of the sternum. The common situation is a little below the level of the cricoid cartilage. Median cervical fistulse differ from those arising in connection with branchial clefts in the fact that they are never congenital ; they may occur soon after birth or make their appearance as late as the fourteenth year. Eaymond Johnson* has clearly pointed out that median cervical fistulas are often preceded by a swelling in the middle line of the neck which either ruptures or is opened by the surgeon ; this leaves a sinus which never closes. Johnson illustrates these facts by careful descriptions of three cases that he observed. In some cases an oval swelling the size of an almond forms in the middle line of the neck, at the level of the thjToid isthmus ; from this a rounded cord may sometimes be felt passing upwards to the hyoid bone. The fistulse easily admit an ordinary probe, which always passes upwards to the body of the hyoid. Hence when the surgeon attempts to dissect out these sinuses he finds that they run upwards between the steriio-hyoid muscles and beneath the deep fascia of the neck to reach the hyoid bone. Few of these fistulse have been examined microscopically, but in one of Johnson's cases the cord dissected out was 4 cm. in length, equal in calibre to a No. 6 English catheter, and com- posed of concentric layers of fibrous tissues. The inner surface was covered with stratified epithelium. Unless the whole length of the duct is extirpated, the sinus will persist. The fact that these median cervical fistulas are preceded by a swelling is a fact of great interest. Cussetf described the case of a little girl five years old, in the middle line of whose neck there was a swelling beloAv the hyoid bone ; this opened * Trans. Path. Soc, -pol. xli. 325. t " Kystes et Fistules d'origiue 'brano'hiale." Paris, 1S77. TUBULO-DERMOIBS. 313 and discharged a glairy fluid and left a sinus that passed upwards to the base of the tongue ; but Johnson seems to be the- first to emphasise the fact that a swelling in the neck precedes the sinus. Our knowledge of the nature of these fistulae was not very satisfactory until the publication of an able paper by Dr. C. F. Marshall * detailing an account of the anatomy of the parts in the neighbourhood of the hyoid bone of a child five years old, who had a median sinus in the neck. The patient was admitted into a hospital for the purpose 6i having the duct excised; it contracted diphtheria and died before the operation could be performed. In the median line of the neck, 2-5 cm. (1") above the sternum, there was a sinus which, during life, discharged a small quantity of mucous fluid. From this opening a hard cord could be felt extending up to the hyoid bone. On dissecting the front of the neck this cord was found to be tubular and patent up to within 1 cm. of its termination : the upper end was firmly attached to the hyoid bone, the lower end dilated into a thin- walled sac opening on to the surface of the skin. The sac and tube lay between the skin and the anterior layer of the deep cervical fascia : at no place was there any connection with the thyroid gland. On dividing the hyoid bone the tube could be traced as an ill-defined fibrous cord on to its dorsal surface, to which it was closely attached, and through the substance of the tongue to the foramen csecum. About 2 cm. from the foramen it again became patent, and continued so up to the surface of the tongue. The canal was thus open at both ends, but impervious in the middle. On further dissection a lob us pyramidalis was found con- nected with the left side of the thyroid isthmus, its upper end being united to the median fibrous cord at the same place as the above-mentioned canal. In other words, the fibrous cord behind the hyoid bone was continuous both with the pyramidal lobe of the thyroid and with the tube leading to the superficial sinus. The relations of the parts are admirably shown in Fig. 148, which indicate exceedingly well the probable mode by which * Journal of Anat. and Fhvs., vol. xxvi., p. 94. 314. BEBMOIBS. these median fistulse arise, for a glance at the diagram is suiEcient to suggest that they are in the first place retention cysts formed in a persistent thyroid duct, and the pressure of the cyst ultimately causes the skin to yield and form a sinus. Marshall is of opinion that the canal is the remnant' of one of the bifurcations of the original median thyroid rudi- ment, the remaining bifurcation forming the pyramidal lobe of the thyroid body. At pre- sent there is little to support Kostanecki and Mielfcki's* contention that median cer- vical fistulse arise in connec- tion with the "precervical sinus." Accessory Thyroids. — The consideration of accessory thyroids naturally follows on the description of median cervical fistulfe, for there is good reason to believe that the thyroid duct is the source of some of these bodies. The existence of accessory thyroids has long been known,t and in recent years they have been carefully studied. It wUl be convenient to consider them parts in a"case of median eevvicaf flstalf aCCOrding tO their sitUation : if^^in^gu'^aiSr'' A, foramen caecum; (j) Median accessory thyroids ; (2) lateral accessory thyroids. 1. Median Accessory Thyroids.— The most freq^ent situation in which to find these small bodies is in the neighbourhood of the hyoid bone, and Streckeisen, who has pubhshed the results of a careful inquiry into this question, divides them into four groups :—(l) Those superficial to the mylohyoid mnscle—pre-hyoid. (2) Between or in the substance of the genio-hyoids — supra-hyoid. (3) Above the * Tirchow's " Archiv," bd. cxx. 385 and cxxi. 53. + Albers' " Atlas der Path. Anat.," Abth. ii., Ted. xxv., xxvi., and xxxix. ; also Virobow, "Die Krankhaften Geschwulste," bd. iii. s. 13. Pyramid of the- thyroid gland. Canal. — Thyroid gland — Tradhea, ^ TUBULO DERMOIDS. 315 gonio-hyoid—epi-hyoid. (4) They may be lodged in the hollow or even in the substance of the hyoid bone — iyitra- hyoid. Another common place in which to find them is in the hollow formed by the two lobes of the thyroid. It has already been pointed out that the lingual duct is, in the early embryo, directly continuous with the thyroid duct, and that the continuity of the two is interrupted by the development of the body of the hyoid. It was also stated that the terminal portion of the thyroid duct bifurcates and gives rise to the isthmus of the thyroid and adjacent portion of each lateral lobe. Usually all traces of the duct disappear, but in a fair portion of cases it forms a pyramidal process for the thyroid, and not infrequently it persists as a duct running from the hyoid bone to the thyroid isthmus, and contains a lumen capable of admitting an ordinary probe ; in some instances it is an impervious cord, and occasionally it is moniliform. As the duct is directly associated with the formation of the thyroid body, and as median accessory thyroids are found directly in its track from the hyoid to the thyroid isthmus, it is not unreasonable to regard these little bodies as remnants of this remarkable tube. %. Lateral Accessory Thyroids. — The thyro-glossal duct is not responsible for all accessory thyroids, for they occa- sionally arise in connection with the germs of the lateral lobes of the thyroid. This variety is most commonly found in the neighbourhood of the greater cornua of the hyoid. Accessory thyroids are in the main innocent structures, but occasionally they give rise to troublesome tumours. It is well known that when the thyroid body becomes goitrous, and accessory thyroids co-exist, the latter will enlarge and become in fact, goitrous. Apart from this, accessory thyroids wiU enlarge on their own account and give rise to tumours that closely simulate unilateral enlargement of the thyroid, and occasionally give rise to bronchoceles of moderate dimensions. Pollard* has carefully described a tumour removed by Barker from the anterior triangle of the neck of a man aged * Trans. Path. Soc, vol. xxxvii. 507. 316 ■ DEBMOIDS. thirty-five years; the tumour was cystic, and from ij;s inner' wall numerous villous processes, covered with a single layer of cubical epithelium, projected into the cavity. The Infundibulum and Pituitary Body.— The close structural relationship of the glandular portion of the pitui- tary body to the thyroid gland makes it desirable to describe tumours of this structure in sequence with those connected with the thyro-glossal duct. The infundibulum arises as a ' diverticulum from the , first encephalic vesicle, and ends blindly in the substance of the pituitary body. This body also comes into relationship with a diverticulum from the developing pharynx known as the pouch of Rathk^. Although the pouch and the infundibulum come into close relation- ship with the pituitary body, they do not communicate with each other. Dermoids, adenomata, and cysts are met with in connection with these structures : — 1. Dermoids. — Bowlby* described a tumour as large as a walnut of the pituitary body, composed of vascular connective tissue, spaces lined with epithelium and bone, in a man twenty-two years old. Hale Whitef met with one the size of a nut ; it contained besides connective tissue, vessels, fat cells, nerve fibres, ganglionic cells, and striped muscle fibres. The patient was a boy twelve years old. 2. Adenomata. — These resemble in structure the thyroid gland, and bear much the same relation to the pituitary body that parenchymatous goitres do to the thyroid body; indeed, they are sometimes referred to as pituitary goitres. A few cases have been observed in man. J Goodhart§ described an interesting case in a baboon, with its clinical history ; and Sibley II observed a specimen in an ewe. These tumours are at first isolated from the general cavity of the cranium by the circular fold of the dura mater known as the diaphragma sellce, and they generally produce erosion of the pituitary fosSa. As they increase in size, tumours of * Trans. Path. Soc, toI. xxxvi. 35. t Trans. Path. Soc, vol. xxxvi. 37. X Wills, Brain, vol. xv. 465 ; Loeb and Arnold, Virchow's " Archiv," bd. Ivii. 172. § Trans. Path. Soc, vol. xxxvi., 36. II Trans. Path. Soc, vol. xxxix. 459. TUBULO-DEBMOIDS. 317 the pituitary body usually implicate tlie optic chiasma and the third pair of nerves, thus producing visual disturbances. Sometimes the tumour will bulge upwards into the third ventricle. ■ 3. Cysts. — When the pouch of Rathke persists it some- times dilates and forms a cyst in the pharynx near the junction of the posterior wall with the roof Such cysts have been known to reach the size of a ripe cherry ; usually they are very much smaller. Laryngologists sometimes regard them as sources of inconvenience, and attack them with the galvano-cautery. A cyst in this situation as large as a cherry would doubtless impede nasal respiration and cause the breathing at times to be unpleasantly audible. 318 CHAPTER XXXIV. TUBULO-DERMOIDS (continued). DERMOIDS OF THE RECTUM. In order to appreciate the nature of dermoids arising in the; immediate neighbourhood of the rectum, it will be necessary to consider a few points connected with the embryology of this portion of the alimentary canal. In the early embryo, the central canal of the spinal cord and the alimentary canal, are continuous around the caudal extremity of the notochord. This passage, which brings the developing cord and gut into such intimate union, is known as the neureuteric 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 neurenteric 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." Afterwards this post-anal section of the embryonic intestine 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 regard the post-anal gut as the source of that variety of congenital sacro-coccygeal tumour which was named by Braune* and several writers who followed him '' congenital cystic sarcoma." These tumours will be referred to as thyroid-dermoids. In addition it will be necessary to consider dermoids situated between the rectum and the hollow of the sacrum — post-rectal dermoids — and certain pedunculated tumours situated within the rectum — rectal dermoids. Thyroid-dermoids in structure resemble the thyroid body, for they are composed of closed vesicles lined with glandular epithelium, and contain glue-like fluid. Many of these tumours are composed of cysts and duct-like passages lined with cubical epithelium, held together by richly cellular connective tissue. In many situations the epithelium is columnar, set upon flatter cubical cells. The cysts are filled * Die Doppelbildunffeii, 1862. TUBULO.DEBMOinS. 3I9 with ropy mucus, and vary in size from a nutshell to the smallest space visible to the naked eye; many contain , mtracystic processes. These tumours present such very definite characters that they are sure to attract attention and their large size makes them very conspicuous. (Figs' 149 and 150.) v s • Middeldorpf* was the first to associate clearly a conaenital sacro-coccygeal tumour with the post-anal gut. His specimen was re- moved from the neigh- bourhood of the anus of a girl a year old. The tumour contained connective tissue, mu- cous membrane with characteristic follicles, submucous tissue, lon- gitudinal and circular layers of muscle fibres. I had come to the same conclusion in regard to the probable origin of these tumours before the publication of Middeldorpfs paper ; his case is the most conclusive on record. Alexander Mackay,-f- in a pamphlet, gives accounts of two cases in which he suc- cessfully removed two of these tumours from female infants aged two and a half^ and three months respectively, at Hueiva. Post-rectal dermoids are very rare, and do not form such large projecting masses as the preceding species. In many instances they are not noticed until after infant life, and their clinical tendencies are of a different character. It is also somewhat remarkable that dermoids, although they are met « Virchow's " Archiv," bd. 101, o. 37. t " Surgery in Spain," 1889. Fig. 149.— Tliyroid-dei'moid. (HutcMnson.) 320 DERMOIDS. with in many parts of the body, contain teeth only in certain situations ; the post-rectal region comes into this category. The museum of the Middlesex Hospital contains an example of post-rectal dermoid which contains hair and teeth ; the specimen is without history, and it probably occurred as a post-mortem surprise. Such tumours sometimes occur as surgical surprises. Thus a lad aged nineteen years was under Bryant's care for a discharging sinus on the ventral aspect of the coccyx, which had existed since he was three years old. When this was explored a tumour was found between the rec- tum and coccyx. When re- moved it was as large as an orange, and consisted of loouli filled with pultaceous material, and contained a piece of bone. The cysts were lined with columnar epithelium. Post - rectal dermoids sometimes attain very large dimensions, and extend upwards behind the pelvic peritoneum in men and women. Ord* described a case in which a dermoid weighing fourteen and a half pounds was found in the pelvis of a man twenty- eight years of age. The tumour contained pultaceous material mixed with hairs. The inner wall of the cyst was lined with piliferous skin ; it contained sebaceous glands. Frederick Paget has described a case in which he removed, through an incision across the space between the anus and coccyx, a large post-rectal dermoid which occupied the hollow of the sacrum in a woman forty-seven years of a^e. The tumour lay behind the rectum and peritoneum. On opening * Med.-Chir. Trans., vol. Ixiii., p. 1. f Brit. Med. Journal, 1891, vol. i., p. 406. Fig. 150. — Tliyroid-dermoid of tlie coccygeal region, in section. {After SlKdlock.)" TUBULO-DEBMOIDS. 321 the cyst putty -like- material mixed with hair was removed by means of a spoon ; the cyst was then enucleated. The cyst and contents weighed three - pounds. When dried and stuffed it assumed an ovoid form measuring 76 cm. in circumference in one direction, and 44 cm. in the other. The patient recovered. Rectal Dermoids. — Several examples of dermoid tumours have been described growing from the mucous membrane of the rectum : a curious feature in these cases is that the tumours are furnished with long locks of hair, which protrude from the anus and annoy the patients. Like post - rectal dermoids, they sometimes contain teeth. The case described by Port* may be selected as a typical specimen. (Fig. 151.) The tumour was removed from the rectum of a girl sixteen years of age. It measured 5 cm. in the long and about 4 cm. in its short axis. It was covered with skin furnished with hair and glands: it also presented a tooth. The bulk of the tumour was made up of fat and fibrous tissue. Danzel f observed a similar tumour in a woman twenty-five years of age. It was as large as an apple, and was said to contain brain substance enclosed in a bony capsule; a tooth projected from it. (Fig. 152.) This woman was troubled with long hairs which protruded at the anus and she used to pull them out with her hands. CluttonJ exhibited a specimen at the Pathological Society which, in conjunction with Floyer, he had removed from the rectum of a girl nine years of age. The patient had on two occasions been troubled with tufts of hair projecting from the anus. Two of these tufts measured 25 cm. The tumour, after removal, measured about 7 cm. in its longest * Trans. Path. Soc, vol. xxxi.,p. 307. f Langenteck's " Arcliiv," td. xvii., s. 4-12. J Trans. Path. Soc, vol. xxxvii, 25J. Fig. 151. -Rectal dermnid in section. (A/ler Port.) 322 BEBMOIDS. diameter. In its general characters it resembled the two specimens figured (Figs. 151 and 152). It appears to have been attached, however, at a higher point in the rectum. The student should compare rectal with pharyngeal der- moids : it is somewhat, curious that pedunculated dermoids Fig. 1 52. — Rectal dermoid. {After Danzel. ) should be peculiar to the two extremities of the alimentary canal. It was formerly suggested that rectal dermoids of this character originated in the ovary, and afterwards invagi- nated the rectum, finally presenting themselves at the anus. No one can, with our present knowledge, seriously advocate this theory. Pedunculated dermoids growing from the wall of the rectum must not be confounded with those ovarian dermoids which erode the wall of the rectum, then suppurate and discharge their contents into it. 323 CHA.PTER XXXV. TUBULO-DERMOiDS {concluded). BRANCHIAL FISTULiE AND CYSTS. Since 1875, when Rathke found evidence in the embryos of pigs, horses, and chicks, of the branchial clefts so characteristic of fish, many eminent anatomists have confirmed his observa- tions. Rathke was also fortunate enough to detect the fissures in an early human embryo. (Fig. 153.) It appears that in 1789 Hunozowski* described two cases of congenital fistulous openings in the side of the neck. In 1829, Dzondi described similar openings under the name of tracheal fistula ; and Ascherson, three years later, showed that such fistulee communicated with the pharynx and not with the trachea. Heusinger,t in 1864, collected a number of recoraed cases, ana was the first clearly to niiiiian embryo, suow- , . , . , . ing the gill-eletts. associate these congenital cervical openings with the branchial clefts detected by Rathke. It has been asserted by His, and in this he has been followed by other writers, that the supposed clefts are merely furrows between the arches ; the furrows being visible on the inner as well as on the outer surface, but they are separated from each other by membrane. This view, as will be shown afterwards, is not in harmony with facts. The human embryo has four branchial clefts. Of these, the first becomes the tympano-Eustachian passage, and the three posterior clefts usually suffer obliteration. Frequently, one or more of the clefts persist wholly or in part, and are then known as " congenital cervical fistulse." These fistulse appear as fine canals, capable of admitting a bristle, and some a , fine probe. The orifice usually opens in the neck ; but when complete into the pharynx also. There is reason to believe that they may open into the pharynx, but end externally as a * Fischer, "Deutsche Zeitsch. fiir Chir.," b-1. iL f Virehow's " Archiv," bd. .\:xix., 35S. :524 DEBMOIDS. cul-de-sac. One, two, or three fistulse may be present in the same individual ; they have a great tendency to be bilateral, to affect several members of the same family, and to be trans- mitted to several generations. The canals, which may vary in length from 2 to 5 cm., are lined by mucous membrane, sometimes with ciUated epithelium, or by skin containing Fig. 154. — Diagram to indicate the orifices of persistent braucliial fistulse. sebaceous glands. The lining membrane of the canal usually secretes a thin mucous fluid, which may become increased during catarrhal conditions of the respiratory passages. Occasionally the canal inflames and an abscess results, which may give rise to considerable pain and difficulty in deglutition. The external orifice of a branchial fistula may be indicated by a tag of skin, containing a piece of yellow elastic cartilage. These cutaneous processes, or cervical auricles, as they are called, are of sufficient interest to require separate con- sideration (page 330). Neglecting for the present the first cleft — the tympano- Eustachian passage — it may be convenient to consider the TUBULO-DEBMOIDS. 325 situations usually occupied by these fistulfe when they occur in man. The external orifices of the fistulse are apt to vary, but they usually open in the positions shown in Fig. 154. The first becomes the tympano-Eustachian passage ; the second opens close behind the angle of the jaw anterior to the line of the sterno-mastoid muscle : in a few cases it may be on a level with, and slightly posterior to, the lobule of the pinna. The third is situated on a level with the thyro-hyoid space close to the anterior border of the sterno-mastoid ; this position is very constant. The fourth usually opens near the sterno-clavicular articulation ; it may open 3 or 4 cm. higher in the neck, but always in relation with the anterior border of the sterno-mastoid muscle. The internal orifices of these fistulse may be indicated in the following way. The second opens into the recess con- taining the tonsil ; the third and fourth are in relation with the sinus pyriformis. To reach this sinus, a fistula corre- sponding to the third cleft must pass over the loop formed by the superior laryngeal nerve. Hueter's* observation is interesting in this connection : " In a young feUow who wished to become a trumpeter I dissected out one of these fistulous tracks, following it between the two carotids to the pharyngeal cavity." Prof His is of opinion that when these fistulse com- municate with the pharynx, it is the result of incautious sounding. I have satisfied myself that these fistulse do open into the pharynx in cases where no probe has been passed. This I have demonstrated by allowing a child with a second cleft persistent to swallow milk ; drops of milk found their way through the fistula and appeared on the skin of the neck. Abnormal persistence of branchial clefts occurs in four forms : — 1. Complete fistula. 2. The external half persists. 3. The internal half persists. 4. The external and internal orifices are obliterated but an intermediate section persists. * " GrundrJss der Chirurgie," vol. ii., 328, 1st edition. 326 DEEMOIDS. The first form, conaplete fistulse, as far as my own obser- vations extend, occurs most frequently in connection with the second cleft. In one case, a youth aged fifteen years, the con^munication with the pharynx was so complete that when he swallowed milk some of the fluid occasionally passed through the fistula and appeared at the cutaneous orifice. In another case, that of a little girl aged ten, saliva issued at the cervical orifice when the child had been talking freely, and excited the parotid gland. The second set of cases, those with external openings, but blind internally, are the most common examples, and need no i'urther comment. The third class are rarely recognised ; this is not remark- able when we remember that they open into the pharynx, but end externally as cul-de-sacs. Heusinger was of opinion that some pharyngeal diverticula are of this nature, and Sir James Paget refers to the probability that some rare instances of diverticula from the pharynx may be regarded as dilatations of portions of branchial fistulse, closed externally, but remain- ing open within. The most remarkable case of this nature that has been placed on record is the specimen that occurred in the body of an adult male dissected in the University of Edinburgh, and described by Morrison Watson * (Fig. 155). A tube, terminating inferiorly in a cul-de-sac containing a large quantity of grumous material, was found extending from the pharynx, immediately behind the tonsils, to the interclavicular notch. This tube possessed muscular walls, and in the deep part of its course passed between the fork of the carotids and over the loop of the superior laryngeal nerve ; its lower part was parallel with the anterior border of the sterno-mastoid muscle ; it rested on the sterno-hyoid and sterno-thyroid muscles. It communicated with the pharynx by means of a slit-hke opening, not more than 3 mm. in length, the margins of which were so closely in contact that the entry of solid particles into it from the mouth must have been prevented. The diverticulum itself increased in calibre from above downwards, so that whilst at the upper end a crow-quill could with difficulty be introduced, at the lower a pencil could readily be passed along the lumen of the tube. * Journal of Anatomy and Tht/siolor/p, toI. ix., p. 134. TUB CLO-DERMOIDS. 327 It is further noteworthy that the pharyngeal orifice was situated between the lower jaw and the stylo-hyoid ligament. Its point of departure from the pharynx corresponds to the supratonsillar fossa. The muscle fibres were, for the most Fig. 166.— Pliaryngeal diverticuliiin. (AJter Moriisoii Watso^i.) part, red and striated, and the mucous lining resembled that of the oesophagus. The fourth class, those closed at each end, leaving a portion of unobliterated canal in the neck, cannot be recog- nised except by the effects to which they give rise. It has long been suspected that the so-called sebaceous cysts which occasionally occur in the neck, below the deep cervical fascia, take origin in unobliterated branchial spaces. 328 DEBMOWS. and are dermoids. A convincing case of this kind is de- scribed by Virchow* A woman aged twenty-four had noticed, since the age of fourteen, a tumour between the angle of the jaw and the mastoid process. When she came under observation it was of the size of a goose's egg, there was also a small tumour immediately above the sternum, Avhich she would not allow to be removed. The larger tumour Avas extirpated, and found to contain sebaceous matter and Fig. 156 — Head and neck of a yonng woman, sliowing branchial fistulse in the neck, a; and a sinus in tlie helix, A ; for &, see text. {After Heusiijger.) epidermal scales. The wall of the cyst was covered with epidermis, and sebaceous glands were disseminated in it. Lingual dermoids lying between the mylo-hyoid and genio-hyo-glossi muscles most probably arise in a partially obliterated second branchial cleft. A retention cyst, arising in a partially obliterated branchial cleft, need not necessarily contain sebaceous matter, it may be filled with mucus. , This apparent contradiction is capable of easy explanation. The internal segment of a branchial fistula is lined by mucous membrane continuous with that of the pharynx, whilst its external segment is a continu- ation of the surface epithehum of the neck. It is on this * " Arohiv," bd. xxxv. 208, 186G. TUBULO-DEUMOIDS. 329 account that some branchial fistulae possess ciliated epithe- lium, others squamous, and so forth. If a cystic dilatation arise in connection with the inner segment, a cavity with mucous contents would be the result, whilst in a similar cyst arising from the external segment epidermal scales, sebaceous matter, and cholesterine would be expected. As far as my own observations go, mucous cysts originating in this manner attain larger dimensions than the dermoid varieties. Cervical cysts arise in other ways, and the chapter on hydrocele of the neck should be studied in relation with this subject. In the copy of Heusinger's sketch (Fig. 156) we find a clear space indicated by the letter b, which is thus described in the original : " Immediately above the opening is a slight eleva- tion of normal-coloured skin." In Knox's translation ol Dzondi's paper the translator remarks that in many persons, in the region where fistulas have been observed, he had noticed one or more discoloured spots, which spots are either rounded and of a pale red colour, or brownish, or like subtile stria3 of hairs, superior in whiteness to the surrounding skin, but conspicuous only to very sharp sights. I have occasionally found these spots referred to by Knox in persons with branchial fistulse ; they are not infrequent near the angle of the jaw, and correspond to the external orifice of the second cleft. Examples of persistent branchial clefts have been observed in horses and sheep. Heusinger* has described examples in horses ; they open immediately below the pinna, and are noticed more frequently in carriage than in draught horses, as the secretion from the fistula soils the surrounding skin and attracts the attention of the grooms. An example of such a fistula in a sheep is illtistrated in Fig. 172 (page 349), and corresponds in position to a persistent second branchial cleft in the horse. * "Deutsche Zeitschiift fiii- Thicrmedioin," bd. ii. 1, 1S7G. 330 CHAPTER XXXVI. DERMOIDS. CERVICAL AURICLES. In describing branchial fistulse in the preceding section it was mentioned that the cutaneous orifices are in some cases sur- mounted by tags of skin. These tags, or processes, sometimes Figi 157.— Cervical auricles in a child. occur unassociated with fistuljE, but always in situations where fistulse, when present, open on the skin. Usually they are short, in some cases mere nodules, but in others form prominences 2 to 3 cm. in height. These processes have been described under a variety of names, and classed among tumours, but at the present time they are commonly known as cervical auricles. Like branchial fistulse, they are always congenital, and sometimes affect several members of a family. The mother may have a cervical auricle, and one of her children a branchial fistula, whilst another child may have an auricle CEUVIGAL AURICLES. 331 associated with a fistula; they are often symmetrical. (Fig. 157.) A cervical auricle consists of an axis of yellow elastic cartilage which sometimes extends deeply into the tissues of the neck ; muscle-fibres from the platysma are attached to the cartilage, and the whole is surmounted with skin containing hairs and sebaceous glands. A small arterial Fig. 158.— Haid and neck of a goat with cervical auricles. twig runs into the auricle and ramifies in the fibrous tissue and fat in which the cartilage is embedded. Thus, structurally, cervical auricles are identical with the normal auricle or pinna, and they agree with the pinna morphologically, inasmuch as they are developed like it from that portion of a branchial bar which is directly in relation with the corresponding cleft. . In sharks the gill-slits open separately on the surface of the body; from the branchial bar, anterior to each slit, a fold of skin is formed which closes upon the slit like a lid, and is named from this resemblance the operculum. In mam- malian embryos a slight prominence or tubercle is for a time visible anterior to each of these clefts. In most cases the 332 DERMOIDS. tubercles disappear from the' posterior bars, bul those in relation with the anterior cleft enlarge and are joined by accessory tubercles to form the pinna. Thus embryology has taught me to regard the pinna as consisting mainly of an operculum which has become modified for acoustic purposes, for we may regard the tubercles formed in relation with the branchial clefts of man as representatives of the opercula of Fig. 159. -Horned sheep with cervical auriules. certain Ichthyopsida. As the pinna is mainly derived from opercular tubercles, and cervical auricles, in all probability, represent persistent opercular tubercles, it is reasonable to term them cervical auricles. The homology of at least a part of the pinna and cervical auricles with the opercula of fish has been made clearer by Schwalbe's* discovery of auricular tubercles in the embryo of the turtle {Emys lutaria taurica) ; in the adult condition chelonians have no vestige of auricles. Cervical auricles occur in mammals other than man. Heusinger, in 1876, mentioned the frequency with which pendulous tags of skin occur in the necks of pigs, goats, and sheep, yet very little has been done to extend his observations. As a matter of fact these pendulous bodies are extremely common in the necks of goats. * "Ubor AuricularhiJcker bei Reptilien." Attat. Anzeiger, vi Jahrgang, 1891, Nr. 2. CEEVIOAL AURICLES. 333 The anatomy of these auricles in the goat is similar to that of cervical auricles in man: there is an axis of yellow elastic cartilage embedded in fibrous tissue and fat, the whole being covered with hairy skin. In size they are very variable, and in the goat from which the drawing (Fig 158) was made the auricles were unusually large. Cervical auricles are occasionally present in sheep, and a Fig. ICO. —Head of a pig with cervical auriclea (the Bell-pig of Australia) . good specimen is sketched in Fig. 159. The most remarkable examples of cervical auricles in sheep are those associated with a persistent second branchial fissure. {See page 172.) In Great Britain cervical auricles are rare in pigs, but Professor Anderson Stuart has drawn attention to the exist- ence in Australia of a breed of pigs known as the Bell-pig, on account of the presence in the neck of pendulous folds of skin in the neck. It may here be mentioned that in Germany these auricles in sheep and pigs are known as glockchen oder Berlocken. The sketch of the Bell-pig was obtained from the stuffed head of a pig which Professor Stuart was good enough to bring me from Sydney (Fig. 160). The original I presented to the museum of the Royal College of Surgeons. 334 BEEMOIBS. Before co^cluding the subject of cervical auricles reference must be made to the presence of these appendages on the necks of satyrs. My friend Mr. Shattock drew my attention to this matter. In the statues of many satyrs we find in the neck, in the situation where cervical auricles are usually found, Fig. 161 — Fami and goat with (lervical aui-icleH. prominences which in their variety of form resemble the cer- vical auricles of goats and men. In the segipans (goat-footed satyrs) the auricles in the neck are pointed like their ears, and are sessile, but in the fauns they are usually pendulous. In the statues of many satyrs, both fauns and segipans, no auricles are represented, and they are less constant in modern than in ancient statues of fauns, and in some they are unilateral. It is an interesting subject for speculation whether the sculptors obtained their notion of the cervical auricles from CERVICAL AURICLE S. 3S5 human models or from goats. The pendulous forms were probably copied from goats. This is well illustrated in the faun from the Capitol (Fig. 161), for we see at his side a goat with unmistakable auricles, and a goat's skin is thrown over the faun's shoulders. The hircine element in the composition of these mythical satyrs is evident in more ways than one. The £egipans are goat-legged, and their tails, as well as those of their fabled sensual relatives, the fauns, are excellent copies of goats' tails. A study of many satyrs induces me to believe that some Fig. 162 Two drawings representing tlie development of the iinricle. {Modified from His.) of the auricles are copies from human models. A good instance of this is a marble head in the Glyptothek at Munich, described as "The head of a laughing faun." In this specimen the auricle is imilateral and identical in shape with those in the necks of children. AURICULAR DERMOIDS AND FISTULA. We may assume that the auricle or pinna consists mainly of an enormously' developed operculum which has become utilised for acoustic purposes. It has already been pointed out that in the embryo, each branchial cleft is surmounted by a swelling or tubercle corresponding to the operculum of the shark. In mammals, and as Schwalbe has shown, in reptiles, the first cleft, which ultimately becomes modified into the tympano-Eustachian passage, is surrounded by additional tubercles, some of which belong to the mandibular and others to the hyoid bar. (Fig. 162.) It is by the subsequent growth and coalescence of these tubercles that the auricle is formed. 338 DESMOIDS. These tubercles have received the following names from His*: — I., tuberculum tragicum; ii., tuberculum anteriiis; III., tuberculum intermedium ; IV., tuberculum anthelicis ; v., tuberculum antitragicum ; and vi., lobulus. The subsequent fate of these tubercles may be briefly given. The tuberculum tragicum unites across the cleft, with the tuberculum antitragicum, the space formerly Fig. lOJ.— Congenital fistula in the, helix. tAfter Paget.) separating them being simply indicated by the incisura inter- tragica. The tuberculum mtermedium is the source of the helix, whilst the tuberculum anthelicis furnishes the anthelix ; the nodule vi., cut off by the fusion of tragus and antitragus, becomes the lobule. Imperfections in the development and union of these tubercles will serve to explain several congenital defects to which the auricle is liable. Of these, three are of especial interest:— (1) Auricular fistulie; (2) dermoids; (3) accessory tragus. Anat. Men. Emhryoihen, 188.5, hoft. iii. CERVICAL FISTULJE. 337 1. Auricular Fistulse. — Heusinger seems to have been the first to describe a congenital fistula in the helix. (Fig. 156.) For the first complete account of these fistulse in England we are indebted to Sir James Paget.* The fistula usually appears as a small opening leading into a canal ending blindly in the substance of the helix. The auricle may be of good shape, but often it is deformed. (Fig. 163.) Usually a small quantity of greasy material exudes from the Fig. 164. — Dermoid of the auriole and nffivns of tlie palpebral conjunctiva. (After Lantielflngue.) orifice of the sinus, which varies from 2 to 6 mm. in depth. These fistulse sometimes exist in individuals who also have branchial fistulse; or one member of a family will have a congenital fistula in the auricle, and another a congenital fistula in the neck ; they are hereditary. It is far rarer to find congenital fistulse in the lobule. Very few examples have been observed. A little girl (daughter of a friend) was born with a perforation in the lobule of the left auricle exactly in the spot for wearing an earring, and to this day she wears a ring in this lobule and refuses to have the other pierced. The facts now at our disposal enable us to understand how such fistulse arise, for it seems reasonable to conclude that if the various lobules which conspire to form an auricle * Mei-Chir. Trans., vol. Ixi., p. 41, 1878. 338 DERMOIDS. unite imperfectly, the intervening spaces would persist as sinuses or fistulse. (2) Auricular Dermoids. — From what has just been- stated regarding the probable mode of .origin of auricular fistulse, it will be obvious that if unobhterated skin-lined spaces are left between the tubercles uniting to form the auricle, and the skin lining such spaces possesses glands (sequestrated tracts of skin are unusually rich in sebaceous glands), we have in such a space a potential dermoid. The auricle is not an uncommon situation for cysts often described as sebaceous ; usually they are smaU, but sometimes attain the dimensions of a cherry or even larger. When these supposed' sebaceous cysts are examined microscopically they sometimes turn out to be dermoids (Fig. 164). It is a curious fact that unless small dermoids in unusual situations are very cautiously examined, they run a great chance """^ of being put aside as sebaceous cysts. Fig. 165. — Auricle . . , i • n p r ■ • with an accessory Auncuiar dermoicls 01 lair size some- times occupy the groove between the pinna and the mastoid process ; if allowed to grow they will form a deep hollow in the underlying bone. (3) Accessory Tragus. — One of the commonest malforma- tions of the pinna is reduplication of the tragus. The accessory tragus is extremely variable in form; often it assumes the form of a low conical projection in front of or above the tragus (Fig. 165); sometimes it is pedunculated and hangs as a small cutaneous tag slightly in front of the tragus, beset with pale dehcate hair. Occasionally an accessory tragus is associated with a circular cicatrix-like depression in the cheek immediately in front of the pinna. It is a fact of some interest that mal- formations of the tragus, and the presence of an accessory tragus, are often associated with defects in the mandibular fissure, such as macrostoma, mandibular fistula, and tubercle. This association is shown in Figs. 130, 131 and 179. 339 CHAPTER XXXVII. DERMOIDS (concluded). OOPHORITIC (ovarian) CYSTS.* Ovarian Cysts, formerly included in one genus, comprise four distinct species. Of these, three species, parovarian cysts, paroophoritic cysts, and ovarian hydroceles, are considered in Group IV. In this chapter we have to deal with those cysts to which the term ovarian strictly appHes, and as they arise in the oophoron, or egg-bearing portion of the ovary, it will avoid confusion to refer to them as oophoritic cysts. Of these there are three varieties : — 1. Simple oophoritic cysts. 2. Ovarian adenomata. 3. Ovarian dermoids. 1. Simple Oophoritic Cysts. — These may be unilocular or multilocular. When the cysts are large it is difficult to demonstrate an epithelial lining on the interior of the loculi, but in their early stages they have a membrana granulosa. When they attain the size of a melon stratified epithelium may be sometimes demonstrated. In very large cysts, such for instance, as have a capacity of one or more gallons, the walls consist of fibrous tissue only, the epithelium atrophies from the pressure to which it has been subjected. 2. Ovarian Adenomata. — These are always multilocular. They have a fibrous capsule through which the various loculi project and produce a lobulated surface. On section the tumour displays a honeycomb appearance, the loculi of which are of various shapes and sizes ; many do not exceed 1 cm. in diameter, others are as large as melons. These cavities are filled with viscid fluid identical in its physical characters with mucus. The walls of many of the smaller loculi are covered with a regular layer of tall columnar epithelium ; many of them contain in addition complex mucous glands, ♦ In this work the characters of ovarian cysts are only hriefly described, as they are considered very t'uUy in my work on Surgical " Diseases of the Ovaries." 340 DERMOIDS. and others are indistinguishable from ovarian foUicles. When these tumours are fresh, if some of the smaller locuh are punctured with a knife and the fluid watched as it flows through the opening, a small opaque body about the size of a rape-s°eed will be detected; it floats on the mucus like the cicatriculum on the yolk of an egg. 3. Ovarian Dermoids. — A very large proportion of oophoritic cysts contains skin and mucous membrane, or ?^ m& w. ')m Fijj. 166. — Mucous membrane from an ovari-on dermoid. ^ both these stmctures, and one or many of the appendages peculiar to them. In a unilocular cyst, the skin or mucous membrane may line it throughout, or be restricted to a very small area. In some multilocular cysts one cavity will be lined with skin, whilst others possess mucous membrane ; many are filled with glandular tissue, and others have an epithelial lining which will stand for skin or mucous mem- brane. The skin in an ovarian dermoid may be bald, or it may be richly furnished with cutaneous appendages, such as hair, sebaceous glands, sweat glands, mammae, nippleless OVABIAN DEltMOTDS. 341 mammae, and nipples witliout mammae. Teeth sometimes occur in prodigious numbers (300 have been counted) ; un- striped muscle-fibre, dermal bone, and bone cancellous in texture ; horn and nail are occasionally present, and very rarely brain-like tissue. The important fact to bear in mind is that the structures found in dennoids of the ovary are always those normally belonging to skin or mucous mem- brane. Formed organs, such as limbs, vertebree, long bones, or cranial bones, do not occur. The imagination of dis- sectors sometimes leads them to see in these irregular bony masses, maxillae, mandibles, parietals, etc. ; others have found perfect foetuses, but these were calcified extra-uterine fcetuses (lithopaedia). In past times ovarian dermoids have been mis- taken for extra-uterine foetuses, and vice versd. Such errors, now unpardonable, gave colour to the parthenogenetic theory of ovarian dermoids. No one has demonstrated liver, heart, lungs, intestine, kidney, bladder, etc., in an ovarian dermoid. Oophoritic cysts, simple, adenomatous, or dermoid, some- times attain prodigious proportions — fifty, sixty, and one hundred pounds. A cyst with its contents has been known to weigh one hundred and sixty pounds (Cullingworth). Oophoritic cysts occur at all ages, from the seventh month of foetal life to the eighty-fourth year. There is no satisfactory record of the dermoid variety having been observed before the end of the first year of life. Secondary Changes. — Three accidents to which ovarian cysts are Hable — viz., axial rotation, rupture, and suppuration — must be considered. Axial Rotation. — Ovarian cysts, in common with many varieties of pedunculated cysts, are liable to rotate on their axes, a movement ■which leads to torsion of the pedicle and consequent interference with the circulation of the tumour. When the torsion is acute, severe pain and venous engorge- ment are the usual effects ; when the rotation occurs slowly, it may so completely arrest the venous and arterial current through the pedicle that growth is stopped, and in exceptional cases the cyst slowly atrophies. In a small proportion of cases the life of the tumour is preserved in consequence of adhesions it acquires to surrounding tissues, especially omen- tum. When this happens the original connections of the cyst &12 DERMOIDS. with tKe uterus are gradually severed, and its nutrition is derived from the omentum in virtue of new vessels formed in the adhesions. When an operation is carried out for the removal of such a tumour the surgeon is surprised to iind an Omentum. Fallopian tube Fig 1G7.— Ovarian dermoid detached from the uterus and hanging from the omentum. {Removed by Sir George Humphry.) ovarian dermoid with a Fallopian tube hanging from the omentum, unconnected with the uterus. (Fig. 167.) Rujyture. — When simple ovarian cysts rupture, the bland fluid they contain rarely gives offence to the peritoneum ; it is quickly absorbed and excreted by the kidneys. When ovarian dermoids rupture, the richly cellular contents are scattered OVARIAN DERMOIDS. 343 over tlie peritoneum and give rise to grave disturbance. The most interesting event that follows the intraperitoneal rup- ture of an ovarian dermoid is the appearance of secondary dermoids on the peritoneum. This rare form of epithelial infection may take the form of minute granules on the peri- toneum, each of which is furnished with a tuft of delicate lanugo-Uke hair,* or they may give rise to tumours as large as cherries or even Tangerine oranges. These may hang from the under surface of the hverf or form clusters like " cherries upon a branch," J or be embedded in adhesions between coils of intestine. This mode of dissemination of dermoids is analogous to the epithelial infection of the peritoneum occasionally observed with paroophoritic cysts. Suppuration. — When air or intestinal fluids gain access to ovarian dermoids, then suppuration with all its attendant evils is the result. Contamination may also arise from punctures \vith trocars or aspirating needles. More frequently it is due to entrance of fluids from the intestine, due to adhesion of the bowel to some part of the cyst-wall, with subsequent thinning of the adherent parts until the septum becomes so thin that osmosis of intestinal fluids occurs and fouls the cyst. When suppuration happens, the pus may find an outlet through the rectum, vagina, or bladder. Sometimes a sinus forms in the .anterior abdominal wall, and it is not rare in such cases for the pus to point at the umbilicus. THE NATURE OF THE OVARIAN FOLLICLE AND THE MUTABILITY OF SKIN AND MUCOUS MEMBRANE. Oophoritic cysts of the three varieties discussed m the first part of this chapter arise in ovarian follicles. The re- remainder of this chapter wLU be devoted to the consideration of the nature of the ovarian follicle and to the relation- ship of skin and mucous membrane ; it will also be necessary to discuss briefly the mutability of epithelium. The Nature of the Ovarian Follicle. — The phylogeny of the ovarian follicle is intimately bound up with the history of the peritoneum. The pleuro-peritoneal cavity in most verte- * Kolaczek, Virchow's " Archiv," bd. Ixxv. 399. f Hulke, Trans. Path. Soc, vol. xxiv., 137. t Fraenkel, Wien. Med. Wochenschrift, 1883, p. 865. 344 DEliMUIVS. brates arises as a schizoccfile, due to the splitting of tlie lateral walls of the embryo into splanchno-plenre and somato-pleure.'| This mode of origin is secondary, for in simpler forms the coelom (pleuro-peritoneal cavity) is derived from abstrictions 1 of the archenteron. Thus the coelom is a derivative of the primitive gut, and its surface is covered with epithelium. The cells of the genital ridge, which form ova and line the follicles, are of the same nature as those which give rise to mucous glands in the intestine. Morphologically, an ovarian follicle is a modified mucous gland. It will be necessary to discuss the relationship of skin and mucous membrane. Skin covers the exterior of the body, and possesses in addition to the homy layer a rete mucosum containing pigment. In many animals it furnishes protective structures such as scales, horns, scutes, quills, bristles, feathers, hair, etc., all of which are modifications of the epidermis or its papillary processes. Glands derived from the surface epithelium may furnish mucus, poisonous fluids, and milk. Subject as skin is to external modifying influences (environ- ment), we need not express surprise at the variety of structure and modification exhibited by it. Mucous membrane in its most typical form exists in the intestine. It has a single layer of columnar epithelium, which may be ciliated (amphi- oxus, petromyzon, ammocoetes). The epithelium dips into the underlying tissue to form mucous glands. Instead of intestinal mucous membrane, let us select a piece from the buccal cavity. Here we find it lined with layers of flattened epithelium surmounting papiUae ; some of these papillae are calcified and form teeth. Many rodents have hairy patches on the buccal aspect of the cheek. In dogs the mucous membrane of the mouth contains pigment; this is occasionally the case with the lingual mucous membrane in man ; and the vagina sometimes contains tracts of blue pig- ment in monkeys. Sebaceous glands are not peculiar to skin ; they are large and numerous in the mucous membrane of the nymphae, and occasionally in the lips. Mucous glands occur in the skin of batrachians, worms, and as slime glands in fish. In snails, oysters, mussels, etc., the mantle secretes a shell , in reptiles, and such speciahsed vertebrates as birds, the glands in the mucous membrane of the oviduct perform a OYABIAN DERMOIDS. 345 similar function ; calcareous formations resembling shells are constantly formed by the glands in the prostate of man. A single layer of epithelium avails little in the argument, for -worms have a single layer of columnar epithelium to their skin. Amphioxus is similarly provided in the gastrula stage, the cells being ciliated. It has been urged that the lining membrane of the mouth is practically skin, inasmuch as it is derived from the epiblast, and it has been said that, to render the argument valid, hair should be found on the mucous membrane lining the stomach or intestine. Such is, in fact the case, in the re- markable bird, the Darter (Plot as anhinga) ; its pyloric orifice is guarded by a tuft of hair.* It is well to bear in mind that skin in at least one situation — the conjunctiva — has become modified into mucous merribrane and not rarely reverts to its original form. (See page 355.) It used to be taught that epithelium was very stable, but we know that the columnar variety is very mutable. When exposed to external influences and pressure it quickly grows stratified. Examples have been mentioned (page 130). The columnar cells of the intestine become stratified at the margin of a colotomy wound, or on the exposed surface of a pUe, and the change from columnar to stratified epithelium occurs normally on the dorsal wall of the cat's trachea, in con- sequence of the overriding of the extremities of cartilaginous semi-rings under the influence of the trachealis muscle, t In order to appreciate the high potentiality of the mem- brana granulosa it should be studied in the cat (Fig. 168), then the student will cease to wonder whence the tall columnar epithehum so characteristic of an ovarian adenoma (Fig. 166) is derived. * " The CoUected Works of Garrod," p. 334. f Haycraft and Carlier, Quart. Jour. Mici'os. Sci., -vol. xxx., 519, 1890. Fig. 168. — Ovum in its follicle ; froin a cat. (After Klein.) CHAPTER XXXVIII. PECULIARITIES IN THE DISTRIBUTION OF CUTANEOUS APPENDAGES IN DERMOIDS. In the preceding chapters the various species of dermoids are arranged in their respective genera and their chief chnical features indicated. It will now be useful in bringing this ■/. -^r -_. V ivy ' ^ i .:y - ' ? .. f ^ V c > J- ^^a ■; I f~ Xf. /y~ Y- ^ -/ ^ £_ ^ . T ^--5^5^). ^ Fig. 169. — Magnified section of an ovarian dermoid, to show the large size of t^iC sebaceous glands. section to a conclusion to draw attention to some peculiarities in the distribution of cutaneous appendages found in der- moids. The distinguishing feature of dermoids is the presence of skin or mucous membrane, and the structures found in these tumours are those normally associated with skin or mucous membrane. Hair is the most frequent of the many cutaneous append- ages in dermoids and occurs in all the genera. In the case of man it is identical with that which grows on other par.ts of the body ; but its colour is capricious, and usually bears little HAIB IN DERMOIDS. 347 relation to that on the body of the individual. In an ovarian dermoid from a negress the hair may be curly, but light-brown in colour. In other animals dermoids contain hair or wool according to the nature of the tegumental covering. It is said that in birds they contain feathers; I have never had Twisted pedicle. Coi-pus luteum. Fig. ]70.— 0\arian dermoid with a sebaceous adenoma, from a woman. It contained hair, but its walls were bald. an opportunity of verifying this statement. Dermoids in pigs contain bristles. It is a curious fact that hair in sequestration dermoids is rarely longer than 3 em., whereas in ovarian dermoids it is often 15 or 20 cm. long, and a specimen 1-50 m. (5 ft.) long has been described by Mund6.* The hair on rectal dermoids is sometimes very long. In all genera the hair raav become * Am. Journal of Olstet., vol. xxiv. 854. 348 jjjunMUj-uo. white with age, and in elderly individuals a hairy dermoid, like the scalp, may become bald. (Fig. 170.) The number and size of the sebaceous glands m dermoids are very variable. They are numerous and well formed in almost all sequestration dermoids, but attain their greatest size in ovarian dermoids, where they occasionally form a pedun- culated tumour— a sebaceous adenoma. (Fig. 170.) The highest variety of secreting gland found in these tumours is Fig. 171. — Ovarian mamma ; hair and teeth are also present. {Museum, Middlesex HospiUU.) a mamma. Ovarian dermoids sometimes contain nipple-hke processes of skin which may or may not be associated with a skin-covered mass of fat, shaped like a mamma ; exceptionally these nipples are traversed by ducts associated with glandular tissue which secretes colostrum. (Fig. 171.) A few gland- containing colostrum-secreting mammae are nippleless. Mammae and pseudo-mammse are peculiar to the ovarian genus of dermoids. The distribution of teeth among dermoids is somewhat curious. So far as my observations go they are not found in the sequestration genus, but are of fairly frequent occurrence in ovarian dermoids, and sometimes are present in prodigious numbers (300). Teeth also occur in rectal and post-rectal dermoids. (Figs. 151 and 152.) Exceptionally they have been found in dermoids arising OVAlilAN TEETH. 349 in the branchial clefts. This is a matter of some interest, because teeth are somet'mes found associated with persistent branchial fistulas. In 1890 I exhibited at the Pathological Society, London, an example of a persistent second branchial fistula in a sheep (Fig. 172) ; it was surmounted by a prominent cervical auricle beset on its posterior surface by a number of processes resembling the buccal papillae of sheep. Protected Auditory meatus. Fistula. Eig. 172. — Head of a sheep with a hranchial iistula, cervical auricle, and tooth. In the lower figure the auricle and tooth are shown of natural size. by this auricle there was a slender, ill-formed, incisor tooth mounted on a pedicle of bone, surrounded by mucous mem- brane.* It is preserved in the museum of the Koyal College of Surgeons. Kostanecki t has since published an account of a similar specimen. {See also Gurlt. J) Teeth are occasionally associated with the second branchial * Trans. Path. Soc, vol. xlii. 477. f Virchow'a " Archiv," bd. cxxiii. 401. f Thierische Missgebwrten, 1877. Taf. xv. 350 BEBM0ID8. cleft in horses. These specimens throw spme light upon teeth found on the petrosal bones of oxen, of which some' examples are preserved in the Veterinary Museum at Alfort, and render it possible that some of the curious cases of cervical teeth in the human subject, usually described as errant wisdom teeth, belong to the same category. Teeth in dermoids are composed of dentine, enamel and Fig 173. — The germ of an ovarian tootli, from a dermoid. E, the enamel-organ ; p, dentine papilla. cementum arranged in the same manner as in normal teeth, and developed on the same plan. (Fig. 173.) The consideration of glands and teeth in dermoids would be incomplete without an account of those peculiar concentric bodies known as epithelial pearls. These bodies vary some- what in structure and probably arise in different ways. The common form of epithelial pearl consists of concentric laminaj of horny epithelium ; the central portions in some specimens are structureless and transparent like horn (Fig. 174"); in others the cells are large and distinct ; in some the epithelium forms onion-like layers without any tendency to cornification. The common mode by which epithelial pearls are formed is by the retention and subsequent moulding of shed epi- thelium in the recesses of sebaceous glands, in mucous crypts. ■EPITHELIAL TEARLS. 351 or in folds of epithelial-covered surfaces. They are sometimes found on the forehead along the margin of the hairy scalp ;* they are common in the penis, at the junction of the prepuce and glans, and in the tonsils of children. Ttiere is another variety which occurs in situations where epithelial surfaces become fused in the process of development, as, for example, along the middle hne of the hard palate. It jft^ '^ ijy" J*' ' /'7 f, 1/. * '"^t * Ft 'J \ Fig. 174. -Epithelial pearl. (After Kanthaclc.) is not unusual to find them in this situation in children at birth, and occasionally they will be found hanging by short pedicles, especially in the neighbourhood of the pre-maxillis. They are sometimes met with on the under surface of the penis. Epithelial pearls are often found in the gums. The largest examples that have come under my notice occurred in ovarian dermoids. In one remarkable specimen which I examined it was possible to trace every stage between a typical epithelial pearl and an enamel-organ. In a series of sections some showed the ingrowth of epithelium from the surface of a loculus ; in a few, pearls were visible composed of large epi- thelial cells ; whilst others exhibited laminse of horny material * See remarks on Cholesteatoma, p. 182. ■Jb'-Z VEMMUIVS. and in some of the sections a developing tooth with its papilla, enamel-organ, and gubernaculum could be seen. These observations suggested that, apart from the retention of shed epithelium and the inclusion of epithelium between opposed surfaces, it is probable that pearls may arise in some in- stances by ingrowths of epithelium on the principle of enamel- oreans. This view would be consistent with Kanthack's* observation on pearls of the hard palate, to the effect that when a series of sections is made it wiU usually be found that the pearl is connected with the surface by a tract of epithelium. This is further interesting, for it may serve to throw some light on meso-palatine teeth. It is well known that small supernumerary teeth in young children are not uncommon in the anterior segment of the meso-palatine suture. These teeth, which must not be confounded with the occasional third incisor, are usually lodged in the nmcous membrane onl}'. In 1890 I ventured to suggest that meso- palatine teeth are probably associated with these pearls.t * Journal of Anatomy and Physiology, vol. xxv. 155. t Trans. Odont. Soo. Gt. Britain, vol. xxii. 156. 353 .CHAPTER XXXIX. MOLES. Moles are pigmented and usually hairy patches upon the skin. They -are congenital or appear during the first few weeks of birth. Moles vary greatly in size ; many are no Fig. 175i — Extensive hairy inole upon tlie face of a boy a year old. larger than split peas, while others cover an extensive area of the trunk, face, or limbs. The common variety consists of a slightly raised patch, usually brown in colour ; but it may be qtiite black, and is, as a rule, covered abundantly Avith hair. As moles occur in situations where hair is generally scanty, they are conspicuous objects. The hair growing upon the mole is commonly short. 3.54 DEBMOinS. like that upon the skin covering the trank of a dog. Occasionally, however, it is as long as that naturally found upon the scalp. In a boy a year old I have seen ne9,rly the whole of the trunk covered with a mole, and the hair growing from it was as long as that upon his head. When moles exist on the forehead they sometimes appear to be an exten- sion of the hairy scalp. The hair upon moles does not differ Fig. 176.— Extensive hairy mole on tlie trank of a man, 47 years rf ags. which became the seat of sarcoma, from which the patient quicltly died. {After LawsoJi,*) from hair in general, and is furnished with sebaceous glands ; sweat glands are present when the mole is seated on a part of the skin where these glands normally exist. The amount of pigment varies much ; in some moles it is so abundant as to produce an inky blackness. Moles are always very vascular ; but the most striking feature in their histology is that the tissue immediately underlying them is often similar to that characteristic of an alveolar sarcoma. The rarer form of mole consists of a patch of black, or deep-brown pigment overlying tissue similar to that of an alveolar sarcoma. These patches may or may not be raised above the level of the surromiding skin. The pigmented area * Trans. Patli. Soc, vol. xxiv. 2.56. MOLES. 355 contains a few hairs which are not larger or longer than those in the immediate neighbourhood of the patch. Small hairy moles do not as a rule cause much incon- venience even when they occur on the face, in which situation they are known as " beauty spots." As many as fifty moles may be present on one individual. When a mole is extensive, and occurs in an exposed situation (Fig. 175), it is a serious disfigurement. When very large moles occur on the trunk the hairy part is sometimes very sensitive, almost hyper- ffisthetic. In large moles pendulous skin folds are sometimes present; these folds are large in the young, but, as a rule, they shrink and become quite small in the adult. Moles bleed freely when their surfaces are abraded or incised. They are also liable to ulcerate spontaneously; the ulcerated surface bleeds freely. The most important change to which they are liable is to become later in life the starting- point of melanomata, some of which are very infective, and quickly destroy life. (Fig. 176.) The relation of melanomata to moles is considered in chapter xiii. Moles on the Conjunctiva.— The mucous membrane lining the ocular surface of the eyelids, and covering the cornea and adjacent portions of the eyeball, occasionally presents patches of skin which, in appearance and structure, are identical with hairy moles. These dermoid patches, or conjunctival moles, occur most frequently at the margins of the cornea, and usually in the line of the palpebral fissure — that is, directly in the equator of the cornea; but they are by no means confined to these situations. Usually they are limited to the conjunctiva covering the sclerotic, or trespass but little on the cornea. Sometimes, however, they involve a considerable extent of the corneal surface. (Fig. 177.) Wardrop* described a conjunctival mole in a man fifty years of age ; it was congenital. Twelve long hairs grew from , its middle, passed between the eyelids, and hung over the cheek. These hairs did not appear until the sixteenth year, at which time the beard began to grow. Occasionally a mole will be found on each side of the * " Morbid Anatomy of the Human Eye," 1834. 356 DERMOIDS. cornea in the line of the palpebral fissure. A very rare variety is limited to the caruncle. A good example is depicted in Fig. 178, associated with an eccentric pupiL This is simply an excessive development of the delicate hairs that normally beset the caruncle. These moles are occasionally associated with malformations Fig. 177.— Oonjnnctival mole— common variety. of the eyelids, especially the one known as coloboma of the upper eyelid, of which a good example is given in Fig. 179. When this association occurs, the defect in the lid corresponds Fig. 178.— Mole on the caruncle, associated with au eccentric pupil. (After Demmirs.*) to the cutaneous patch on the conjunctiva. This combination is of some importance as it is used as evidence in support of an explanation that has been put forward in regard to these moles, based upon the development of the eyelids. In the embryo the tissue covering the outer surface of the eyeball, Avhich ultimately becomes the conjunctiva, is directly continuous, and in structure is identical with the skin at the margin of the orbit. Very early cutaneous folds arise, * Maladies des Yetix, 1818, pi. Ixiv., fig. 1. MOLES. 357 gradually grow over the surface of the eyeball, and come into apposition at a spot corresponding to the future palpebral fissure. These folds ultimately become the eyelids. The sur- faces of these folds, which are continuous with the covering of the eyeball, become converted into mucous membrane, and are termed conjunctiva. In every normal eye the conjunctiva Fig. 179.— Conjunctival mole associated with coloboma of tlie eyelid, a mandibular tubercle, and accessory tragus. ^CoweWa* case). bears evidence of its transformation from skin, inasmuch as the caruncle at its inner angle is furnished with delicate hairs. It is reasonable to suppose that, as the occlusion of the proper covering of the eyeball by the eyelids is the cause of the con- version of the conjunctiva into mucous membrane, if from any cause a part, or even the whole of it, were left uncovered, the exposed part would persist as skin. This is precisely what occurs. When the eyelid is in the condition of coloboma (Fig. 179) — a defect due, in all probability, to the imperfect union of the embryonic eyelid to the skin covering the fronto- nasal plate — a piece of conjunctiva persists as skin, and forms * Tranf. Ophthal. Soc, vol. xi., p. 214. 353 JDEBMOIDS. a mole occupying the gap in the lid. Moles occur on the conjunctiva unassociated with colobomata, but in nearly every instance they are situated on the cornea in the line of the palpebral fissure. This circumstance would indicate ithat during development the conjunctiva was imper- fectly covered by the developing hds. It should be re- membered that in many eyes exactly in the situation in which moles are most frequently found, slight elevations or pingfueculae of the conjunctiva occur. These, when examined microscopically will be found to contain epithehal elements. Vig. 180.— Conjunctival mole in a sheep. In a few very exceptional cases the eyes have been found completely covered with skin without any traces of eyelids. Such a condition is known as cryptophthalmos, and the explanation offered concerning it is, that in these cases the eyelids have failed to appear and in consequence the con- junctiva has persisted as skin. Conjunctival moles have been observed in horses, sheep, oxen, and dogs, and are furnished with hair or wool according" to the nature of the tegumentary covering characteristic of the mammal in which they occur. (Fig. 180.) 359 CHAPTER XL. THE TREATMENT OF DERMOIDS. Dermoids are innocent tumours. Some of them attain a certain size and then cease to grow ; others will remain, as it were, torpid for years, then, without any obvious reason, suddenly resume active growth and reach a large size in a comparatively short space of time. Many, and perhaps the majority, steadily grow without intermission, uninfluenced by the rules of growth which govern the dimensions of organs in general. Thus no experience, however extensive, will enable a surgeon to assure a patient that a given dermoid will remain quiescent, or that it will become a large tumour. The closest observation by the best observers has failed to detect any laws regulating the growth of dermoids or of other tumours. Take, for example, dermoids of the scalp, or those at the angle of the orbit : some of these in an ordinary lifetime will not exceed the dimensions of a walnut, yet cases are known in which a dermoid of the scalp has grown as large as a cocoa- nut. (Fig. 142.) It may be stated generally of sequestration dermoids that, as a rule, they remain of small size; but many exceptions occur. (Fig. 122.) Knowing then, the potentiality of these' tumours, it is the custom, whenever they occur in accessible situations, to remove them early in infant life. , There are situations where the removal of a dermoid is not attempted — e.g., when it grows between the laminae of the .tentorium cerebelli, or when a sternal dermoid invades the mediastinum or pleura. These cases are in the main post- mortem surprises. There is a fact that should not be overlooked in regard to dermoids : so long as their capsules remain intact any evil influence they exert is mechanical ; but when from any cause — e.g., injury, ulceration, or communication with a hollow viscus like the intestine, bladder, or bronchus — putrefactive organisms gain access to their contents, rich in dead organic matter, decomposition with all its attendant evils is the result. This is well illustrated by the distressing histories of patients 360 DERMOIDS. with ovarian dermoids that have coinmunicated with the bladder. In three situations dermoids are very liable to destroy life : — (1) Intracranial dermoids, by the pressure they exercise on the brain ; (2) intrathoracic dermoids, by interference with the lung; (3) pelvic dermoids which lead to intestinal obstruction by pressing on the rectum, or establish urinary troubles by becoming impacted in the pelvis and compressing the urethra or the ureters, or lead to septicaemia by the decomposition of their contents. Occasionally an ovarian dermoid interferes with delivery and causes the death of two lives, mother and child. At present no one has succeeded in removing an intra- cranial dermoid. An accurate diagnosis is impossible, but it is highly probable that a surgeon, in operating for an intra- cranial tumour, will one day find himself face to liaceNwith a dermoid. In the thorax the signs are usually those of emptyema until " hair-spitting " occurs. The successful removal of an intrathoracic dermoid awaits accomplishment, whereas ovarian dermoids are removed successfully almost daily. Other varieties of pelvic dermoids, especially the post-rectal species, have been successfully enucleated by Bryant, Frederick Page, and W. W. Keen. {See page 320.) Pedunculated rectal dermoids only require the same treat- ment as polypi — viz., ligature of the pedicle and detachment of the tumour. The large tubulo-dermoids found in the coccygeal region demand considerable judgment. In the majority of cases nature disposes of the difficulty either by destroying the child's life before it is born, or in the, process of delivery. A few survive this event for some' days or even weeks. Those which successfully escape these disasters are brought to surgeons, who endeavour to remove the tumours when they are satisfied that the children are strong enough to be submitted to this ordeal. Some successful cases have been reported ;* but many have failed. I collected the scattered records of surgical enterprise in this direction, but the analysis reveals that the various genera of sacro-coccygeal tumours have not been appreciated by surgeons; * Mackaj' was suocossful in two cases. [See p. 319.) TREATMENT OF DERMOIDS 361 sD that it is difficult to decide wiietlier the individual cases ■were dermoids, tubulo-dermoids, lipomata, teratomata, or spina bifida cysts. Thus the facts were useless for the purpose. It is to be hoped that future records will be more precise. Dermoids in connection with the mouth do not offer any difficulty in treatment. Pharyngeal dermoids are easily avulsed, and in some cases have become spontaneously detached. Palatine dermoids and adenomata may be easily enucleated after their capsules have been incised; and in removing lingual dermoids it is only necessary to take care to thoroughly extirpate every portion of their cyst-walls, or troublesome sinuses will remain. In removing a dermoid at the root of the nose the surgeon must not be surprised to find the capsule running deeply between the bones in that situation, and it not infrequently rests upon the dura mater. The treatment of the various deformities connected with the fissures about the face — such as hare-lip, cleft palate, coloboma of the eyelid, etc. — does not come within the scope of this book. It Avill be necessary to consider the treatment of branchial fistulse, median cervical fistula;, cervical auricles, etc. In the majority of cases cervical fistulas give no trouble, but there are instances in which a fistula discharges fluid so as to become a source of annoyance, or it gets inflamed from time to time. Under these conditions it should be dissected out. Such operations must be recommended with caution, as these fistulas extend deeply into the neck and run in very intimate relation with the great vessels of the neck and the vagus nerve. Attempts to obliterate them by such methods as the application of caustics, heated wire, etc., are worse than useless. In .removing median cervical fistulse it is necessary to dissect the duct quite up to the body of the hyoid bone to ensure its thorough eradication. Cervical auricles are, in most children, easily dissected out. When the auricle has connections extending to the deep surface of the sterno-mastoid, the operation requires care. ' Hairy moles, when small and in situations where they cause disfigurement, should be excised. When carefully 362 BEEMOIDS. performed the operation leaves scarcely a scar. Extensive moles upon the trunks and limbs are beyond treatment, but in the case of a large hairy mole on the face, it is necessary to adopt some method for its relief. Great good may be ef3f'ected by the ingenious plan, introduced by Morrant Baker,* of carefully shaving the mole with a sharp scalpel so as to remove the pigmented portion of the skin and the layer that contains hair bulbs. The operation is usually attended by free but easily controlled bleeding, and the shaved : surface heals without the formation of cicatricial tissue". Should some of the hairs persist after this treatment they may be destroyed by the application of nitric acid and similar caustics. Such an extensive mole as that represented in Fig. 175 is unfortunately beyond the reach of surgical art. Small conjunctival moles may be dissected off as in the case of a ptergium ; and if a coloboma of the lid is associated with it, the edges cleft may be vivified and united on the same principles employed in the treatment of hare-hp. * Med. Chir. Trana., vol. bd. 33. 363 CHAPTER XLI. TERATOMATA. Strictly, the consideration of teratomata belongs to that department of pathology known as teratology ; but as certain Kadici D}odica, Fi^. 181. — The twin sisters Eadica and Doodica at the age of 3^ years; horn in 1889 at Noapara, a village in the province of Orissa, India.* species are so very apt to be confounded with dermoids, it is necessary to give a brief account of them here. A teratoma is an irregular conglomerate mass containing the tissues and fragments of viscera of a suppressed foetus attached to an otherwise normal individual. * Of. The Medical Week, vol. i., p. 11. 364 TEEATOMATA. In order to appreciate the nature of these singular mal- formations it will be necessary to consider the subject of conjoined twins, supernumerary Umbs, and acardiac foetuses. In the animal and vegetable kingdom it occasionally happens Fig. 182.— Laloo, a Hindoo, with an acardiac parasite attached to his thorax. that a single ovum gives origin to two embryos, which may be quite separate from each other or they may be united, a condition known as conjoined twins. (Fig. isi.) When two embryos are conjoined, and one goes on to complete development, whilst only certain parts of its com- panion continue to grow, the result is a parasitic foetus. The mature individual supporting it is the autosite. (Fig, 182.) In other examples the suppressed foetus consists of an irregular-shaped tumour growing, perhaps, from the posterior TERATOMATA. 365 Fie 183 —Chick with a supernumeiary pair of legs projecting from the ventral aspect "' ' of the pelvis. "^^E^^iV- Fiff 184 -Chick with a supernumerary pair of legs projecting from the dorsal aspect of ■° **" the pelvis. A, anus ; a, supernumerary anus. 366 TEBATOMATA. surface of the sacrum, or within the abdomen or thorax, which on dissection contains a few vertebrae, or ;processes of skin resembling digits, associated with a piece of intestine or an imperfect liver. This is a teratoma. In order to demonstrate the relation between parasitic fcBtuses such as Fig. 182 and teratomata, it will be useful to refer to dichotomy. In animals and vegetables there is a strong tendency for parts ending in free extremities to bifurcate or dichotomise. When this affects digits the result is supernumerary fingers and toes- Should it extend to the axis of the limb, supernumerary legs, wings, or fins are produced. Dichotomy is not confined to the limbs, but affects also the axis of the trunk. When the, whole embryonic axis dichoto- mises, twins are produced. Should cleavage be partial, and affect the caudal end of the trunk, it is spoken of as pos- terior dichotomy. When it involves the anterior end it is called anterior dichotomy. With complete dichotomy iu which both embryos go on to full development, either as separate or conjoined twins, we are not further concerned, and the conditions arising from the imperfect growth of one embryo whilst its companion con- tinues to develop, must be deferred until we have discussed the results of partial dichotomy. Posterior Dichotomy. — When cleavage involves the caudal section of the trunk axis to any serious extent it necessarily follows that the pelvis as well as the vertebral column will be reduplicated ; it is also obvious that the reduplication of the pelvis involves a corresponding increase in the number of the pelvic organs, including the limbs. Thus it follows that supernumerary hind limbs may arise from dichotomy affecting the embryonic limb, or from cleavage of the caudal end of the trunk. The two modes also hold good for reduplication of * Journal of Anatomy and Physiology, vol. xx., p. 616. Fig. 185. — Frog {Ravu palustris) with i supernumerary hind leg. {J/ter Tucli erman,*) TEBATOMATA. 367 the fore limbs. The conditions and positions of supernumerary limbs due to posterior cleavage are represented by the chicks and frog in Figs. 183, 184, and 185. Thus the limbs may Fig. 186. Louise L., dame a quatrejambes. {Ed. Eugnion.) project from the ventral aspect of the pelvis, or be, as it were, dislocated on to the dorsal surface, as in Fig. 184. Occasionally they occupy a position midway between these two extremes and lie more or less parallel with the normal hind limbs, as in 368 TEBATOMATA. Fig. 185. In some of the specimens the supernumerary legs fuse throughout the greater part of their extent, and in some, one leg becomes completely suppressed. It is a noteworthy fact that in all specimens of supernumerary limbs due to posterior dichotomy there is an accessory, but usually imperforate, anus. Supernumerary hind limbs in every way identical with those exhibited by the chicks occur in the human species. A woman with an extra pair of Umbs identical in its relations to -^ DIMPLE a Fig. 187. — Sacral teratoma with a supernumerary Ic. the pelvis with those in the chick (Fig. 183) has been carefully described by Bugnion.* (Fig. 186.) In this case the woman could not initiate any movement in the accessory limbs, although she readily localised the prick of a pin made upon any part of them; she was also uncomfortable when the parasite was cold. In the furrow between the buttocks of the accessory limbs there was a fossa representing the imperforate anus and genital orifice of the parasite, situated about 12 cm. from the vulva of the woman. _ An example corresponding to the dorsal limb in the toad (Fig. 193) is represented in Fig. 187. For an opportunity of studying this rare condition I am indebted to Dr. Matthews Duncan and Mr. H. Huxley. It was a female child ; over the * Mvue Med. de la Suisse Itomande, June 20th, 1889. TERATOMATA. 369 posterior aspect of the Scacrum there was an irregular lobulated mass, from which an ill-shaped limb projected, the foot being m the position known as taUpes equino-varus. At the lower part of the tumour there was a depression indicating an imperforate ano-genital orifice. The third variety is ilhistrated by the celebrated Jean Battiste dos Santos of Portugal. The chief features of this case were well described in 1846 by W. Acton,* and nineteen Fig. 188. - Posterior view of J. B. dos Santos at the age of six montlis. (After Acton.) years later by Ernest Hartf in London, and by HandysideJ in Edinburgh. The chief features of the case are shown in Fig. 188. The child has a median unpaired limb projecting from the pubes and situated between the normal limbs ; its extremity has nine separate digits, but the middle one consists of two coalesced big toes. On that part of the limb which corresponds to the buttock there is a dimple represent- ing the imperforate anus of the parasite ; and there are two penes. Keduplication of the pelvic limbs occurs frequently in * Med-Chir. Trans., vol. xxix., p. 103. •f Lancet, 1865, vol. ii., p. 124. X ^d. Med. and Surg. Journal, 1866, vol. xi., part ii., p. 833. Y 370 TSRATOMATA. sheep, calves, and birds, and has been especially studied by Cleland. Anterior Dichotomy. — Cleavage may affect the facial portion only and produce reduplication of the jaws, or it may involve the head and produce a two-headed individual. Should it extend to the thoracic region of the spine, then an animal with two heads and reduplicated fore limbs is the result. When partial dichotomy attaclis the head the median parts of the reduplicated face are so conjoined and malformed that they are sometimes found hanging in the pharynx, being attached to its roof by a pedicle. Such tumours, called basicranial teratomata,* are very apt to be confounded Avith pharyngeal and palatine dermoids. {See page 298.) Examples of dichotomy involving the whole length of the cranial axis are by no means infrequent, but they occur more frequently in some groups of annuals than in others. Many examples have been recorded in foals, in calves, and especially in snakes. (Fig. 189.) Among the cases illustrating redupli- cation of the body as far backwards as the umbilicus the best known is the celebrated Ritta-Christina, born at Sassari, in Sardinia, 1829. After surviving her birth eight months and a hah' she died in Paris. Isidore Geoffrey Saint-Hilairef gives an interesting a'ccount of the anatomy and physiology of this remarkable girl. HarrisJ has carefully described a similar case known as the blended Tocci brothers. In these cases the adjacent upper hmbs were quite distinct and well formed, but in some similar cases the hmbs have coalesced, forming a median limb. Tlius far we have been concerned with reduplicated parts that reach such a standard of development that their identification is neither a matter of difficulty or doubt. It will * For some examples, of. Trans. Odont. Soc. of Great Britain, vol. xxi. 27. ■)• L' Anomalies clc V Organisation, tome iii., p. 119. J American Journal of Obstetrics, vol. xxv., 460. Fig. 1S9. — Cephalic extre- mity of a two-lieaded snake. TEBATOMATA. 371 now be necessary to consider tlie meaning of those attached parts named parasitic foetuses, and the shapeless masses to which the term teratomata in all strictness applies. This involves the consideration of the condition termed acardiacus. It happens, and not infrequently, that in cases of twins Fig. 190. — Acai'diac foetus. (.Ifitseiim, Midillesex Hospital) one of the fcBtuses is of natural shape and proportions and viable, but its companion is very imperfectly developed, and as it lacks a heart (or if this organ be present it is rudimentary and functionless) is said to be acardiac. The degree of development varies greatly. 372 TERATOMATA. A common example is sketched in Fig. 190. The head and neck are absent, the upper limbs are exceedingly rudimentary, and there is a hernia-like protrusion of viscera at the umbilicus. This specimen had no heart, lungs, or liver; but intestines, kidneys, and female genital organs were present. In rarer cases the foetus may be merely represented -by an irregular- shaped mass consisting of oedematous integument surrounding a portion of the skeleton, usually an innominate bone with some of the bony elements of a lower limb. In some specimens no particular skeletal element is Tuhercle mark- ing the eud of the rudimentary spinal cord. Fig. 191. — Acaraiac ftjetus. recognisable, but a portion of intestine, or rudiments of the genito-urinary organs can be detected. To such examples of acardiacus the adjective amorphous is applied, and to French Teratologists they are known as "anidian monsters." An acardiac such as Fig. 191 has been described as a dermoid of the umbilical cord.* ((S'ee also Fig. 192.) Between the two forms represented in Figs. 190 and 191 every variety is met with, and in cases which admit of the determination of the sex this is invariably the same as that of the well-developed twin. It is also important to bear in mind that acardiacs can only occur in plural births. Acardiacs are not necessarily separate from the well- * Budin, Pngrcs Medicale, Deo. 31, 1887. TEBATOMATA. 373 developed twin, but may be attached to it in a variety of ways. Many such examples have been placed on record, and in a few the autosite and acardiac parasite have lived and attained maturity. One of the best examples of this was the Indian lad Laloo. He was born at Oovon in Oudh, and at the age of seventeen years was brought to London. This boy was exhibited at the Cervical vertebra. Centrum of vertebra. Spinal coi d Fig. 192.— Aeardiao iu Fig. 191 shown in section. Pathological Society in 1888, and in the Transactions for that year there is a detailed report of the lad drawn up by Mr. S. G. Shattock and myself. The general features of the case are shown in Fig. 182. The degree of development of the parasitic foetus is similar to the variety of acardiacus shown in Fig. 190. It has arms and legs, a pelvis, urinary organs, and a well-formed penis. The parasite is attached to the thorax of the autosite by a bony pedicle near the xyphoid, but somewhat to the' right of the middle line ; its anus is imperforate and indicated by a shining Unear scar. It is an interesting fact that individuals such as Dos Santos are capable of begetting children, and the offspring do not share the deformity of the father. This also holds good for females with parasitic foetuses. The woman represented in Fig. 186 had brought forth several well-formed children. 374 TEBATOMATA. The explanation of acardiac foetuses, whether free or parasitic, seems to be this:— Two embryos arise from a single ovum ; in some instances the cleavage is complete, but the heart of one embryo is defective. The circulation of the two embryos is continuous at the placenta, and the heart of the normal embryo is able to maintain, in a measure, the blood- current in its companion, and thus save it from complete suppression. Sir Astley Cooper* demonstrated this com- pensatory mechanism in the case of an acardiacus placed in his hands by Dr. Hodgkin. An inspection of the drawing of Fig. 193. — Young toad with a supernumerary hind limb. {Museum, University College, London.) the placenta from this case (Plate VII.) shows that the umbilical vessels in the two sections of the compound placenta were directly continuous. In the case of a parasitic acardiac — e.g., Laloo — the circula- tion must be directly maintained by the heart of the autosite, as an independent heart has not, so far as I am aware, been detected in the parasite. The blood current is always ex- tremely slow in the acardiac, and thermometric observations demonstrate that its temperature is several degrees lower than that of the autosite. Thus a study of the circumstances surrounding the development of twins and duplex monsters brings us to the conclusion that teratomata may arise either from partial dichotomy of the trunk axis of the embryo, or from complete dichotomy. In the latter case, while one twin has gone on to full development the growth of the other has been arrested, * Guy's Hospital Reports, vol. i. 218, 1S3G. m Placenta of the Acardiac, A rtery and Vein distributing Blood to the Acardiac. bilical Cord of ealthy Twin. PLATE VII,— Placenta from a Case of Twins, one of which was an Acardiac. (Astley Cooper.) TETIATOMATA. 375 and in some cases the suppression has been so great that the companion fetus is represented by a deformed or shapeless mass consisting of integument covering ill-formed pieces of the skeleton and portions of viscera. In a few cases of parasitic foetuses we are able to offer a probable opinion as to whether the reduplicated parts are due to partial dichotomy of the trunk or are the result of complete cleavage, in which one of the foetuses becomes an acardiac. In very many, indeed in the majority of teratomata, it is absolutely impossible to decide in favour of one method or the other. Treatment. — Parasitic acardiacs are in almost all cases so extremely valuable as sources of gain in fairs, shows, and large cities that the parents, or the unscrupulous individuals Avho get possession of these children, will not permit operative interference. When the parasitic acardiac is of the amor- phous variety (Fig. 191) and attached to the dorsal surface of the sacrum, attempts may be made to remove them. The children rarely survive the interference. 376 CHAPTER XLII. GEOUP IV. CYSTS. Cysts or Cystomata result from the abnormal dilatation of pre-existing tubules or cavities. In the simplest forms they consist of a wall usually composed of fibrous tissue, but it is not infrequently mixed with muscle-fibre. The cyst-contents may be mucus, bile, saliva, etc., according to the nature of the organ with which the cyst is associated. Genera. Species, Retention cysts. IL Tubulo-cysts. Hydrometra. Hydrosalpinx. Hydronephrosis. Hydrocholecyst. ViteUo-iatestLaal. Allantoic (urachal). Paroophoritic. Parovaiian. Cysts of Gartner's duct. Cystic disease of testis. Encysted hydrocele of testis. Cysts of Miiiler's duct. Of the tunica vaginalis. Of the canal of Nuck. Of the ovary. Of the neck. Ranulse. Pancreatic-cysts. Chyle-cysts. D aery ops. There are conditions often classed as cysts which are arranged in a sub-group entitled Pseudo-cysts. I. Diverticula. Intestinal ', Vesical ; Pharyn- geal; (Esophageal; Tracheal; Synovial ; Meningeal. II. Burs«, Bursa. III. Hydroceles. IV. Gland cysts. RETENTION CYSTS. 377 Genera, Species. III. Neural cysts. Hydrocephalus. Hydrocele of fourth ventricle. Meningocele (cranial). Spina bifida. IV. Parasites. Hydatids. RETENTION CYSTS. When the duct of a gland becomes obstructed the fluid, hindered from escaping, accumulates in the ducts and acini and dilates them. If the hmdrance to the free flow of the secretion is maintained, or oft repeated, the glandular tissue becomes impaired, then atrophies, and finally the gland and its duct become converted into a fluid-containing sac or cyst. It is generally believed that when the duct of a gland is completely obstructed the conversion of the parts into a cyst is a passive process ; but occasion will be taken in the course of this section to show that this is not the case. When an excretory duct is so completely obstructed that no secretion escapes, then the gland rapidly atrophies. Retention cysts are due to obstruction to the free flow of secretion, or temporary arrests of the flow frequently recurring. The best example of cysts arising in this way are those due to dilatation of the pelvis and infundibula of the kidney — a condition known by the term hydronephrosis. The purest forms of retention cysts arise in connection with hollow organs, the inner walls of which are provided with glands. The vermiform appendix is a case in point. This tubular structure is richly provided with glands. (Fig. 194.) Occasionally the communication of the, appendix with the caecum is obstructed, and the glands continuing to secrete, the accumulating fluid distends the appendix into a sausage- shaped cyst and sets up local symptoms of great severity. The uterus is another example. After a diflficult labour the walls of the cervical canal are not infrequently damaged, and in the process of repair, the canal may become obstructed. This leads to retention of the products secreted by the uterine glands, and the uterus will attain such proportions as to cause the enlargement to be attributed to pregnancy ; the condition is known as hydrometra. It is occasionally seen in women, but is more common in mammals normally furnished with 378 CYSTS. bicornuate uteri, such as ewes, cows, mares,. and sows. It may be unilateral or bilateral When occurring in mammals in which the uterus has long cornua — e.g., cat, bitch, hare, etc. — the distended cornua are apt to be confounded with Fallopian tubes. It may affect one or both cornua of a bihorned uterus in women. The danger of retention of this kind is not so much due to the size of the cyst as to the great risk that ensues when .„„.,^„-:.';,.sji.!-"' Fig. ] 94.— Section through the tip of the vermiform appendix, to show the ahundance of its glands. A, outer coat ; b, adenoid tissue ; c, muscular capsule to the adenoid tissue. large collections of retained secretions are invaded by putre- factive organisms. The cysts in such an event become con- verted into abscesses and the life off the individual is greatly imperilled. These changes in retention cysts are indicated by special names— as pyometra, pyonephrosis, etc. HYDRONEPHROSIS. The mode of origin of retention cysts may be studied in the kidneys. The secretion from these glands is conducted into the bladder by means of two ducts 35 cm. (14 inches) BETENTION CYSTS. 37'J long, known as the ureters : the urine is discharged from the bladder through the urethra. If from any cause the urine is hindered from escaping freely, either from the bladder or from Fig. 195.-Hyaronephro.is .econaary to a la se caleulu| >" the blad ler t ™ fra^ments^of ■^^^ZrTllv^^^i:tmLZU:i%r!flie, al^^':! oo^pfete suppression of urine. (Musnm, Middlesex Hospital.) [^ nat. size.] the ureters into the bladder, it accumulates in the ureters and dilates them ; the pressure then acts upon the pelvis of the kidney, and if maintained causes the renal pelvis to be dilated into a large sac, converts the infundibula into large tubes, and finally induces atrophy of the renal tissue until the kidney is 380 CTSTS. converted into a multilocular sac. To a kidney thus converted the term hydronephrosis is applied. (Fig. 195.) Hydronephrosis arises from a variety of causes. It must be borne in mind that when the obstruction is complete and persists, the kidney very rapidly atrophies. Large examples of hydronephrosis are produced by partial obstruction to the Fig. 19 -Bilateral hydronephrosis in a new-born child. {Mmeum, Middlesex Hospital.) ' flow of urine, or frequently recurring attacks of complete obstruction. Hydronephrosis may be bilateral or unilateral. When the obstruction is at the neck of the bladder or in the urethra, it will be bilateral. ' - The chief causes of bilateral hydronephrosis are Impacted calculus in the urethra, or near the neck of the RETENTION CYSTS. 381 bladder (Fig. 197) and urethral stricture. Tumours of the prostate gland, especially pedunculated adenomata (Fig. 115), or pressure upon the urethra by an impacted uterine myoma. Bilateral hydronephrosis may also arise from pressure on both ureters — e.g., by a hydatid cyst of the pelvis, by a large uterine myoma, or other variety of pelvic tumour (page 173). The condition is occasionally congenital, and the most careful examination fails to detect a cause. (Fig. 196.) Unilateral hydronephrosis has many causes :^The reten- tion of a calculus in the vesical segment of the ureter ; tumour (villous) of the bladder situated near or at the vesical orifice of the ureter; calculus lodged in the pelvis of the kidney; papilloma of the renal pelvis ; axial rotation of the kidney leading to kinking of the ureter; tumours involving the ureter, as in cancer of the uterus ; or pressing upon it from without, as myomata of the uterus; ovarian cysts and tumours of the pelvic bones. In double hydronephrosis secondary to obstruction at the neck of the bladder an interesting change may sometimes be observed at the vesical orifices of the ureters. Normally, these openings scarcely admit a fine probe, but under the con- ditions just mentioned will assume a circular form, and be so large as readily to admit the tip of the httle finger, so that fluid injected into the bladder through the urethra will enter the ureters and gain the dilated pelvis of the kidney. This condition is particularly apt to supervene upon oft-repeated attacks of retention of urine, secondary to pressure on the urethra exercised by a myomatous uterus lying low in the pelvis, and becoming impacted immediately before, and at the incidence of each menstrual period. It is a curious fact that some of the largest hydronephroses, uni- lateral and bilateral, that have come under my notice have been cases in which it was impossible to assign an adequate cause. (Fio-. 198.) The most remarkable example of this is the celebrated case of Mary Nix,* aged twenty-three years. She died at Hampton-Poyle, near Oxford, with a large hydronephrosis containing fluid to the amount of thirty gallons, wine measure. The dissection of the body was * Phil. Trans., 1747, vol. xliv. p. 337. 382 m CYSTS. .„adeby Samuel Glass, with " some learned gentlemen of the university." I have read the account very critically, and feel ^S^s^ Fig. 197. — Calculus impacted in the uretlivii of a gelding, producing wide dilatation of the vesical oritices of the ureters and double hydronephrosis. there is no doubt as to the renal origin of the hydronephrosis. Nothing was found to account for it. Intermitting Hydronephrosis. — When a hydronephrotic kidney is of large size it can be perceived clinically as a definite tumour. It occasionally happens that patients come under observation with a swelling in the loin which can be RETENTION CYSTS. 383 readily perceived at one examination but not at another, or it obviously dirninisbes in bulk without completely vanishing. In some of these cases the patients are able to state definitely that, coincidently with the diminution in the volume of the tumour, there has been a sudden increase in the quantity of the urine voided. The urine in some instances has been Fig. 19S.— Unilateral (intermitting) hydronephrosis. The nreter, at tlie point where it left tlie renal sinus, had a diameter of 8 cm. {Mnse%im, Middlesex Hospital.) found to contain traces of blood and mucus. To hydrone- phrosis of this kind the term intermitting is applied. It must be borne in mind that there may be difficulty in some cases in deciding clinically between a very large hydronephrotic cyst and an ovarian or parovarian cyst, and it is well established that cysts of the ovary and parovarium sometimes rupture, and the fluid, escaping into the peritoneum, is absorbed into the circulation and rapidly excreted by the kidneys. Thus, pro/ttse diuresis following ivpon the sudden disappearance or diminution of an abdominal tum,our is as 384 0YST8. characteristic of mixture of an ovarian cyst as of an intermitting renal cyst. ■ ■ There can be little doubt that nearly all hydronephroses ' intermit, but the term intermitting hydronephrosis is reserved for those examples in which great diminution, and in some ,^ Orifice of the ureter. Pig. 199. -Pyonephrosis of one half of a horse-shoe kidney (Museum, Middlesex Hospital) (H. Morris.) instances temporary disappearance, oi the swelling takes place. Exceptionally, both kidneys when hydronephrotic may intermit alternately. Of this rare form I have had one case under my care ; as the diagnosis was somewhat obscure, PLATE VHI.— Right Kidney with two Ureters, one of which opens into the Bladder at the vesical orifice of the Urethra ; the lower half of the Kidney drained by this Ureter is converted into a pyonephrosis. The upper half drained by the normal Ureter is healthy. The left Kidney was normal. (Museum, Middlesex Hospital.) \ nat. size. RETENTION CYSTS. 385 the tumours were explored through an abdominal incision. In the course of the proceeding the phenomenon of inter- mission was actually observed. The hydronephrosis diminished in size, and the bladder slowly filled. There are a few rare varieties of renal cysts that may be mentioned, such as hydronephrosis of one half of a horse-shoe kidney (Fig. 199); or a kidney may have two ureters, one of which, with the portion of the kidney drained by it, becomes dilated and sacculated, the other half of the kidney remaining healthy. (Plate VITI.) When putrefactive organisms gain entrance to a dilated renal pelvis, either from the bladder by way of the ureter, or from the colon adjacent, suppuration ensues and the cyst becomes a pyonephrosis. Hydrocholecysts. — The gall bladder consists of three coats of which the middle one contains unstriped muscle fibre ; the inner one is mucous membrane, its epithelium being directly continuous with that lining the hepatic ducts on the one hand and with the epithelium covering the duodenum on the other. The outer coat is derived from the peritoneum and subserous tissue. Bile from the hepatic ducts finds its way into the gall bladder by way of the cystic duct, and when it escapes from the gall bladder it again traverses the cystic duct and passes along the common bile duct to the duodenum. The common duct just as it enters the wall of the intestine receives the duct of the pancreas. The point of junction is indicated by a slight recess known as the diverticulum of Vater. The peculiar arrangement of the ducts leading to and from the gall bladder renders it peculiarly liable to have its communications interfered with. Obstruction may occur in the cvstic duct, in the common duct, in the diverticulum of Yater, or in the wall of the duodenum. The obstruction ina}^ be due to impacted gall-stones, a pancreatic concretion in the diverticuluiri, tumouis of the pancreas, duodenum, etc. When obstruction in the common duct is complete and persistent, the gall bladder may atrophy. When incompletcy or if complete the obstruction be only temporary, and especially if frequently repeated, the gall bladder will become greatly distended. When the cystic duct is obstructed, and no bile finds its way into the gall bladder, the latter may become 386 CT8T8. so distended with mucoid fluid, and attain such large propor- tions as to be mistaken for an ovarian cyst. The fluid that accumulates in the gall bladder under these conditions is probably the result of cholecystitis; such a distended gall bladder is called a hydrocholecyts. Sometimes adhesions occur between the dilated gall bladder and adjacent intestine (duodenum or colon), intestinal fluids gain access to it, and suppuration ensues, converting it into a pyocholecyst. Some- times a fistula forms between the intestine and the cyst. Suppuration may occur in the gall bladder in consequence of septic organisms finding their way into it from the intestine >long the ducts of the gall bladder. Treatment. — During the last ten years very great advances have been made in the surgical treatment of cystic tumours of all kinds, and the principle is gaining ground that when it is possible to remove them without greatly endangering life, this radical mode of treatment gives the most satisfactory results. This is well borne out in the case of unilateral hydro- nephrosis. When the surgeon is satisfied that an individual has a large sacculated kidney, and the fellow gland is in good condition and performing its functions properly, the hydro- nephrotic cyst can be removed through an incision in the loin with as little risk as attends the excision of simple ovarian or parovarian cysts. It is undesirable in a work of this kind to enter into details regarding the surgical treatment of such cysts. Certain it is that surgeons were formerly content, when they considered it necessary to interfere with a hydronephrotic cyst, to expose the cyst-wall through a lumbar incision, incise it, evacuate the contents and, by stitching the cyst to the edges of the skin-wound, establish a fistula. Henry Morns, however, has demonstrated that the best method of dealing with a unilateral hydronephrosis is to remove the cyst completely (nephrectomy), and this excellent practice is becoming universal among surgeons and is as successful as ovariotomy. It is .a peculiar circumstance that in many instances a hydronephrosis has assumed such large dimensions as to extend into the false pelvis and simulate an ovarian tumour. In many instances the resemblance has been so close that RETENTION CYSTS. 387 experienced physicians and expert surgeons have been so deceived that operations have been performed as for ovario- tomy, until the abdomen was opened and the error discovered. In such a case the surgeon should ascertain if the companion kidney is healthy, then close the abdominal incision and remove the hydronephrosis through an opening in the loin. This class of case furnishes admirable results. The surgical treatment of dilated gall bladders (hydro- cholecysts) is in a sort of transition stage. The ideal operation is removal of the gall bladder after ligature of the cystic duct (cholecystectomy) ; but there are many difficulties to surmount before it will be possible to carry out this manoeuvre, save in exceptional cases. At present the safest practice consists in exposing the gall bladder through an incision in the belly- wall, evacuating its contents, and removing the blockade if possible ; the cyst is then stitched to the edges of the peritoneum and the wound allowed to close by granulation. The Guttural Pouches of the Horse. — In man the pharyngeal orifice of each Eu8tachiau tube opens in relation with a bay or recess termed the J'ossa of Bosenmuller. In the horse they terminate in a very difEerent manner. When the head is removed at the occipito-atlantal articulation, and the pharynx, with the associated structures, carefully dissected from the muscles on the ventral aspect of the cervical region of the spine, it will be found, as a rule, difficult to avoid cutting into two large sacs separated from the atlas and axis by loose connective tissue. These sacs reach to the base of the skull, extend downwards to the larynx, and send processes to occupy the intervals between the long styloid processes and the mandible. These sacs are the guttural pouches ; they abut upon, but have no communication with each other, and occupy the whole of the nasn-pharynx. Each pouch is lined with delicate mucous membrane containing glands and furnished with ciliated epithelium. The mucous membrane of the guttural pouches is directly continuous with that lining the Eustachian tubes. The pouches themselves appear as large saccular dilatations of the terminal ends of the tubes, and for this reason they are termed by some writers the Eustachian pouches. Each pouch opens into the pharynx immediately above the soft palate by a vahnilar orifice ; one side of the valve is formed by the leaf -like termina- tion of the Bustaehian tube. Of the functions of these pouches nothing is known. Tliey are often a source of inconvenience to horses, for the mucous membrane is very prone to become inflamed, and the scanty outlet for the secretion leads to its retention and the consequent dilatation of the sacs. When enlarged in this way they may have a capacity of six or more ounces each. The retained secretion may decompose, and the sao 388 CYSTS. become distended with pus. which is discharged at intervals through the nose ; or the pharyngeal orifice may be occluded, and the pouches enlarge to such an extent as to require an incision through the skin of the ueck, or tlirough the mouth. Not infrequently the contents of the pouches become inspissated and formed into concretions. Tliese are of different shapes and sizes, and vary Fig. 200.— Concretions from the guttural pouches of horses. (Nat. size.) in number from one, two. or three to fifty or even more. Generally they are of an oval shape; not infrequently they resemble beans. In con- sistence these concretions are like cheese, and on section have a laminated appearance. They are composed of mucus and inflammatory products mixed up with inorganic particles. (Fig, 200.) The grit in these concretions enables an explanation to be offered concerniug the liability of the pouches to attacks of inflammation. As the orifices of the pouches are in direct communication with the nasal passages, dust can easily gain entrance into them when snuffed up with, fragments of hay, straw, dried seeds, and other organic and inorganic' particles from dusty nose-bags and mangers. , CHAPTER XLIII. TUBULO-CYSTS. The human body, in common with that of many mammals, contains a certain number of tubes which, so far as is known, serve no useful purpose in the adult, and may be called in consequence functionless ducts. Some of these — e.g., the vitello- intestinal duct and the urachus — were probably useful to the embryo ; others, like the paro- varium and Gartner's duct, are serviceable in the male, as they act as conduits to the testis. Functionless ducts must not be confounded with obsolete canals : these serve no useful purpose in man, but were, in aU probability, functional in the ancestors of existing vertebrata (page 308). Both sets of canals are of interest to the patholo- gist, as they are the source of cysts which are not only inconvenient to the individual, but actually dangerous to life. The genus Tubulo-Oysts in- cludes the seven following species : — (1) Cysts of the vitello- intestinal duct ; (2) Allantoic (urachus) cysts; (3) Paroopho- ritic cysts ; (4) Parovarian cysts ; (5) Cystic disease (adenoma) of the testis ; (6) Cj^sts of Gartner's duct ; and (7) Cysts of Miiller's duct. Cysts of the Vitello-Intestinal Duct. — It is not uncommon to find connected with the umbilicus of babes and young children small tumours varying in size from a pea to a cherry. These tumours are of a bright red colour, soft and velvety to the tou6h, and are, as a rule, connected to the navel by Fig. 201.- Congenital peflnneulated tumour of tlie navel. 390 0Y8TS. Lung diverticulum, Stomach. slender pedicles, and in appearance resemble red currants; occasionally they are sessile. (Fig. 201.) These tumours are composed of unstriped muscle fibre, mucous membrane, Lieberkuhn's follicles, and. columnar epi- thelium collected into a mass. Typical cases have been care- fully described by Kolaczek,* Colmanf, and others. In rarer cases the umbi- licus is occupied by a cyst, which may project externally or internally. Such a cyst is lined with mucous membrane furnished with villi, columnar epithelium and follicles. A cyst of this character is easily confounded with the sac of an umbilical hernia. RoserJ reported a case in which a young man came under his care with a sinus at the umbilicus from which a slimy discharge issued. Vitello-intestinal duct. ;. 202. — Diagram of the alimentary canal of tlie embryo, showing the position of the yolk sac. Some time before, a surgeon had removed a small cyst Avhich projected from the navel, but the wound never healed. The discharge from the sinus frequently corroded the surrounding skin. On introducing a probe, the sinus was found to lead into a cavity measuring six centimetres in diameter. The cyst was removed, and microscopical examina- tion showed it to present all the histological characters of intestine. Zumwinkel§ has described the case of a girl seven years of age who had a small fistula on the left side of the navel from which shmy fluid issued. The sldn surrounding the fistula was ulcerated. A probe introduced into the opening entered * Langenbeck's "Archiv," td. xviii., s. 349. f Trans. Path. Soc, vol. xxxix., p. 110. J Langenteck's " Archiv," bd. xx., s. 472. § Langeabeok's "Archiv," bd. xl., 8. 838. TUBUL0-CYST8. 391 to the depth of 1 cm. The parts were explored through an incision, and a cyst the size of a cherry exposed and removed. The cyst exhibited the histological features of small intestine. The structure and position of pedunculated tumours and sessile cysts at the navel indicate the structure from which they arise — viz., a remnant of the vitello-intestinal duct which, in the embryo, traverses this part of the abdominal ■wall (Fig. 202). In transverse sections of the umbilical cord, close to the belly-wall of the embryo at the fifth month, the vitello-intestinal duct can often be detected, with its lumen lined with sub-columnar epithelium. It is also well known that the duct, instead of shrivelling, sometimes grows pari passu with the gut to which it is connected, and acquires a lumen almost equal to that of the ileum. Instead of persisting from the gut to the navel the duct may atrophy, leaving a small portion attached to the intestine or to the abdominal wall. Such remnants may develop into cysts the walls of which are identical in structure with those of small intestine. A much rarer variety of cj'st arising in a remnant of the vitello-intestinal duct is due to the distension of that portion of the duct which is connected with the ileum. In recently hatched chicks the intestinal attachment of the duct is often indicated by a nipple-like process on the free border of the gut. This is hollow, but does not communicate with the lumen of the ileum. As a rule it atrophies completely. It may, however, grow and form a large cyst. In Fig. 203 a piece of intestine from an emu chick is shown with a large cyst suspended from it by means of a narrow and acutely- torsioned pedicle. This cyst in all probabihty originated in a persistent portion of the vitello-intestinal duct. Cysts of like proportions and of identical origin have been recorded in the human subject. One of the best-known cases was reported by Roth.* Occasionally a persistent vitello-intestinal duct will remain open at the umbilicus and discharge fseces. Such cases have been successfully dealt with by surgeons.f There are tew structures in our bodies more capable of exciting philosophical speculation than the yolk sac and its * Virchow's "Archiv," bd. Ixxxvi., s. 371. f Battle, Trans. Clin. Soc, vol. xxvi. 392 OYSTS. duct. This organ may in man and all the higher mammals be regarded as vestigial, for its duties have been in part abro- gated by the allantois, but more completely by the placenta. In the human embryo, it is the function of the allantois to Pig. 203.— Cyst, probabl)' of t.lie vitello-intpstiiial duct, attached to the intestine of an einn. (Museiim, UoyaZ College of Sitrgeons.) convey the blood-vessels which it receives from the developing aorta and distribute them to those chorionic villi destined to form the foetal portion of the placenta. In some sharks the yolk sac is covered with vascular villous tufts which fit into depressions of the oviduct. Even in some mammals — e.g., guinea-pigs — the yolk sac enters into vascular connection with the uterine mucous membrane. There are abundant and good reasons for Balfour's conclusions TUBUL0-CYST8. 393 tliat placental mammals are descendants of forms the embryos of which had large yolk sacs ; but the yolk became reduced in quantity owing to the nutriment the embryo received from the maternal tissues by means of the vascular connection of the yolk sac with the uterine wall. Subsequently the function of the yolk sac became limited by the allantois and the gradual evolution of the placenta, and finally, so far as man is concerned, abolished. Thus in man it is vestigial, and like such structures in general, is liable to many vagaries. There is good reason to be- lieve that the vitello-intestinal duct, besides being a source of cysts, is also responsible for the curious defect in the ileum to which I have applied the name imperforate ileum. It occa- sionally happens that the lumen of the ileum is interrupted by a perforated diaphragm (Fig. 204). To such a condition the term septate ileum is applicable. When such a diaphragm is pre- sent its situation is sometimes indicated by a marked con- striction of the gut. In other specimens a more or less perfect valve of this kind is associated with a persistent duct (Fig. 205). In such cases the duct opens into the ileum on the distal side of the valve. In other instances the ileum becomes greatly dilated near its middle, and the walls are much hypertrophied ; to this succeeds a narrow isthmus which opens into a normal segment of ileum. Lastly, in the complete form the ileum is interrupted as in Fig. 206. These curious defects are attributable to the influence of the vitello-intestinal duct because they always occur in that portion of the ileum to which the duct, when per- sistent, is attached — that is, they do not occur within 30 cm. of the ileo-cffical valve, and are rarely found at a greater distance than 1 m. from the caecum. Fig". 204. — Septate ileum. (Musettm, Middiesex Hoapital.) 394 CYSTS. I The most reliable evidence for associating these defects with the duct of the yolk sac is that furnished by Fig. 205, in which a persistent duct and a valve co-exist. In my early observations I had regarded imperforate ileum as depending upon the influence of the vitello- intestinal duct, and subsequent observations put the speculation on a sound basis.* The specimens which demonstrate these views are preserved in the museum of the Middlesex Hospital. An imperforate ileum is, of course, incompatible with life, but an individual with a septate ileum niay attain adult life. The consideration of imperforate ileum has been introduced here because it throws a large amount of side - light on pharyngeal diverticula and imperforate pharynx. Treatment. — The small pedunculated cysts and polypi of the umbilicus only require the application of a thread or silk ligature to the pedicle and a snip with a pair of scissors. Sessile cysts require to be dissected out. The grosser mal- formations, such as imperforate and septate ileum, have in a few instances been submitted to surgical treatment, but the eflbrts have not been successful.. Allantoic (Urachus) Cysts. — The uiinary bladder of man in common with that of mammals generally presents at its apex an impervious cord that passes to the umbilicus. This cord is known as the urachus. At birth the urachus is usually traversed by a narrow canal lined with epithelium directly continuous with that lining the bladder. ;. 205.- hapersistent vitello-infces- tinal clnct associated with a valve. (Museum, Middlesex Hospital.) * British Medical Journal, 1891, vol. i., p. 342. TUBULO-CYSTS. 395 The urinary bladder with the urachus is the persistent portion of the allantois, the organ which in the early embryo conveys blood-vessels from the aorta to the developing placenta. In the adult the urachus lies in the subperitoneal tissue exactly in the middle line of the anterior abdominal wall, between the summit of the bladder and the umbilicus. When the urachus becomes dilated it forms a cyst lying outside the peritoneum and in close relation with the bladder. Proximal of ileum segment. Free edge of mesenterj'. ^^g Distal segment of ileum. Fig. 206. — Imperforate ileum. (Museum, Middlesex Hospital.) Instead of a portion of the allantois narrowing to form a urachus, the whole of its intra-abdominal portion may dilate and form a large urinary bladder. Shattock* has carefully described an example of this. Several cases are known in which the umbilical end of the urachus has remained patent so that urine was voided at this spot. A urinary calculus has been extracted from such a persistent urachus.f Allantoic cysts arise from dilatation of a urachus which is * Trans. Path. Soc, vol. xxxix , p. 185. f Thomas Paget, Med.-Chir. Trans., vol. xxxiii., p. 293, and vol. xliv., p. 13. 396 CYSTS. occluded at the umbilicus and at the summit of the bladder. Such cysts are usually of the size of a ripe cherry. Sometimes several very small dilatations are formed, causing the urachus to assume a moniliform appearance. In rarer cases the urachus may dilate into a cyst as large as a distended bladder. The structure of these large cysts is identical with that of the bladder, and consists of unstriped muscle fibre, lined on the inner side with epithelium similar to that covering the vesical mucous membrane. In some of the specimens phosphates are deposited on the cyst-wall. In large cysts there is, as a rule, a commimication with the bladder, and the cyst contains urine. A urachus cyst must not be confounded with a sacculus at the apex of the bladder extending into the suspensory ligament. Lawson Tait* has published details of allantoic (urachus) cysts that have attained large dimensions ; in one case the cyst had a capacity of ten pints. These cysts were situated between the peritoneum and the anterior abdominal wall. Allantoic cysts have been observed in many m.ammals, such as the pig, horse, ox, mole, etc. Treatment. — In a few instances large allantoic cysts have been removed and some of the patients have survived. At present so little is known about the cysts that it is impossible to decide as to the best method of dealing with them. * The Brit. Gyn. Journal, vol. ii. 328 ; Wutz, " Ueber Urachus und Urachusoysten " ; Virchow's "Archiv," bd. xcii. 387. 397 CHAPTER XLIV. TUBULO-CYSTS (concluded). CYSTIC TUMOURS ASSOCIATED WITH REMNANTS OF THE MESONEPHROS (WOLFFIAN BODY), ITS TUBULES AND DUCT. It is well established diat in the embryo the mesonephros is closely associated with three organs, the testis, ovary, and kidney. It is also a fact that in at least two situations — viz., in the ovary and in the testis — remnants of the glandular elements of the mesonephros may be occasionally met with in the adult. Many of the tubules of the mesonephros and its duct function in the male as excretory ducts for the testis, but in the female they persist in a vestigial condition, as the parovarium and Gartner's duct. There is abundant evidence for the belief that many cysts connected with the testis, ovary, parovarium, and vagina arise from vestiges of the mesonephros and its excretory canals. It will be convenient to begin the description of these cystic conditions by considering those which arise in vestiges of the glandular portion of the mesonephros in the female. Cysts of the Paroophoron. — The ovary consists of two parts, the oophoron and the paroophoron. The egg-bearing portion is the oophoron. The paroophoron contains no ova, but receives the tubules of the parovarium. (Fig. 207.) It represents the remnants of the mesonephros, and is homo- logous with the paradidymis of the testis. In the adult ovary the paroophoron consists mainly of fibrous tissue permeated with blood-vessels, but in the fcetus and young child it retains, in a measure, its glandular character. The paroophoron is the probable source of cysts that present peculiar characters. In the early stages they resemble parovarian cysts in their relation to the mesosalpinx and Fallopian tube, but as they increase in size they burrow deeply between the layers of the broad ligament, and make their way by the side of the uterus, travel under the peritoneum, and strip it froni the floor of the pelvis. When lai-ge, these cysts will come into contact with the common iliac veins at the brim of the pelvis, or they may raise up the anterior layer of the 398 ' CYSTS. broad ligament so as to invade the subserous tract of the anterior abdominal wall. In addition to their burrowing tendencies these cysts are peculiar in that their inner walls are papillomatous. The number of warts varies in different cysts. Some have, only a small cluster; in others the clumps are so large and so numerous that the cyst-wall bursts from the pressure exercised by them. The warts are usually very vascular, bleed freely when handled, and are frequently calcified. When Fig. 207. — Diagram to represent the cyst regions of the ovary, a, oophoron ; b, paro- ophoron ; c, parovarium ; k, Kobelt's tubes ; g, Gartner's duct. a papillomatous cyst ruptures, the cell-laden fluid it contains is dispersed throughout the belly, and it frequently happens that the cells become engrafted upon the peritoneum and grow into warts. In such cases the warts are usually most numerous on the peritoneum in the recto-vaginal pouch. Exceptionally, the cyst will rupture into the connective tissue of the broad ligament, and warts sometimes spring up in this tissue, and I have seen them clustering around the urachus as high as the umbilicus. Occasionally the warts may make their way through the cyst-wall and protrude as in Fig. 208. Such emancipated warts grow luxuriously, and the movements of adjacent coils of intestine detach the surface cells and spread them about the belly. It frequently happens that surgeons are alarmed when they find warts on the peritoneum, as they mistake them for nodules of cancer or sarcoma. There TUBULOCYSTS. 399 is, however, uo cause for alarm, as the warts quickly disappear after removal of the primary tumours. In this respect these warts agree with those which grow on the skin {see page 168). Skin warts often appear suddenly, and almost as suddenly disappear. Thus the life of a wart is often very transient. So with peritoneal warts ; but as long as the seed supply continues new warts spring up, last for a time and die, to be * I IJ^ J ,/ — Fallopian tube. 4 I . Parovarium. - Ovarian ligament. Fig. 208. — Ruptured paiiillomatous (paroophoritic) cysts of the ovary. (J.) succeeded in their turn by a new crop. When the tumours are removed the supply of germ epithelium ceases, the warts die, and the crop is not renewed. Paroophoritic cysts may be unilocular or multilocular ; some attain great proportions, but the infective qualities of the cysts are in no way influenced by their size. These cysts are rare before the twenty-fifth year. The period of life in which they are most common is between the twenty-fifth and fiftieth years. Coblenz* was probably the first to distinguish them clearly from parovarian cysts, and to associate them with definite structures. His observations have * Virchow's " Archiv," td. Ixxxiv., 26. 400 CYSTS. been confirmed by Doran* and myself t by investigations on tbe ovaries of foetuses and infants. Although one of the distinguishing features of a paroophoritic cyst is the presence of papillomata, it must not be imagined that all wart-containing cysts of, or near, the ovary arise in the paroophoron. Undoubted parovarian cysts sometimes contain warts, and there is a species of cyst occasionally met with in the mesosalpinx in relation with the tubo-ovarian ligament which often contains warts. Every projection in a cyst is not a wart. In many oophoritic cysts the microscope has shown that some wart-like structures are clusters of glands. Parovarian Cysts. — The parovarium consists of a number of narrow tubules situated between the layers of the mesosal- pinx. It is- easily seen, when the mesosalpinx is stretched and held between the eye and a light, as a series of narrow tubules radiating from the ovary to join a longitudinal tubule situated at a right angle to them. In form and disposition these tubules resemble the vasa efferentia of the testis. The par- ovarium and the vasa efferentia are homologous structures, for they are the persistent tubules of the mesonephros (WolfiSan body). That portion of the ovary into which they dip, the paroophoron, is derived from the glandular portion of the mesonephros. The parovarium in its typical condition consists of three parts : — (1) An outer series, free at one extremity, and known as Kobelt's tubes. (2) An inner set formed of about twelve tubules ; these are often referred to as the vertical tubules. (3) A straight tube running at right angles, and occasionally traceable through the broad ligament to the vagina ; this is Gartner's duct ; it is homologous with the vas deferens of the male (Fig. 207). The cysts that arise in the parovarium are of two kinds. Small pedunculated cysts often form in Kobelt's tubes ; they rarely exceed a currant in size, and do not call for comment, as they are of no clinical importance. These cysts are very frequently mistaken for the hydatid of Morgagni, which, when present, hangs from a fimbria of the tube. The * Tranij. Path. Soc, vol. x.\xii., 147. T Journal of Anatomy and Physiology, vol. xx., 432. TUBUL0-CYST8. 401 important cysts arise from the vertical tubules, and separate the layers of the mesosalpinx, and burrow towards the Fallopian tube. When small, parovarian cysts are transparent, and have very thin walls, but after they attain the size of a cocoa-nut the walls become thick, and the mesosalpinx in relation with the cyst becomes thickened, and sometimes the muscle fibre contained in this part of the broad ligament becomes greatly increased. Parovarian cysts sometimes attain a great size. I removed one that had a capacity of four gallons and a half Small parovarian cysts are lined with columnar epithe- lium which is ciliated in some specimens. In large cysts it becomes stratified, and in very big cysts it atrophies. The fluid in small cysts is limpid, slightly opalescent, sp. gr. 1002 — 1007, and contains a substance that forms a flocculent precipitate when the cyst is immersed in alcohol. In large cysts the fluid is usually turbid and sometimes con- tains cholesterine. The fluid is not harmful, for when parovarian cysts rupture into the peritoneal cavity the fluid is absorbed and excreted by the kidneys. After rupture the rent will heal and the cyst refill, and in some cases the cyst has burst and refilled many times without causing more than temporary inconvenience to the patient. The cyst may rotate on its axis and twist its pedicle. This movement may even lead to complete detachment of the cyst. Exceptionally, parovarian cysts suppurate. Although these cysts occupy the mesosalpinx, they do not burrow between the layers of the broad ligament below the ovarian ligament, but rise up out of the pelvis. This accounts in a large measure for the safety with which they may be removed. Parovarian cysts are almost invariably unilocular. The chief features which distinguish a parovarian cyst from other cysts of the broad ligament and ovary are these : — (1) It is easily shelled out from the mesosalpinx. (2) The ovary may often be found attached to the side of the cyst. (3) The Fallopian tube is stretched over the crown of the cyst, but never communicates with it. (Fig. 209.) Before the sixteenth year the parovarium appears to be quiescent, but on the advent of puberty it seems to become A A 402 ' CYSTS. stimulated. A considerable proportion of cysts, genericd,lly classed as ovarian, removed between the seventeenth and twenty-fifth years, arise in the parovarium. There is no trustworthy record of a parovarian cyst being observed before the sixteenth year. Oysts of Gartner's Duct. — It has already been mentioned in the description of the parovarium that the vertical tubules of this structure are received into a tube running at right angles to them. This tube when persistent throughout its course makes its way between the layers of the broad ligament and runs downwards on the uterus, to open into the Fig. 209.— Cyst of the parovarium, sliowing its relation to ovary and tube. Two-thirds its natural size. a, oophoron ; b, paroophoron ; f, Fallopian tube. vagina near the orifice of the urethra. This tube is known as Gartner's duct, and is the duct of the mesonephros (Wolffian duct), which in the male becomes the vas deferens. Gartner's ducts rarely persist throughout their whole extent in women. The portion that receives the tubules of the parovarium (Wolffian tubules) is often detected, and the terminal seg- ment, known as Skene's tube, may be occasionally recognised in the vagina, and is frequently the seat of a trouble- some inflammation. The intermediate segment, as a rule, disappears. In the sow, and especially in the cow, Gartner's ducts often persist ; in the cow they are sometimes s'een as large as crow-quills. In many cows they become gradually lost on the sides of the uterus, but in some cases TUBULO-CYSTS. 403 GartDer's duct. they may be traced easily to their termination, and are found to open in the vagina. The interest of Gartner's duct to the pathologist depends on the fact that the terminal segments are apt to become cyst-germs, and there is no doubt that some of the cysts that occasionally require removal from the vagina arise in Gartner's ducts, especially those which are lined with stratified epi- thehum. Such cysts have been known to attain the size of a fowl's egg, and are usually filled with mucus. The evidence that some species of vagiiial cysts arise in Gartner's duct is not merely circumstantial. A specimen that came under my notice in a cow is re- presented in Fig. 210, in which the vaginal segment of the duct expanded to tt form two large oval dilata- tions, each of which was large enough to accommo- date a hen's egg. The specimen is preserved in the museum of the Royal College of Surgeons. In the male, cystic tumours that arise in the vestiges or remnants of the mesonephros (Wolffian body) and its tubules are of two kinds : (1) Encysted hydrocele of the testicle, and (2) general cystic disease of the testicle. Encysted Hydrocele of the Testicle. — In addition to cysts arising in connection with the funicular pouch and its sub-divisions described in chap, xlv., there is another class termed " encysted hydroceles of the testicle." In order to appreciate the nature of encysted hydroceles it will be necessary to consider a few points connected with the development of the testicle. This gland is very complex, for its Fig. 210.— Anterior portion of a cow's vagina, showing two large cysts developed in the terminal segment of Gartner's duct. 404 CYSTS. ducts, the vasa efferentia, epididymis, and vas deferens, were originally the excretory ducts of the mesonephros (Wolffian body). A study of the evolution of the male secretory organ of vertebrates indicates clearly enough that the ducts have undergone a change of function, and their relation to the testicle is secondary. An examination of the embryonic testis shows that remnants of the mesonephros persist among the r^i^ Paradidymis. ^Ji^AlM Kn^Blt'9 tubes. Fig. 211.. -Diagram to show the relation of the mesonephros and its ducts to the adult testicle. ducts, and only a few of the Wolffian tubules are utilised by the testicle. The relation of the various embryonic structures to each other is shown somewhat diagrammatically in Fig. 211. In the adult testis it will be readily seen that a few of the Wolffian tubules become the vasa efferentia, the remainder usually atrophy ; but in many individuals one, two, or more persist, usually as pedunculated cysts of small size at the top of the testicle. The shrunken remains of the mesonephros (Wolffian body) sometimes persist as a collection of csecal tubes furnished with epithelium, lying among the vasa efferentia, between the epididymis and the testis, and often extending a little distance into the tissues of the cord. These remnants are known as the paradidymis. Thus in the male the mesonephros is TUBULO-CTSTS. 405 represented by the paradidymis, its tubules by the vasa efferentia and Kobelt's tubes, and its duct by the epididymis and vas deferens. The cysts to which the term encysted hydrocele of the testicle should be applied arise sometimes in the vasa efferentia of the testis and sometimes in Kobelt's tubes, and it is a Fig. 212, — Hydrocele of the tunica vaginalis, and an encysted hydrocele associated with the same testis. (Mitseitm, Middlesex Hospital.) curious fact that these cysts arise in those structures which in the female give rise to parovarian cysts. As encysted hydroceles in the male and parovarian cysts in the female arise in homologous organs, these cysts are morphologically homologous. The anatomical characters of encysted hydrocele must now be considered. These cj^sts are always closely associated with the testis, but lie outside its tunica vaginahs, but they may project into 406 CTSTS. the cavity of this sac. Occasionally a hydrocele of the tunica vaginalis is associated with an encysted hydrocele. (Fig. 212.) When an encysted hydrocele is very large it may so over- lap the testis that it is difficult to differentiate between it and a hydrocele of the tunica vaginalis, until actual dissection in the course of an operation shows that the cyst is independent of the tunica vaginalis. The lining epithelium of these cysts may be of the stratified, cubical, columnar, or even of the ciliated variety ; they contain fluid, which may be clear, or white hke milk, due to the presence of fat ; sometimes it contains spermatozoa. It may be blood-stained. In size these cysts vary greatly. As a rule, they do not exceed the dimensions of an egg, and often are much smaller ; exceptionally, one of them may exceed a fist in size. An encysted hydrocele must not be confounded with a cyst arising in an unobliterated funicular process. In addition to the sessile form of encysted hydrocele of the testis, there is a pedunculated variety which is usually described as a supernumerary hydatid of Morgagni. These cysts rarely exceed a cherry in size and arise in Kobelt's tubules. As a rule, only one cyst is present, but two or three are not uncommon. Sometimes they wiU, like the hydatid of Morgagni, project into the cavity of the tunica vaginalis. Our knowledge of the different species of hydrocele has become more definite since surgeons have followed the practice of dissecting out these cysts rather than trusting to the uncertain method, formerly so much in vogue, of injecting them with irritative and corrosive solutions. Adenomata (General Cystic Disease) of the Testis. — The tumours of the testis that will be described under this heading are those to which Astley Cooper* gave the name of "hydatid disease." They were made the subject of careful study by Curling,-|- who designated the condition, "general cystic disease of the testis." The morphology of these tumours has been investigated * " Diseases of the Testis, 1830." f Med.-Chir. Trans., vol. xxxvi. 449. TUBUL0-0T8TS. 407 independently by Eve* and myself.f We find good evidence that they originate in the remnant of the niesonephros (Wolffian body) which hes between the globus major of the epididymis and the testis proper. This remnant of the mesonephros is known as the paradidymis. (Fig 211.) It often presents, as has already been mentioned, a distinctly glandular structure. Testicular adenomata in their typical condition arc made up of large numbers of cystic spaces. These cavities vary greatly in size ; some are no larger than rape-seed, others may attain the size of a cob-nut. Many are distinctly tubular, and the cysts may communicate with each other. The loculi are lined with regular columnar, cubical, or stratified epithelium, and intracystic papillomata are not uncommon. The con- nective-tissue frame-work of the tumour consists mainly of simple fibrous tissue, but it may be so abundant as to form the bulk of the tumour, the cysts being sparse. In some of the specimens, especially those met with in infants, plain muscle fibre has been detected. In at least one instance hair has been detected in the loculi of a testicular, adenoma. J Many of these tumours have been described as cystic sarcomata, cystic fibromata, myxomata, etc. — all unfortunate names. In size they vary greatly; specimens are known as large as melons. The best examples for investigation are those which do not exceed the size of an egg. In these the relation of the tumour to the testicular structures is, very instructive. As the tumour increases in size it flattens the body of the testicle until it is reduced to a narrow stratum intervening between the tunica vaginalis and the adenoma. (Fig. 213.) In the large specimens it is often difficult to detect any remnant of the testicle. Testicular adenomata have been observed within a few months of birth and as late as the fortieth year. In all strictness testicular adenomata should have been described in chap. xxvi. ; but as they are so closely related to the vestiges of the mesonephros, it was more convenient to describe them in this chapter. ♦ Trans. Path. Soc, vol. xxxviii. 201. •j- Zancet, 1887, vol. i. 254. J D'Arcy Power, Trans. Path. Soc, vol. xxxviii. 224. 408 CYSTS. Treatment. — The most satisfactory method of dealing with paroophoritic and parovarian cysts is prompt removal. Parovarian cysts are the simplest and most satisfactory cysts with which surgeons have to deal ; they rarely contract adhesion and are almost always unilocular. Paroophoritic cysts stand in striking contrast to those which arise in the parovarium, for they burrow deeply beneath The secreting tissue of the testis. The tumour. I Fig. 213. — Testicular adenomn, (Miissum, St. Mar^fs Hospital.) the pelvic peritoneum and give rise to great difficulty in consequence of the close proximity of such structures as the ureter, iliac arteries and veins, and the inferior vena cava. When small they are sometimes removed as easily as parovarian cysts, but when large, and they have burrowed deeply, the process of enucleation is both difficult and dangerous. The presence of an abundant crop of warts, or hydroperitoneum should not deter the surgeon from removing a paroophoritic cyst, as the exudation of fluid will cease and the warts disappear when the cyst is removed. Cysts in the vagfina due to vestiges of Gartner's duct should be completely dissected out. When the cyst is large the surgeon must be prepared for a delicate and deep dis- section that may lead him very close to the bladder in front. TUBULO-CYSTS. 409 the ureter at the side, the rectum behind and the peritoneum above. It is absohitely necessary to dissect out the whole of the cyst. Measures short of this are useless. The most satisfactory method of treating encysted hydro- cele of the testis is to expose the cyst through an incision in the scrotum, tap the cyst, and then enucleate its walls, taking care not to damage the testis or the vas deferens. The cavity is then drained and allowed to close by granulations. Such procedures as tapping and the injection of irritating fluid are troublesome, inconvenient, and often end in dis° appointment. The method of incising the cyst and stitching its edges to the skin and allowing the sac to granulate is practised by a few surgeons : it is slow and unsatisfactory when compared with radical extirpation of the sac. There are no signs that enable a surgeon to diagnose with certainty a testicular adenoma : it has been confounded with hsematocele, tubercular disease, and sarcoma The appropriate treatment is castration. Cysts of Mailer's Ducts. — In many vertebrata the eggs, after their .escape from the ovary, are conveyed to the exterior by means of a muscular conduit known as the oviduct. The general disposition of these ducts, for there are usually two, may be gathered from an examination of a female frog or toad. The ducts extend from the cloaca posteriorly to the roots of the lungs anteriorly ; they are supported on the dorsal wall of the abdomen by means of a delicate fold of peritoneum, and each duct communicates with the peritoneal cavity by a dilated orifice known as the infundibulum. In the breeding season the ducts become greatly enlarged and convoluted, resembling coils of small intestine. Normally, oviducts are present in the female only. It is, however, remarkable that the embryos of those forms in which the sexes are distinct in the adult condition, have the rudiments of the sexual organs peculiar to the male and female ; they are hermaphrodite. As development continues one set of organs usually attains a functional condition ; the other atrophies more or less completely. The distinguisliing features of the internal sexual organs of a female frog are two ovaries and two oviducts. In the male the oviducts are usually absent. It is, however, an interesting fact that in many male frogs the oviducts may be detected as thin, delicate threads ascending in the peritoneum from the structures called vesiculse seminales to the roots of the lungs. Sometimes the ducts are of large size, almost equal to the oviducts in the female. Persistent Mullerian ducts are more common in male toads than in frogs. Often they are associated with the malforma- tion of the genital gland known as an ovo-testis; but they are fairly 410 CYSTS. freqiaent even when the genital g'land is a tj'pieal testis. No one can donbt that an oviduct in a male frog or toad is fiinctionless, and it is not uncommon to meet with small dilatations or cysts lying in the track of, and arising from, the fanctionless oviducts. Persistent Miiller's ducts are by no means confined to batrachians, but they have been observed in fish, lizards, stallions, birds, and men. Good examples of cysts arising in functionless duets are sometimes met with in birds. In birds, as in frogs and toads, the eggs are conveyed to the exterior by means of an oviduct, but in the case of birds the duct is functional on the left side only. Each chick has two oviducts, but the right ovary and duet, from some unexplained cause, atrophies, leaving, as a rule, a small, narrow tubule surmounted by a lobule of fat. This remnant of the right. duct is very apt to dilate and form a cyst. When the stump of the duct is longer than usual it will sometimes become unequally dilated and form a chaplet of cysts. 411 CHAPTER XLV. HYDROCELE. The name hydrocele is applied to several different kinds of cystic tumours, and as the name is so deeply rooted in surgical literature it would be very inconvenient to attempt to discard it. It will be used in this work in a generic sense, and will include the following species : — (1) Hydrocele of the tunica vaginalis ; (2) Hydrocele of the canal of Nuck ; (3) Ovarian hydrocele. (1) Hydrocele of the Tunica Vaginalis.— Each testicle is preceded in its descent by a diverticulum of the parietal peritoneum, which enters the scrotum by way of the inguinal canal As the testicle descends behind this diverticulum, or fanicular pouch as it is termed, it invaginates the membrane in such a way as to invest the anterior two-thirds of its surface with a double layer of peritoneum. When the testicle first gains the scrotum the funicular pouch is in free communica- tion Avith the general peritoneal cavity. It is a remarkable fact that in almost every mammal, male and female, save man, this relation of the funicular pouch to the peritoneal cavity persists throughout life. In exceptional instances this communication persists even in man, but in him it is distinctly abnormal. Normally the peritoneum becomes adherent immediately above the testis, this adhesion dividing the pouch into two parts; that in relation to the testis persists throughout life as the tunica vaginalis, whilst that above the testis usually undergoes obliteration in the course of the early months of infant life. Occasionally, occlusion of this pouch is delayed for some years, and in rarer cases it may persist throughout life. Normally, the only portion of the funicular pouch that persists throughout life is that which is in im- mediate relation with the testis — the tunica vaginalis — and when this becomes distended with fluid it is termed hydro- cele of the tunica vaginalis. When containing blood it is called hoematocele of the tunica vaginalis. Should the whole of the funicular pouch persist and become occupied by fluid. 412 CYSTS. Covering of the cord. Cremaster muscle." Tunica vaginalis.- — it is called a congenital hydrocele. Frequently the tunica vaginalis is formed as usual, but the portion intervening between it and the internal abdominal ring persists, and may become distended with fluid. This is known as funicular hydrocele ; it is often called encysted hydrocele of the cord. Hydrocele of the Tunica Vaginalis appears in two forms, acute and chronic. Acute hydrocele is due to inflammatory eff'usion into the sac, either as the result of injury or second- ary to acute orchitis. This is the rarer form and, as a rule, the fluid is absorbed and the parts return to their normal con- dition as the inflam- matory trouble that caused it subsides. Exceptionally, a hy- drocele appearing in this way persists. The common form of hydrocele is a passive effusion into the tunica vagi- nalis, usually appear- ing about the middle period of life, and in most cases without any exciting cause, either local or consti- tutional. It is very common in men Av^ho have lived in the tropics. This form of hydrocele is not infrequent in infants, but as a rule, quickly disappears. Hydrocele is met with in extreme old age, and is occasionally bilateral. The amount of fluid in hydroceles varies greatly ; in some it amounts to one or two ounces, whilst in others it measures a pint or more. It is related of Gibbon the historian, that he had a hydrocele which Cline tapped and from which six quarts of fluid were drawn off. (Erichsen.) The fluid when withdrawn from a hydrocele is limpid, of a Hydrocele. ■ Testicle.... Fig. 214. — Hydrocele of the tunica vaginalis testis. HYDROCELES. 4,13 Straw colour, with a sp. gr. of about 1015. It contains a large amount of albumen and the substance known as fibrinogen. When allowed to stand after withdrawal it spontaneously coagulates. When the fluid is removed by tapping, it usually quickly reaccumulates, so that the amount of fluid furnished by a large hydrocele in the course of a few years is often consider- able. Even the withdrawal of large quantities of fluid from a hydrocele at frequent intervals seems to exercise no evil influence upon the health of the patient. The presence of a large quantity of fluid in the tunica vaginalis leads to changes, not only in the membrane itself, but also in the testicle, for this gland, pressed upon by the fluid, will in course of time atrophy. In most specimens the testis is situated in the lower and back part of the sac, as in Fig. 214. In those cases in which the testis is inverted the hydrocele projects posteriorly, and the testis hes in front and at the upper part of the sac. In addition to atrophy of the testis, the diminution in the size of its secreting tissue may be masked by great thicken- ing of its tunica albuginea, a condition termed periorchitis, which is by no means infrequent in old hydroceles, especially those which have been repeatedly tapped. This thickening, or sclerosis, manifested by the immediate covering of the testis is often seen in the tunica vaginalis throughout its whole extent, and in some cases this membrane may be as thick and almost as hard as paste-board. The hardness of these thick sacs is sometimes increased by calcareous matter. When such sacs are dissected out they are not unlike a cocoa-nut in shape, size, and even in consistence. Secondary changes of this kind may be due to repeated attacks of inflammation set up by tapping. A slight degree of inflammation following this slight operation may be useful, as it may induce adhesion of the serous surfaces and lead to obliteration of the sac. This, however, is rarely complete. In some cases bands of adhesions or broad septa form and produce a loculated cyst. In other cases suppuration ensues which may lead to serious con- sequences. Occasionally, loose bodies are found in the sac of the tunica vaginahs, often associated with, but sometimes independent of, hydroceles. Some are no larger than the 414 CYSTS. head of a pin ; others attain the dimensions of a cherry. The larger examples consist of dense structureless laminae. The variety known as Congenital Hydrocele is due to the persistence of the funicular pouch throughout its whole extent. In this form we meet with two conditions — viz., the sac may retain its connection with the general peritoneal cavity, or it may be occluded at the internal abdominal ring. When the orifice of the sac is not occluded, the fluid that accumulates in the sac gravitates into it from the peritoneal cavity during the day ; but during the night, when the body has been in a recumbent position for a prolonged period, the fluid returns wholly or in part into the abdomen, so that in the morning the scrotal swelling wiU. be found greatly diminished, if not entirely gone. As the day goes on the fluid will slowly reaccumulate in the tunica vaginalis. This alteration in size of the swelling is characteristic of this variety of hydrocele ; but it is sometimes simulated by, and mistaken for, inguinal hernia. When the funicular pouch is shut off at the inguinal canal and becomes distended with fluid it is diflicult to distinguish it, except by dissection, from a hydrocele of the tunica vaginalis. Congenital hydrocele is most commonly met with in children, and is very rare after the fifteenth year. Funicular Hydrocele is another variety frequently referred to as encysted hydrocele of the cord. It is due to eftusion of fluid into that portion of the funicular pouch which intet- venes between the tunica vaginalis and the internal abdominal ring, and which, under normal conditions, suffers obliteration. This form of hydrocele is very frequent in infants, and presents itself as an ovoid tumour lying between the testis and the inguinal canal. Although it possesses very characteristic features, this variety of hydrocele is frequently confounded with hernia of the intestines into the funicular pouch. Funicular hydroceles occasionally occur in young adults. It should be borne in mind that an inguinal hernia may be associated with a hydrocele, and it happens very rarely that the neck of a hernial sac may become so narrowed that gut and omentum no longer pass through it. A pouch of this kind would, if distended with fluid, simulate a hydrocele HYDROCELES. 415 of the tunica vaginalis. In exceptional cases, hydrocele of a hernial sac accompanies ascites. In several instances collections of ascitic fluid have been evacuated through trocars inserted into the sac of an old hernia. (2) Hydrocele of the Canal of Nuck.— In female foetuses a diverticulum of the parietal peritoneum descends into the inguinal canal, and is in all respects identical with the funicular pouch in the male, and is known as the canal of Nuck. Usually this pouch becomes obliterated, but it is by no means rare to find it patent in young females. Occasion- ally the canal becomes distended with fluid and forms a cyst occupying the inguinal canal, and is then termed a hydrocele of the canal of Nuck. Treatment of Hydroceles. — The routine practice of treat- ing hydroceles is to draw oft' the fluid by means of a narrow trocar and cannula. The cyst almost invariably refills, neces- sitating repeated tapping. To remedy this, various plans, such as injecting the sac with tincture of iodine, carbolic acid, and good port wine, have been employed. Some surgeons incise the sac and stuff it, permitting the walls to -granulate. The most satisfactory method is to expose the tunica vaginalis and dissect it away. I have practised this radical method on patients as young as fifteen months and as old as eighty-three years. It is the most satisfactory and successful of all methods, and is safer than the uncertain plan of injecting irritating fluids into the sac. (3) Ovarian Hydrocele. — The ovaries in rats and mice are contained within a serous sac derived from the peritoneum. The abdominal ostium of the Fallopian tube communicates with the ovarian sac ; hence when the ova escape from the ovary they enter the Fallopian tube and gain the uterus with- out entering the general peritoneal cavity, as is the case with the human ovum. This serous sac investment of the ovary reminds us of the tunica vaginalis of the testicle, and like it the ovarian sac is hable to become distended with serous fluid, a condition to which I have applied the name ovarian hydro- cele. Cysts of this kind in rats may attain a large size, and their general features are well illustrated in Fig. 215. The Fallopian tube in the rat is coiled up between the cornu of the uterus and the ovarian sac, but when the sac becomes 416 CTST8. COItep TUBE distended it uncoils the tube and stretches it around Lhe circumference of the cyst; the tubal ostium opens on the inner wall of the hydrocele, and the adjacent section of the tube is, as a rule, dilated. The ovary, when the cyst is small, projects into the cyst, but in very large hydroceles it atrophies from pressure. As the ovarian sac is m communica- tion with the uterine cornu it sometimes becomes implicated in septic conditions of the uterus, and the sac is sometimes found distended with pus. No mammal nor- mally possesses such a complete ovarian sac as do rats and mice, but many have a pouch that com- municates with the general peritoneal cavity by a small aperture; in others the pouch has a narrow slit; whilst in women the ovary, in its virgin condition, lies in a shallow recess. Notwithstanding the fact that the mouth of the ovarian pouch is in women very wide, there is good reason to believe that its edges may unite when the pouch is abnormally deep and convert it into a closed sac, which subsequently becomes a hydrocele. Ovarian hydroceles occur in the human female and sometimes attain a large size. They present the following anatomical features : — The sac projects from, and is intimately connected with, the posterior layer of the broad ligament. In small hydro- celes the ovary projects into the cavity of the cyst, but in large examples it is atrophied. The Fallopian tube lies on the crown of the cyst, its outer half is dilated and tortuous ; the ostium opens into the hydrocele by a large circular or ellip- tical aperture. Ridges of mucous membrane issue from the interior of the tube and pass on to the walls of the hydrocele Fig. 215.— Ovarian iiydrocele in a rat. (iTat. size.) RYDBOCELES. 417 in a radiating fashion. When the specimens are examined in a fresh state it is not rare to find the aperture fringed with tubal fambrise. The general appearance of a typical ovarian hydrocele suggests "a retort with a convoluted delivery-tube" (Griffith). In some of the specimens (Fig. 216) there appear VESTIBULE OSTIUM TUBE Fig. 216. — Ovarian hydrocele : the interior of the sac is beset with warts. to be three parts : — (1) The dilated ampulla of the tube, which opens by its fringed ostium into (2) a vestibule, which opens into (3) the hydrocele proper. In wom-en the hydrocele contains, as a rule, serous fluid, but it is easy to understand, considering its relations with the tube, that if the latter become septic the hydrocele would become filled with pus. I have never been able to demonstrate an epithelial in- vestment on the inner wall of an ovarian hydrocele, but warts may occur in great number. The ovary may be cystic and mask the nature of the specimen, and greater obscurity pre- vails when an ovary, associated with a hydrocele, contains a dermoid. Besides finding them in rats and women, I have 418 C7ST8. detected an ovarian hydrocele in a guinea-pig, and Schnei- demtihl has observed it in the mare. The cysts Hable to be confounded with ovarian hydro- celes are parovarian cysts : small paroophoritic cysts and large hydrosalpinges. A parovarian or paroophoritic cyst is distinguished from a hydrocele of the ovary by the fact that the Fallopian tube is stretched across the cyst but does not communicate with its cavity. In the case of a large hydrosalpinx the ampulla is often so flexed on the tube as to produce a retort-shaped cyst; but there are no fringes or ridges of the mucous membrane at the orifice of communication, and the ovary Hes free of the cyst- waU and is often lodged in the flexure of the tube. Ovarian hydroceles must not be confounded with tubo- ovarian cysts and abscesses the result of salpingitis. Ovarian hydroceles demand careful study; they are often a source of difiiculty in diagnosis, and their appearance is some- times puzzling to beginners in abdominal surgery, and their successful removal occasionally an anxious proceeding. 419 CHAPTER XL VI. CONGENITAL CYSTS (HYDROCELES) OF THE NECK AND AXILLA. The term " hydrocele of the neck " has been used in a generic sense for various congenital cysts occasionally found in the anterior and lateral regions of the neck. (Fig. 217.) The term should be reserved for those congenital cysts with serous contents situated beneath the deep cervical fascia. These cysts present easily recognisable characters. They are always noticed at or immediately after birth ; even at birth they are sometimes of very large size, and exhibit a preference for the anterior triangle, and in some instances extend into the axiUa and superior mediastinum ; sometimes they occupy the middle line of the neck, and occasionally project into the posterior triangle. Their upward limit is, as a rule, indicated by the hyoid bone, but they have been known to reach as high as the parotid gland. The cyst may be unilateral or bilateral ; it may consist of a single cavity, or be multi- locular, and the various chambers may intercommunicate. In size they vary greatly ; some equal a fist, others are bigger than the head of the patient. When the walls of the cyst are thin and the overlying skin is stretched, the tumour is as translucent as a thin-waUed hydrocele of the tunica vaginalis testis. These cysts originate below the deep cervical fascia, but a portion may make its way through this membrane and become subcutaneous. The fact that these cysts always arise beneath the deep cervical fascia, gives colour to the view that they may be in some way related to the air-sacs which exist in this situation in many monkeys. In their anatomical relationship and the way they ramify among the big vessels at the root of the neck, cervical cysts in children and cervical air-sacs in monkeys are on aU-fours. It is possible, indeed very probable, that some of these congenital cysts of the neck arise as dilatations of lymphatics. On "several occasions I have dissected foetuses born at full- time with large subcutaneous cysts on the back and the abdomen filled with straw-coloured fluid, and in at least 420 GYSTS. one instance a cervical cyst has been associated with macro- glossia* Some of these cysts remind me of the large lymph- spaces beneath the skin of frogs. Perhaps the most remarkable fact in connection with them is the tendency they exhibit to shrivel and disappear ; they are exceptionally Hable to inflame, and several cases have been recorded in which they have been burst by the children Fig. 217.— Congenital cervical cyst extending into tlie axilla. (After T. Smith.) falling upon them. Their proneness to spontaneous cure explains the extreme rarity of these cysts after puberty. Attempts to cure them by tapping, injections, or setons are usually attended by grave danger ; this is equally true when the surgeon tries to remove them, as the dissections are deep and tedious, and complete extirpation is sometimes impossible. It has been many times observed that the spontaneous effacement of these cysts is preceded by a sudden increase in their size ; they become hot, tender, and pass into a state of inflammation, and as this subsides the cysts slowly disappear. * Maguire, Journal of Anatomy and Physiology, vol. xiv. 416. HTDBOGELES OF THE NECK. 421 Congenital cervical cysts do not always atrophy. Birkett* has recorded the details of a case in which one of these cysts was observed in the neck just above the clavicle soon after birth ; it gradually increased in size and extended into the axilla. When the patient was three years of age the cyst was Fig. 218. - Congenital cervical cyst iu a man twenty years of age. {After BlrUett.) tapped and nine ounces of clear serum were withdrawn. Severe constitutional symptoms followed this PJ-ocedure the life of the patient being placed in great jeopardy. J f child recovered and in a short time the cyst refilled. Mr. Birkett did not see this boy again until he was twenty years old. He then presented himself at Guy's Hospital with the tumour m the condition represented in Fig. 218, and as it caused the man Med.-Chir. Trans., vol. li., p- 185. 422 CYSTS. much inconvenience he was anxious to get rid of it. Attempts were made to cure the cyst by withdrawing the fluid by repeated tappings. In the course of seventeen days five punctures were made, and in all one hundred and eighty-one ounces of dark-brown serous fluid flowed out; but this treat- ment made no difference to the tumour, and as it seemed to affect the patient profoundly, it was deemed prudent not to resort to more active mea- sures, and the man returned to his home. It is necessary to point out that in some of these cervical cysts, as well as those which occur in the axilla — for cysts of this character are sometimes met with in the axilla unassociated with cer- vical cysts — the walls consist of tissue so vascular as to merit the term nsevoid. In some of the cases that have been carefully observed and dissected, the tissue so strongly resembled erectile tissue that some writers have considered that these cysts should be regarded as nsevi that have undergone cystic de- generation, and some have even ventured the opinion that they arise in the intercarotid body, a theory which Luschka regarded as probable. Julius Arnold * eff"ectually disposed of this conjecture by publishing details of two cases which he dissected, in which he found in addition to the cyst an intercarotid body. It is also necessary to point out that congenital cysts of this character are met with on the thorax, unassociated with cervical cysts (Fig. 219). Birkett, in the paper previously mentioned, has described two cases in which he enucleated ■Fig. 219.— Congenital cyst of the thorax with naivoid walls. (After HutcMiism.) * Virchow's "Arohiv," bd. xxxiii., B. 209. ETDBOOELES OF THE NEGK. 423 a nsevoid cyst from the axilla. Similar cysts have been observed and described by surgeons on the back and even on the limbs. In concluding this account of congenital cervical and axillary cysts it is well to point out that some of them probably arise on the same plan as the laryngeal saccules of certain apes ; a few may be due to secondary changes in nsevi, and others may originate in the lymphatics. Some of the smaller unilateral cysts confined to the neighbourhood of the sterno-mastoid are due to the distension of imperfectly obhterated branchial clefts. These are fully dealt with in chap. xxxv. Lastly, it must not be forgotten that typical dermoids, with skin, hair, and even teeth, are occasionally met with in the neck. Laryngoceles. — In certain adult monkeys, particularly the chimpanzee (Simia troglodytes) the deep cervical fascia is undermined by diverticula from the laryngeal mucous mem- brane. This large sub-fascial air-chamber communicates with the larynx through the thyro-hyoid membrane ; it extends downwards to within 2 cm. of the pre-sternum. Exceptionally it dips into the anterior mediastinum, and laterally into the arm-pits, the axillary fasciae forming the lowest limits of the sac. In one fine chimpanzee I injected this huge reservoir, and found it would hold three pints of injection mass. In the Howling monkeys (Mycetes) the air-sac is very large, and the basi-hyal is hollowed to form a resonance chamber. Cervical air-sacs exist in many mammals, and can be inflated at will. They arise as diverticula from the larynx, either from the ventricle, or from the pouch of Morgagni in the middle line of the larynx below the epiglottis. In the early stages the lateral pouch resembles the human saceulus laryngis inflated. Gradually the sacs undermine the deep cervical fascia and subsequently coalesce. The air-sac of the adult chimpanzee is formed by fusion of two lateral and a median pouch. There is great variety in the degree of development of the cervical sacs in different genera and species of mammals. In 1888 I stated the following reasons for regarding some 424 CYSTS. Icinds of congenital cervical cysts in children as examples of laryngeal saccules : — 1. The congenital nature of the cysts. Repetitions of animal structures of this kind are always congenital. 2. Their relation to the hyoid bone and larynx. The hollow of the basi-hyal in man represents the large cavity in the basi-hyal of many mammals. 3. The situations of the cysts beneath the deep cervical fascia and their occasional extension into the axillae. Treatment. — It has already been mentioned that "hydro- celes of the neck" very rarely require treatment, as they almost invariably shrivel and disappear spontaneously. 425 CHAPTER XL VII. CYSTS OF THE SALIVARY GLANDS — EANUL^. — PANCREATIC CYSTS — DACRYOPS. The term ranula is probably one of the oldest in surgery. and its etymology is not very obvious. Until recently it was applied to all cysts in the floor of the mouth, and as cysts in this situation are of various kinds and arise from different structures, it naturally followed that the term gradually came to possess merely a topographical significance. There is at the present time a strong tendency to restrict the name ranula to cysts arising in connection with the ducts of the three sets of salivary glands opening into the mouth, and to designate them as submaxillary, sublingual, or parotid ranulse, according to the gland affected. If surgeons would use the term in this definite sense much unnecessary discussion would be saved. In the majority of cases ranulse are probably retention cysts due to obstruction of a duct. They are common in connection with the submaxillary and sublingual glands. The cysts are, as a rule, thin-walled, and lie in the furrow between the gum and the tongue and bulge upwards into the floor of the mouth. When large thoy cause a prominence in the submaxillary triangle. The cyst may be filled with saliva. Sometimes it contains mucus and a yellow substance resembling the yolk of an egg. Occasionally the obstruction is caused by a calculus impacted in the orifice of the duct, but cases come under observation in which the duct is not completely obstructed, yet the fluid is retained. It is reasonable to believe that ranulse sometimes arise independently of obstruction to the main duct, and, as in the case of pancreatic so-called ranulse, observation supports the view that there is, in all probability, a pathological cause apart from mere obstruction concerned in their production. Parotid ranulae are rare in the human subject, but they have been observed in calves, oxen, and horses. 426 GY8T8. Submaxillary and sublingual ranulse occasionally foUow amputation of the tongue, due, no doubt, to injury of the duct or its implication in cicatricial tissue. Much needless discussion has taken place in regard to the sources of ranulse, because the various writers seem to forget that, in addition to salivary glands, there are mucous glands, and one of variable size near the tip of the tongue known as Nuhn's gland. Any of these may dilate into a cyst. Still further to complicate the diagnosis, dermoid cysts not infrequently arise in the floor of the mouth near the frsenum of the tongue or deeply in its substance (see page 308). It has also been urged as an objection to the view that ranulse arise in the ducts of the salivary glands, that the fluid they contain is not always saliva. This is very weak argument. Many hydronephrotic cysts contain fluid which it would be difEcult to regard as urine, and an obstructed gall bladder is sometimes filled with fluid that does not possess a single attribute of bile. So a cyst arising in connection with a salivary gland wiU sometimes contain fluid that fails to furnish the characteristic reactions of saliva. Treatment. — The method of treating a ranula consists in excising a portion of the wall of the sac, evacuating the contents, stufling the cyst, and allowing it to granulate. It is, however, much more satisfactory to dissect out the whole of the cyst. This is an insurance against its return, and, as ■svirrgical wounds of the mouth heal rapidly, recovery after complete extirpation of the cyst is quicker and more complete than when the sac is left to obliterate by granulation. Pancreatic Cysts. — It has long been known that the duct of the pancreas is liable to become dilated, and as the con- dition is analogous to the distension of the ducts of the buccal salivary glands, dilatation of the pancreatic duct (canal of Wirsung) is sometimes referred to as a " pancreatic ranula." Virchow recognised two varieties of pancreatic ranula. In one variety the canal is dilated irregularly throughout its whole extent, so that it assumes the appearance of a chaplet of cysts ; in the other the duct is dilated immediately behind its terminal orifice. Such cysts, he writes, may attain the size of a fist, and are consecutive to cicatricial contractions and com- pression by tumours. The cysts are not filled simply with GT8TS OF SALIVARY GLANDS. 427 pancreatic secretion, for when the cysts attain a certain size they will be found to contain mucoid material, products of hisraorrhages, and, not rarely, calculi. Judging from what is known of retention cysts in general it would, as a matter of simple inference, be thought that pancreatic ranulse arise from partial obstruction to the pancreatic duct, either from impaction of a pancreatic calculus in the terminal segment of the duct, a gall-stone lodged at the duodenal orifice, or a tumour arising in connection with the ducts or tissues, in the immediate neighbourhood. This, however, does not appear to be the case, for pancreatic ranulfe have been observed and no obstruction has been detected by the most careful dissec- tion. Besides this, the duct of the pancreas has been found •completely obstructed by a calculus, and the gland, instead of being converted into a cyst, has been foimd atrophied, its secreting elements being largely replaced by fibrous tissue. Experimental evidence also supports this conclusion, for it has been demonstrated that when the pancreatic duct is occluded during life by a ligature the gland does not become cystic, but atrophies. Thus experimental and clinical evidence indicates that pancreatic cysts are the result of pathological changes which may, or may not, be associated with obstruction of the duct. A great deal of attention has, during the past ten years, been devoted to pancreatic cysts in their clinical as well as their pathological aspect, and certainly the evidence indicates that other causes than obstruction, partial or complete, are responsible for their production. Cysts described as pancreatic sometimes attain very large proportions, and examples have been reported with a capacity of two gallons or more. These very big cysts form smooth globular swellings in the upper part of the belly. They lie behind the peritoneum, and of course, have the stomach and transverse colon in front ; when very large these cysts will extend some distance below the transverse colon. The fluid contained in large pancreatic cysts is usually turbid. Sometimes it is white or even opalescent, occasionally it is clear, and in some cysts it will have a brown or even a green tint. The specific gravity varies between 1010 and 1020, and there is a small trace of albumen. Mucin is often 428 CYSTS. present, also tyrosin and blood pigment ; and traces of urea have been detected. The fluid is sometimes capable of emul- sifying fats. The modes by which very large pancreatic cysts arise is not by any means clear, but it is important to bear in mind that there is, in a very significant proportion of cases, a definite history of antecedent injury. This fact gives colour to the suggestion that some of the cysts are due primarily to laceration of the pancreas and subsequent extravasation of its secretion behind the peritoneum. Another very impor- tant feature of these cysts is the hability to haemorrhage, and this may take place so abundantly into the cyst as to jeopardise the life of the patient; indeed in some cases it has been fatal. Pancreatic cysts occur at almost all periods of life. Ex- amples have been reported as early as the eighth year of life and as late as the seventy-third. They appear to be most frequent in men, but a number of cases have been reported in women. Pancreatic cysts attributed to injury have followed a variety of accidents, such as falls from a great height, followed by abdominal pain ; a crush of the abdomen between the buffers of railway waggons ; fall from a horse, or from a vehicle ; kicks from men, and in several cases from horses. Jordan Lloyd* has attempted to show that the large pancreatic cysts that follow injury to the abdomen are really collections of fluid in the cavity of the lesser omentum, and when the fluid has the property of rapidly converting starch into sugar it may be assumed that the pancreas has been injured. He also points out that the characteristic feature of so-called pancreatic cysts — viz., a swelling occupying the epigastric, umbilical, and left hypochondriac regions — is precisely that which would result from distension of the lesser bag of the peritoneum. It is probable that some cases of supposed pancreatic cysts were really effusions into the lesser bag of the peritoneum, for undoubted examples of distension of this cavity with fluid have been observed, dissected, and described. * Brit. Med. Journal, 1892, vol. ii. 1051. CYSTS OF SALIVARY GLANDS. 4f;9 Treatment. — The method of treatment that gives best results is to expose the cyst through an abdominal incision, and, after emptying the cyst, stitch its cut edges to the margins of the wound in the belly-wall and drain ; it is also desirable to make a counter-opening into the cavity of the cyst through the loin. Our knowledge of pancreatic cysts has been greatly in- creased since Senn* of Chicago drew attention to them in 1885. Active surgical treatment of pancreatic cysts has been the consequence, and it has been accompanied by remarkable success. Chyle Cysts. — This is perhaps the best place to mention a rare but interesting kind of tumour which would certainly complicate the diagnosis of a pancreatic cyst. It is known as chyle cyst of the mesentery. The sac of the cyst appears to be formed of the separated layers of the mesentery, the inter- space being occupied by fluid identical in its physical and chemical characters with chyle. Such tumours sometimes attain very large sizes. They require the same treatment as pancreatic cysts. Dr. Adolph Raschf has written an excellent account of a typical example of chyle cyst. Dacryops. — This term is applied to cysts occurring in the upper eyehd ; they are due to distension of the ducts of the lachrymal gland. Thoy appear, as a rule, in the upper and outer part of the eyelid, the cyst extending beneath the border of the orbit towards the lachrymal gland. The cyst enlarges when the patient weeps. Dacryops may arise in two ways— either as a consequence of wound or abscess of the lid, or as a congenital defect. As a rule, they are of traumatic origin. The condition is one of extreme rarity. Hulke,t in an interesting paper on this subject, states his belief that these cysts were first accurately described by » The American Journal of the Med. Sciences, 1885, vol. xc, p. 18. Newton, Pitt, and Jaoobson (Med.-Chir. Trans., vol. Ixxiv., 4.55), give a good list ot T'ATftT't^TlCGS t Trans Obslet. Soc, vol. xxxi. 311. See also Bramann, Arch. fUr Klin Chir. (von Langenbeck). bd. xxxv., s. 201; Mendes de Leon, A. M of Obstet., vol. xxiv., p. 168 ; Fetherston, Austrahan Med. Journal, 1890, p. 47o. + K,. Lond. Ophth. Hosp. Eeports, vol. i., p. 285. 430 CYSTS. Dr. J. A. Schmidt in 1803, and that Beer (1817) mentions that he had seen six cases of this kind, which he describes under the name " dacryops" which Schmidt had applied to them. When these cysts arc opened through the skin a fistula is sure to be the result. The same thing often happens when the cysts have a traumatic origin. The condition is then termed dacryops fistuLosua. 431 CHAPTER XLVIII. PSEUDO-CYSTS— DIVERTICULA AND BURS^. The term diverticulum is used to denote hernia or protru- sion of the lining membrane of a cavity through a detective spot in its walls. Such protrusions occur in connection with the oesophagus and intestines ; the bladder ; the trachea ; also in relation with joints and tendon-sheaths forming synovial cysts and ganglia; and in blood-vessels forming sacculated aneurysms and varices. Intestinal Diverticula. — These are hernial protrusions of the mucous membrane of the bowel through interspaces in the muscular coat. Structurally they consist of mucous membrane with a covering of peritoneum. Sometimes a few strands of muscle fibre can be detected stretched across tlie pouch. Frequently diverticula occur in multiples; as many as two hundred have been found in one case. These pouches occur in all parts of the intestine, but are most frequent in the colon, and especially about the sigmoid flexure. In the small intestine they usually occur along the line of the attach- ment of the mesentery. In the colon they are found about the attachment of the appendices epiploiciB, and may even project into them. In dimensions diverticula vary greatly— some are as small as peas, others as large as oranges. When the pouches are numerous, as a rule, they are small; when few in number, or solitary, they may be large. Intestinal diverticula are common in old persons, but they rarely lead to serious consequences. Some writers describe diverticula of the intestmes as con- sisting of two varieties, true and false. According to this arrangement a persistent vitello-intestinal duct would be called a true diverticulum. {See page 389.) Vesical Diverticula.— Hernial protrusions of the mucous membrane of the bladder between the fasciculi of the muscular coat are of frequent occurrence. The cause of the protrusion 432 PSEUDO-GYSTS. is impediment to the free flow of urine ; the obstruction may be seated in the urethra or at the neck of the bladder. Under such conditions there may be several diverticula ; the bladder is then said to be sacculated. Sometimes there is only one saccule, and this may attain a large size. Yesical diverticula usually communicate with the cavity of the bladder by large orifices. A sacculus extending into the suspensory ligament of the bladder must not be confounded with a urachus cyst. Sacculated bladders, apart from the cause that produces the saccules, do not often give rise to trouble. Calculi are sometimes found within them, and in cases where the Outflow of urine is seriously obstructed the walls of a sacculus wiU sometimes yield, and allow the urine to extravasate into the surrounding loose connective tissue.* As impediments to the free escape of urine from the bladder occur more frequently in men than in women, it naturally follows that sacculated bladders are most common in men. Nevertheless, vesical diverticula of large size are occasionally found in women, and in exceptional cases have caused death.f Pharyngeal Diverticula (Pharyngoceles).— Localised dila- tations of the pharynx are of three kinds : — 1. Abnormal persistence and distension of certain pouches which, as a rule, exist in the embryo only — e.g., the pouch of Rathk^ and the branchial clefts, t 2. Pouching of the phaiyngeal -^all at its junction with the oesophagus. 3. Protrusions (hernise) of the mucous membrane lining Rosenmtiller's fossa. The cysts of the first kind have been already discussed in chapter xxxv. Dilatations of the pouch of Rathke are considered at page 317, branchial cysts at page 327, and the curious guttural pouches of the horse at page 387. * For an interesting account of the relation of diverticula of the bladder to extravasation of urine cf. Lane, Guy's Hospital Reports, 1885. + Hale White, Trans. Path. Soc, vol. xxxiv. 146. J Pouches of the naso-pharynx have been described in detaU by Kostanecti, virchow's "Archiv," bd. cxvii., 108. BIVEBTIGULA. 433 Pharyngoceles.— In order to appreciate the nature of at least one form of pharyngeal pouch it will be necessary to take into consideration an interesting congenital defect to which the pharynx is liable. _ It occasionally happens that children are born with what is known as an imperforate pharynx, that is, instead of the pharynx and oesophagus forming a continuous tube, the pharynx terminates as a cul- de-sac near the level of the cricoid cartilage. In such cases the upper end of the oesophagus termi- nates by opening into the trachea through its posterior wall. The situation of the ceso- phago-tracheal fistula varies in different specimens ; some- times it is as high as the third tracheal semi-ring, or it may be as low as the bifurcation of the trachea, and in at least one case it opened into the left bronchus. In most ex- amples of imperforate pharynx the oesophagus is connected with the lower end of the pharynx by a fibrous band, which indicates that the two structures were originally continuous, but that their continuity has been disturbed by secondary changes. (Fig. 220.) The constant association of an oesophago-tracheal fistula and imperforate pharynx indicates some relation between the two conditions. The explanation which at once suggests itself is, that it may be due to some influence exercised by the pulmonary diverticulum which leaves that portion of the embryonic fore-gut ultimately represented by the (Esophagus.* {See also Imperforate Ileum, page 393.) Aperture by which the cesophagus coininunieates with the trachea. Fig. 220.— Imperforate pharynx. * This subject ia handled with remarkable acumen by Shattook, Trans. Path. Soc, vol. xli., p. 87. cc 434 PSEUD0-G7STS. In some cases the pharynx instead of ending bhndly may be abnormally narrow at its junction with the oesophagus, and a valve may exist. An imperforate pharynx is incom- patible with life, but the oesophagus may be considerably stenosed and cause no inconvenience in deglutition (Fig. 221). It is necessary to describe con- genital imperfections at the junction of the pharynx and oesophagus, be- cause it is at this point that pouches are apt to form. A typical example of a pharyngeal pouch, or pharyngo- cele, is shown in Fig. 222. The case is very carefully described by Worth- ington.* The parts were obtained from a man sixty-nine years of age. There was a stricture of the oeso- phagus at the level of the cricoid cartilage that would admit merely a urethral bougie. This obstruction ultimately led to the death of the patient. He could swallow food and retain it for a time; it would then regurgitate. At the post-mortem dis- sectiou the pouch was detected ; it was in shape like the finger of a glove, and had a depth of 9 cm. and a circumference of 6 cm. The mu- cous membrane at the seat of the stricture was quite healthy. About two-thirds of the pouch were covered with muscle derived from the inferior constrictor. An examination of pharyngeal pouches such as exist in museums would lead the observer to believe that the orifice of communication between the pharynx and the pouch was circular ; but there is good reason to believe that it assumes a slit-like form even when the pouch is full of food. So far as our knowledge at present extends in regard to this variety of pharyngocele, it would appear that they arise in all probability as congenital effects, but it is important to * Med. Chir. Trans., vol. xxx. 199. Fig. 221.— Septate pharynx. DIVEBTIGULA. 435 remember that the pouch rarely causes inconvenience until late in life. Thus Ludlow's* patient was sixty ; Worthington's, sixty-nine ; Chavasse's.f forty-nine ; and Butlin's.J forty-seven. It is necessary to point out that a pharyngocele of the character represented in Fig. 222 arises in a different manner to that depicted in Fig. 155 ; the latter is probably due to a persistent branchial cleft. It is also quite certain that any attempt to dissect out a lateral sac of this Itind would require more skill than such a pouch as that shown in Fig. 222. Treatment. — Pharyngoceles are likely to be much more care- fully studied in the future than they have been in the past, for the condition has on more than one occasion been correctly diag- nosed, and the pouch removed through an incision in the neck, and its slit-hke orifice of com- munication with the pharynx occluded by sutures, a manoeuvre that has been followed with complete success in the hands of Bergmann§ and Butlin. (Esophageal Diverticula. — Hernial protrusions of the mu- cous membrane of the oesopha- gus through the muscular coat are not common. They vary greatly in size. Some are no larger than cherries, others may attain the size of a closed fist. Diverticula arise in any part of the oesophagus ; nothmg is known as to their cause. Tracheal Diverticula.— These are small hernial protru- sions of the mucous membrane of the trachea; they are uncommon and invariably occur near the junction of the Fig. 222, ■Pharyngeal diverticulum. {After Worlhington.) * " Medical Observations and Inquiries," 1767, vol. iii., p. 85, pi. f Trans. Path. Soc. , xlii. 82. J Med. -Chir. Trans., vol. Ixxvi. 5 Langenbeok's " Archiv," bd. xliii., 6. 1. 436 PSEUDO-CYSTS. trachealis muscle with the cornua of the semi-rmgs of the trachea Rokitansky regarded them as dependent on chronic catarrh of the trachea. Gruber, on the other hand, was of opinion that they are retention cysts of the glands m the tracheal mucous membrane; they are of little chnical mterest. Adventitious *■ '^ septum. **^ Tracheal opening. Wall of pouch. . ul de sac. ^- Adventitious f rSvL ^ septum. Wall of pouch. Fig. 223. — Tracheal opening and pouch of an emu. The pouch is cut so as to expose its interior. The surrounding feathers are cut short. (After Murie.) The Tracheal Diverticulum of the Emu. — The emu {Dromceus novce-hollandice) is normally provided with a tracheal diverticulum of great interest. In this bird there is a natural defect in the front of the trachea, at a spot varying between the fiftieth and sixty-fifth ring. The deficiency, may involve six or more rings. In the emu chick the defect is scarcely noticeable, and the extremities of the rings are almost in contact. As the bird grows the tracheal mucous membrane becomes slowly herniated through the opening until it forms a huge sac between the skin of the neck and the trachea. The cyst-wall is composed of connective tissue with BIVEBTICULA. 437 scattered bundles of striated muscle fibre ; its mucous Uuing is directly continuous with tliac of the windpipe, and is dotted with the orifices of glands. (Fig. 223.) The adult emu inflates this sac when it produces the peculiar booming sound which resembles the noise made by blowing across the mouth of a large bottle. This large tracheal sac may inflame and become distended with mucus. In a specimen which I secured and forwarded for preservation iu the museum of tbe Royal College of Surgeons, London, tlie sac contained two piuts of mucus. The bird was unfortunately drowned in this fluid, for while I was making an attempt to evacuate the contents of the sac the fluid entered the opening in the trachea and suffocated it. Murie* has written an excellent account of the anatomy of the trachea of the emu. I can confirm his observations, having enjoyed the oppor- tunities of dissecting the adult emu and the emu chick. Concerning tlie function of this pouch nothing is known. Synovial Cysts. — Cysts containing synovia arise in three ways : — (1) Hernial protrusions of the synovial membranes of joints. (2) BursiB in the immediate neighbourhood of joints. (3) Hernial protrusions of the synovial sheaths of tendons. Synovial cysts arise in connection with the hip, knee, ankle, shoulder, elbow, and wrist joints. They have been most carefully studied in connection with the knee joint. The cysts form swellings, in some cases as large as an orange, situated near the knee joint, usually in close relation with the tendons of the semi-membranosus, biceps, or gastrocnemius muscles. Occasionally the cyst will be situated in the calf on the inner side, sometimes as much as 8 cm. below the knee. When the swelling is situated near the joint, pressure will cause it to disappear, the synovia it contains passing into the general cavity of the joint. When the cyst is situated at a distance from the joint, pressure upon it has no effect m dhninishing its size, because in many cases the communication between the cyst and the joint cavity is by a very narrow, ahnost capillary channel. _ The cysts arise usually in connection with joints which are chronically diseased and seem to be common in tubercular joints. It is believed by those who have devoted special * Proo. Zool. See, 1867, p. 405. 438 PSEUDO-CYSTS. attention to these cysts that when the joints become dis- tended with synovia, the internal pressure causes the synovial membrane to protrude through weak spots in the capsule, the diverticula making their way along the intermuscular planes. Opening of bursa into the joint. ... Bursa. , Hemains of a previous cyst. Fig. 224.— Bursa under tlie senii-membranosns tendon communicating with the knee-ioint. A cyst had been incised and rti'ained sixteen months previously. Its partially obliterated channel persists. {D'Arcy I'ovjer.) This mode of origin is on all-fours with that which obtains in the case of sacculated bladders. It is also certain, for it has been demonstrated by dissection, that some synovial cysts are due to bursse normally existing under the adjacent tendons, becoming abnormally large BIVEBTIGULA. 439 and communicating; ■with the joint cavity in consequence of absorption of the contiguous parts of the wall by pressure. (Fig. 224.) This seems to happen most frequently in the case of the bursa under the semi-membranosus. It does not necessarily follow because an individual has a synovial cyst near the Icnee that the joint is diseased; attendance in an out-patient room will show that many synovial cysts slowly disappear without treatment. This is important to bear in mind, for interference with these cysts is, as a rule, needless and often productive of much harm. Aspira- tion, injection of iodine, and the insertions of setons may lead to suppuration and destruction of the joint, with which the cyst is connected. Mr. Morrant Baker, who first drew special attention to these synovial diverticula, states that when they arise in connection with the knee, the cyst will project in the popliteal space, the upper part of the calf, or on the inner side of the calf as much as 10 cm. below the head of the tibia. In the case of the shoulder the cyst projects in front of the joint a little below the clavicle, or in the upper third of the arm in the course of the long tendon of the biceps. In the case of the elbow, the cyst projects on the inner side of the arm above the condyle. I have seen a cyst of this kind as high as the insertion of the coraco-brachialis, connected with the elbow joint by a tubular process of the diameter of the anterior interosseous artery. When they arise from the carpal joints, the cysts project on the back or front of the wrist. (See under Ganglion) When connected with the hip- joint, the cyst forms a swelling in Scarpa's space, and in the case of the ankle the bulging is most marked in front and to the outer side of the joint. The fluid contained in synovial cysts is in most cases identical with synovia. When the joint is the seat of tuber- cular disease the fluid in the cyst will contam pus cells and occasionally it is true pus ; when the skin over these swellings is red and glossy they have been mistaken for simple abscesses ^"""^Rarelf the cyst contains melon-seed bodies. In one case Mr. Bentlif opened a cyst of this kind connected with the shoulder and removed two thousand of these bodies. Most ot 440 PSEUDO-CYSTS. them were of the shape and size of apple-pips, and like pips, had small stalks or tails. Ganglion. — A ganglion is a cyst formed by the hernial protrusion of the synovial lining of a tendon sheath. There are two species — simple and compound. A simple ganglion is seen in its most typical condition on the back of the carpus, where it forms a rounded, sessile, elastic swelling which becomes tense when the wrist is flexed, and partially, or wholly, disappears when the wrist is extended. Many of these swellings, which are entered in clinical records as ganglions (or ganglia), are not all connected with tendon sheaths. I have satisfied myself by careful dissections that many of them are diverticula from the carpal joints, and in some instances they arise from the inferior radio-ulnar joint. During life it is difficult to distinguish between a hernia of the sheath of a tendon or a diverticulum from a carpal joint. As in the case of the larger joints, synovial cysts arising from the carpus are occasionally associated with tubercular arthritis. Ganglia are sometimes met with on the fingers in connec- tion with the sheaths of the long flexors, and on the dorsum of the foot, as well as on the outer side of the ankle, in relation with the tendons of the peroneus longus and brevis. The fluid in a simple ganglion is clear, transparent and viscid, and resembles apple jelly. The compound ganglion is a much more serious condition. It occurs mainly in connection with the flexor and extensor tendons at the wrist ; it also occurs occasionally on the tendons of the peronei muscles, where they lie in relation with the calcaneum. A compound ganglion at the wrist assumes an irregular shape and extends for a variable distance up the forearm ; it also sends a prolongation under the annular hgament to appear in the palm, when it arises in connection with the flexor tendons; a similar extension under the posterior annular ligaments is usually noticed when a ganghon is connected with the extensor tendons. A compound ganghon is usually soft and elastic, and imparts a crepitant sensation to the examining fingers when the tendons are set in action. This crepitant sensation is due to the presence in the ganglion of small bodies famiharly known as melon-seed bodies from BUBSM 441 their shape and consistence; they are sometimes present in enormous numbers. There is much difference of opinion as to the source of these bodies. I have seen them hanging from the inner wall of the ganglion. An examination of many of the loose bodies will show that they have slender stalks: these appear more clearly when they are floated in water. Bodies identical in structure are met with in synovial diver- ticula and even in bursal sacs, particularly the prepatellar bursa. Treatment. — A simple ganglion, such as is so common on the back of the wrist, is in a general way successfully treated by bursting it subcutaneously by the direct pressure of the thumb, and then applying a graduated compress for a few days. When the wall is so thick that it will not rupture the swelling may be punctured with a very narrow scalpel ; this allows the mucoid contents to escape, and the application of a firm compress for a few days will obliterate the sac. Compound ganglia require more radical treatment. Many have been successfully treated by incising the sac, squeezing out the contents — particularly any loose bodies the sac may contain — and detaching those which may happen to hang from the wall by means of a scoop. The sac should be care- fully drained. Now and then severe complications have followed this method of treatment, and it has been necessary to amputate through the forearm. In some cases the ganglion has been successfully dissected out as if it were a tumour, and it would appear that the patient runs less risk from this mode of treatment than by the common practice of incision and drainage. It is well to bear in mind that some of these ganglia are associated with the early stages of tubercular disease of the wrist joint, and a few are undoubtedly due to tubercular infection of the tendon sheaths. BUKS^. On many parts of our bodies where muscles and tendons glide over osseous surfaces, or in situations where skm hes m close contact with bony prominences, membranous sacs occur filled with glairy fluids; such sacs are known a^ bursae. Structurally a bursa consists of a thin-walled sac fiUed with 442 PSEUDO-CYSTS. glairy fluid. The inner wall of the cyst is .quite, smooth and, as a rule, devoid of epithelium. In certain situations, such as the anterior surface of the patella and the posterior surface of the olecranon, a bursa is normally present. Bursal sacs may form in any part of the subcutaneous tissues when the overlying skin is submitted to ~ unusual intermittent pressure, as in talipes when the patient walks on the dorsum or side of the foot ; beneath corns ; and at the metatarso-phalangeal joint in the condition termed bunion. Such are called adventitious bursae. When bursse arise in connection with tendons, they are spoken of as subtendinous bursse, and thej^ often communicate with the sheath of the tendon, and even with an adjacent joint. The large bursa so constantly present at the insertion of the semi-membranosus often has a direct communication with the joint (Fig. 224). The origin of bursal sacs has been explained in the following manner : — When the skin moves over joints, or passes over hard prominences, the intermediate connective tissue becomes torn or ruptured, thereby leading to the formation of spaces in which fluid collects. The boundary walls are at first irregular, and formed by adjacent connective tissue. Finally this becomes smooth and forms the sac-wall. Bursse may arise during intra-uterine life when the foetus is submitted to abnormal pressure. Many remarkable in- stances of this have been recorded, especially in association with talipes. Most subcutaneous and many subtendinous bursje arise after birth. When a subcutaneous bursa attains an abnormal size it is invariably due to unusual pressure associated with particular occupations. For instance, too much kneeling on hard material, whether in housemaids, devout persons, or carpet-layers, produces the familiar prepatellar bursa; repeated blows on the elbow produce miner's elbow; from carrying weights on the shoulder porters are Hable to get a bursa over the acromial end of the clavicle ; tailors from their cross-legged habit of sitting are sometimes troubled with one over the external malleolus; whilst weavers and lightermen from prolonged sitting on hard seats suffer from BJJBSM. 443 bursse over their ischial tuberosities ; soldiers when sleeping too frequently on the hard floor of the guard-room get them over their greater trochanters ; the pressure of ill-fitting boots develops a bursa over the enlarged head of the metatarsal bone of the hallux ; when associated with partial dislocation of the first phalanx it is known as a bunion, and bursas are quite common on the ends of amputation stumps. Clement Lucas* has described as the needlewoman's bursa a cyst that formed on the palmar surface of the terminal phalanx of the middle finger in an old seamstress. A bursa is often present between the body of the hyoid bone and the thyro-hyoid membrane ; sometimes it is very large and may attain the dimension of a fist. Bursse are liable to inflame, a process that may lead to suppuration, or stop short of that condition and become chronic or recurrent and lead to secondary changes in the walls of the sac, so that its cavity becomes almost obliterated. Chronically-inflamed bursse sometimes attain the size of fists, especially the prepatellar and ischial varieties. Jephson, in his interesting account of " Emin Pasha and the Rebellion at the Equator," relates that the women and many men of the Bari tribe whom he saw working in the fields, had enlarged prepatellar bursas (housemaid's knee) due to kneeling whilst at work and to the fact that the entrances to the huts were so low that it was necessary to enter on the hands and knees. Treatment.— An inflamed bursa demands rest and the local treatment usually employed for inflamed parts. When the bursa is distended with fluid, it is the custom to apply a plaster of mercury and ammoniacum over the swellmg and fix it firmly with a bandage. It is probable that the firm compression is the chief agent in promotmg the absorption of the fluid. In som« cases the swellmg subsides spontaneously, and this probably explains the supposed efiicacy of the application of tincture of lodme. When bursas are repeatedly irritated, the walls become so thick that it is necessary to excise the tumour. When the bursa is situated over the patella, malleolus, ischial * Guy's Hospital Eeports, vol. xliii. 143. 444 FSEUDO-CYSTS. tuberosity, or trochanter its, removal is a very simple pro- ceeding. When a bunion inflames and suppurates it may involve the underlying metatarso-phalangeal joint. Many of these cases, especially in elderly individuals, demand amputation of the toe. When it is necessary to carry out this measure, I find it much more satisfactory to remove the metatarsal bone as well as the toe. When the bursa between the body of the hyoid bone and the thyro-hyoid membrane is very large it should be incised and drained. Care is necessary to avoid confounding an enlarged thyro-hyoid bursa with a cyst of an accessory thyroid gland and vice versa. 445 CHAPTER XLIX NEURAL CYSTS. Under this heading it is proposed to consider a number of conditions some of which, like hydrocephalus and one variety ol spma bifida, should be described in the genus, tubulo-cysts Fig. 225.— Hydrocephalic skull, from an infant. ^Museum, Middlesex Hospital') Other varieties of spina bifida should be discussed with diver- ticula. On the whole it is more convenient to consider them collectively as a genus — neural cysts. Hydrocephalus. — This term is applied to the head when abnormally enlarged in consequence of excessive accumulation of fluid in the ventricles of the brain. By far the larger majority of cases are congenital, or commence in the early months of infancy. Occasionally it will arise at a later period of life, when the fontanelles are obliterated ; expansion of the skull is then impossible. Hydrocephalus very frequently accompanies spina bifida. Very many hydrocephalic fcetuses die during delivery, the large size of the head hindering its successful transit through the maternal passages. In some 446 P8ETJB0-CYSTS. cases the head ruptures in consequence of the pressure, to which it is subjected, or is intentionally perforated. In most cases of hydrocephalus which survive delivery, distension is only slight at birth. The frequency with which hydrocephalus and hydramnios CO- exist would indicate that the association is something more than mere coincidence. Statistics respecting the frequency of Fig. 226.— Hydrocephalic skull, showing Wormian bones. (Musmm, Middlesex Hospital.) hydrocephalus drawn from living children are untrustworthy, as pre-natal hydrocephalus is very fatal. In typical cases of hydrocephalus attention is arrested by the large size of the cranium and the smallness of the face. This is due to the slow accumulation of fluid within the cerebral ventricles, distending them and causing wide separa- tion of the cranial bones, whilst the bones of the face retain their natural proportions. The two halves of the frontal bone are separated from each other ; the spaces between the parietal bones, and between these and the occipital, are far wider than usual. (Fig. 225.) Indeed, the bones of the cranial vault are NEURAL CYSTS. 447 SO separated from each other, whilst those of the base retain their usual juxtaposition, that the bones of a hydrocephalic skull were compared by Trousseau* to the petals of an openmg flower. The head may become so large as to attain a circumference ot a metre, or even a metre and a half when measured horizon- tally—that IS, from the superciliary ridges to the occiput. The Fig. 227.--Sngittal section of a hydrocephalic sltuU from a child, with the brain in situ. The head of the arrow is in the fourth and its feathers in the third ventricle. The infun- dibuluin is widely dilated. {Museum, Middlesex Hospital.) bones are excessively thin, and consist of a single table. The vault presents large membranous spaces irregularly dotted with ossific deposits. The sutures in relation with the parietal bones are occupied with Wormian bones ; as many as two hundred have been counted in one skull. (Fig. 226.) In hydrocephalics who attain adult life the skull may become completely covered in with bone. * Cliniqiie Midicah, torn, ii., p. .321. 448 PSEUD0-0Y8TS. The brain presents great changes. The lateral ventricles are widely distended, and the crura cerebri, corpora striata, optic thalami, and other structures in the base of the brain are flattened. The cerebral hemispheres form thin boundaries to the ventricles, often less than 10 mm. in thickness ; the convolutions become obliterated. In nearly all the specimens the distension is limited to the lateral and third ventricles : occasionally the fourth ventricle is also distended. (Fig. 227.) In some specimens each lateral ventricle has been known to attain a length of 20 cm. and to communicate with its fellow- through an opening the size of an orange. When the ventricles are very distended and the skull is proportionally thin, a wave of fluctuation may be transmitted from side to side. In exceptional cases the head is trans- lucent. In an account of hydrocephalus it is diflScult to avoid reference to the classical case of James Cardinal, especially as a cast of his head is to be found in many patWogical museums. (Fig. 228.) James Cardinal died at the age of twenty-nine years in Guy's Hospital under the care of Sir Astley Cooper, in 1824. He was bom at Coggeshall, Essex, in 1795. At birth his head was very little larger than natural. A fortnight later it began to increase, and gradually grew until he was five years old ; it then appeared to remain stationary. He was unable to walk until six years of age, but went to school and learned to read and write. His head was at this period translucent when placed between the eye of the observer and a bright light. Cardinal continued in tolerable health until twenty- three years of age, when he began to have fits, for which he applied to the hospital. His manners were childish, otherwise his mental faculties were well developed. Death eventually supervened from lung disease. When the head was examined the brain ~^as found lying at the base of the skull. Between the membranes there were seven pints of fluid. The ventricles contained one pint. It appeared as if the fluid had originally been contained within the ventricles, but had burst through an opening on the corpus callosum and compressed the brain downwards. The cranium measured 82-5 cm. (33") in circumference, and had a NEURAL CYSTS. 449 capacity of ten pints. The skeleton is contained in Guy's Hospital museum. The fluid in hydrocephalus is identical with cerebro-spinal fluid. Occasionally it has been found to contain albumen. This may be attributed to inflammation, and has been observed in those cases where paracentesis has been performed. The Fig. 22S. - Drawing from a oast of the. Lead of James Cardinal.* amount of fluid may be very large. Six and eight, and even ten pints have been recorded. Little is known as to the cause of hydrocephalus. In many cases obstruction to the interventricular communications has been detected. Hydrocephalus is often associated with spina bifida, and all the passages in the brain with the central canal of the cord have been found dilated._ I" ^ewa . cases m which hydrocephalus supervened on spina bifida I tound he central 'canal of the cord normal Interference with th interventricular passages will produce hydrocephalus. In D D 450 PSEUD0-GY8T8. Fig. 229 the head of a lion-whelp is shown in sagittal section. The ossified tentorium is abnormally thick in consequence of rickety changes. This had depressed the vermiform process of the cerebellum and obstructed the Sylvian aqueduct, lead- ing to distension of the lateral and third ventricles and th'6'' infundibulum. The great difficulty encountered in iuvestigating the pathology of this condition arises from the soft and diffluent nature of the brain of hydrocephalic foetuses, especially when stillborn. It should also be remembered that many grave Thickened tentorium. Dilated infundibulum Fig. gSB.— Head of a lion's wlielp in section, showing great dilatation of the cereliral ventricles clue to obstruction of the interventricular jiassages by a thickened (rickety) teutorium. malformations of the limbs and viscera are often associated with hydrocephalus, and it is well to bear in mind the fre- quency with which it is accompanied by hydramnios. Hydrocele of the Fourth Ventricle.— Leadmg from each lateral angle of the fourth cerebral ventricle there is a tubular process encircled by a duplicature of the ligula termed the cornucopia. These passages or lateral recesses are traversed by the choroid plexuses of the fourth ventricle, and the re- cesses themselves open into the subarachnoid space at the base of the flocculus, close beside the root filaments of the facial, auditory, glosso-pharyngeal and vagus nerves. These passages establish free communication between the fourth ventricle and the general subarachnoid space. When one ot these processes becomes occluded, the recess will dilate and form what Virchow* terms hydrocele of the fourth ventricle. * "Die Krankhaften Geschwiilste," bd. i. 183. NEURAL CYSTS. 451 This pathologist has figured a specimen that had attained the size of a cherry-stone and pressed upon the floccukis and the facial nerve : remnants of the choroid plexus of the fourth ventricle projected into the cyst. Though the walls of this cyst were thin, its pressure had caused paralysis of the facial nerve. Recklinghausen* has described a case in which there was a hydrocele on each side of the fourth ventricle. The museum of the Middlesex Hospital contains a specimen described and figured by Sir Charles Bell, who ^ .^j. also gives a history of the patient. Attached to the in- ferior surface of the left pedun- cle of the cerebellum, close to its junction with the pons, is a cyst the size of a pigeon's egg; it was filled with fluid the colour of urine. The fifth nerve, at- tenuated and flattened, appears to issue from the tumour, and ,,„<■»,. .-, ,, Fi.-. 230.— Hvclvooele of the fourth ventricle. can be traced along its walls up {After sir cimries bm.) to within 1 cm. of its origin. The seventh and eighth nerves are lost in the tumour from within 5 mm. of their origin as far as the internal auditory meatus. (Fig. 230.) For tumours occurring in relation with the cornucopia, which might be confounded with "hydrocele of the fourth ventricle," the student should refer to the chapter on Psammomata. . Cranial Meningocele.— This term is applied to a hernial protrusion of the meninges of the brain through an unossified portion of the skull. When the protrusion consists ot brain matter as well as membranes it is described as a meningo- encephalocele. , Meningoceles, using the term in its general sense, occur in definite regions. The commonest of all situations is the occiput; in about two-thirds of the cases the tumour projects in this part of the skull. Next in frequency to their appearance * Virchow's "Archiv," bd. xxx., s. 374. 452 PSEUDO-CTSTS. at the occiput, meningoceles appear at the root of the nose. In other regions of the skull they are excessively rare. It is usually stated that they may appear at the anterior fontanelle, but critical examination of the descriptions of suspected cases makes it probable that many of the supposed meningoceles were dermoids, and this was demonstrated in the cases described by Giraldes and Arnott and referred to at page 301. Occipital meningoceles appear, during life, to protrude through the foramen magnum ; when the parts are dissected the pedicle will be found to make its way through a gap in Flocculus. Fig. 231. — Occipital ineniugo-enceplialocele. (.\htseum, Middlesex Hospital.) the supra-occipital between the posterior margin of the fora- men magnum and the occipital protuberance. This space during early embryonic life is occupied by a fontanelle.* When the meningocele is examined it will be found to be covered externally by skin, and usually lined internally by tissue directly continuous with the ependyma of the ventricles. This is shown in Fig. 231. In this specimen the cyst was as large as the child's head ; the cerebral matter projecting into it represented the corpora quadrigemina, whilst choroid plexuses floated in the fluid of the cyst. The cyst itself probably represented a dilated fourth ventricle. There was no cerebellum, but the flocculus was large and conspicuous. The relation of the flocculus in cases of occipital meningo- cele is of importance. On reading the descriptions of reported cases of this malformation the cerebellum,, if referred to, is described as rudimentary or absent. As a matter of fact, in * Med.-Chir. Trans., vol. Ixvli., p. 167. NEURAL CYSTS. 453 the&e cases the cerebellmn is absent, and that which is sup- posed to represent this part of the brain is an enlarged floc- cuhis. Oleland* has pointed out that the flocculus is developed from a lateral outgrowth of the floor of the third encephalic ■vesicle, whilst the cerebellum is developed from the foremost part of the roof of that vesicle. An appreciation of this fact throws valuable light on the nature of occipital meningocele, for the absence of the cerebellum indicates that the hernial protrusion is the third encephalic vesicle ; instead of its walls thickening to form a cerebellum, they become passively dilated into a cyst. Indeed this form of meningocele bears much the same relation to the fourth ventricle and the cerebellum, that hydrocephalus bears to the lateral ventricles and the cerebrum. An occipital meningocele might not inaptly be described as hydrocephalus liTnited to the fourth ventricle. My observations lead me to believe that a cranial meningo- cele (a cyst formed of cerebral membranes only) is excessively rare. Occipital meningo-encephaloceles often hang so low as to render it difficult to decide whether the cyst belongs to the cranium or to the cervical region of the spine. There is reason to believe that the pedicle of a cranial meningocele may become obliterated so as to cut off the communication between the cyst and the subdural space. I have never had an opportunity of dissecting a specimen in which this has happened. Such an event certainly occurs with spinal meningoceles. A cranial meningocele is sometimes associated with spina bifida; such a combination is, as a rule, accompanied by gross malformations, especially in connection with the lower limbs. It has already been mentioned that dermoids are apt to be mistaken for meningoceles, and it is certain that meningo- celes are sometimes mistaken for dermoids. Thus Powellf operated on a Bengali, twenty-two years of age, at the Kona- para Hospital, Cachar, for a supposed sebaceous cyst, about the size of a tennis-ball, situated in the left temporal region. On incising the cyst it was discovered to be a meningocele * Journal of Anat. and Phys., vol. xvii., p. 257. t Brit. Med. Joiirnal, 1893, vol. i., p. 232. 454 PSEUB0-CY8T8. and the hole in the skull would admit an index finger. The cyst was removed and the patient recovered rapidly. For one case that recovers from operations on a cranial meningocele ten die. Individuals with meningoceles, particularly when the cyst is large, rarely survive their birth many weeks. Death is usually due to sloughing of the sac and consequent septic meningitis. Cephalhaematoma is the name giv^n to a collection of blood extravasated in consequence of injury between the vault of the cranium and the pericranium. It is most commonly seen in newly-born children that have pre- sented by the head. The swelling in these cases is familiar to practitioners as the caput succedaneuTU. In the course of a few days it will completely disappear. Cephalhaematoma arises on the heads of children as a consequence of blows or falls, and in the majority of cases the eft'used blood is slowly absorbed. In a certain proportion of cases suppuration occurs, and the hsematoma is converted into an abscess. This is particularly liable to occur if air is admitted either through abrasion of the parts at the time of the accident or by exploratory punctures made by the surgeon. In most cephalhgematomata a few days after their formation a hard ridge forms around the confines, and this when con- trasted with the pulpy, yielding sensation imparted to the finger by the rest of the swelling often gives rise to the im- pression that the individual has sustained a depressed fracture of the skull. Knowledge of the fact is, as a rule, sufficient to prevent error in diagnosis. This hard ridge is interesting in another way, for it is liable to ossify. In many cases as the blood is absorbed this ridge likewise disappears, resembling in this respect callus around a fractured long bone. In rare instances adventitious, bone thus formed may persist and form a large bony crater to the skull. A very remarkable example of this has been placed on record by Treves.* The patient, a boy eleven years of age, had a large swelling on the head strictly limited to the right * Trans. Olin. Soc, vol. xxi., p. 285. NEUEJ17-(JY8TS. 455 parietal bone and covered with hairy scalp. (Fiyal College of Surgeons.) at the edges of these bones were probably due to the move- ments of the cyst during their formation, for it was noted that there was slight pulsation. Oephalhydrocele.— This is usually defined as a puisatile tumour containing cerebro-spinal fluid communicating with the interior of the skull through an abnormal opening the result of injury ; it does not demand further consideration here.* * Smith, St. Barth. Hospital Exports, vol. xx. 233; Lucas Guys Hospital Reports, 1876, 1878, 1881, and 1884; Godlee, Trans. Path. Soc, xxxvi. 313. 458 PSEZTDO-OYSTS. Treatment. — It Ls rare that meningoceles, even small specimens, are submitted to treatment. Sometimes a menin- gocele is mistaken for a wen or dermoid and excised ; during the operation the surgeon finds that he has opened the dura mater. This adventure generally ends in disaster; excep- tionally, it has cured the patient. Even in successful cases, hydrocephalus has followed the removal of the meningocele.* {See also page 470). In several cases dermoids have been mistaken for meningoceles, and have remained undisturbed by the surgeon until some change in them has led to the discovery of their true character. * Wright, Srit. Med. Journal, 1893, vol. i. 9i9. 459 CHAPTER L. NEURAL CYSTS (concluded). Spina Bifida.— The term spina bifida is applied to con^e they attain m this organ, and the risk they occasion to wi!^ ''''"' *° ^^ ^"""^ attentively studied When the cyst ruptures spontaneously it may take various directions. Thus it may burst into the pleura and give rise to fatal pleurisy. Should the lung be adherent to the diaphragm, the cyst may open into it and the contents be discharged through the bronchial tubes and trachea. Under these conditions gangrene of the lung may follow the rupture. In a few instances the cyst has burst into the pericardium Such an accident is rapidly fatal, as the inundation of the Fig. 249. — Multitude of minute hydatids on the pelvic peritoneum, probably secondary to the tapping of a cyst in tlie liver. (After Gralianu) pericardial cavity by fluid and vesicles embarrasses the heart. In some cases death has followed from pericarditis. Kupture of a large cyst into the peritoneal cavity leads to serious consequences, but when the cyst is small it may lead to general infection of the peritoneum (Fig. 249). In a case under. my care there was reason to believe that a hepatic cj^st had ruptured into the lesser bag of the peritoneum, for the whole of the small omentum was thickly beset with small hydatids. Graham records a similar observation. The cyst has been known to rupture into the stomach, the vesicles being afterwards vomited ; and in a few cases they perforated into the intestine, the contents of the cyst being discharged by the anus. Among the rarer directions, hydatids have been known to rupture into the biliary passages, and the obstruction caused 478 PSEUnO-GYSTS. by the vesicles has induced jaundice, and their subsequent passage along the common duct has produced biliary colic. Another excessively rare direction is for the cyst to rupture into the inferior vena cava, the contents reaching the right side of the heart. Gases have been reported in which the pressure of a cyst has induced atrophy of the intercostals and its contents discharged externally. They have also been known to burst externally near the umbilicus. Suppurating cysts may' terminate in any of the directions mentioned above. Hepatic hydatids may cause death by their size embar- rassing respiration, or by pressure on important organs, such as the vena cava, producing anasarca; or hindering the circulation through the vena porta, and causing ascites ; whilst suppuration will lead to exhaustion or induce death by septicaemia or pyaemia. When hydatid fluid escapes into the peritoneal cavity it is apt to produce an urticarial eruption known as the hydatid rash. It usually appears shortly after the cyst has been ruptured or punctured ; it itches intensely, lasts two or three days, and is usually accompanied by high temperature and sometimes by abdominal pain. It is referred to by several observers. Krabbe writes : — " A curious phenomena is habitu- ally observed when hydatids rupture into the peritoneal cavity : it provokes a transient urticaria." * Finsenf refers to two cases worth mentioning in relation to the rash. Paul Helgason, aged twelve years, had for four years a large tumour in the right hypochondrium extending to the umbilicus. The lad received a blow from a cow's horn upon the belly that caused the tumour to disappear. Almost immediately the body was covered with a rash lilce an urticaria, but it soon disappeared. In another patient, a pregnant woman had a hepatic hydatid for six years. Three days after delivery, whilst lying quietly in bed, she was suddenly seized with acute pain in the abdomen ; the tumour of the liver disappeared, and in a short time the skin presented a papular rash. Hepatic hydatids may be accidentally ruptured in a variety * " Eecherches Helminthologiques en Danemark et en Islande." 1866. t Arch. Gen. de Med., 1869, xiii. 23. HYDATIDS. 479 of ways— such as blows, falls on the be%, by the wheels of a cart, or during an embrace in " a moment of exuberant affection." * The Heart. — Hydatids of the heart occur under two con- ditions : — (1) The cyst may form in the muscle tissue of the heart — that is, in the walls of the ventricles or auricles ; or (2) the Tesicles are conveyed to the cavities of the right side of the heart as emboli, in consequence of the rupture of a hydatid cyst into some large vessel such as the vena cava. When a cyst forms in the heart it may develop in the walls of the auricles. Of this many cases have been recorded.f In the walls of the ventricle they appear to be rare and never attain a large size. J Graham states that in the Sydney University pathological museum there is a specimen in which a hydatid occupies the interventricular septum. Cardiac hydatids usually terminate the life of the patient suddenly, sometimes without rupture ; but as a rule, the fatal event is due to this cause, the cyst-contents being discharged into the pericardial, auricular, or ventricular cavities. When the cysts open into the right cavities of the heart the vesicles may be carried as emboli into the pulmonary artery. If into the left cavities, they may be carried into the systeuiic arteries. Oesterlen§ recorded a case in which a girl, twenty-three years of age, developed gangrene of one leg. This was amputated and she died of pytemia. A cyst the size of a pigeon's egg situated in the cardiac wall had burst into the left auricle ; hydatid membrane was discovered in adherent thrombi in the common iliac artery, and an entire vesicle was found in the deep femoral artery. The Lungs.— Hydatids occur in the lungs under two conditions :—(l) The cyst, for it is usually single, may be situated wholly withm the substance of the lung, and in most cases chooses the lower lobe, especially of the right lung ; or (2) it may grow in the tissue immediately beneath *Troves, Trans. CHn. Soc, vol. xxi. 82. ,-,t i<-> tMoxon, Trans. Path. Soc, vol. xxi., p. 99; and Graham, "Hydatid Disease,"' p. 134. J Trans. Path. Soc, vol. xv. 247. § Virchow's " Archiv," bd. xlii., p. 404. 4S0 PSEUDO-CYSTS. the pulmonary pleura and project as an outgrowth from the lung into the pleural cavity. When the cysts are small they occasion little incon- venience, but increasing in size they compress the lung and lead to haemoptysis. Apart from the mere pressure effects produced by the cyst, it is liable to rupture into the bronchial tubes, and pieces of membrane and vesicles are coughed up and indicate the nature of the case. When the cyst communicates with a bronchial tube, suppuration of the cyst is the inevitable consequence. Should the cyst rupture into the pleural cavity, empyema is the usual result.* It is well to bear in mind that because hydatid vesicles and membrane are coughed up it does not necessarily follow that the cyst is seated in the lung. Hepatic hydatids are sometimes evacuated by this route. Hydatids of the Kidney. — A large number of cases of renal hydatids have been recorded. The cyst may occupy the substance of the kidney or grow immediately beneath the capsule. In each situation the hydatid may attain a very large size and lead to extensive atrophy of the renal tissue. When of small size they rarely give rise to trouble or even inconvenience during life, and their existence is only known in the course of a post-mortem examination (Fig. 247). Large hydatids appear as fluctuating tumours in the loin and simulate hydronephrosis. There are good reasons for believing that the greater pro- portion of hydatids of the kidney rupture into the pelvis of the organ, the fluid and vesicles passing down the ureter to be discharged by the urethra. This is, of course, the most satisfactory mode of termination, except perhaps, death of the parasite with subsequent calcification. Now that surgeons are so interested in renal tumours it is very probable that more accurate information will soon be accessible. Bones. — Hydatids occur much more frequently in long than in flat bones, but in either situation they are extremely rare. When occupying the medullary cavity of a bone they induce atrophy of the shaft from the persistent pressure they * Curnow, Trans. Path. Soc, vol. xxxiv., p. 24. HYDATIDS. 481 exercise, and at lengtli the bone breaks (spontaneous fracture) from some trivial injury. In some of the cases operations have been undertaken for the relief of abscesses supposed to be d^ie to necrosis, and when the bone has been opened up, hydatid vesicles have escaped. Hydatids appear in the medullary cavity of bones in two forms : — (1) The cyst may be sterile. An example of this is pre- served in the museum of the Royal College of Surgeons ; the cyst occupies the medullary cavity of the humerus of an ox. (2) There is no mother-cyst, but the medullary cavity is occupied by a midtitude of vesicles. This appears to be the usual condition in which hydatids occur in bone. Hydatids have a preference for the tibia among bones ; tbe museum of Guy's Hospital contains one, and the museum of St. Mary's Hospital* two examples. In Coulson's f case the tibia was occupied by hundreds of vesicles. The patient, was a woman twenty-iive years of age. The cyst extended to near the ankle. The symptoms had existed for nearly eight years. Graham J has recorded and figured a good example in the humerus. (Fig. 248.) The patient was a woman, thirty-five years of age, who had a tense swelling in the lower part of the arm ; this was incised, when pus and a number of small vesicles escaped. The arm was amputated at the shoulder joint. At the lower part of the bone the shaft was converted into a fusiform sac in which there were large numbers of vesicles, most of them entire and healthy. The head and lower extremity were the only parts of the bone free from the parasite. There was no trace of a parent-cyst. Webb § has recorded a case that occurred in the shaft of the femur. The patient, a man twenty-six j-ears of age, com- plained of pain over the trochanter of the left femur ; soon a swelling appeared. Eventually this was incised, and two or three hundred vesicles in various stages of development and degeneration escaped. There was no appearance of a mother-cyst. * Cat. Museum, St. Maiy's Hospit:il, 1891, f Jled-Chir. Trtinsi., vol. xli., p. 307. + "Hydatid Disease," p. 132. § Aiisl. Mid. Journal, 1S91. FF 432 rSEUnO-CYSTS. When the hydatids occupy the ends of bones they may break into the adjacent joint. In the well-known case of Travels the cysts t>ccupied the lower end of the femur and the upper end of the tibia. The cysts that had suppurated communicated with each other through the knee joint.* Carline'st extraordinary specimen, represented in Plate IX., is almost the counterpart of this. Thomas has reported a case which grew in the ilium. The museum of St, Bartholomew's Hospital contains half a pelvis in which hydatids occupied the ilium and the sacrum. Virchow refers to a specimen of hydatids in the sternum. They have also been found in an ungual phalanx. Hydatids of the thyroid gland are very rare ; they usually terminate by bursting into the trachea. This is always a fatal accident. Hydatids have been observed in the adrenal. Birch-Hirschfeld:|: reported an instance of a hydatid lying in the cavity of the vermiform appendix, which was dilated to twice the thickness of the thumb. It contained the remains of hydatid membrane, which presented under the microscope the characteristic lamination. The appendix contained a great number of semi-transparent vesicles, varying from a pin's head to a pea in size : most of these were sterile. The comnmnication between the appendix and the caecum was obliterated. The walls of the appendix and its nmcous mem- brane were atrophied from the pressure exerted by the cyst, and presented mosaic-like impressions caused by the pressure of the vesicles. The patient was a man thirty-eight years of age. The Mamma. — Echinococcus cysts in this gland are very rare : records of at least twenty cases are accessible. . The patients were in nearly all instances adult women. The disease takes the form of a slowly increasing, painless swelling, which may involve the whole breast or project as a smooth, elastic, fluctuating tumour from some portion of its circum- ference. These cysts may exist in the breast for ten years or longer without producing much inconvenience : they have * Cat. St. Thonias's Hospital Museum, 1890, part i. t Brit. Med. Journal, 1892, vol. ii., p. 632. J Arch. d. ILUktinde, 1S71, p. 191. PLATE IX.-Lower two-thirds of a Femur, with the upper fourths of the Tibia and Fibula. The remnants of the Femur and Tibia are fenestrated osseous shells, in consequence of the pressure exercised by multilocular hydatids which began in the Femur, invaded the knee-joint and involved the Tibia. There is a sequestrum in the Femur measuring 7'5 cm. by 4 cm. Carline's case. (Museuviy Royal College of Surgeons.) i nat. size. EYBATIBS. 483 been reported with a capacity of twenty ounces. Occasionally the cyst suppurates. Diagnosis, in' countries where the echinococcus is not common, is' very difficult without the assistance of an ex- ploratory puncture. This will clear up the case. In most of the cases that occurred in England the nature of the swelling was revealed when the surgeon made an incision into the breast for the purpose of removino- it. Drawings of mammary hydatids are given by Astlcy Cooper,* Bryant,t and others. The Subperitoneal Tissue and Omentum.— Hydatids occur in these situations frequently in great numbers, and are often of large size. They may be pedunculated or sessile. Muskettt reported a remarkable case in which the patient was supposed to be suffering from a hydrocele the size of an emu's eg^. When tapped it was found to be a hydatid cyst. As a rule, \vhen abdominal hj-datids are numerous they are of small size ; when solitary they may be very lai'ge. Should a solitary cyst be sterile, its true nature is liable to be over- looked. Hydatids grow in the mesentery, the meso-rectum, or between the layers of the broad ligament of the uterus. In men many cases have been recorded in which a cyst of large size grew in the connective tissue between the bladder and rectum. Many echinococcus cysts described as growing in relation with the liver, spleen, and uterus really lie in the tissue immediately beneath the serous covering of these organs, anrl are in a sense subperitoneal. If these cases be included it will be clear that the subperitoneal tissue is an exceedingly favourite situation for hydatids. Connective Tissue of the Trunk and Limbs.— Many cases have been recorded in which hydatids have been found in the axilla, orbit, posterior triangle of the neck, etc. Their nature is rarely suspected until the swelling is incised. Brain.— Hj^datids of the brain occur either in connection ■with the meninges or in the brain substance. In either * t Diseases of the Breast," plate i.'c. t " Diseases of the Breast," 1S87, plate viii., figs. 3 anJ -1. + Aust. Med. Oaz., 1886, p. 57. 484 FSEUD0-CY8TS. situation they are not common. The cerebrum seems to be • the most frequent seat of the cyst, and the right hemisphere lodges them twice as often as the left. In the cerebellum they are rare. When the cyst occupies the membranes it presses upon and produces a bay in the cortex of the cerebrum. In any part of the brain they rarely attain a large size, as their position causes them to bring about serious disturbances. It is often remarked by those who have recorded examples of intracranial hydatids that the damage produced by the cyst on the brain is out of proportion with the symptoms ; but the same is equally true of almost all cerebral tumours. Intracranial hydatids are not furnished with the thick adventitious capsule that surrounds them in most other situations ; hence the cyst-wall is extremely delicate, and it" is remarkable that hydatid cysts of the brain are nearly always sterile. Echinococcus colonies are found occasionally in the brain. Mudd* has described a case that occurred in a girl of twelve years. The colony was lodged in the right motor area of the cerebral cortex, and produced absorption of the overlying bones and bulged externally. It was successfully treated. Spinal Canal. — Hydatids occur in connection with the spinal canal under three conditions : — (1) The hydatids are situated entirely within the canal. Such cases are divisible into two sets : {a) those inside the dura mater — such cases have been described by Bartelst and WoodJ ; or (6) the cysts lie in the connective tissue between the bone and dura mater, as in a case recorded by Maguire.§ In several of these cases the hydatids were i»f the multilocular variety. Thus in Maguire's case there was a large number of vesicles, varying in size from a pin's head to that of a small chestnut, lying between the dura mater, the last cervical and upper six thoracic vertebrte. Ransom || has published a com- plete account of a case in which a hydatid the size of a * Internal. Jour. Mrd. Sci., 1892, p. 412. t I>eul. Arch. f. Klin. Med., bd. v., s. 108. X Aitst. Med. Journal. 1879, p. 222. j Brain, vol. x., p. 451. jl Ilrii. Med. Journal, 1891, vol. ii. 1144. BYDATIDS. 485 Chestnut grew from the arch of the tenth thoracic vertebra and produced paraplegia. (2) The hydatids affect the vertebral and extend into the canal. Ogle* has described an example of this in which the cyst contammg a large number of vesicles, was lodged in the spmous process of the seventh cervical vertebra ; it projected into the canal and pressed upon the cord. (3) The hydatids grow in the tissues outside the vertebra;, which are secondarily involved, the cyst extending into the canal. Several examples of this are known. Wilks and Moxonf describe a preparation in which numerous small hydatids extended widely in the subpleural tissue in the neighbourhood of the spine, which they perforated by eroding the vertebra and then entered the neural canal and compressed the cord producing paraplegia. In this case the cysts were not enclosed by a mother-cyst (multilocular hydatids). CruveilhierJ has given a good example of this which occurred in a woman r.hirty- eight years of age. It grew among the muscles in the vertebral groove and made its way between the arches of the twelfth thoracic and first lumbar Vertebraj, and compressed the cord without entering the dural sheath. Treatment. — ^The principles on which hydatid cysts are treated by surgeons consist : — 1. In removing the cyst entire tvhenever this is possible. Failing this : — 2. To incise the cyst-wall, evacuate the contents, and when- ever possible rernove the true cyst, and allow the cavity hounded by the capsule to close by granulation. The particular manner of carrying out the treatment varies with the situation of the cyst. The simplest condition is when a hydatid, or even six or eight, the size of cocoa-nuts hang from the great omentum. In such a case the tumours are exposed through an abdominal incision and withdrawn ; the omental pedicles are tied and the cysts cut away. In * Trans. Path. Soc, vol. xi., p. 299. f Path. Anatomij, 1875, p. 64. j Anat. Path., liv, xxxv., plate vi., figs. 1 and 2. 486 PSEUDO-CYSTS. many cases they are so firmly adherent to surrounding structures that they cannot be removed ; it is then necessary to incise the fibrous capsule, or tear through them carefully with forceps and expose the mother-cyst, which is then easily enucleated. The empty capsules give no trouble. Suppurating hydatids demand incision and drainage. In the case of hydatids in the liver, incision and drainage give excellent results. Great care should be taken to evacuate the cyst-contents thoroughly, and whenever possible, without the exercise of too much violence, the mother-cyst should be enucleated. The subseqtient decomposition of this highly albuminous tissue is a source of very great danger to the patient. All such methods of meddling with abdominal hydatids, as aspiration, punctures with trocars, and electrolysis, should be unhesitatingly condemned. No one should venture to tap or aspirate an abdominal cyst for diagnostic purposes. Such interference often works incalculable harm ; whereas an exploratory incision carried out by a surgeon familiar with abdominal surgery is an operation infinitely safer than a thrust in the dark from a trocar. I have never seen an exploratory puncture of the belly do good ; often it misleads, frequently converts a simple into an anxious case, and occasionally encompasses the death of the patient. Hydatids in the cerebral cortex have been localised, exposed by trephining, and successfully drained. Yerco* is of opinion that in about one-third of the cases of hydatids. of the brain the cysts communicate with the lateral ventricles ; hence when a c^^st is opened by operation the cerebro-spinal fliud also escapes, drains the ventricles, and causes death. To obviate this he suggests that no drainage-tube should be employed, the flaps being closely stitched so as to seal up the cavity. In the case of bones the treatment consists of incision, evacuation of the vesicles, and drainage. Exceptionally, when the bone is seriously damaged, fractured, or a large joint invaded, amputation has been necessary. Large hydatid cysts of the lung require to be treated on the principles of empyema. * Jiril. Med. Journal, 1892, vol. ii. 1066. 437 CHAPTER LII. THE ZOOLOGICAL DISTRIBUTION OF TUMOURS. Throughout the course of this book many incidental references have been made to tumours occurring in verte- brate animals ; it will perhaps be useful to summarise our knowledge on this matter, because there are many facts con- nected with it of great interest in their bearing on the Biology of Tumours. As man in his bodily structure is kindred with the brutes, it would be expected that the various tumours known to occur in him would have their counterparts in vertebrata generally. For example, we should expect to find lipomata, especially as fat is a tissue so widely distributed in the animal kingdom ; but this is not the case, and the few that have come under my observation occurred chiefly in horses, oxen, and sheep, and belong mainly to the subserous species. {See page 8.) In stall-fed oxen excessive accumulation of fat is common in the subperitoneal tissue, especially in the omentum ; but such formations accompany general obesity, and do not come into the category of tumours. It is a fact that in man the largest lipomata usually occur in particularly lean individuals. Osteomata are very generalised tumours ; they have been met with in several species of tish. Gervais* has described many examples; reference has already been made to the singular condition of the bones in Ghcetodon (page 29). The bony outgrowths to which the term exostosis is apphcable are of fairly common occurrence in mammals, and their frequency on the bones of horses can only be appreciated after a visit to a veterinary museum. _ _ In regard to odontomes, it would, of course, be antici- pated that such tumours occur more frequently in other mammals than in man, in consequence of the peculiar con- ditions of growth that prevail in such orders as Modentia and Frohoscidea. * Journal de Zoologie, vol. iv., 1875. 483 TUMOUBS. The marmot, agouti, and porcupine have supplied me with verj' interesting specimens, and I have obtained as many as four large odontomes from the mouth of one marmot. Many excessively large odontoraata have been obtained from horses and elephants. Goats, sheep, bears, and kangaroos have furnished me with excellent specimens of fibrous odontomes. Some of them are described in chapter iv. Myomata furnish material for speculation. Probably the uterine myoma is the commonest tumour that aftects the human female, but it is a singular fact that uterine myomata are almost unknown in mammals. The only specimen that has come under my observation occurred in a female baboon, and was rather a general enlargement of the uterus than an actual tumour. Even among domestic mammals, such as the mare, cow, ewe, goat, bitch, and cat, uterine myomata are almost un- known ; indeed, the details of the few recorded cases are stated in such vague terms that the descriptions are useless. When the situations of uterine myomata in women come to be examined it will be seen that they are extremely common in the walls of the uterus, and they also grow from the cervix, but they are excessively rare, indeed almost unknown, in the Fallopian tube. In the majority of mammals the greater part of the uterus consists of two muscular tubes, the uterine cornua ; whereas in women the tubes become con- fluent to form a median uterus. Seeing that myomata are common in the wall of this compound uterus, but almost unknown in the Fallopian tubes and in bicornuate uteri, it would seem to favour the view that uterine myomata may in some cases arise from " rests " in the uterine walls due to imperfect coalescence of the MilUerian ducts, in the same way that dermoids of the sequestration species are so common in the lines of coalescence in the embryo. Of all the connective-tissue tumours, sarcomata have the widest zoological distribution, and they occur with very great frequency, especially the round-celled and the spindle -celled species. They are met Avith in fish, birds, rats, mice, horses, sheep, dogs, cats, goats, oxen, monkeys, bears, marsupials — indeed, in all the orders of mammals and in snakes. Sarcomata ZOOLOGICAL DISTRIBUTION OF TUMOURS. 489 in dogs often grow with extreme rapidity, and this may in nm^oo™^^"''''^ ^® explained by their elevated temperature (101-8° Fahr.). Periosteum and skin appear to be the common situations attacked by sarcomata, especially in dogs. In horses and dogs I have been able to satisfy myself that spindle-celled sarcomata often contain hyaline cartilage. Retinal sarcomata have been observed in horses and sheep, and I have obtamed an excellent specimen from the eye of a monkey. Melano-sarcomata in the horse have been already referred to on page 116. Supposed sarcomata in the lower mammals, especially the lympho-sarcomata of dogs, need careful study from those engaged in bacteriology, for the rapid manner in which they grow and the profound effects they produce on the general health of these animals, suggests very strongly that they are the product of some very active species of micro-parasite. The occurrence of epithelial tumours in animals, wild or domesticated, is a subject of great interest in its bearing on cancerand itsallies. Unfortunatelyfew trustworthyobservations are forthcoming. For instance, a cursory review of veterinary periodical literature would give colour to the opinion that epithelioma of the penis is a common disease in bulls and in horses, but on looking into the matter a re-examination of suspected cases shows clearly enough that many supposed examples of epithelioma are, as a matter of fact, instances of penile warts, and all competent histologists who have inquired into the matter are unanimous that penile epithelioma in horses and bulls is excessively rare. Warts are common enough in dogs and lambs, not only about the mouth and lips, but along the coronets of lambs and on the pads of the feet of dogs and many carnivora. Warts being abundant, it naturally follows that wart-horns would be frequent. This inference is confirmed by reference to examples described in chapter xx. An extended inquiry concerning adenomata and carcino- mata in mammals generally, reveals an extraordinary condi- tion of things. Wild manmials in a state of nature and those living in confinement appear to be absolutely free from cancer. 490 TUMOURS. On one occasion I found a mammary adenoma in a pHalanger ; it is preserved in the museum of the Royal College of Surgeons, and this single specimen represents the extent of my know- ledge concerning adenomata and cancers in wild mammals. It is fair to emphasise this statement by mentioning that during the eight years I was in close attendance in the Prosector's room of the Zoological Society's Gardens, I was particularly on the look-out for tumours of all kinds. Adenomata occur in domestic mammals. The bitch is especially liable to tumours of the mammary gland that are analogous to the large cystic adenoceles of women. These tumours are sometimes so large as to exceed in weight the carcase of the bitch to Avhich they are attached. As far as iny observations extend, these tumours do not infect the lymph glands nor become disseminated. Large cystic adeno- mata, with intracystic processes, are occasionally seen in the udders of cows. The mammary glands of cats are liable to a disease that is 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 liable to a species of tumour that occurs with tolerable frequency in the skin around the anus. It exhibits the structure of a sebaceous adenoma and after attaininsr the size of a walnut ulcerates. Such tumours quickty recur after removal, but they do not, as a rule, infect the lymph glands or become disseminated. Very little is known concerning the occurrence of dermoids in mammals. Considering the frequency of these tumours in man it might be imagined that they would be widely distributed among mammals. Of sequestration dermoids, a fair number of specimens have been obtained from sheep and oxen, but most of these belong to the implantation variety. (Page 305.) Ovarian dermoids have been observed in the mare and the ewe. Dermoid patches on the conjunctiva have been reported many times in all species of domestic mammals except the ass and cat. Teratomata are common enough among domestic animals, and many examples have been described in fish, frogs, and other batrachians, lizards, snakes, birds, rabbits, hares, etc. ZOOLOGICAL DISTRIBTITION OF TUMOURS. 491 The frequency of cystic tumours in vertebrata generally forms a striking contrast to the infrequency of connective- tissue and epithelial tumours. Such conditions as hydro- nephrosis, congenital cystic kidney, 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. (Esophageal diverticula are often seen in horses, and these useful mammals are exceedingly liable to synovial cj'sts and ganglia. Parasitic cysts are very common in animals of all kinds. 4S2 CHAPTER LIII. .. THE CAUSE OF TUMOURS. It is a very difficult task to discuss the cause of tumours ; nevertheless it is far easier to-day than it was fifty years ago. Pathological histology has taught us to narrow the term " tumour " within certain limits, and bacteriology has enabled us to reject many morbid conditions that were formerly called tumours. Virchow rendered excellent service in separating the Infective Granulomata, and it was afterwards demonstrated that many of them — e.g., tubercle, glanders, actinomycosis, etc. — are caused by micro-organisms. Another example of greater precision in the use of terms is furnished by hydatids ; this name was formerly used in the loosest sense, but is now restricted to the cystic stage of Taenia echinococcus. Increased precision in the use of names may be expected to continue with the advance and diffusion of knowledge concerning tumours, and by degrees the name "tumour" will have a still narrower meaning. Recent in- vestigations in the pathology of morbid growths teach us to look for a variety of causes. Take, for example, the interesting speculation, usually termed Cohnheim's theory, in which tumours are supposed to spring from unutilised fragments of ' tissue, or residues, some of which may be due to faults or em- bryonic irregularities. Such residues or " tiimour-germs '' may, early in life, even in the fcEtus, develop into tumours, or remain many months, or even years, quiescent, then suddenly, and apparently without provocation, take on active growth. This theory, unsupported as it was, without the least evidence of a concrete character, was advanced by Cohnheim as an explana- tion of the origin of connective-tissue and epithelial tumours. The great argument against it was to the effect that unutilised embryonic tissue (tumour-germs) had not been demonstrated. The theory, however, indicated a line of inquiry in which observation and experiment have demonstrated, in regard to some genera of connective-tissue tumours and very many dermoids, that it offers a solution of several difficult problems. THE CAUSE OF TUMOURS. 493 It is undeniable that our knowledge of unutilised tissue and vestiges of organs has of late years been widened, and it will be useful to summarise briefly what is now known in regard to them. It is desirable to arrange tumour-germs in two groups viz., vestiges and rests. The term vestige should be reserved for structures that are remnants of organs functional in vertebrates lower than man ; for those organs that are of importance to the embryo, but useless in the adult ; and a few which, though utilised in the male, are useless, or almost useless, in the female, and vice versa ; as well as for those structures which, as far as we know, serve no useful purpose in any vertebrate at present living, but were doubtless of importance in their ancestors. Many examples of vestiges and their relation to tumours have already been considered in the preceding pages — e.g., the mesonephros, the parovarium Gartner's duct, the urachus, the vitello-intestinal duct, the central canal of the cord, etc. The term rests should be reserved for detached fragments, of glands and isolated portions of tissue and epithelium. That they are the sources of many tumours there can be no doubt, and it is equally certain that when more attention is devoted to the question, many additional examples of " rests " will come to hght. The number already known is by no means insignificant. The easiest demonstrable example occurs in connection with the spleen. It is the normal condition to find in the gastro-splenic omentum of a child at birth a miniature spleen or splenculus. It is no uncommon event to find two or three splenculi, and as many as five have been counted. In many instances these accessory spleens atrophy, but frequently they may be detected in adults. When the abdominal viscera are transposed the spleen is, as a rule, represented by a cluster of splenculi. The pancreas furnishes a similar example. Several in- stances have been recorded in which an accessory pancreas has been detected. It is usually situated in the wall of the duodenum or jejunum, between the serous and muscular coats, and it is important to remember that these detached fragments ma} occur at some distance from the main gland. Accessory 494 TUMOURS. thyroid glands — neolecting those which lie in the tract of the thyro-glossal duct— illustrate this, for they have been detected on a level with the episternal notch, and in the trachea as low as its bifurcation. Kests associated with an adrenal occur in the kidney, immediately beneath the capsule, as cuneiform, yellowish- white nodules ; they have been described as renal lipomata, and there is reason to believe that they are occasionally the germs of very large tumours. (See page 98.) Detached fragments of liver occasionally occur in the falciform ligament and in the neighbourhood of the transverse fissure ; but no one, so far as I know, has succeeded in demon- strating the origin of a tumour from these rests ; but it is easily conceivable that they might under exceptionable con- ditions play the part of tumour-germs. As fragmentary livers, so to speak, occur beyond the actual hepatic territory, it is very probable that portions of glandular tissue may be isolated within the liver itself, and there are strong grounds for the belief that certain adenomata of the liver do arise from such sequestrated tracts of hepatic tissue. This mode of origin of adenomata gains strongest support from our knowledge of mammary tumours. Outlying pieces of mammary gland are occasionally met with, merely joined to the main gland by connective tissue, and it is reasonable to believe that they are the source of some of the cncapsuled adenomata that occur at the periphery of the breast. The mammary rests must not be confounded with accessory mammae arising as neomorphs in the adjacent skin, especially in the skin of the axilla. It is also probable that isolated encapsuled portions of gland are the source of the fibro -adenomata so common in the mammae of young women. {See page 221.) The same explanation holds good for some of the small cystic tumours of the parotid gland. Tracts of epithelium occur as vestiges and as rests. As vestiges, epithelial tracts occur in the tongue — the lingual duct ; in the neck — branchial clefts ; in the naso-palatine suture — Stenson's canal; in the brain — infundibulum ; and in other situations the vestigial character of some of the tracts and their tendency to form tumours has been already described. The tumour - forming proclivities of THE CAUSE OF TU2IUU11S. 495 Others has been abundantly demonstrated in the section on Dermoids. As rests, epithelial tracts occur in the line of the meso- palatine suture, in the gums derived from enamel-organs, and in the lines of coalescence of the trunk, the scalp and face. In these situations they give rise to tumours. Epithelial rests may be produced accidentally by surface epithelium carried into the deeper tissues by cUts, punctures, etc. These give rise to small tumours, when the conditions are favourable, known as implantation cysts. (See page 304 and Fig. 250.) Bests are known in connection with non-epithelial tissues, but they do not admit of such ready demonstration. In the neighbourhood of epiphysial lines, particularly in the long- bones of rickety individuals, islets of cartilage have long been known, and it is not unreasonable to believe that such belated fragments may be the source of some enchondromata and osteoniata. It is certainly probable that some forms of uterine myo- mata arise from sequestrated portions of the uterine tissue, especially encapsuled myomata of the uterine walls. (See page 488.) It is curious that many vestiges and rests lie latent several years. Take, for example, accessory thyroids: rarely they give trouble before puberty ; many never cause the least incon- venience, and a few become active even late in life. Goitre of the parenchymatous kind is occasionally congenital ; but I am not aware that the cystic variety is common until the accession of puberty ; after this event it is frequent. Mammary adeno- mata are of common occurrence between the sixteenth and thirtieth years, but they are ahnost unknown before the four- teenth year. The best instance of this sudden awakening may be studied in the parovarium ; its ducts are quiescent during the early years of life. So far as I have collected the evidence — and my search has been a broad one — there is no case on record of a parovarian cyst occurring in a girl under fifteen years. Between the ages of sixteen and twenty-fire years a laro-e number of parovarian cysts have been removed. T^ake cysts of the paroophoron : they are almost unknown before the twenty-fifth year of life. Certain it is that small paroophoritic cysts have been detected in infant ovaries, but 496 TUMOURS' these were not appreciable to clinical observation. The exist- ence of tumour-germs is demonstrable in the case of cysts. There is scarcely a cyst known to which pathologists cannot ascribe an origin in some pre-existing duct, tube, gland,- or vestige. One of the most extraordinary features connected with some cysts is the physiology of secretion. For instance, a parovarian, or a simple ovarian cyst containing only two or three ounces of fluid in a tense sac with thin walls, may in spite of the intracystic pressure continue to increase until it attains a capacity of three, four, or more gallons. Hydrocephalus and meningoceles illustrate the same inexplicable phenomenon, for they are devoid of glands and lack epithelium, at least in their late stages. In the case of simple tumours we know that they arise from a matrix similar in structure to the tumour. These facts should cause us to keep a keener look-out for isolated fragments (rests) of organs and tissues. A very suggestive in- stance is a fatty tumour of the broad ligament of the uterus. Under normal conditions there is no fat between the layers of this serous ligament, yet lipomata have been observed in that situation, sometimes of great size. A careful examination of the parts has taught me that the parovarium is sometimes buried in a layer of rich yellow fat. The tumours to which Cohnheim's theory cannot be re- garded as in any sense applicable are the sarcomata, epithelio- mata, and cancers. Although Cohnheim's theory of tumours concerns a limited number of genera, it commands attention because it is in itself a brilliant generalisation, and has served a valuable purpose in directing inquiry upon particular lines, which has led to a great extension of knowledge in regard to vestiges and rfests. Before discussing the probable cause of cancer it is neces- sary to consider some points in its morphology. A com- prehensive study of the histology of cancer indicates that the method of dividing it into three varieties — scirrhus, ence- ■ phaloid (medullary), and colloid — is not only misleading, but the division has no structural basis. It is also of great im- portance to bear in mind that many misconceptions arise from the ciicumstance, that pathologists have been in the habit of interpreting the structure of cancers from plane THE CAUSE OF TUMOURS. 497 sections, without in the least taking into consideration the relation of a given section to the entire tumour ; hence a scirrhous cancer was said to be composed of an alveolar mesh- work of fibrous tissue, the alveoli enclosing epithelial cells. If, instead of drawing conclusions from one or two sections selected haphazard, a number of consecutive sections be taken and a composite picture framed from them, it will at once become clear that the cellular alveoli are sections of glandular acini and ducts filled with cells cut in various directions, some transverse, others oblique, and many in their long axes. This fact is admirably illustrated in the case of rectal cancer ; frequently sections of these tumours take the form of closely packed cylinders. In others a number of epithelium-lined bays or recesses are found, and in some parts of the tumour these spaces are of irregular shape and embedded in young connective tissue. When the sections are examined col- lectively we find that these alveoli with their epithelial con- tents are really greatly enlarged Lieberkiihnian follicles cut in various planes. What is true of the rectum holds equally for the mammary gland, the prostate, the mucous membrane of the stomach, and the uterus. Of all organs in the body none illustrate the relation of cancer to glands so well as the uterus, for cancer of the cervical canal is constructed on the type of the glands normally found in the mucous membrane lining it ; cancer of the body of the uterus is constructed on the type of the uterine glands. Thus cancer of this organ alone offers sufficient evidence that the notion of cancer in general con- forming to three types must be cast aside. Even the most conservative surgeons will find Httle difiiculty in rejecting the old misleading terminolog}% for it has long been known that adenomata absolutely conform in structure to the glands in which they arise, and as cancer is best described as malignant adenoma, there will be little difficulty in per- ceiving why the type of structure is maintained. This preservation of the type of driicture is well iUustrated in other mammals where adenomata are also structural repeti- tions of the glands in which they arise. A correct appreciation of the morphology of adenomata and carcinomata is of the first importance as a prelude to the study of the cause of cancer. The ducts of all secreting GG 498 TUMOURS. glands open on free surfaces and are therefore accessible to minute organisms ■which may be contained in the air, in food, and in water. It is therefore conceivable that such bodies may gain entrance into the ducts and find their way thence into the recesses of the glands and give rise to such changes as manifest themselves as cancer. So far all this is problem- atical, for no one has succeeded in demonstrating satisfactorily Fig. 250. — Cyst (implantation) of the palm, {Kumvier.) the presence of a specific parasite in those tumours which cor- respond to the definition of a cancer as laid down in this book. That parasites find their way into glands is weU known^ — e.g., the demodex, so common in the sebaceous glands of the, skin, and the coccidium oviforme, which infests the bile-ducts in rabbits and produces adenomatons-like nodules in the liver. In this last case it would appear that the coccidia are admitted with food into the alimentary canal, and invade the liver by the common bile duct. But there is this important fact : in the rabbit no one has demonstrated that these coccidia nodules become disseminated over the body and pro- duce secondary tumours in the bones, brain, lungs, ovaries, and elsewhere. This is one of the characteristic features of cancer. To find a tumour in the body of a vertebra, or in ^^h^f^f THE CAUSE OF TUMOUBS. 499 the humerus, reproducing all the structural features of a rectal, thyroid, or prostate gland, is one of the most surprising phenomena in the whole range of patholog}'. The vitality of epithehum is very great, and its capabihty of growth when transplanted has been demonstrated experimentally in addition to the evidence furnished by observations on peri- toneal warts and implantation cysts (Fig. 250). We may be prepared to find that a colony of tubercle bacilli will, when lodged in the calcaneum, give rise to lesions identical with those found associated with these bacilli in muscles, the brain, or lymph glands, as each of them contains connective tissue ; but to find a secondary nodule containing rich, regular colunmar epithelium exactly reproducing the structure of the primary tumour in situations where there is no epithelium normally, is at present inexplicable on the theory that cancer is due to coccidia, and it becomes more so to find that secondary nodules of cancer in the liver do not caricature the hepatic cells, but are faithful reproductions of the primary tumour, as certain as a fertilised ovum, if it completely develops, will reproduce an animal like to the animal from whose ovary it issued. There are many facts indicating that cancer is induced by minute parasites, for those glands which are in most direct communication with the air or intestinal gases are most prone to become cancerous — e.g., the breast, rectum, and stomach ; whereas cancer of the prostate and thyroid gland is, in England, at least, rare. The great frequency of cancer of the cervical canal of the uterus in comparison with its rarity in the body of that organ is another case in point. These are all significant facts in relation to parasitic invasion. The opinion that all varieties of cancer are due to one cause I cannot entertain. Assuming cancer to be the product of such agents as produce tubercle, glanders, or actinomycosis, it is much more probable that under the term cancer, even with the limitation imposed upon it in this book, many tumours are grouped together, on account of structural Ukeness, that have a widely different cause, and the same view holds for sarcomata and epitheliomata. Of all the tumours that affect the human body, the most 500 TUMOURS. mysterious are the melanomata, and especially those which arise in pigmented moles. I have not deemed it necessary to discuss injury (trauma) as a cause of tumours. Cohnheim has ably disproved this in the famous lecture on tumours in his " Vorlesungen iiber allgemeine Patholgie," 1877-78. It is a noteworthy fact that most pathologists who have taken comprehensive views of tumour formation, and have made it the subject of serious and prolonged study, are of opinion that tumours innocent and malignant are, in the beginning, local troubles, and that the safest and most effectual method of dealing with them may be expressed in one short sentence : — Thorough removal of the tumour, whenever this IS possible, at the earliest possible moment. The End. INDEX TO I^AMES. Acton, 369 Adams, 121 Albert, 38 Allbntt, C, 175 Alsberj;, 120 Anuandale, 43 Arnold, 298, 316 Ariiott, H., 801 Arnott, J. M., 134 Ashby, 181 Baillie, 23 Balding, 153 Balfour, 392 Baker, M., 362 Barker, 121, 166, 304, 308 Barling, G., 280 Bartels, 484 Barwell, 162 Battle, 93, 391 Bayer, 102 Baylia, 214 Beale, 0., 107 Beck, M., 210 Beevor, 179 Bell, Sir Clias., 451 Bell, J., 161 Bell, W., 28 Bentlif, 21, 188 Berger, 12 Bergmann, 429, 435 Bernays, 311 Berry, 214, 241 Billroth, 170, 206 Bircli-Hirsclifeld, 482 Birkett, 421 Bowlby, 20, 95, 112, 316 Biumanii, 283, 296, 429 Brauiie, 318 Broca, 35 Brock, S., 47 Brokaw, 120 Bruns, 11, 19, 152, 162, 241 Bryant, 160, 247, 271, 320 Bryck, 32 Budin, 372 Bugnion, 367 Butlin, 13, 92, 202, 208, 311, 435 Cahen, 28S Cameron, 123 Carline,'481 Cayley, 64, 182 Cliavasse. 160, 435 Clienowctli, 123 Cleland, 370 Glutton, 20, 118, 284, 321 Coats, 239, 244 Coblenz, 399 Cohnlieim, 103, 244, 492 Colmnn, 390 Collins, Treacher, 88, 115, 124, 306 Cooper, Sir A., 11, 239, 299, 374, 406, 448, 483 Coote, H., 161 Coulsou, 481 Cowell, 2S9, 357 Cripps, H., 266 Croft, 120 Crooni, H., 123 Cruveilhier, 188, 485 Curling, 406 Curnow. 480 Cusset, 312 Cuvier, 28 Czerny, A., 120 Banzel, 320 Davies-Colley, 74 Davis, B., 25 Demours, 368 Dickinson, 64 Doran, 135, 277, 400 Douty, J. H., 176 Dnka, 44 Duncan, M., 138, 141, Edmunds, 189, 255 Eriehsen, 412 Eve, 11, 32, 237, 407 Fagge, H., 143 Falkson, 32 Fehiny, 11 Fergusson, Sir W,, 112, 124, 247 Fetherston,429 Feurer, 293 Fiulay, 136, 238, 261 Fischer, 120 Flower, Sir W., 66, 186 Floyer, 321 Forster, C.,8 Franks, 271 GaiTod, 345 Gay, 4 Gee, 64 Gervais, P., 28 Gibbons, 143 Giraldes, 301 Glass, 382 Godlee, 120, 285, 457 Goodhart, 64, 179, 316 , Gould, P., 209 Growers, 14 Graham, 474, 481 Grawitz, 99 Gray, 310 Griffith, 417 Griffiths, J., 77, 210, 246 Gi'uber, 436 Guilt, 349 Handyside, 369 Hare, 39 Harris, 370 Harrison, R., 247 Hart, E., 369 Hawliins, F. H., 267 Heath, 34, 41 Heusinger, 323, 326, 329, 332 Hilaire, G. St., 370 Hildebrand, 38 Hilton, 45 His, 323, 836 Hodgkin, 374 Holt, 10 Homans, 16 Home, Sir E., 187 Hueter, 120, 325 Hulke, 160, 206, 306, 343, 429 Humphreys, 38 Humphry, Sir G., 166, 342 Hunter, 28 Hutchinson, 27, 107, 112, 298 302, 318 Hutchinson, Junr., 7, 116, 149 Huxley, H., 368 Image, 160 Irvine, P., 302 Jacobson, 60, 429 Jalland, 198 Jessop, 120 Jephs'.>n, 443 Jocqs, 149 Johnson, E., 312 Junes, 11, 13 Kanthack, 352 Kast, 17 Keen, W. W., 251 Keith, S., 121 Kelly, 123 Kidd, P., 64, 161, 249 Klebs, 157 Knox, 329 Kocher, 120 Knlaczek. 343, 390 Konig, 120 Kostanecki, 314, 349 Lagrange, 215 Lambl, 298 Lamprey, 27, 54 Lane, A., 161, 293, 432 Langhans, 239 Lannelongue, 292, 302 Lawford, 88, 124 Lawson, G., 89, 124,. 153, 354 Lebert, 186 Leboucq, 297 Lediard, 112 Legge, W., 114 Listen, 161 Lloyd, J., 47, 428 Lockwood, 4 Leon, Medes de, 429 Logan, 38 502 TUMOURS. Lucas, C, 118, 443, 457 Ludlow, 435 Macalister, 27 Mackay, 319 Mackenzie, M., 19 Marteluiig, 292 Malins, 123 Magilire, 420, 484 Mnrc, 144 Marchand, 65, 102 Marsliall, 313 Masse, 306 Matliias, 37 McCarthy, 121, 168 Mc^Gill, 248 Meredith, 8, 120 Michon, 44 Middeldorpf, 319 Money, A., 64 Mott, v., 54, 125 Moore, 87 Moore, N., 13, 217, 262 Morgan, C. de, ] 53, 160 Morris, H., 100, US, 121, 24S, 884 Moxon, 259 * Mudd, 484 MuUer, H., 102 MuUer, J., 1, 9 MundiS, 347 Murchison, 174 Murie, 437 Muskett, 483 Musser, 217 Neumann, 101 Nulm, 426 Nunn, 13, 112, 235 Obri, 14 Ogle, 302, 485 Oilier, 120 Ord, W. M., 320 Ord, W. W., 285 Orlow, 26 Osier, 76 Owen, B., 12, 120 Page, F., 320 Paget, Sir J., 77, 93, 326, 837 Paget, S., 298, 309, 311 Paget, T., 895 Faker, E., 42, 311 Parker, R. W., 143 Parono, 8 Paul, 97, 260 Payne, 151 Peniice, 102 Pick, 8 " Pitt, N., 77, 429 Pitts, 271 Pollailon, 804 Pollard, B., 176, 282, 315 Pollock, 66 Port, 821 Powell, I)., 285 Power, D'Arcy, 13, 282 Power, H., 306 Pradden, 102 Pughe, 120 Eanke, 11 Ransom. 484 Rasch, 429 Rathke, 823 Rawdnn, 120 Recklinghausen, 14, 17, 159, 247 Reclus, 203 Reid, 26 Reisinger, 66 Reverdin, 240 Riljbert, 97 Richet, 309 Riudfleisch, 251 Ris, 121 Rokitansky, 436 Roser, 890 Roth, 391 Schulz, 64 Schwalbe, 332 Schweizer, 239 Senn, 429 Sharkey, 66, 256 Shattock, 236, 264, 304, 334, 373, 395 Sheild, 474 Sibley, S., 160 Sibley, W. K., 816 Sibthorpe, 300 Silcook, 247, 455 Sims, 88 Smith, 161, 156 Smith, N., 290 Smitli, T., 13, 467 Solly, 463 Stanley, 222 Stelnheil, 4 Steudel, 18 Strahan, 179 Streckeisein, 314 Stuart, A., 333 Szabo, 123 Tait, 396 Targett, 102 Taylor, P., 13, 179 Taylor, 57, 120 Tellander, 36 Tfemoin, 14 Thomas, 481 Thornton, 99, 121, 123 Tomes, Chas., 37, 39, 42 Tomes, Sir J., 37, 39 Toynbee, 160 Travers, 482 Treves, 8, 56, 119, 271, S04 Trousseau, 447 Tsander, 123 Tuokerman, 366 Turner, Sir W., 25, 302 Verco, 485 Virchow, 1, 10, 17, 66,. 63, 143, 256, 328, 460, 464, 473 Wagner, 123 Walsham, IS, 120, 327 Wardrop, 355 Watson, 30 Webb, 4S1 Webb, W., 46 Weichselbaum, 20 Welcker, 20' Wells, ah- S., 16, 121, 141 Wesnor, 143 Whipharn, 64 White, H., 284, 298, 316 Whitehead, 121 Wild, 280 Wilks, S., 259, 291 Williams, J., 212, 277 Windle, 38 Witsenhausen, 210, 239 Wolf, 311 Wood, 50 Worner, 167, Wright, 66 Wright, G. A., 468 Zahn, 306 Zenker, 102 INDEX TO OEGAI^S. Adrenal — hydatids of, 482 tumours of, 98 Adrenals, accessory — tumours of, 99 Adrenal goitres, 99 Bartholin's Glands — adenoma of, 239 carcinoma of, 239 cysts, 239 Bladder— diverticula, 431 epithelioma, 210 myoma, 143 papilloma, 172 villous tumours, 172 Brain — glioma of, 63 hydatids, 483 hydrocephalus, 446 meningocele, 451 neuroma, 157 papilloma, 175 psammoma, 177 sarcoma, 78 Bone — chondroma of, 17 hydatids of, 480 femur, 482 humerus, 474, 481 ilium, 482 Upoma of, 13 osteoma of, 23 auditory meatus, 24 frontal, 24 maxilla, 24, 27 vertebra, 25 phalanx, 482 sarcoma of, 78 clavicle, 82, 118, 128 femur, 81, 82 fibula, 80, 82 humerus, 82 ilium, 82 mandible, 83 maxilla, 83 radius, 82 ribs, 82 scapula, 82 skull, 82 sternum, 82 Bone {continued). tibia, 82 ulna, 82 sarcoma (myeloid) — clavicle, 118, 125 mandible, So maxilla, 85 radius, 118 ulna, US tibia, 481 vertebrue, 485 Breast {see Mamma) Cicatrix — epithelioma of, 213 horns of, 187 keloid of, 56 Clitoris — epithelioma, 211 Colon — carcinoma of, 264, 267 Conjunctiva — angeioma of, 158, 337 dermoid patches, 355 epithelioma, 214 lipoma, 11 moles, 355 Cowper's Gland — carcinoma of, 239 Digits — bursa, 443 chondroma, 18 dermoids, 304 hydatids, 482 lipoma, 4 melanoma, 112 Ducts — functionless, 389 obsolete, 308 Dura mater — dermoids of, 302 Eyeball — carcinoma, 115 cysts (of cornea), 306 cysts (of iris), 305 dermoids, 355 epithelioma, 214 glioma (see Sarcoma) melanoma, 112 sarcoma, 87, 112 504 TUMOURS. Eyelid— coloboma, 295, 357 dermoids, 294 nsevi, 158 Face — angeioma, 15S dermoid, 287 epitheUomii, 191 fissures, 287 keloid, 56 moles, 353 mandibular tubercles, 289 Fallopian tube — adenoma, 276 carcinoma, 27C cysts, 376-378 myoma, 142 Gall bladder— epithelioma, 215 hydrocholecyst, 385 pyocholecyst, 3^6 Gums — epithelioma, 200 fibroma (epulis), 49, 84 sarcoma, 84 Hands — chondroma, 18 cysts (implantatiom) 304 synovial, 439 gauglion, 410 lipoma, 4 melanoma, 112 neuroma, 149 sarcoma, 82 Heart — hydatids, 479 lipoma, 13 Intestine — adenoma, 263 carcinoma, 267 diverticula, 431 fibroma, 52 lipoma, 8 myoma, 143 sarcoma, 78 Jaws— epithelioma, 200 epithelioma (boring), 203 exostosis, 27 fibroma (epulis), 49 odontome, 31 sarcoma (antrum), 84 (of tooth follicle), 85 (periosteal), 84 /myeloid), 85 Joints— hydatids, 482 lipoma, 9 loose bodies (chondromata), 20 synovial cysts, 437 Kidney— adenoma, 252 carcinoma, 250 congenital cysts, 252 hydatids, 473, 480 hydronephrosis, 378 papilloma, 174 pyonephrosis, 385 sarcoma, 96 Labium — • adenoma (Bartholin's glands], 239 aiigeioma, 158 cysts (sebaceous), 234 epithelioma, 211 lipoma, 7 myxoma, 61 papilloma (warts), 168 Lachrjmial gland — chondroma, 92 dacryops, 429 Larynx — angeioma, 161 diverticula, 423 epithelioma, 205 fibroma, 52 lipoma, 10 lympho-sarcoma, 107 papilloma (warts), 171 Lips — angeioma, 158 cysts (mucous), 238 dermoids, 292 epithelioma, 197 lymphangeioma, 165 Liver — adenoma, 250 angeioma, 161 carcinoma, 251 dermoids (secondary), 343 hydatids, 476 Lungs — carcinoma, 238 hydatids, 479 sarcoma (secondary), 72 Mamma— adenocele, 221 adenoma, 221 angeioma, 159 carcinoma (acinous), 222 carcinoma (duct), 228 chondro-sarcoma, 94 cysts (involution), 228 INDEX TO ORGANS. 505 Mamtna {continued). iiydatids, 482 sarcoma, 94 Mucous membrane — angeioma, 160 dermoids, 297, 321 diverticula, 431 epithelioma, 200 moles, 355 myoma, 129 myxoma, 59 papilloma, 171 sarcoma, 78 Muscles — angeioma, 160 sarcoma, 73 Nerves — neuroma, 147 sarcoma, 153 Omentum — colloid disease, 261 cysts, 342, 428 dermoids, 342 hydatids, 483 (Esophagus — diverticula, 435 carcinoma, 260 epithelioma, 203 myoma, 143 papilloma, 171 Orbit— hydatid, 483 lipoma, 11 myosarcoma, 102 neuroma, 149 osteoma, 30 sarcoma, 89 Ovary — adenoma, 257, 339 carcinoma, 257 cysts, 339 dermoid, 340 fibroma, 52 hydrocele, 415 myoma, 141 • pa!pilloma, 399 sarcoma, 94, 123 Palate — Adenoma, 298 dermoid, 297 epithelial pearls, 350 epithelioma, 200 moles, 298 sarcoma, 84 Pancreas — carcinoma, 248 Pancreas {continued). cysts, 426 sarcoma, 92 Parotid gland — adenoma, 248 carcinoma, 248 chondro-sarcoma, 90 cysts (ranula), 426 sarcoma, 90 Penis — carcinoma, 237 epithelioma, 208 horns, 184 papilloma, 168 Parovarium— cysts, 400 Pinna — cysts (sebaceous), 338 dermoids, 337 epithelioma, 206 fistula (sinus), 337 horns, 172 keloid, 56 Pituitary body — adenoma, 316 cysts (infundibulum), 316 dermoids, 316 Prostate — adenoma, 246 carcinoma, 247 Eectum — adenoma, 263 angeioma, 160 carcinoma, 264 dermoids, 321 polypus, 263 Retina (see Eyeball), sarcoma, 87 Sacrum — dermoids, 280 hydatids, 482 lipoma, 14 spina bifida, 460 teratoma, 366, 368 Scalp— angeioma, 163 cephalhydrocele, 457 eephalhaematoma, 454 dermoids, 299 horns, 185 lipoma, 6 meningocele, 451 myoma, 144 molluscum fibrosum, 67 sebaceous cysts, 233 sebaceous adenoma, 236 506 TUMOURS. Scrotum — dermoids, 282 epithelioma, 207 horns, 185 hydatids, 483 hydrocele, 411 lipoma, 7 myoma, 144 Skin- adenoma (sehaceous), 236 angeioma, 158 cysts (sebaceous), 231 dermatolysis, 53 dermoids, 279 epithelioma, 213 fibroma, molluscum, 53, 160 fibroma, simple, 50 horns, 183 keloid, 56 lipoma, 3 lymphangeioma, 164 melanoma, 110 moles, 353 myoma, 144 myxoma, 60 papilloma, 168 sarcoma, 78 Spinal column — hali- vertebra, 470 hydatids, 485 lipoma, 14 osteoma, 25 sarcoma, 82 spina bifida, 459 Spinal cord — glioma, 65 lipoma, 14 myxoma, 150 psammoma, 181 sarcoma, 78 Stomach — adenoma, 259 carcinoma, 259 lipoma, 10 mj'oma, 143 Subserous tissue — angeioma, 161 hydatids, 483 lipoma, 6 myoma, 131, 139 Teeth- fibroma (epulis), 49 odontome, 31 sarcoma, 85 Testicle - adenoma, 257, 406 carcinoma, 257 chondro-sarcoma, 93 dermoids, 282 hydrocele, 411 myo-sarcoraa, 101 sarcoma, 107 Thyroid gland — accessory thyroids, 241, 314 adenoma, 240 bronchocele, 240 carcinoma, 241 cysts, 240 hydatids, 482 Tongue— angeioma, 160 dermoids, 308 epithelioma, 199 ichthyosis, 199 lipoma, 11 lymphangeioma (macroglossia), 165 lympho-sarcoma, 106 sarcoma, 106 Tonsil— epithelioma, 200 lympho-sarcoma, 106 Uterus — adenoma, 272, 275 carcinoma, 273, 275 epithelioma, 212 hydatids, 483 myoma, 126 polypi (myomata), 129 sarcoma, 102 Uveal tract — melano-caroinoma, 115 melano-sarcoma, 112 Vagina^ cysts, 402 epithelioma, 211 my 0- sarcoma, 102 Vermiform appendix — hydatids, 482 INDEX TO TUMOUES. Adenoma — characters of, 218 species of, 219 Fallopian, 276 gastric, 2S9 hepatic, 250 intestinal, 263 mammary, 221 ovarian, 257, 339 parotid, 248 prostatic, 246 rectal, 263 xenal, 252 sebaceous, 236 thyroid, 240, 314 uterine cavity, 275 uterine cervix, 272 Angeioma— characters of, 158 species of, 158 cavernous, 159 nsevus, 158 plexiform, 161 treatment of, 163 arm, 162 of brain, 63 of breast, 159 of conjunctiva, 158, 337 of face, 158 of labium, 158 of larynx, 161 of lip, 158 of liver, 161 of mamma, 159 of mucous membrane, 160 of muscles, 160 of rectum, 160 of skin, 158 of subserous tissue, 161 of tongue, 160 Bursse, characters of, 441 varieties of, 442 bunion, 443 digital, 443 ischiatic, 442 malleolar, 442 prepatellar, 442 stumps, 443 thyro-hyoid, 443 trochanteric, 443 treatment of, 443 Cancer (carcinoma), 219 characters of, 219 dissemination of, 220 species of, 220 breast, 222 ciliary, 115 gastric, 259 hepatic, 251 intestinal, 267 mammarj', 222 ovarian, 257 pancreatic, 248 parotid, 248 prostatic, 247 rectal, 264 renal, 256 sebaceous, 237 testis, 257 thyroid, 241 uterine cavity, 275 uterine cervix, 273 Chondroma, characters of, 17 classification of, 17 species of, 1 7 chondroma, 17 ecchondroses, 18 loose cartilages, 20 of bones, 1 7 of cartilage, 18 of joints, 20 of larynx, 18 Chondrosarcoma {see Sarcoma) Cysts, characters of, 376 classification of, 376 species of allantoic, 395 chyle-cysts, 429 dacryops, 429 Gartnerian, 402 hydroceles, 411 hydrocholecyst, 385 hydrometra, 377 h3'dronephrosis, 378 hydrosalpinx, 376, 418 Miillerian, 409 pancreatic, 426 paroophoritic, 397 parovarian, 400 ranula, 425 testicular, 403, 406 tubulo-cysts, 389 vermiform appendix, 377 508 TUMOURS. Cysts {contimced), vitello-intestinal, 389 of cornea, 306 linger, 304 iris, 305 kidney, 378 labium, 239 lachrj'mal gland, 429 mamma, 228 neck, 327, 419 ovary, 339 pancreas, 426 parotid, 425 pharynx, 316, 432 skin," 233 spinal column, 459 testicle, 403 thyroid gland, 240 Dermoids, characters of, 279 classiiication, 279 genera of, 279 dermoid patches, 353 ovarian dermoids, 339 sequestratioQ dermoids, 279 tuhulo-dermoids, 308 treatment of, 359 of hack, 279 coccyx. 318 conjunctiva, 355 dura mater, 302 face, 287, 353 lingers, 304 hand, 304 inguinal canal, 282 lips, 291 liver, 343 neck, 327 orbit, 293 ovary, 339 palate, 297 pharynx, 326 pinna, 335 pituitary body, 316 rectum, 321 sacrum, 280 scalp, 299 scrotum, 282 spine, 279 sternum, 283 testicle, 282 thorax, 283 tongue, 308 Diverticula, characters of, 431 classification, 376 ganglion, 440 intestinal, 431 oesophageal, 435 pharyngeal, 327, 432 synovial, 437 Diverticula [eontiniied). tracheal, 435 vesical, 431 Diverticulum, trachea of enm, 436 Epithelial Feaxls — dermoids, 350 ovary, 351 penis, 351 Epithelioma, 191 boring, 203 characters of, 191 course of, 194 dissemination of, 196 lymph glands in, 195 mode of origin, 192 terminations of; 195 treatment of, 196 varieties of, 192, 203 of anus, 213 of bladder, 210 of cheek, 200 of clitoris, 211 of conjunctiva, 214 of gall-bladder, 215 of gums, 200 of labium, 211 of larynx, 205 of lips, 197 of mouth, 200 of oesophagus, 203 of palate, 200 of penis, 208 of pharynx, 200 of pinna, 206 of scars, 213 of scrotum, 207 of skin, 213 of tongue, 199 of tonsil, 200 of urethra, 209 of uterine cervix, 212 of vagina, 211 Ti!pithelioma and horns, 184 Exostosis — of femur, 26 of fish, 28 maxilla, 27 subungual, 27 Fibroma, characters of, 49 classification, 50 species of neuro-fibroma, 147 moUuscum fibrosum, 53 simple fibroma, 50 of gum (epulis), 52 of intestine, 52 of larynx, 62 of ovary, 62 INDEX TO TUMOURS. 509 Fibroma {continued). of skin (keloid), 56 of uterus, 52 Glioma, cliaractera of, 63 of cerebrum, 63 crura cerebri, 64 medulla, 64 poDS, 64 retina {see Sarcoma) spinal cord, 65 Guttural pouches of horses, 387 Ilair-fields, 467 HomB, cutaneous, 183 varieties of, 183 cicatrix, 187 nail, 189 sebaceous, 183 wart, 184 Hydatids — characters of, 472 distribution of, 475 geographical, 475 topographical, 475 zoological, 475 treatment of, 485 varieties of, 473 colonies, 473 multilocular, 473 sterile cysts, 473 Hydatid rash, 478 Hydatids of adrenal, 482 of bones, 480 of brain, 483 of breast {see Mamma) of connective tissue, 483 of heart, 479 ■ of joints, 482 of kidney, 473, 480 > of liver, 476 of lung, 479 of mamma, 482 of mesentery, 483 of meso-colon, 483 of meso-rectum, 483 of omentum, 483 of orbit, 483 of pelvis, 483 of pericardium, 477 of peritoneum, 477 of pleura, 477 of scrotum, 483 of spiual canal. 484 of subserous tissue, 483 of thyroid gland, 482 of tunica vaginalis, 483 of uterus, 483 of vermiform appendix, 482 of vertebras, 485 Hydroceles, classification of, 376, 411 canal of Nuck, 416 congenital, 414 encysted, 403 fourth ventricle, 450 funicular, 414 hernial sac, 415 neck, 419 ovary, 415 tunica vaginalis, 411 treatment of, 415 Ichthyosis of the tongue, 199 Keloid, 56 Lipoma, characters of, 3 classification of, 3 treatment, 16 species of, 3 intermuscular, 11 intramuscular, 13 meningeal, 14 parosteal, 13 subcutaneous, 3 submucous, 10 subserous, 6 subsynovial, 9 arborescens, 9 of axilla, 5 of bones, 10 of broad ligament, 8 of fingers, 4 of foot, 4 of hand, 4 of heart, 1 3 of hernial sacs, 6 of jejunum, 10 of joints, 9 of labium, 7 of larynx, 10 of muscles, 13 of neck, 7 of orbit, 1 1 of periosteum, 1 3 of sacrum, 14 of scrotum, 7 of skin, 3 of spinal column, 14 of spinal cord, 14 of stomach, 10 of subserous tissue, 6 of subsynovial tissue, 9 of tongue, 1 1 Lymphangeioma, 164 Myoma, characters of, 126 treatment, 144 of bladder, 143 of broad ligament, 139 510 TUMOURS. Myoma {continued). oH Fallopian tiihe, 142 of intestines, 143 of oei-ophaguH, 143 of ovarian ligament, 141 of ovary, 141 of skin, 144 of stomach, 143 of uterus, 126 varieties of, 126 intramural, 127' submucous, 129 subserous, 131 Myxoma, characters of, 59 claB8i6cation, 59 species of aural polypus. 60 cutaneous myxoma, 60 neuro-myxoma, 147 treatment of, 61 myxomatous disease of chorion, .61 Neural Cysts, 445 hydrocele of fourth ventricle, 450 hydrocephalus, 445 meningocele (cranial), 451 , spina bifida, 459 chissification of, 460 treatment of, 469 Neuroma, characters of, 147 classification, 147 treatment of, 156 species of neuro-flbroma, 147 plexiform, 151 traumatic, 154 of auditory nerve, 149 of brain, 157 of facial nerve, 148 of fifth nerve, 149 of infraorbii nerve, 148 of nmsculo-spiral nerve, 182 of optic nerve, 149 of radial nerve, 149 of sciatic nerve, 153 of stumps, 154 malignant, 153 ganglionic, 1.57 Odontomas — classification, 31 treatment, 48 species of cementome, 34 compound, 36 composite, 41 epithelial, 31 fibrous, 33 follicular, 32 radicular, 38 Osteoma, characters of, 23 classification, 23 treatment, 28 species of, 23 cancellous, 25 compact, 23 of auditory meatus, 24, 30 of frontal sinus, 23 of odontoid process, 25 of orbit, 23, 30 Painful subcutaneous tubercle, 50 Papilloma, characters of, 168 classification, 167 species of cutaneous, 167 intracystic, 173 psammoma, 177 villous, 172 of skin, 168 of larynx, 171 of oesophagus, 171 of peritoneum, 398 of pia mater, 175 of renal pelvis, 1 74 Post-anal dimples, 280 Precancerous conditions, 199 Psammoma — of fourth ventricle, 178 lateral ventricle, 179 spinal membrane, 181 Pseudo- cysts, characters, 431 classification of, 376 genera of buisae, 441 diverticula, 431 hydatids, 472 neural cysts, 445 Sarcoma — characters of, 67 classification of, 67 malignancy of, 67 treatment of, 117 species of alveolar, 70 lympho-, 68, 104 melano-, 71, 108 myeloid, 70, 85, 118 round-celled, 67 spindle-celled, 68 varieties of spindle-celled chondro-sarcoma, 70, 90, 94 fibro-sarcoma, 70 myo-sarooma, 70, 96 of bone, 78 of breast, 94 of digits, 112 of eyeball, 87, 112 of gum, 84 INDEX TO TUMOURS. 611 Sarcoma (continued). of jaw, 83 of kidney, 96 of larynx, 106 of mamma, 94 of mediastinum, 104 of muscles, 73 of nasal septum, 86 of naso-ptarynx, 86 of nerves, 153 of ovary, 94 of parotid, 90, 102 of retina, 87 of skin, 110 of teeth, 85 of testicle, 92, 107 of thyroid, 77 of tongue, 106 of uterus, 102, 135 of uveal tract, 112 Sarcoma [eontiiiiced). of veins, 74 of vagina, 102 Spina bifida — complications of, 487 species of, 460 masked, 464 meningocele, 462 meaingo- myelocele, 461 myelocele, 460 occulta, 464 syringo-myelocele, 461 treatment of, 469 Tails, 471 Teratoma — acardiacs, 371 conjoined twins, 363 parasitic acardiucs, 364 PbINTED by CA93ELL & COMPANY, LIMITED, La BelLE SaUVAOE, LONDON, E.G. 5.29t '"^m