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 HX64066720 
 RD651H181892 Lectures on tumors t 
 
 iimors. 
 
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GASTRIC DERANGEMENTS 
 
 HORSFORD'SACIU PHOSPHATE. 
 
 Unl ke all other forms of phosphorus in combination, such as dilute 
 phosphoric acid, glacial phosphoric acid, neutral phosphate of lime, hypo- 
 phosphites, etc., the phosphates in this product are in solution, and readily- 
 assimilable by the system, and it not only causes no trouble with the 
 digestive organs, but promotes in a marked degree their healthful action. 
 
 In certain forms of dyspepsia it acts as a specific. 
 
 Dr. H R. Merville, Milwaukee, Wis., says: " I regard it as val- 
 uable in the treatment of gastric derangements affecting digestion." 
 
 Dr. E. Osborne, Mason City, la., says: "I consider it a valuable 
 addition to the remedies in use for the relief of gastric disorders depend- 
 ent on enervation." 
 
 Dr. Albert Day, Superintendent of the Washington Home, Bos- 
 ton, says: " For several years I have used it in cases of alcoholism and 
 gastric irritation. It is of special value." 
 
 Dr. T. G CoMSTocK, of the Good Samaritan Hospital, St. Louis, 
 says: ' For soie years we have used it in a variety of derangements 
 characterized by debility, as also in chronic gastric ailments. It is ap- 
 proved of, unanimously, by the medical staff of this Hospital." 
 
 Dr. G. W. Whitney, Marshall, Minn., says: "I have used it in 
 debility of the nervous system, and deranged condition of all the secre- 
 tory organs. I esteem it highly." 
 
 Send for descriptive circular. Physicians who wish to test it will be 
 furnished a bottle on application, without expense, except express 
 charges. 
 
 Prepared under the direction of Prof, E. N, Horsford, by the 
 
 HUMFOED CHEMICAL WORKS, Providence, R. L. 
 
 Beware of Substitutes and Imitations. 
 
 <'A ffTfO\:—Jif nitre the tvovd "■ Florsford's" is Printed on tlie Inbel. 
 All otlii-rs fire »j>iirions. Neiier sold in hulk. 
 
LECTURES ONTUMORS 
 
 FROM A 
 
 CLINICAL STANDPOINT. 
 
 BY 
 
 JOHN B. HAMILTON, M.D., LLD., 
 
 Prof essor of Principles of Surgery and Clinical Surgery, Rush Medical 
 College, Chicago; Professor of Surgery, Chicago Policlinic; Sur- 
 geon, formerly Supervising Surgeon-General, U. S. Marine 
 Hospital Service; Surgeon to Presbyterian Hospital, Chica- 
 go; formerly Professor of Surgery in Georgetown Uiii- 
 versity. Surgeon to Providence Hospital, Etc., Etc. 
 
 FOR THE USE OF STUDENTS. 
 
 SECOND EDITION. 
 
 1892. 
 GEORGE S. DAVIS, 
 
 DRTROIT, MICH 
 
Copyrighted by 
 GEORGE S. DAVIS. 
 
 1893. 
 
 Hi? 
 
PREFACE TO THE SECOND EDITION. 
 
 The fact that a new edition of this book has been called 
 for so soon after its first appearance is a gratifying evidence 
 that it was needed, and that it measurably met the wants of 
 those for whom it was intended. It made no pretense of 
 being exhaustive; it simply dealt with the elementary prin- 
 ciples of the subject, and was intended for students. Ex- 
 tended references to more elaborate works, it was thought, 
 would detract from its simplicity by overloading, and thus 
 tend to create confusion in the minds of beginners in the 
 study. 
 
 The author sincerely thanks the reviewers of the Medi- 
 cal Press who gave the first edition such a very cordial re- 
 ception, and were 
 
 " To its virtues very kind 
 And to its faults a little blind," 
 
 and he sincerely hopes that they will find the second edition 
 an improvement on its predecessor. He also thanks the pub- 
 lisher for the promptness with which the work was pub- 
 lished after the manuscript was placed in his hands. 
 
 John B. Hamilton. 
 United States Marine Hospital, 
 Chicago, Dec. 31, 1891. 
 
PREFACE TO THE FIRST EDITION. 
 
 I have been repeatedly asked by my students to recom- 
 mend a book on Tumors, in English, which would give them, 
 in condensed form, a practical acquaintance with the subject. 
 I was obliged to say I knew of no single treatise which brought 
 together the varieties of tumors set forth in our present no- 
 menclature, and gave the symptomatology and treatment. 
 
 I therefore had a stenographer take the lectures as they 
 were delivered, and, as the colloquial form has thus been 
 preserved, it is thought to bring a little relief to the hard- 
 and-fast lines in which articles on tumors are usually cast. 
 
 Original discovery has not been attempted; but with 
 knowledge of the fact that the subject is always considered 
 a bugbear by the student, the lectures only aim to impart the 
 current information in a form intended to fix it in the memory. 
 
 The experience of the author in over twenty years of 
 surgical practice has been freely made use of, and the state- 
 ments made in the course are naturally such as square with 
 the clinically observed facts. 
 
 For the last ten years the surgical wards of the Provi- 
 dence Hospital have afforded abundant material for the pro- 
 secution of the clinical study of tumors, and a specimen of 
 every tumor removed has been submitted to my friend, Prof. 
 E. M. Schaeffer, the accomplished histologist, for his opinion 
 and remarks. 
 
 In a short time it is proposed to supplement this vol- 
 ume by another on the "Tumors of the Regions," in which 
 the operative surgery will be fully considered. 
 
 As these lectures only give the general pathology, clin- 
 ical history, and treatment of neoplasms, the illustrations are 
 necessarily limited to simple types, with the exception of the 
 remarkable specimens inserted as surgical curiosities. 
 
 John B. Hamilton. 
 924 McPherson Sq., Washington City, 
 October 30, 1890. 
 
DEDICATION. 
 
 This book is respectfully 
 DEDICATED TO THE STUDENTS 
 
 OF THE 
 
 Medical Department 
 
 OF 
 
 Georgetown University, 
 To whom the lectures were originally delivered. 
 
LIST OF ILLUSTRATIONS. 
 
 Frontispiece. page 
 
 Diagram of Ganglion 44 
 
 Parasitic Cyst 66 
 
 Section of Molluscum Fibrosum 79 
 
 Unusual Tumor of the Thigh (Front) 84 
 
 (Back) 85 
 
 Yaws 121 
 
 Small Round-celled Sarcoma 127 
 
 Giant-cell Sarcoma 128 
 
 Spindle-celled Sarcoma 129 
 
 Stroma of Carcinoma 135 
 
 Diagram representing changes taking place during the 
 
 invasion of connective tissue by epithelial columns. 136 
 Case of Epithelioma, starting from Cicatrix of Burn. 139 
 Case of Scirrhus of Neck 141 
 
Representation of a tumor growing nearly the full length 
 of the body. From the Medical Repository, 
 
INTRODUOTIOI^, 
 
 The purposes of diagnosis usually require that 
 the microscope be employed in the examination of 
 specimens. The student wishing to perfect himself in 
 the knowledge of the histology of tumors should 
 make their microscopical examination a part of his 
 course, but it is certain that nearly constant practice 
 in microscopical technique will alone produce satis- 
 factory results. The busy and often overworked prac- 
 titioner has sometimes little inclination to make sec- 
 tions and mount specimens, and oftener has no time 
 to do the work. It thus results that in most places 
 there are within reach physicians devoting themselves 
 especially to microscopy, who may be depended upon 
 for furnishing a diagnosis at short notice and much 
 more accurately than a diagnosis arrived at by imper- 
 fect methods of examination. 
 
 The appliances necessary for the histological ex- 
 amination of tumors are: Jars for temporary preserva- 
 tion of the specimens; preservative fluids; staining 
 fluids; microscope slides and cover-glasses; section 
 cutter, or freezing microtome; watch-glasses; a special 
 razor for cutting sections; forceps; and a good micro- 
 scope. Expensive stands and elaborate stages are not 
 necessary, and scarcely desirable, but the lenses should 
 be good and should well define the edges of the ob- 
 
ject. Four lenses, i inch, ^ inch, ^ inch, and ^^ inch, 
 respectively, will be quite sufficient. 
 
 The easy solubility of the haemoglobin causes the 
 fading of the material in ordinary preservative fluids. 
 Hamilton (of Aberdeen) recommends the following 
 composition: 
 
 " Make a saturated solution of arsenious acid in 
 water by boiling; filter, and, when still warm, mix 
 together equal parts of this, of glycerin, and of meth- 
 ylated spirit. It is well to mix the glycerin and arse- 
 nious acid solution, to heat them, and afterwards to 
 add the spirit. The advantages of this liquid are that 
 it keeps the color of the organs better than spirit, it 
 does not destroy their pliability, and it is a good pre- 
 servative. If several organs are placed in one jar 
 they should be separated by pieces of washed linen 
 cloth; and a piece of the same, soaked in saturated 
 solution of corrosive sublimate, should be placed over 
 them. They should not be steeped long in water 
 before being placed in the preservative; it is usually 
 sufficient simply to wash them. Hearts, livers, kid- 
 neys, lungs, and muscular structures keep beauti- 
 fully in it." 
 
 The fluid above described is only intended for 
 the preservation of organs, as preliminary to section- 
 cutting. 
 
 Before proceeding to cut a section of an organ 
 or pathological specimen it is usually placed in a 
 hardening fluid, and experience has shown the fluids 
 
— 3 — 
 best adapted to each variety. The reagents and solu- 
 tions necessary are as follow: (Altered from D. J. 
 Hamilton.) 
 
 1. Methylated spirit. 
 
 2. Absolute alcohol. 
 
 3. Miiller's fluid. 
 
 4. Miiller's fluid and spirit (i part spirit and 3 
 
 parts Miiller's fluid). 
 
 5. Chromic acid (% to ^ per cent, solution). 
 
 6. Chromic acid and spirit (keep in the dark). 
 
 7. Perosmic acid {}( to ys per cent.). 
 
 8. Gold chloride (^ to 2 per cent.). 
 
 9. Picric acid. 
 
 10. Decalcifying and hardening solution (Ruth- 
 erford). 
 
 The solutions have the following formulge: 
 
 3. Miiller's fluid. 
 
 Potassic bichromate. . . 45 grammes. 
 
 Sodic sulphate 20 grammes. 
 
 Water 2 litres. 
 
 M. 
 
 10. Rutherford's fluid. 
 
 Chromic acid i gramme. 
 
 Water 200 c. c. 
 
 Then add: 
 
 Acid nitric 2c. c. 
 
 Frequent changes of the fluids are necessary 
 when the specimens are bloody, and friction with the 
 
— 4 — 
 tissue is prevented by wrapping each piece in a thin 
 sterilized linen cloth before dropping it into the fluid. 
 When the tissues have been sufficiently hardened to 
 enable a thin section to be cut, the section after cut- 
 ting may then be placed in an appropriate staining 
 fluid. 
 
 I pass over the technique of embedding and sec- 
 tion cutting, for full instructions may now be found in 
 almost any recent work on pathology and in the differ- 
 ent manuals of histology. After cutting the section, 
 before staining, it is usually dropped into a watch- 
 glass containing glycerin. The following carmine 
 solutions are in common use as staining fluids: 
 
 a. Carmine gm. 4. 
 
 Liquor ammon (fort) c. c. 6. 
 
 Water c. c. 120. 
 
 [Z>. y. Hamilton. 
 
 Mix the carmine into a paste with a little of the 
 water in a mortar, add the ammonia, and when thor- 
 oughly mixed, the remainder of the water. 
 
 b. Carmine gm.0.5. 
 
 Sodii bibor. " 2.0. 
 
 Aquse destill c. c. 100. 
 
 M. 
 
 \I). J. Hamilton. 
 
 These are mixed in a porcelain evaporating dish 
 and heated to boiling. To this bluish-red liquid, 
 dilute acetic acid (about 5 per cent.) is added till the 
 
— 5 — 
 color changes and comes to be more like that of 
 ammonia carmine. It is allowed to stand for twenty- 
 four hours, decanted, and is then filtered. A drop of 
 carbolic acid is added to preserve it. 
 
 c . Picro-carmine 
 
 Carmine gm. i. 
 
 \Ranvier. 
 
 Dissolve in to c. c. of water and 3 c. c. liquor 
 ammonise in a mortar, add this to the 200 c. c. cold 
 saturated solution of picric acid. Evaporate either on 
 a water-bath or by exposure to the air, to one third, 
 and filter. 
 
 d. Picro-lithium carmine 
 
 Carmine gm. 2.50. 
 
 \^Friedldnder. 
 
 Dissolve in 100 c. c. saturated solution lithium 
 carbonate. To this add from 2 to 3 c.c. of a saturated 
 solution of picric acid. 
 
 There is also an alum-carmine and an indigo- 
 carmine solution. 
 
 To stain nuclei logwood is used. The following 
 is given by D. J. Hamilton: 
 
 Haematoxylene gm . 12 . 
 
 Alum "• 50. 
 
 Glycerin c.c. 65. 
 
 Distilled water c.c. 130. 
 
 Boil, and while hot add 5 c. c. liquid carbolic 
 acid. This mixture should be exposed to the sun- 
 
— 6 — 
 
 light for at least a month before using. This stains 
 nuclei a most beautiful blue almost instantaneously- 
 after application. After the section has been stained, 
 it may be placed on a slide and examined. 
 
 For directions for making museum preparations, 
 and mounting sections in permanent form, the student 
 is referred to the large works on pathology and his- 
 tology. It is impossible, in the scope assigned to these 
 general lectures, to undertake to give directions for 
 examination of the various micro-organisms and for 
 "smear" preparations, made according to bacterio- 
 logical methods. 
 
LECTURE I. 
 
 GENERAL CONSIDERATIONS. 
 
 We are about to consider one of the most inter- 
 esting subjects in the whole range of surgical topics, 
 and when we think how often the patient's knowledge 
 of his chances for life or death hangs on our diag- 
 nosis of a tumor, whether or not it is malignant, we 
 cannot fail rightly to regard its importance as second 
 to no other. If we will examine the records of the 
 civil hospitals in this and other countries, we will find 
 that tumors of one form or another constitute a very 
 large proportion of all the cases in the surgical wards, 
 outside of the general class of injuries. 
 
 Technically the term tumor is applied to a neo- 
 plasm only, but to conform to the existing nomencla- 
 ture, which includes cysts and hsematomata, we define 
 a tumor to be a generally non-inflammatory, abnormal 
 swelling of some of the tissues of the body, due either 
 to retained secretions, extravasated fluid, or new form- 
 ation. The term tumor, surgically applied, means 
 more than a simple swelling. If that were a true 
 definition, the colloquialism which makes use of the 
 word tumor, to describe the projecting end of a 
 luxated bone, would be correct. 
 
 I have said non-inflammatory, but, our Professor 
 of Pathology will doubtless tell you, it is a moot point 
 whether or not certain new growths have their origin 
 
in the exudation thrown out in the inflammatory pro- 
 cess. True inflammatory products are temporary in 
 their character, and the part in which they are seen 
 has passed through the various stages of inflamma- 
 tion, hypersemia, congestion, and exudation. 
 
 A tumor rarely terminates by a natural process. 
 It grows until removed by the surgeon, or ulceration 
 takes place, or the patient is poisoned through the 
 lymphatics. We may qualify that statement by say- 
 ing that a tumor may occasionally be the seat of an 
 inflammation; pus is formed by the infection and death 
 of the exudate and escapes, the tumor consolidates 
 and contracts. This is necessarily rare and confined 
 to certain non-malignant growths. 
 
 A foreign body is sometimes mistaken for a 
 tumor, when imbedded in the tissues, especially when 
 encapsulated. In one of the European Universities, 
 where the code duello was the rule, it is reported of 
 Dupuytren that a medical student was brought to 
 him, who said he had a tumor which had been grow- 
 ing for some time. He thought it originated from an 
 injury received in a duel. A conical swelling over 
 the buttock was the outward indication. On cutting 
 into the tumor, Dupuytren found the point of a sword. 
 
 The celebrated Professor South, who edited a 
 translation of Chelius, relates a case where a man was 
 in bed smoking a chalk pipe, and while asleep received 
 an injury. Time passed on, and a swelling super- 
 vened. He consulted surgeon after surgeon, until 
 
■finally it was decided that there was a tumor in the 
 ■check, which should be removed. Upon examination 
 it was discovered that a piece of the pipe-stem,' one 
 and one-half inches long, had broken off in the cheek. 
 In the, Museum of the Royal College of Surgeons, 
 London, there is a piece of glass mirror, which was 
 found encysted in a patient's breast. Dr. Jos. M. 
 Toner, of this city, related to me a case where a wax 
 tube (one and three-fourths inches in length) re- 
 mained encysted in the breast for one year. There 
 are numerous examples of these encysted bodies 
 which are likely to be mistaken for tumors. In the 
 Army Medical Museum, at this Capital, you will find 
 a specimen deposited by myself, consisting of exfoli- 
 ated pieces of bone, as large as a grain of rice and 
 upward. These I found, packed together and 
 •encysted in the thigh of a patient. From the history 
 -of the case, they appear to have been the bony debris 
 of an antecedent abscess of the periosteum. 
 
 Chemistry in the diagnosis of tumors is of little 
 use. You will find that the same chemical elements 
 ■enter into the composition of a tumor as into the body 
 in general. With the microscope, however, you have 
 an exact means of diagnosis. Very incorrect ideas 
 prevail about the microscope. Some apparently be- 
 lieve that you can put a small piece of tumor under 
 the glass and at a glance tell just what the specimen 
 is. You cannot do anything of the kind. To use the 
 microscope intelligently you must become an expert. 
 
It is not enough to make a thin section and place it 
 on a slide. One must be familiar with the different 
 forms of cells and animal tissues; and its use requires 
 constant and steady practice. Not one man in a 
 hundred can demonstrate the bacilli of tuberculosis, 
 or the comma bacillus. The specimen must be prop- 
 erly treated by staining in order to render the bacilli 
 visible. This staining process requires a special train- 
 ing. So it is with the diagnosis of tumors. A man 
 must prepare himself, before he can make a correct 
 diagnosis. Many surgeons content themselves with 
 an approximate diagnosis, or bring the services of an 
 expert into requisition, and here, as in most other 
 schools, opportunity will be given you by the Profes- 
 sor of Histology to see all forms of tumors under the 
 microscope. I have made this statement for the 
 simple reason that a man giving a snap diagnosis, in 
 making up his opinion of a tumor, will in many cases 
 make a-mistake, especially if one have a preconceived 
 notion. 
 
 Now let us compare morbid growths with hyper- 
 trophy. In hypertrophy there is no departure from- 
 the normal structure. The hand of a baseball player, 
 the arm of a blacksmith, the leg of a danseuse, are 
 well known examples of hypertrophy. These hyper- 
 plasia are not circumscribed. We see the same in- 
 crease of growth in any organ called ito excessive ac- 
 tion for a considerable time. 
 
NOMENCLATURE. 
 
 The ancients recognized three grand divisions of 
 tumors: Tumores secundum naturam, tumor es supra 
 naturam, and tumores prceter naturamj but in the be- 
 ginning of this century cUnicians had practically 
 agreed on an extremely simple classification of tumors 
 by which they were divided into two great classes: 
 Benign and malignant. It was of practical utility. 
 A benign tumor was one which did not directly destroy 
 life. A malignant tumor was one which, sooner or 
 later, destroyed life. It was, however, found that 
 these classes shaded into one another so that some- 
 times the line was obliterated. It was seen that a 
 tumor which might be " benign " in the beginning be- 
 came " malignant " later on. The advance of anatom- 
 ical knowledge and of knowledge of the development 
 of cells necessitated subdivision. Then the type of 
 structure began to be discussed, and there was in- 
 vented the term " homologous," meaning similar in 
 morphological structure to that of the organ in which 
 the neoplasm grows; and " heterologous," meaning a 
 variation from the normal type of structure. The 
 degree of " heterology " was supposed to represent 
 the degree of malignancy. This proved to be not all 
 the truth. Virchow says: " One cannot, in my opin- 
 ion, distinguish these tumors according to the tissues 
 in such a manner that tumors which inclose in them- 
 selves certain tissues may be regarded as homeoplas- 
 
tic, and those inclosing other types of tissues hetero- 
 plastic; on the contrary, the same species of tumor 
 may be in one circumstance homologous and in the 
 other heterologous — for instance, where you have a 
 hair developed in the stomach or in a vessel wall, or 
 a cartilaginous tumor growing in the muscle; if you 
 have a mucous tumor growing in the bone, such a 
 tumor would be a heterologous tumor — that is to say, 
 a growth which may be like a normal structure, but 
 not like the structure in which it is located." Broca 
 has used the terms " homomorphic " and " hetero- 
 morphic " to denote similarity or dissimilarity of 
 structure. The modern terms homotopia and hetero- 
 topia are perhaps more correct. Now we define 
 hyperplasia as equivalent to the term neoplasm, ex- 
 cept that a neoplasm must be circumscribed— that is, 
 all growths growing from a parent cell from the edges 
 of the tumor. These tumors may be single or multi- 
 ple; we have, for instance, multiple fibromata; these 
 may grow all over the body. I have had a case on 
 which I think there must have been twenty-five tumors 
 of the size of a filbert— so that would be called a mul- 
 tiple tumor. The large cancerous growths are usually 
 single, primarily. So much for the general nomencla- 
 ture, but I shall again revert to this topic when I 
 speak of the classification. 
 
 A tumor's growth varies according to the relative 
 malignancy of the tumor —the more rapid the growth 
 the greater the malignancy. A carcinoma (which is a 
 
— 13 — 
 
 malignant tumor) attains its growth and destroys the 
 life of the patient comparatively soon. This is a very 
 interesting point in the diagnosis, with reference to 
 the future of the patient, and with reference to an 
 operation. If you have a clear case of fibrous tumor, 
 you need be in no hurry about the operation. It does 
 not destroy life, and its growth is comparatively pain- 
 less. In a case of cancer, on the contrary, its growth 
 is rapid, and- surgical interference must be immediate 
 if success is to be hoped for. So that the rapidity of 
 growth of a tumor is a guide to the diagnosis of its 
 variety, and a sure guide to the therapeutics of the 
 case. In regard to the diagnosis of tumors, the con- 
 figuration and outward appearance give you some- 
 thing of an idea of the nature of the case. If it be a 
 chain of glands which is involved, such as those of 
 the groin, axilla, or neck, and there be a clear history of 
 tuberculosis, in that case you know that it is not a ma- 
 lignant tumor. If you find in the breast small nodules, 
 that feel like small filberts, or hard bodies like hazel 
 nuts, but distinctly connected together by connective 
 tissue, then you probably have carcinoma. Then in 
 the cervix uteri, when carcinoma is present, it is com- 
 mon to find nodules. If you put your finger on the 
 side of a raspberry you have almost the same sense of 
 touch. Palpation in -some circumstances does not 
 give you a conclusive conception of' the actual con- 
 dition present. It may have progressed to the stage 
 of abscess, and when that comes you simply feel 
 fluctuation in the tumor. 
 
— 14 — 
 
 The size of the tumor is another element to take 
 into account. I should, in speaking of the configura- 
 tion of the tumor, mention that lipoma and fibroma 
 are usually conical, and may weigh anywhere from a 
 few grains up to fifteen or twenty pounds. They are 
 sometimes to outward view as conical as a sugar loaf. 
 Such tumors frequently have a long pendulous body, 
 pedunculated. Cancerous tumors are generally broad 
 at the base, and not very movable. The mobility of 
 a tumor depends very largely on its site. If it 
 springs from the bone it is fixed and immovable. If 
 it is located on the soft parts it may be movable. 
 Sometimes it is located directly over an artery, and 
 may then be mistaken for an aneurism. The infiltra- 
 tion of the skin and tissues is another guide to the 
 diagnosis of the malignancy or benignancy of a tumor. 
 I doubt the entire propriety of the term "benign." I 
 do not think a tumor, as we understand the term, is 
 meant to be a part of the normal frame; in that sense 
 all tumors are malignant. If you substitute the 
 French term bonne nature, or good natured, for benign, 
 you have an expression of sentiment more properly 
 characterizing those tumors which do not destroy life. 
 The infiltration of a tumor is a pretty fair measure of 
 its malignancy. We have, for instance, the carcino- 
 mata. We find that there is an infiltration or projec- 
 tion of epithelium, with much dense fibrous structure 
 {stroma). The connective tissue is separated later- 
 ally and great pain produced. The intense pain of a 
 
— 15 — 
 cancerous tumor is due to the infiltration of the tis- 
 sues, precisely as if a foreign body were driven into 
 the flesh. That is one direct reason for the pain. We 
 do not find infiltration in a case of fatty tumor. It 
 does not push anything but the skin out of the way. 
 I have now given you a general reason for painless 
 and painful tumors, excepting those composed of 
 nervous tissue, neuromata, which cannot occur with- 
 >out producing great pain. You would suppose that 
 an intra-ocular tumor would be very painful, whether 
 malignant or not, but the rule holds good even here. 
 Then the extent of the growth of the tumor alone pro- 
 duces great pain. I remember a case that I referred 
 to Professor Burnett some years ago. (November, 
 1883.) In that case there was no pain. The patient 
 was unable to see, and there was a growth filling the 
 lower part of the posterior chamber of the globe. 
 The globe was extirpated, and the patient in 1890, 
 5ix years later, was still living in the enjoyment of 
 good health. 
 
 Now as to the color of tumors. They are usually 
 situated under the skin, and not much can be judged 
 from that. There are, however, certain tumors 
 characterized by pigmentous infiltrations, so that two 
 forms of tumor are named from the black pigment 
 (melano-carcinoma and melano-sarcoma). The 
 glandular extension of tumors depends almost entirely 
 upon their malignancy. I will take cancers of the 
 female breast as an example. They are sooner or later 
 
— i6 — 
 
 followed by glandular infection. The fluid follows 
 the lymphatic channels, and the gland itself becomes 
 infiltrated; cancer cells effect a lodgment, and set up 
 a new growth like the original typical structure from 
 which they sprang. Now as to recurrence: You 
 might suppose that rapid recurrence would be evi- 
 dence of its malignity. Not so. You might remove 
 a polypus, and it might recur in a few days. Polypus 
 of the ear may recur very soon; it is the same with 
 uterine polypi. So that the mere recurrence of a 
 tumor is no evidence of its malignity. The site of a 
 tumor is variable; you may have one in almost any 
 structure of the body. The ulceration of a tumor is 
 a matter of time. In the case of a fluid tumor, the 
 pressure of the clothing, any injury to the skin, may 
 produce ulceration. In the case of other tumors, 
 where an inflammatory process has gone on, there 
 will be a breaking down of the tissues, due to inflam- 
 mation, and an abscess will result. The vascularity 
 of these tumors is considerable. Sometimes a tumor 
 will be supplied by a blood vessel of considerable size, 
 and the vessel may grow proportionately with the 
 tumor. In Professor Frank Hamilton's Surgery, he 
 describes a case where he was operating for an exten- 
 sive tumor of the neck. He was explaining to the 
 students there present how easy it was to separate the 
 tumor from the tissues so that no haemorrhage could 
 result. He got ready to lift the tumor out, when a. 
 gurgling sound was heard, and a gush of blood fol- 
 
— 17 — 
 lowed, and he thought he had lost his patient. He 
 found that a large artery was attached to the tumor 
 at the base— a thing that could not have been discov- 
 ered before. He relates how easy it is to be surprised 
 in a case of that kind, so that in operations you .should 
 in all cases be prepared for haemorrhage. Remember 
 that the venous blood vessels are, not uncommonly, 
 abnormally distended. In a sarcomatous growth you 
 will find that the superficial veins are very greatly 
 distended. You can see them swelling through the 
 skin, almost changing the configuration of the tumor 
 by their immense size, their profusion, and tortuous 
 course. 
 
 For our knowledge of the general pathology of 
 tumors we must depend principally upon the micro- 
 scope Tumors may be called typical, that is, com- 
 posed of typical structure— where they are formed of 
 normal tissue. For instance, the fatty, fibrous, carti- 
 laginous, and lymphatic tumors are typical. 
 
 All these are formed from structures like the 
 type from which they are named; they are properly 
 called typical. We may further classify them accord- 
 ing to their constituent structure, as neuromata, 
 lymphangeiomata, angeiomata, myomata, etc. Now 
 the term Ai's/ou/ is applied to this class of tumors; 
 that is to say, where they are composed of a single 
 typical structure. A neuroma is a histoid structure. 
 Then we have the organoid, where there is more than 
 one kind of .structure. The term teratoid is applied 
 
to the highest type of development of these abnormal 
 growths. Also the " combination " tumor of Pro- 
 fessor Gross, which consists of two or more different 
 structures, as naevoid, cystic, fatty, fibrous, calcareous,, 
 or osseous, in the same neoplasm. It is not an infre- 
 quent thing to find several kinds of cells in an ovarian 
 tumor. 
 
 The origin of tumors is sometimes very obscure. 
 They are frequently the direct result of an injury. 
 Polypus of the nasal passage for, example, is apt ta 
 follow an injury to the nasal bones. The so-called 
 cryptorchids, or persons whose testicles have not 
 descended fully, or are lodged in the inguinal canal, 
 are very apt to have carcinoma or sarcoma in the 
 retained testicles, by reason, perhaps, of the pressure 
 of the abdominal muscles; especially if the testicles 
 be partially descended so that they are lodged in the 
 inguinal canal. In regard to the non-traumatic origin 
 of a tumor, we have the cell theory of Schwann, by 
 which the " caudate corpuscles " were the supposed 
 progenitors of the fibres of connective tissue. That 
 is the original theory on which all modern cellular 
 pathology is based. Miiller then followed with a 
 study of morbid growths. Johannes Miiller, you no 
 doubt recollect, was the originator of the term " con- 
 nective tissue." Then Vogel started the dyscrasia 
 theory. That is the theory that the blood alone is 
 principally affected; but, in fact, the solids as well as. 
 the blood are affected. Then the theory of "consti- 
 
— 19 — 
 
 tutional taint;" that is, that ail cancerous growths 
 depend upon constitutional taint, which involves the 
 supposition of congenitally defective cells Then 
 came Virchow (still living, in this year of our Lord 
 1892, and at this time as active as ever), who by the 
 production of his immortal cellular pathology laid 
 down clear lines for the study of abnormal growths 
 His later work on tumors gave a classification which 
 has been adhered to for a quarter of a century almost 
 without change. Virchow adopted the law of Miiller 
 "which is in effect that the substance of all tumors 
 has Its counterpart in some tissue existing normally 
 m embryonic or after life." Cohnheim, the pupil of 
 Virchow, who died in August, 1884, believed that al 
 tumors are congenital. They may exist in all forms 
 and are simply, while undeveloped, stored up for 
 future use, and remain latent until the conditions are 
 favorable for the formation of a new growth Then 
 we have the abnormal "nerve influence" theory that 
 the cell, by reason of some chemical change in its 
 structure, begins the generation of an abnormal brood- 
 but an atypical cell cannot produce a healthy cell It 
 IS impossible, within the intended scope of these 
 elementary lectures, even to glance in passing at the 
 various ingenious theories that have been propounded 
 on the origin of tumors, and we cannot to-day satis- 
 factorily explain that indefinable factor in their pro- 
 duction which we term individual susceptibility We 
 cannot understand, for example, why one of a dozeca 
 
shoemakers, each pounding a piece of sole leather on 
 his thigh, should have a sarcoma of traumatic origin, 
 and all the others escape. So, gentlemen, you need 
 not fear but there are plenty of unsolved problems to 
 engage your highest powers. 
 
LECTURE II. 
 
 CLASSIFICATION. 
 
 In the preceding lecture, I briefly referred to the 
 classification of tumors. I do not pretend to defend 
 the classification on which I shall base the description 
 of these tumors. In fact, I am convinced that the 
 classification is inaccurate, and that it should be 
 changed. Why, then, you naturally say, do you use it? 
 I answer, because it is the nomenclature and classi- 
 fication adopted some years ago by the Royal College 
 of Physicians of London and the American Medical 
 Association. American physicians had a voice in the 
 ' Committee that drew up the nomenclature, at its last 
 revision, and I adhere to it simply for the purpose of 
 uniformity. I am confident that, in many respects, 
 this classification will be changed. My dear friend, 
 Professor Gouley, of New York, in one of the most 
 learned works produced in any language on the sub- 
 ject of medical nomenclature, says of Virchow's classi- 
 fication:* "The high reputation of this great master 
 in patho-anatomy has caused his nomenclature and 
 classification of tumors to be largely accepted by the 
 profession without question. This classification an- 
 swered a good purpose twenty-five years age, and 
 
 * Diseases of Man: their Nomenclature, Classification, 
 and Genesis, New York, 1888, page 334. 
 
was a forward step, but the advances since made in 
 patho-histology forbid its continued use. Neverthe- 
 less, there are many physicians and surgeons who still 
 adhere to this arrangement of tumors. In the present 
 light of science, probably no one sees better than 
 Professor Virchow the faults of this as well as of all 
 other classifications, and if his occupations should 
 permit him to undertake its reconstruction, he would 
 doubtless do so consistently on the anatomical basis 
 which does not abrogate, but rather enforces, Miiller's 
 law. He would probably abandon the word tumor, 
 and reject the hiiematomata, and also the cysts. He 
 would drop the terms histoid and organoid, and place 
 the teratoid growths under the caption terata, and 
 make a very different disposition of the mixed growths 
 ©f his- fourth group." Cornil and Ranvier, in propos- 
 ing their classification, say that their aim has been " to 
 treat simply from the histological pmnt of view, and 
 we have therefore included under the head of inflam- 
 mation and haemorrhage what seemed to us to rightly 
 belong to them, blood tumors; hygromata for example. 
 We also think we have a right to reproach Virchow 
 with having invented new words, drawn from gross 
 physical characters, whereby to designate certain 
 tumors, instead of employing words representative of 
 the tissue. Thus, he uses the word psammoma to 
 signify a tumor of the meninges, because, it contains 
 calcareous granules similar to fine sand, and the word 
 glioma is applied to tumors of the brain, because they 
 
— ^2> — 
 are of a consistency analagous to glue. He thus de- 
 parts from the classification which Miiller's law sug- 
 gests, and which we intend to follow absolutely." 
 
 There is no denying the impeachment in the in- 
 stances cited, but Gouley has pointed out that the 
 authors are themselves inconsistent in many instances. 
 
 Cornil and Ranvier, however, admit that no an- 
 atomical classification can serve to determine the 
 ■degree of the gravity of a tumor, and it must be ap- 
 parent that the correct classification can only follow 
 positive and unchanging facts of histogenesis. Re- 
 cent research has shown us positively that certain 
 forms of tumors are due to the presence of a specific 
 micro-organism, and that a great many of them at the 
 next revision must therefore be taken from the class 
 in which they are now arbitrarily placed by our 
 nomenclature I many particularly mention tubercle, 
 lupus, syphilitic gumma, and leprosy. 
 
 I trust, therefore, that you will take our nomen- 
 clature as an arbitrary one, subject to decennial re- 
 vision, as we now revise the PharmacopiKia; and bear 
 in mind that we already have considerable material 
 for the Committee of Revision. Every man cannot 
 have his own classification, because there would then 
 be no uniformity of terms in medical literature. 
 
CLASSIFICATION OF TUMORS, COMPREHEND- 
 ING MALIGNANT NEW GROWTHS, NON- 
 MALIGNANT NEW GROWTHS, 
 AND CYSTS.* 
 
 CLASSES. 
 
 I. Extravasation Tumors. 
 ir. Transudation and Exudation 
 
 Tumors. )■ CystJ 
 
 III. Retention Tumors. I 
 
 IV. Proliferation Tumors. j 
 Class J. — Extravasation Tumors. 
 
 I. Hsematoma : Synonym, blood- tumor. 
 
 (7. Cystiform. 
 
 d. Parenchymatous.. 
 
 c. Polypoid. 
 
 Class II. — Transudation and Exudation 
 Tumors. 
 
 1. Hygroma: Synonym, watery tumor, or 
 
 dropsy. 
 
 2. Dropsy of bursse mucosae. 
 
 3. Proliferating hygroma of bursse mucosae. 
 
 4. Ganglion. 
 
 [In deference to the needs of the various registration 
 authorities, a distinction has been made in the general and 
 local tables between malignant and non-malignant new 
 
 growths. The tumors are, however, here classified accord- 
 
 01 
 
 * From the last revision of the nomenclature of diseases 
 of the" Royal College of Physicians. 
 
Class III. — Retention Tumors, or Cysts. 
 
 1. Retention in loco formationis. 
 
 a. Ranula. 
 
 b. Parovarian cyst. 
 
 c. Wen: Synonym, sebaceous cyst, or tumor. 
 
 d. Mucocele. 
 
 2. Retention in loco distante. 
 
 Class IV. — Proliferation Tumors. 
 I. Fibroma: Synonym, fibrous tumors. 
 
 Varieties: 
 a. Diffuse. 
 
 I. Elephantiasis. 
 h. Papillary. 
 
 c. Polypoid: Synonym, fibrous polypus. 
 
 I. Molluscum fibrosum. 
 
 d. Tuberous. 
 
 I. Epulis in part. 
 
 e. Bony. 
 /. Keloid. 
 
 ing to their mode of origin and their structure Such a 
 classification involves, in certain cases, the association under 
 one head of malignant and non-malignant growths, as, for 
 instance, under Sarcoma. To facilitate returns under the 
 general tables, the malignant growths are here marked by 
 two asterisks; the names which include both kinds of 
 growth, by one. The classification of tumors, to be com- 
 plete, must include cysts as well as new growths. The 
 cysts are accordingly introduced, but in italics; and should 
 be returned severally among the local affections of organs.] 
 
— 26 — 
 
 2. Lipoma: Synonym, fatty tumor. 
 *3. Myxoma: Synonym, nrucous tissue tumor. 
 
 4. Chondroma: Synonym, cartilaginous tumor. 
 
 Varieties: 
 
 a. Ecchondrosis. 
 *b. Enchondroma. 
 *c. Osteoid Enchondroma. 
 
 5. Osteoma: Synonym, bony tumor. 
 
 Varieties: 
 
 a. Exostosis. 
 
 b. Hyperostosis. 
 
 c. Osteophyte. 
 
 d. Odontoma. 
 
 6. Psammoma: Synonym, brain-sand tumor. 
 
 7. Melanoma: Synonym, pigment-tumor of 
 
 meninges. 
 
 8. Myoma: Synonym, muscle-tissue tumor. 
 
 Varieties: 
 
 Myo-fibroma: Synonym, fibroid tumor of 
 uterus. 
 
 Striped muscle tumor: Synonym, rhabdo- 
 myoma. 
 
 9. Neuroma: Synonym, nerve-tissue tumor. 
 10. Adenoma: Synonym, glandular tumor. 
 
 a. Mucous polypus. 
 
 /'. Chronic mammary tumor: Synonym, 
 
 adenoid tumor. 
 c. Molluscum contagiosum. 
 
— 27 — 
 
 IT. Dermoid cyst. 
 
 12. Angeioma: Synonym, blood-vessel tumor. 
 
 a. Simple: Synonym, teleangeiertasis. 
 
 b. Cavernous: Synonym, naevus. 
 
 1. Arterial. 
 
 2. Venous. 
 
 3. Mixed. 
 
 13. Papilloma: Synonym, warty tumor. 
 
 a. Wart. 
 
 b. Mucous tubercle. 
 
 c. Condyloma. 
 
 d. Urethral caruncle. 
 
 *i4. Glioma: Synonym, neuroglia tumor. 
 15. fGranulation tumors. 
 
 Varieties: 
 
 a. Simple. 
 
 b. Lupus. 
 
 c. Gumma. 
 
 d. Lepra Arabum, or elephantiasis Graeco- 
 
 rum. 
 
 e. Yaws . 
 
 /. Glanders . 
 g. Farcy . 
 h. Tubercle. 
 
 *i6. Lymphoma: Synonym, lymphatic-tissue 
 
 tumor, including lymphadenoma. 
 *i7. Sarcoma. 
 
 f Due to infective organisms. — J. B. H. 
 
— 28 — 
 
 Varieties: 
 
 a. Round-celled. 
 
 I). Spindle-celled. 
 
 c. Melanotic. 
 
 d. Myeloid: Synonym, sarcoma giganto- 
 
 cellulare. 
 
 I. Epulis, in part. 
 
 8. Carcinoma: Synonym, cancer. f 
 
 Varieties: 
 
 a. Epithelioma. 
 
 Sub-variety: Rodent ulcer. 
 
 Note. — Chimney-sweeper's cancer is to be re- 
 turned under epithelioma. 
 
 b. Scirrhus. 
 
 c. Medullary. 
 (/. Melanotic. 
 
 e. Osteoid. 
 
 /. Cylindroid: Synonym, adenoid. 
 g. Colloid: Synonym, reticular or alveolar 
 cancer. 
 
 Syphilis. 
 
 1. Primary: State the part affected. 
 
 2. Constitutional: State if congenital. 
 
 a. Inflammatory and "| 
 
 exudative. 
 , r^ ^ Of parts of body ac 
 
 0. Gummatous. I ^ ■' 
 
 c. Ulcerative and 
 
 destructive. | 
 
 d. Cicatricial . J 
 
 r cording to order of 
 local disease. 
 
 t See page 129. 
 
— 29 — 
 
 I. Grey. 
 
 Tubercle. 
 
 Simple. 
 Inflammatory. 
 Ulcerative and 
 
 destructive. 
 Retrograde and 
 
 cicatricial. 
 
 2. Yellow. 
 
 Simple. 
 Inflammatory. 
 Ulcerative and 
 
 destructive. 
 Retrograde and 
 
 cicatricial. 
 
 1 
 
 I Of parts of body ac- 
 
 I cording to order of 
 
 local disease. 
 
 Of parts of body ac- 
 cording to order of 
 local disease. 
 
LECTURE III. 
 
 EXTRAVASATION TUMORS-H/£MATOMA— TRAN- 
 SUDATION AND EXUDATION TU- 
 MORS— HYGROMA. 
 
 The only one of the extravasation tumors is the 
 hsematoma, or blood tumor. We have three varieties 
 — cystiform, parenchymatous, and polypoid. We have 
 first the haematoma auris — that is, the blood tumor of 
 the cartilage of the ear. This you have in the insane 
 more frequently than in any other class — hence it is 
 usually called the "insane ear." It consists partly of 
 extravasated blood between the perichondrium and 
 the cartilage, is occasionally found in the sane, and is 
 supposed to be due to general cerebral congestion. 
 Then we have pelvic hsematoma, or hsematoma proper. 
 We may have this when the blood is infused in the 
 pouch between the rectum and the uterus. Then 
 haematoma pudendse, situated in the vulva, and gen- 
 erally coming on after labor. Then hsematoma scrotal. 
 Then hsematoma of the cord. 
 
 Pelvic Hamatoma. Strictly speaking, this is not a 
 tumor, but as the classification puts it in this place, we 
 will now consider it. It is frequently taken for pelvic 
 cellulitis. Now remember that pelvic cellulitis is an 
 inflammation of the connective tissue of the pelvis, 
 and haematoma is first due to the rupture of a vein or 
 veins between the ovary and the Fallopian tube, in 
 
— 31 — 
 the broad ligament of the uterus, and takes place most 
 frequently after confinement. It comes with a sharp 
 pain generally, but sometimes there is not much pain. 
 Very rarely there is a chill, whereas in cellulitis the 
 disease is ushered in with a marked and distinct chill 
 (rigor). Now if we look at the anatomical structure 
 of heematoma, we find that the blood flowing out 
 pushes one or more of the coverings of the broad 
 ligament before it until the tumor is gradually formed. 
 It pushes aside the pelvic fascia, presses upon the 
 vagina, or rectum, and then we have what is called 
 pelvic hsematocele. 
 
 It is not proper to speak of haematometra as a 
 tumor, because of the damming iip of the blood in 
 the uterus from an imperforate hymen, as it is simply 
 retention of the blood. When we have pelvic hgema- 
 toma it is due to rupture of the blood-vessels from 
 external or internal violence. The first symptoms are 
 those of internal haemorrhage in general — a blanched 
 appearance, white lips, weakness and debility, rapid 
 pulse, watery condition of the blood, and great thirst. 
 After a while this effused blood becomes encysted by 
 a false " membrane," called the limiting fibrin. Then 
 one of two things happens: Either this blood clot 
 softens, becomes infected, and degenerates into pus, or 
 it becomes absorbed and taken up. In either case there 
 is a subsidence of the tumor. The surgeon rarely 
 sees a case until after coagulation has taken place; 
 for this blood does not remain fluid, but by reason 
 
— 32 — 
 
 of the pressure upon it, or the density of the tissue 
 surrounding it, becomes coagulated, slowly but surely. 
 Then after a while a tumor is formed. Very often an 
 ovarian tumor is suspected. The question will then 
 arise as to the differential diagnosis. As I told you, 
 the history of the case will afford pretty clear indica- 
 tions — the absence of the initial chill, the cessation of 
 pain (for the pain of haematomata does not usually 
 continue); the blood slowly coagulates, and it is a 
 painless swelling. In this case we frequently have a 
 complete anteversion of the uterus, as the blood 
 pushes the uterus forward. In cellulitis the uterus is 
 not necessarily displaced, so that in making a vaginal 
 examination you will find that the swelling is uniform, 
 whereas in hsematoma there is a soft tumor situated 
 just behind the cervix, in the cul de sac. In this case 
 there is no fever, while in cellulitis there is fever. 
 Now; you say, how can we make a diagnosis between 
 pelvic haematoma and hsematometra ? The history of 
 the case, and the imperforate hymen or impervious 
 cervical canal, would show you the difference, and 
 you could probably tell at once what was the matter. 
 There is another point of difference between haema- 
 toma— pelvic haematoma— and pelvic cellulitis, in this, 
 that usually the swelling does not materially increase 
 in haematoma after the tumor is formed. Prognosis: 
 The simple form of haematoma has a tendency to re- 
 covery, but the recovery is always slow. Sometimes 
 the tumor points in the vagina or rectum, rupturing 
 
— 33 — 
 the tissue of those organs and making its appearance 
 externally. Another symptom of pelvic tumors, com- 
 mon to all where they press upon the rectum, is spas- 
 modic, violent tenesmus. Sometimes we have a very 
 severe inflammation of the rectum due to mechanical 
 pressure. 
 
 Pelvic hsematoma, coming on in the male or 
 female after an injury, does not materially differ from 
 the form already described, except that in such cases 
 you have a clear history of the injury. If the disease 
 is not recognized, and surgical interference is not 
 made at this point, there will be recurrence, with ali 
 the disastrous consequences which follow septicaemia 
 or saprsemia, not from coagulated blood, but from 
 blood that has broken down and from the formation 
 of pus. In very rare cases these tumors may origin- 
 ate spontaneously. When we have hsemophiles, or 
 persons having a tendency to haemorrhage in general, 
 the blood does not readily coagulate, death is very 
 speedy, and it occurs from syncope due to interna! 
 haemorrhage. The length of time the patient may 
 live will vary, but usually depends upon the amount 
 of blood poured out. I once saw a case of rupture of 
 the spleen where that organ was torn directly across. 
 There was no external wound. The man lived two or 
 three hours. Upon his death, on opening the abdo- 
 men, a clot of blood was found filling the entire cavity; 
 so that the man lived an unusually long time, consid- 
 ering the amount of blood lost. 
 
 3 WW 
 
— 34 — 
 Treatment : The first indication is rest in a re- 
 cumbent position. This is the primary indication. 
 Then, if the bleeding is still going on, and the coagu- 
 lum not formed (but unfortunately you will be very 
 rarely called at that early stage), you must apply some 
 form of haemostatic, ice into the rectum, etc.; and 
 speaking of ice in the rectum, it may be applied by a 
 gold-beater's skin bag probably better than in any 
 other way; the bag being filled with pounded ice, and 
 put directly into the bowel. There is very little diffi- 
 culty in introducing it, if the anus is first dilated by 
 the finger and the outside of the bag well oiled. As 
 to internal means, we may use acetate of lead and 
 opium, aromatic sulphuric acid, or ergot, which latter 
 is a very valuable remedy for the treatment of 'these 
 cases. I remember a case where gallic acid in com- 
 bination with ergot was used to decided advantage. 
 The man recovered, and I have every reason to be- 
 lieve that it was due to the haemostatic. Another 
 antiphlogistic, apart from rest, is a proper diet. The 
 bowels must be kept very quiet for some days. You 
 must do nothing to create any irritation in them. Do 
 not give cathartics. Do all you can to arrest inflam- 
 mation. You must wait until the coagulation is com- 
 pleted and the tumor consolidated. If you find that 
 after an apparent consolidation it fluctuates, it is 
 proper to open it freely through the posterior wall of 
 the vagina. By a free opening I do not mean a large 
 incision. Take a narrow-bladed knife, or bistoury. 
 
— 35 — 
 •and push it directly upwards into the swelling, and 
 having done so, work your finger in and enlarge the 
 ■wound. Professor Simpson recommended that the 
 trocar and cannula be used, but he later retracted that 
 recommendation, saying that he frequently found the 
 blood too thick to flow through the cannula. He 
 subsequently put in a piece of lint to keep the wound 
 ■open and wash out the cavity. At present I use a 
 -very weak bromine solution, and the ordinary rubber 
 ■drainage tube to keep the wound open. Stimulants 
 are to be given the patient, of course. I had a case 
 in 1885, illustrating the traumatic form, in a patient in 
 the Providence Hospital, upon whom I had performed 
 laparotomy for a gun-shot wound. There was a pel- 
 vic hsematoma pressing on the rectum, and violent 
 tenesmus was present. I passed a knife through the 
 anterior wall of the rectum and evacuated the con- 
 tents of the tumor. The patient finally recovered. 
 
 I have now to speak briefly of pudendal hsema- 
 toma. By hgematoma of the pudendum I mean 
 thrombus of the vulva, which is one of the results of 
 pressure upon the veins of the labia during labor. 
 Sometimes an enlargement of the veins and a swelling 
 of the parts begin prior to labor, and the veins are 
 ■often varicose. Rupture of the veins causesthr ombus 
 and great pain, which require surgical interference. 
 The only treatment is to open the thrombus freely" 
 after the coagulum is formed, and if there is consid- 
 ■erable haemorrhage it should be arrested by pressure. 
 
- 36 - 
 
 The varieties of haematoma are: Cystiform, par- 
 enchymatous, and polypoid. One of the most typical 
 forms of haematoma is scrotal haematoma. This, as 
 its name implies, is an effusion of blood into the scro- 
 tum, and, if you will pardon me for omitting to men- 
 tion it before, I found in the College museum a 
 specimen of an ovarian haematoma which shows the 
 internal structure very beautifully, and is well worth 
 looking at. It was removed by the late Prof. Ash- 
 ford. If you will observe, one of the ovaries seems 
 to be perfectly sound, while the other has apparently 
 taken on a cystiform action. But let us return to the 
 scrotal haematoma. This is nearly always caused by 
 direct violence — a kick or blow, or something of that 
 kind, in the groin. I saw it once produced where a 
 sailor had fallen from aloft and caught on the yard- 
 arm of the main mast, striking his scrotum so that it 
 produced this tumor. The history of the case is 
 almost invariably a history of external injury; and 
 you will find that the swelling comes on almost imme- 
 diately after the injury, the pain not ceasing and the 
 swelling remaining. That forms an element in the 
 diagnosis between scrotal haematoma, sarcocele, orch- 
 itis, hydrocele, and the various other diseases of the 
 testicle and scrotum. In haematocele, the increase in 
 the size of the scrotum is sudden, pointing directly to 
 its cause, the sudden outflow of blood producing it. 
 If the first effect has subsided, it is painless; whereas, 
 if it were orchitis, sarcocele, or any other form of car- 
 
— 37 — 
 
 •cinoma, there would be continuing pain. So that if 
 you find a tumor of the scrotum which has grown 
 suddenly after an injury, with no further tendency to 
 increase, then you may suspect that you have to deal 
 with scrotal haematoma. If you examine the tumor 
 by transmitted light — that is, by placing the patient 
 •on a table and looking directly through the scrotum 
 with' a cylindrical speculum or tube — if it be hydro- 
 cele, it will be translucent, whereas hsematoma will be 
 •nearly opaque, the area of opacity depending upon 
 the amount of coagulation present. Opacity would 
 be found in sarcocele also; but you have the history 
 of the case to guide you, sarcocele being of slower 
 growth and, like hydrocele, keeps on growing. Now, 
 in hernia the diagnosis is made by an examination of. 
 the abdominal rings and by grasping the swelling to 
 •detect an impulse. If it be hernia, and the patient 
 «be directed to cough, the abdominal impulse will be 
 transmitted to the tumor, and can be felt by the fin- 
 gers. In case of scrotal haematoma, there is no trans- 
 mitted impulse on coughing. Then we have hgema- 
 ■toma of the cord, in which the diagnosis is much more 
 clear, but you must depend on the history of the case 
 io correct any errors in the physical examination. 
 The diseases known as bubonocele and varicocele 
 ■may confuse the student. Bubonocele is caused by 
 the projection of a knuckle of the intestine which 
 ■does not pass entirely through the external ring. 
 •Of course that disease must be diagnosed from 
 
- 38 - 
 hsematocele of the cord. You can sometimes get the 
 transmitted impulse in bubonocele, but not always. 
 The tissues surrounding the canal are so dense and 
 fibrous that the transmitted impulse is less distinct. 
 When the contents of the bubonocele consist of omen- 
 tum there is frequently no impulse. If you can pusb 
 the tumor to its natural place so that the swelling en- 
 tirely disappears, it is probably bubonocele and not 
 haematoma. Varicocele consists of a swelling and 
 enlargement of the scrotal veins. The swelling feels 
 like a bunch of angleworms, so they say. I have never 
 felt many angleworms, but that is the way it is said 
 they would feel, if we may believe the text-books. 
 
 In the treatment of scrotal hsematoma and hgema- 
 toma of the cord, you must evacuate the coagulum- 
 unless you should find it disperses of its own accord,, 
 for a simple extravasation usually disappears spon- 
 taneously—but if you find in a few days that it doe? 
 not disappear, you must evacuate it. One of the best 
 means is what Professor Frank Hamilton called a 
 long incision. When the scrotum is swollen, an in- 
 cision three inches long, for example, through the- 
 great retraction will not be more than an inch long — 
 so you need not be alarmed about making a long 
 incision in the scrotum when it is distended, for it 
 retracts fully two-thirds. If the incision has been 
 made and you have turned out the clot, you must 
 clear out the wound, and inject a solution of bichloride 
 of mercury, i to 4000 parts, or the compound solutioa 
 of bromine, and put in a drainage tube. 
 
— 39 — 
 
 There is another form of haematoma, or rather 
 the same form in a different part of the pelvis. Some 
 of the vesical veins sometimes burst and form pelvic 
 haematoma of the recto-vesical tissue. That is always 
 the result of injury. It is scarcely possible to diag- 
 nosticate this form except through the rectum, and 
 even that is quite difficult. 
 
 I will now speak of the cystiform variety. By 
 this we mean any effusion into a cyst by sanguineous 
 exudation from the cyst wall, so that when the con- 
 tents of the cyst are evacuated they seem to con- 
 sist of blood. Sometimes there seems to be a pass- 
 ive exudation of the blood, without any visible 
 rupture. In such cases you will find the cyst walls 
 quite rough, from inflammatory exudations. It com- 
 mences as a sort of vegetative growth. We find 
 sanguineous effusion into the cyst, making cystiform 
 hsematoma, also occurring in hsematoma of various 
 organs of the body, and throughout the serous and 
 synovial sacs generally. The bursae mucosae some- 
 times exhibit this form. Some of the older students 
 of this college will remember a case in the Providence 
 Hospital of a young negress with double " house- 
 maid's knee " — that is, a bursa over each patella. 
 One of them was entirely sanguineous, and seemed t© 
 contain nothing but watery blood. The case was 
 cured. There is no difficulty in curing such cases. 
 The treatment is the same as the treatment of cyst, of 
 which I shall speak hereafter. 
 
— 40 — • 
 
 The next form is the parenchymatous. One of 
 the best known varieties, aside from those collec- 
 tions of blood sometimes formed in one of the solid 
 viscera, such as you find occasionally in the liver, is 
 hsematoma of the heart. It is better known than any 
 other because the heart is most carefully looked after 
 in case of death when a post-mortem follows. So that 
 this disease, haematoma of the valves of the heart, has 
 been brought into considerable prominence. These 
 little tumors are situated chiefly in the edges of the 
 valves, sometimes extending along their entire cir- 
 cumference. Then we have, clinically, valvular mur- 
 mur, and all the symptoms due to valvular disease of 
 the heart. Of course no treatment is of any avail in 
 such a case. 
 
 The polypoid is also quite a rare form of hsema- 
 toma. The most common form is that which origin- 
 ates very rarely after the removal of the placenta. 
 The tumor more frequently occurs in abortion than in 
 natural labor. It varies in size from a filbert to a 
 walnut. It seems to be formed where a portion of 
 the placenta has grown to the uterine wall. Just there 
 a clot is formed, which is pushed out and projects 
 into the uterine cavity, in some cases almost entirely 
 filling it. It is termed polypoid because it is like a 
 polypus in appearance, but it is only apparent, as you 
 shall presently see. 
 
 I will now proceed to class 2:— Transudation and 
 exudation tumors. The chief variety is hygroma, or 
 
— 41 — 
 
 watery tumor, or serous cyst, as it is sometimes called. 
 We have dropsy of the bursse mucosae, proliferating 
 hygroma of bursse, and ganglion. 
 
 First is the hygroma, which is the common watery 
 tumor sometimes called a barren cyst, or watery cyst. 
 Sometimes they are called cysts of dilatation, in order 
 to distinguish them from the cyst proper, which is 
 due to retention. Now let us clearly understand 
 what is meant by dilatation and retention. When a 
 cyst is formed by the damming up of a duct, that is 
 a cyst from retention. A cyst from dilatation means 
 a cyst formed by dilatation from an inflammatory 
 process of the sac wall and an actual increase in the 
 natural fluid produced, so that it does not appropri- 
 ately come under the term " cyst," though ordinarily 
 speaking we would call it such. Hygroma proper is, 
 therefore, different from a diseased bursa. Those 
 cysts that are found along the fascia lata are of this 
 variety. 
 
 A proliferating hygroma is an abnormal struc- 
 ture from the beginning. The contents of the. bursa 
 are constantly augmenting. They push aside the 
 covering tissue, and form new fibrous coverings. 
 They are sometimes traversed by bands of connective 
 tissue, which subdivide them, and they are then 
 called multilocular. Housemaid's knee is one of 
 the most common varieties. The origin of house- 
 maid's knee is very doubtful. If this old skeleton, 
 hanging in our lecture room, were a recent subject 
 
— 42 — 
 
 instead of a dried-up old veteran, we would see that 
 the weight of that knee rested upon the condyles 
 of the femur and the head of the tibia, and not upon 
 the patella. The patella is entirely out of harm's 
 way. So that it is very doubtful if housemaid's knee 
 is caused by working in that position. But the irrita- 
 tion of the quadriceps tendon may produce it. If 
 kneeling were the constant cause, carpet-layers would 
 have it; but they are not predisposed to housemaid's 
 knee. The diagnosis is easily established. Upon 
 pressing the patella from side to side, the tumor 
 moves with it. In enlargement of the joint you must 
 remember that the synovial sac extends two or three 
 inches above the patella; so that if you were to press 
 it at the side and above the patella you 'would find 
 fluctuation. In housemaid's knee you cannot do that. 
 There is no distinct fluctuation behind the patella 
 from side to side above the upper border. All fluc- 
 tuation that you can obtain is from before backwards. 
 Then the configuration of the tumor in case of house- 
 maid's knee is conical. It projects directly in front 
 of the patella. 
 
 The treatment of this affection may be external, 
 or you may be able to produce absorption by the in- 
 ternal use of iodide of potassium and the external 
 application of iodine. It is well to try that in the be- 
 ginning, but usually you must not expect to cure your 
 patients by these means. You may finally cure them, 
 for in the majority of cases the treatment will be that 
 
— 43 — 
 of making an incision into the tumor and evacuating 
 its contents, or by a trocar and cannula and the injec- 
 tion of tincture of iodine. Very frequently you will 
 find the contents consist of thick fluid. In that case 
 the use of the trocar will be impracticable, but a free 
 incision might be made directly into the swelling, or 
 you might inject iodine, passing it freely around into 
 the structure. If the sac is multilocular, great care 
 will have to be taken to reach all parts of the struc- 
 ture. It must be almost completely extirpated, or the 
 disease will recur. 
 
 Dropsy of the bursce. mucosce is an increase in 
 the natural fluids of the part. They are usually 
 chronic and pendulous. They do not give the pa- 
 tient any uneasiness or pain, but they are in the 
 way. Proliferating hygroma of bursse mucosae may 
 sometimes co-exist with sarcomatous growths, and it 
 is very doubtful whether they do not belong more 
 properly to proliferation tumors. When co-existent 
 with a sarcomatous growth, they partake of its nature. 
 The treatment of uncomplicated dropsy of bursa is 
 by free incision; and if there is great haemorrhage 
 from the tumor, it should be treated with the thermo- 
 cautery. • 
 
 Last is the so-called ganglion, which is a simple 
 abnormal swelling caused by an exudation or increase 
 in the synovial fluid. The word ganglion is a mis- 
 nomer as applied to these tumors. The term has not 
 the slightest significance as to the nature of the tumors 
 
— 44 — 
 
 —but they are called ganglions. I think I can give 
 you a little diagram here which will show you the 
 nature of this ganglion. We will say that this broad 
 
 line is a tendon, the sheath of the tendon lying just 
 above it. Now you will observe that this sheath has 
 been pushed up. It is simply a protrusion above the 
 tendon. The sheath is not ruptured; it simply pro- 
 trudes, and raises the skin. The contents of this 
 ganglion do not differ from the natural contents of 
 the §heath, except in amount. They most commonly 
 appear on the tendons on the dorsum of the hand, 
 but I have had under treatment a case where the 
 ganglion was situated underneath the flexor tendon 
 of the index finger, under the palmar fascia. The 
 treatment is almost the same as in the other varieties 
 of hygroma. You may lay them open, but the quick- 
 est and easiest way is to take a book and break them 
 by a sharp blow. The forcible rupture of the ganglion 
 will cause it to disappear; placing a bandage on it 
 with moderate pressure will be sufficient. I saw one 
 at Providence Hospital I was unable to rupture by 
 th£ hardest stroke. It seemed to be multilocular. 
 Failing to rupture it in the usual way, I made an in- 
 cision entirely through the tumor down to the tendon, 
 and laid in a pledget of lint saturated with bichloride 
 of mercury solution, after having first injected tinc- 
 ture of iodine, pressing it about so that the iodine 
 
— 45 — 
 penetrated every portion of the tumor sac. The man 
 made a good recovery. We call the thick fluid " meli- 
 ceris," or honey wax. When the ganglion occurs in 
 the palm you will be unable to rupture it by a blow; 
 incision and injection will be required. 
 
LECTURE IV. 
 
 RETENTION TUMORS. 
 
 At the last lecture we considered the first of the 
 two classes of tumors —extravasation tumors, and 
 transudation and exudation tumors; but I did not 
 quite finish the discussion of that class. I should 
 have said that transudation, exudation, and retention 
 tumors are of the cystic variety, as you may notice by 
 looking at your classification table. Now, what do 
 we mean by "cystic" ? We mean a sack or bag con- 
 taining fluid. In the case of retention tumors, it is 
 simply an extension or distension of the normal mem- 
 brane; in transudation and exudation tumors, the 
 membrane is formed de novo from the inflammatory 
 action, as well as by the proliferation of the edges of 
 the original sac. 
 
 According to the Virchownian classification, the 
 retention tumor is simply a damming up of a duct 
 from some gland, or the retention in the gland itself 
 of matter which is there secreted and usually thrown 
 out. In that case we have a dilatation of the natural 
 sac, and a cyst is formed. 
 
 Cysts may be formed in almost every portion of 
 the body, except perhaps in the substance of the 
 lymphatic glands. It is quite probable that this de- 
 generation may take place in all parts of the body, 
 but it is a fact that the lymphatic glands are notably 
 
— 47 — 
 free from cystic degeneration. Billroth says that 
 closed follicles of the lymphatic glands never give 
 rise to cysts, but "any tissue rich in cells may be 
 transformed into a cyst by metamorphosis of proto- 
 plasm, or, as others express it, by separation of the 
 mucous substance, through cells, without connection 
 with development of the mucous glands." Bone 
 cysts, as you may readily imagine, not having any 
 ■ normal membranous structure, must always originate 
 by softening, and are, therefore, practically exudation 
 tumors. Of the bony cysts to which I will direct 
 your attention, perhaps the most important are those 
 of the upper and lower jaw. These cysts are usually 
 in the beginning multilocular — that is to say, divided 
 into compartments — but finally become monolocular. 
 Sometimes we find them in the upper jaw, constituting 
 a cystic degeneration of the antrum Highmorianum. 
 
 In this cavity the mucous lining first becomes 
 irritated at some point, where a papilla appears 
 and a cystic degeneration takes place.' Sometimes 
 these cysts entirely stud the inside lining mem- 
 brane of the canal. In other instances they coalesce 
 and fill up the antrum, and after a while push out its 
 walls so that the face is much deformed, and the jaw 
 becomes diseased. Sometimes these cystic tumors of 
 the upper jaw spring from the alveolar projection of 
 the socket of the teeth, where the fang projects into 
 the antrum. If ydu examined the inside of the upper 
 jaw, you would see that the fangs of the teeth pro- 
 
- 48 - 
 
 jected deeply into it, covered by the bony alveolar 
 process. Sometimes a cystic degeneration takes 
 place from the alveolar process on the outside. First 
 there is a damming up of a mucous duct, which 
 causes distension, and a cystic tumor is formed. We 
 find it occasionally in the case of delayed or displaced 
 teeth, and sometimes in the case of children, where 
 the temporary teeth have been delayed far beyond 
 the normal period. Occasionally the permanent teeth • 
 are delayed, and a cyst forms, which contains teeth. 
 These are called dentigerous cysts. 
 
 The size of a tumor of the antrum may vary from 
 the size of a pea upwards. Sometimes they will be pro- 
 liferating and hard, and you will scarcely know them to 
 be cysts except by examination after removal. At other 
 times the face is greatly distorted and deformed. The 
 contents of these cysts will be found the usual color 
 and consistency of cystic tumors elsewhere in the body. 
 There is generally a pea-green, albuminous fluid, thin- 
 ner than the white of an egg, which upon examination 
 is sometimes found to be highly albuminous. Some- 
 times the contents of these tumors calcify; chalk con- 
 cretions are formed and disappear; occasionally, by 
 reason of the rapid growth of the cyst and the press- 
 ure of contiguous parts, it creates inflammation, when, 
 by means of the suppurating process, we have a spon- 
 taneous cure. All these cystic tumors, especially the 
 benign class, are of very slow growth, and that is one 
 point in the diagnosis. Where these cystic tumors 
 
— 49 — 
 form in the upper jaw, a bulging will take place which 
 not infrequently forces the hard palate down into the 
 mouth. You can sometimes see that the hard palate 
 is pushed down almost to a level with the teeth, and 
 by the finger you can push into the tumor or feel it 
 fluctuate. These tumors are not painful as a general 
 thing. 
 
 Diagnosis: If you take into account their pain- 
 lessness, their slow growth, the absence of any consti- 
 tutional taint, the character of the fluid on examina- 
 tion, you may give a pretty positive diagnosis as t© 
 the character of the tumor. 
 
 Treatment: There are several methods of treaty 
 ment. You may open the cyst and evacuate the con- 
 tents, trusting to nature for a sufficient amount of 
 inflammation to be caused to complete the cure. Or 
 you may push a trocar into the tumor and evacuate 
 its contents, and then inject .it with iodine. That is 
 perhaps the best method; but you must take care 
 that every part of the diseased membrane is reached 
 by the iodine. When these tumors are very large you 
 will usually find that the simple tapping and injection 
 of iodine will not perfectly cure them; so that you 
 must thoroughly extirpate them with the knife and 
 bone-gnawing forceps, or the curette, arresting any 
 hsemorrhage during the process by means of Pacque- 
 lin's thermo-cautery, or the electric cautery. 
 
 Cystic tumors of the lower jaw usually appear 
 near the upper border of the bone. They usually 
 
— 5° — 
 originate in the cancellous structure of the bone— that 
 is, between the two plates — so that in case of cystic 
 disease of that bone it separates the plates. It is not 
 true, however, that the two plates diverge equally; 
 the inner plate being thinner, the tumor encroaches 
 on the mouth. A cystic tumor of the lower jaw is 
 usually quite painful, owing to the pressure upon the 
 inferior dental nerve at that point, and, perhaps, to the 
 stretching of the nerve. I have spoken of the malig- 
 nant form of cystic tumor, and should tell you, before 
 going into the subject of proliferation tumors proper, 
 that cystic tumors of the lower jaw are very apt to 
 take on malignant forms— that is to say, cancer cells 
 may be developed therein. Multilocular cystoma of 
 the lower jaw is frequently cancerous, so it is very im- 
 portant to make an accurate diagnosis, which can 
 only be done by the aid of the microscope. You also 
 find that in these tumors the ordinary cystic, and I 
 might say the sarcomatous tumor as well, does not 
 recur after extirpation, except in cases of round-celled 
 sarcomata, which are malignant. 
 
 It is only necessary to thrust thp trocar into the 
 cavity of the tumor, evacuate the contents, and inject 
 tincture of iodine. Some surgeons press the bony 
 walls together with the thumb and finger, in order to 
 crush the outer plate; this is not always practicable, 
 although the plate is thin. When a sarcomatous 
 tumor has involved the bone so as to cause its en- 
 largement, you will find it necessary to remove the 
 
— 51 — 
 entire bone, by making an incision, separating the 
 bone at the symphisis, with a chain-saw, and dis- 
 articulating the lower jaw. When the periosteum can 
 be saved, it is very desirable to do so, because a bony 
 'Structure may be formed which will aid in preserving 
 the normal contour, and prevent deformity. If not, 
 you have done no better nor worse than the majority 
 of cases; but you have at least had the satisfaction of 
 curing your patients, for they almost invariably get 
 well after the operation. 
 
 The soft parts also take on cystic degeneration, 
 not only in the softer mucous tissues, but the myoma- 
 tous growths and the various viscera of the body. 
 Speaking of myomatous growths, you know what 
 myomata are ? They are tumors composed of muscu- 
 lar structure, and are very frequent in the uterus. By 
 means of what is known as cystic degeneration, they 
 sometimes soften and become cysts. The glands — 
 the thyreoid, for instance — often become the seat of ^ 
 cystic tumors, which originate in the alveolae of the 
 gland, and gradually distend it. Sometimes a haemor- 
 rhage occurs into the sac, and then they are called 
 haemorrhagic cysts. 
 
 Cystic Bronchocele. This always originates as a 
 minute cyst. It may be as small as a pin-head 
 in the beginning, but greatly enlarges, and finally be- 
 comes an immense cystic growth. When the cysts of 
 the thyreoid gland are very large, they are called thy- 
 reoid goitre. They extend sometimes entirely across 
 
— 52 — 
 the front of the neck, swelHng it and raising the chin. 
 Hemorrhagic bronchocele is comparatively easy tO' 
 diagnose from goitre, because goitre proper is simply 
 a hypertrophy of the thyreoid gland — fibrous goitre. 
 There is no fluctuation in goitre. In a cyst there is- 
 fluctuation, because it is fluid. As to the history of 
 the case, it is proper to say that cystic disease of the 
 thyreoid occurs about as often as goitre in those locali- 
 ties where goitre is prevalent, in some of the valleys 
 of the Alps. Professor Frank Hamilton, in speaking 
 of goitre, said he had occasion to go over to Switzer- 
 land, and wanted to see why goitre was more prevalent 
 in the Alps than in other localities of Europe. He 
 found it most prevalent in those deep valleys where- 
 the sun never shone, where it was continuously damp^ 
 where twilight came early, 'and daylight late. The in- 
 habitants were languid and insufficiently fed; so that 
 not only the climate, but inadequate food, aided in its 
 production. But this is a by-path. Let us return to 
 the cystic tumor of the thyreoid. Like its predeces- 
 sors, its growth is very slow. It is annoying to the 
 patient, not from pain, but fram pressure. Sometimes, 
 it presses on the trachea, and then there is difficulty 
 i n breathing and in swallowing. Whenever you are 
 in doubt as to the precise character of the tumor, use 
 the exploring needle. One of the oldest forms of 
 treatment is by the seton, originated in the time of 
 Celsus; but it is not without danger, principally from^ 
 haemorrhage and septicaemia. In fact, modern anti- 
 
— 53 — 
 :septic surgery practically excludes the seton as a 
 therapeutic measure. Occasionally a blood-vessel or 
 vein is involved, and the vein becomes ulcerated; then 
 we may have phlebitis, and pyaemia follows. Tapping 
 is another method of treatment, but not altogether 
 safe, a case having been reported in which rupture 
 into the larynx and pharynx followed. Tapping, fol- 
 lowed by the injection of iodine, has been more satis- 
 factory, and injection of carbolic acid was practiced 
 by the late Professor Gunn, of Chicago, in cases of 
 cystic goitre, with considerable success. 
 
 Incision into these tumors has been practiced 
 very frequently, but that, like all other methods, is 
 -dangerous, the gland being always vascular. A punc- 
 ture in any part is followed by haemorrhage, and an 
 incision by very great haemorrhage. The larger the 
 cyst, the more formidable it is for treatment by in- 
 cision. If it be treated by incision,- it should be 
 tightly packed with lint, having been previously washed 
 out with the mercuric bichloride solution, or tincture 
 •of iodine injected. Beck, of Freiberg, prefers a much 
 more radical treatment. Freiberg is a place where 
 more of these growths are reported than in any other 
 place in the world. Beck treated thirteen cases by 
 complete extirpation. Two of the cases recovered 
 after a long and tedious suppuration; eleven died. 
 The dangers of the operation do not cease with the 
 closure of the wound, for it has been found that after 
 the removal of the gland myxoedema was apt to fol- 
 
— 54 — 
 low, and Horsley has shown that there is a great con- 
 nection between the mental disease and the loss of 
 the gland. But in cystic disease the gland must 
 necessarily have been previously destroyed by the pro- 
 gress of the disease, so that while the observation of 
 Horsley may hold good in true goitre, it has much> 
 less weight in the cystic goitre. Many other opera- 
 tors have followed this plan. Electrolysis has been' 
 proposed as one of the best means of treatment in 
 these cases; but we must learn a great deal more 
 about electricity before we can treat these tumors- 
 with it successfully. The method of treatment by the 
 electric pole is simply by dissolving the tissue. All 
 that you see is a little greenish fluid about the pole, 
 and a bubbling up of gases. In other words, the tis- 
 sue in contact with the electrode is dissolved into its. 
 original elements. It is as near total annihilation of 
 that tissue as you can well imagine. While I would 
 recommend you to use the thermo-cautery in cases- 
 where the whole gland is involved, I prefer extirpa- 
 tion when they are unilateral. It might be well to- 
 note in passing the occasional success of the treat- 
 ment of solid bronchoceles by the internal use of 
 iodide of potassium and the external use of iodide of 
 lead. The operation of removing one-half the gland., 
 having at its commencement tied the isthmus, is quite 
 satisfactory in the young. It is said that myxoedema 
 does not follow in any case where a portion of the 
 gland is allowed to remain, and I have seen no case 
 
— 55 — 
 of partial extirpation where any serious results fol- 
 lowed this operation. 
 
 Retention Tumors. There are several varieties of 
 these to which I shall hereafter invite your attention: 
 
 a. Ranula. 
 
 b. Parovarian. 
 
 c. Wen. 
 
 d. Mucocele. 
 
 The above class belongs to the true cysts. We 
 will take up retention tumors in the various structures 
 of the body. First, in the skin: The retention cysts 
 of the skin are mostly found about the face and nose, 
 in the ducts of the sebaceous glands. They are little 
 black specks on the face, are called comedones, 
 and are due to the damming up of the sebaceous 
 ducts, and the lodgment of dirt, giving the appear- 
 ance, upon being squeezed out, of a maggot with a 
 black head. This is a true cyst. The trachea, almost 
 the last place where we would expect to find a cyst, is 
 frequently the seat of cystic tumors. The mucous 
 glands throw out the secretion which, by retention 
 from damming of the ducts, forms the cystic tumor of 
 the trachea. The stomach is also occasionally the seat 
 of cystic tumors; the result is hypertrophy of the mu- 
 cous membrane, a gastritis called gastritis mucosum 
 occurs, and, as a result, polypoid growths follow. At 
 the base of these polypoid growths we have the dilated 
 mucous ducts, which dilations become cysts, which can- 
 not be distinguished during life. In the liver we some- 
 
times find similar cysts, supposed to be distensions, 
 being composed of minute bile ducts, containing bile, 
 cholesterin, and other salts. The pancreas has a cyst 
 of the ducts. They become filled with a secretion 
 — the so-called acne pancf'eaticus, sometimes called 
 pancreatic ranula. Once in a while these pancreatic 
 ducts become filled with a chalky concretion, and in 
 that case an inflammatory process results. The intes- 
 tines are occasionally the. seat of cystic tumors, pro- 
 duced by the swelling of the ducts of the intestinal 
 follicles. In speaking of intestinal cysts I have not 
 mentioned cyst of the gall-bladder, due to the forma- 
 tion of a large gall-stone; nor of that due to obstruc- 
 tion in the appendix vermiformis. We have a variety 
 of small pin-headed cysts in the kidney; also in the 
 tubules from interstitial nephritis. These are very 
 small, and can be seen only with the microscope. 
 Finally, in the kidney we may have cysts of the most 
 variable size. We have that peculiar cyst found in 
 the new-born child, hydrops neonatorum. In that 
 case it is enormously enlarged. Cysts of the kidney 
 usually follow chronic inflammation of the otgan — 
 very rarely the acute form. Now, the cysts of the 
 kidney sometimes grow very large, and inflammation 
 is set up; and if the patient lives long enough for 
 suppuration to develop, or for the cyst to acquire con- 
 siderable size, the case may fall into the hands of the 
 surgeon. Simple cysts of the uterus are formed from 
 the retained matter of the utricular glands. The 
 
— 57 — ■ 
 mouths of the ducts of these glands become entirely 
 closed, and the secretion is retained. Sometimes the 
 entire surface becomes so generally obstructed that 
 we have the acne formation, like that of the pancreas. 
 
LECTURE V. 
 
 RETENTION TUMORS, CONTINUED. 
 
 At the last lecture I spoke to you hastily on the 
 cysts of the organs in general, the internal viscera of 
 the body, and referred to that other variety of cysts 
 due to the occlusion of the larger canals, such as 
 the bile duct, and those cysts of the liver due to 
 the occlusion of the smaller tributaries of the main 
 duct, and also of the ureter, or kidney. There are 
 still other varieties of cysts which I mentioned, 
 such as those small cysts due to closure of the 
 ducts, with dilatation of the bronchial and tracheal 
 mucous glands. Dropsical or sacculated bronchiec- 
 tases and trachiectases are simple mucous cysts, due 
 to the occlusion of the mucous glands situated in the 
 trachea and bronchi. They cut a very important 
 figure in diseases of the air passages, but are of little 
 practical interest to the surgeon. 
 
 We will now take up the subject of ovarian cysts. 
 I may say at the commencement that I do not intend 
 to discuss it from the standpoint of the gynaecologist, 
 or go deeply into that field, because the gynaecologists 
 have almost captured that branch of surgery. It is 
 yearly growing less common in the larger cities for 
 the general surgeon to be called upon to perform 
 ovariotomy. 
 
— 59 — 
 I have a couple of specimens here which I wish 
 to show you, that were removed by the late Professor 
 Elliott, and beautifully exhibit the structure of the 
 ovarian cyst, which, as a general thing, originates in 
 the Graafian follicles. It is composed of a very 
 tough, dense, fibrous structure, due to the dilatation 
 and growth of the cyst wall — the proper tunic or sac 
 of the ovary. Now this tumor differs from ovarian 
 dropsy very materially, because the latter was origin- 
 ally an inflammation of the membrane. This, on the 
 contrary, is a cystic degeneration of the follicle, while 
 the dropsy originates in the membrane, and the fluid 
 is the serous exudate. Ovarian cysts generally origi- 
 nate before puberty. Virchow relates the case of a 
 child ten years of age in which the cyst was fully 
 formed. I once assisted Professor J. Taber Johnson 
 in performing Battey's operation for hygroma of the 
 ovary, and in its removal we found not only hygroma, 
 but several young cysts of the size of hazel nuts, 
 which in the course of time would doubtless have 
 developed into fully formed ovarian tumors. I will 
 leave the pathology of the ovarian cyst to the Pro- 
 fessor of Gynsecology, and go on to the diagnosis. 
 In the first place, a faecal accumulation may be mis- 
 taken for an ovarian tumor. In fashionable society 
 it is not very uncommon for young ladies to allow 
 great accumulations in their rectums. It is incon- 
 venient to go to the closet; they become perfectly 
 unconcerned as to results, and finally there is a dis- 
 
— 6o — 
 
 inclination to go to stool more than two or three times 
 a week. This results in the development of an 
 enormous amount of gas and a swelling of the abdo- 
 men. The means of making the diagnosis between 
 ovarian tumor and faecal accumulations will be, 
 knowledge of the history of the case; examination by 
 passing the finger along the wall of the vagina and 
 conjoined manipulation of the abdomen will de- 
 tect the swelling in the bowel caused by the faecal 
 accumulation. A more common -affection, known 
 as pregnancy, has been mistaken for tumor. Of 
 course, you will understand that the general signs of 
 pregnancy will be almost entirely absent in such cases. 
 Fibro-muscular tumors of the uterus are very fre- 
 quently mistaken for ovarian tumors. If you intro- 
 duce a sound into the uterus where there is an extra- 
 mural muscular tumor, it will not pass so far as in the 
 impregnated state; in the former three or four inches, 
 whereas in the pregnant uterus it may pass in eight 
 to twelve inches. In uterine tumors, except fibroids, 
 there is but little change in the menstrual flow. In 
 ovarian tumors the flow usually ceases — not always, 
 however, for, if one ovary remains healthy, the menses 
 are affected in a less degree. Ordinary dropsy is 
 sometimes difficult to diagnose from large ovarian 
 tumor. If the patient be placed on the back in 
 ordinary dropsy there will be a general flattening of 
 the tumor, owing to the fluid passing into all parts of 
 the cavity; whereas, in ovarian tumor there is less 
 
— 6i — 
 
 flattening, because the tumor is firmly held by its sac, 
 and does not flatten by the simple weight of its own 
 contents, as a dropsical accumulation would. Then 
 the history of the case gives pretty conclusive 
 evidence of its nature. You will remember in the 
 one case there had been pain in one or other of the 
 iliac fossae. The growth was slow and the health not 
 generally affected, while in ascites there is little pain, 
 and almost always impairment of the health. The 
 ovarian cells, so-called, have not been found so con- 
 stant as the discoverers claimed they would be in the 
 beginning, so that the microscopical examination is 
 not looked upon as a positive diagnosis. Absence of 
 albumen is said to be another diagnostic point, but 
 this also is fallacious, because you will find that the 
 ascitic fluid is, in a greater or less degree, albumin- 
 ous. Hydatid tumors of the uterus — cystic tumors 
 due to parasites, the echinococcus, etc.; these are also 
 to be differentiated. It is very difficult to make a 
 diagnosis between hydatid and ovarian tumor. It is 
 found, however, on investigation of the history of the 
 case, that when it originated there were some uterine 
 disorders, with pain referred almost entirely to the 
 uterus, and swelling referred almost entirely to the 
 median line. I might mention that upon microscopic 
 investigation of the fluid, which can be obtained by 
 means of an aspirator or hypodermatic syringe, you 
 may see the parasite under the microscope. Hsema- 
 tometra, which is an accumulation of menstrual blood 
 
— 62 — 
 
 from an imperforate hymen or from closure of the 
 cervix, might possibly be confused with uterine hyda- 
 tids in diagnosis. There is still another disorder 
 liable to be mistaken for uterine or ovarian tumor — 
 spurious or phantom pregnancy. This will frequently 
 occur in married ladies past 30 years of age, and more 
 frequently in those who have a great desire to have 
 children. There will be observed the same swelling 
 of the abdomen, frequently quite tense. It may be 
 diagnosticated from tumor by giving an anaesthetic, 
 when the tumor will disappear in spurious pregnancy, 
 and the abdomen immediately flatten. The percus- 
 sion note is quite different in a fluid from a solid tu- 
 mor, and by percussion its outlines may be mapped 
 out. Then, if the wall of the cyst be not very tense, 
 you can get fluctuation. Sometimes in multilocular 
 tumors, and those with thick walls, there will be very 
 little fluctuation, if any. Both of the patients from 
 whom these tumors were removed recovered. In 
 this case there was no fluctuation. The cyst wall 
 was so dense, and firm, and strong, that the only 
 means of making the diagnosis was the history of the 
 case, the contents as disclosed by tapping, and bring- 
 ing the tumor into view during the operation. The 
 exploration of these tumors is best performed with an 
 extra-long exploring needle, the trocar and cannula, 
 or the needle of the aspirator. Aspiration with a fine 
 aspiration needle is perhaps the safest method of 
 making a surgical exploration of them. 
 
- 6^ - 
 
 Treatment: Instances of spontaneous recovery 
 have been reported, but they have usually been pre- 
 ceded by violent rupture of the ovarian cyst, setting 
 up inflammation, suppuration, etc. Tapping is not 
 infrequently the first operation resorted to, and sev- 
 eral cases have been cured by that simple process. 
 A special cannula to prevent the entrance of air 
 should be used. Drainage by the ordinary rubber 
 drainage tube, after tapping, is frequently resorted to. 
 There may be many cases where, from advanced age 
 or feebleness of the patient, tapping must be resorted 
 to. I saw such a case last year, in consultation with 
 Dr. Chamberlin, of this city. The patient, 77 years 
 of age and very feeble, was tapped, and about five 
 gallons of melanotic fluid drawn out. After six 
 months had elapsed the tumor had not refilled. 
 About a gallon of fluid was removed May, 1891. 
 
 Incisions have been practiced and injections of 
 iodine given. Peasley announced that the unilocular 
 cyst was the only form that should be subject to in- 
 cision, because in the multilocular we cannot get 
 inflammatory action to supervene in the smaller divi- 
 sions, whereas in the unilocular the inflammation 
 speedily extends to all parts of the sac. Galvano- 
 puncture is also used; and finally the method most 
 commonly used, that of total extirpation, the opera- 
 tion of ovariotomy. I will not stop to describe that 
 now. 
 
 There is another cyst, known as parovarian cyst, 
 
- 64 - 
 
 which I take up a little out of its regular order for 
 convenience. The parovarian cyst originates in the 
 small Wolffian bodies which form the parovarium. Its 
 symptoms, diagnosis, and treatment do not differ 
 materially from those of the ovarian cyst proper, so I 
 shall not go into its minute description. Professor 
 Thomas relates a case of cyst of the broad ligaments, 
 under which name the parovarian cyst is more com- 
 monly described, in which ovariotomy was performed 
 and both ovaries found entirely normal; so you will 
 see that it is possible for the parovarian cyst to de- 
 velop to a considerable size without any disease of the 
 ovaries being present. 
 
 Entire removal is probably the only treatment 
 practicable. Some expert microscopists claim that 
 the difference in the contained fluids is very consider- 
 able, that of the broad ligament approaching more 
 nearly the ascitic fluid found in dropsy. 
 
 We have still another variety of cyst — the para- 
 sitic. These are formed in consequence ^of the pres- 
 ence of echinococcus, cysticercus, etc., and are found 
 in all parts of the body, frequently in the liver and 
 brain, A case occurred in the Marine Hospital at 
 Detroit, Mich., November 23d, 1882, as reported by 
 Surgeon W. H. Long. The cut shows actual size of 
 the tumor. 
 
 W. G. T., captain of schooner "S. H. Lathrop; " 
 aged 50 years; nativity, New York; was admitted to 
 the United States Marine Hospital at Detroit, Mich.,. 
 
-■65 - 
 
 November 23d, 1882, suffering from hemiplegia of 
 right side, and marked aphasia. 
 
 History: The patient was corpulent and weighed 
 about 225 pounds. He was brought to the hospital a 
 few hours after the onset of the attack, which was 
 ushered in by a severe convulsion and all primary 
 symptoms of apoplexy. Full doses of ergot and 
 potassium bromide were administered, with friction 
 over spine and to extremities. The patient sank rap- 
 idly, and died comatose on the following day, Novem- 
 ber 24th. 
 
 Necropsy: When the skull cap was removed, the 
 meninges were found very much congested, a large 
 quantity of fluid in the subarachnoid space, and 
 connective tissue on surface of brain. The brain was 
 removed, and weighed 63 ozs. (a fraction over 2,000 
 grammes). A careful examination was made to dis- 
 cover an extravasation or ruptured artery, but none 
 was found. The brain tissue was congested, and sur- 
 face of cerebellum infiltrated, but the ventricles con- 
 tained only a trace of fluid. In each lateral ventricle 
 there was found a pedunculated polycystic body, of 
 an elongated and ovoid shape, about two inches in 
 length (figure natural size), and free from any attach- 
 ment, except to choroid plexus. They were lying 
 loose on the floor of each ventricle, and connected 
 with one end was a long stem (pedicle), which sprang 
 from within a large capillary given off from the chor- 
 oid plexus — the attachment above mentioned. These 
 
66 — 
 
 ir 
 
 c 
 
 polycysts were composed of a large 
 number of cysts of varying size, and 
 on examination by the microscope 
 g showed them as containing a large 
 ^ number of small, round bodies on 
 o the mner surface of the cyst walls; 
 S they are of different structure from 
 o the cysts, as shown by their polariz- 
 ■g ing, while the cyst walls do not. It 
 o is believed they were echinococci. 
 ^ While " hydatid " tumors containing 
 t' echinococci are commonly single in 
 ^ the brain, they not infrequently occur 
 g in groups, each group having its ped- 
 g icle, as shown in this specimen. 
 •E Ramda. The next variety of these 
 c cysts to which I shall call your atten- 
 g ♦ tion is the so-called ranula. Exactly 
 B why it is called ranula is one of those 
 ^ things past finding out. It comes 
 B' from "rana," a frog; "ranula," a 
 m little frog. The name, is a very 
 S ancient one, and will have to stand. 
 Columellus, a Roman writer on agri- 
 culture, speaks of a swelling on the 
 tongues of beasts as ranula. . We have it as far back 
 as any history of the disease, and several languages 
 have perpetuated it. Although the French usually 
 speak of it as grenouillette, "a little frog," they also 
 
- 67 - 
 
 'Use the term "ranule." This disease is due to the 
 •damming up of the secretion from sub-maxillary and 
 sub-lingual glands. This is precisely the same form 
 of cyst that I described to you in speaking of pancre- 
 -atic cysts. Ranula is sometimes due to a concretion 
 blocking up some of the ducts or the main excreting 
 duct. When the main duct becomes occluded, there 
 is marked swelling in the mouth, which will sufficient- 
 ly indicate where the obstruction is located. I might 
 •say that when the small canals are unaffected, and the 
 main duct itself obstructed by a stone, it is called a 
 ptyalith. Dermoid cysts in this region are sometimes 
 mistaken for ranula, but the diagnosis is easy if the 
 history of the case and the fluid from the tumor be 
 carefully examined. Sometimes, indeed, they are so 
 enormous that the patient might be said to have what 
 Mark Twain describes as " double chins all the way 
 down to his stomach." In these cases not infre- 
 quently both the sub-lingual and sub-maxillary ducts 
 are occluded. In ranula, the patient will have great 
 difficulty in speaking, owing to the pressure of the 
 tongue up towards the roof of the mouth. He will 
 have this difficulty of speaking, besides the deformity. 
 Ranula is almost always painless. 
 
 Treatmefit: Two or three methods; one, little 
 -used at present, by seton, allowing the fluid to escape 
 gradually along the side of the thread until an inflam- 
 matory process has been set up. Another method is 
 iby excision of a portion of the cyst wall. This has 
 
— 68 — 
 
 been done with scissors, snipping the membrane by 
 thrusting one blade into the tumor and cutting out a 
 triangular section; as soon as the fluid escapes, the 
 tincture of iodide is injected. This is the treatment 
 commonly pursued, and is usually followed by no 
 return of the tumor. Occasionally the retained saliva 
 becomes inspissated, and the tumor requires extirpa- 
 tion. 
 
 The next form of retention tumor — the zuen — 
 simply refers to the collection of sebaceous material; 
 by the closure of a sebaceous duct. They may be 
 single, or occur in groups, and may follow where 
 there has been any outside irritation. I have seen 
 several cases where it seemed as if the pressure of a 
 hat obstructed the sebaceous ducts, and a wen formed 
 directly under the hat-band. They are usually pain- 
 less, however, and only annoying on account of their 
 size and the occasional interference with wearing the 
 hat. Treatment is quite simple — that is, the removal 
 of the cystic tumor. On cutting down through the 
 scalp they are seen as white, shining tumors, easily 
 enucleated from the surrounding tissue, and may be 
 removed by the fingers or scalpel handle without 
 difficulty. The operation is followed by little haemor- 
 rhage. 
 
 ■ Mucocele is that form of tumor or cyst due to 
 retention of mucus from closure of the duct. It is 
 formed wherever there is mucous membrane. Muco- 
 cele of the vagina is usually due to obstruction of the. 
 
- 69 - 
 
 vulvo-vaginal glands. These mucoceles are irritable 
 and very apt to terminate in suppuration. This is 
 due, perhaps, to their anatomical position, which 
 renders them liable to invasion by infective organisms. 
 
LECTURE VI. 
 
 RETENTION TUMORS, CONTINUED— PROLIFER- 
 ATION TUMORS. 
 
 I have not by any means exhausted the subject 
 of cysts. There is one other cyst to which I shall; 
 direct your special attention, and to which I referred: 
 in my last lecture — that is, the galactocele, or milk 
 cyst of the mammary glands. I used to think, and it 
 has been frequently taught, that abscess of the 
 female breast, following parturition, was usually due 
 to neglect on the part of the accoucheur or the nurse. 
 But I am sure that I' have seen these tumors and ab- 
 scesses form in the mammary glands where every 
 precaution was taken; galactocele formed, followed 
 by suppuration — for that is the usual termination^ 
 of these cysts of the mammary glands. They arise- 
 sometimes by reason of a sudden "cold," accom- 
 panied by a rise of temperature, and followed by 
 a closure of the smaller milk ducts; and then, when 
 the milk is dammed up, the gland will be enlarged to 
 a considerable size. There will be a severe rigor; the 
 patient shakes as she would with acute ague. Fever 
 follows the chill, and in a little while the tumor is 
 formed; it proceeds through the various grades of 
 inflammatory action, and abscess results, due to in- 
 flammation of the connective tissue around the milk 
 ducts and subsequent infection. These tumors caa 
 
be usually prevented by pumping out carefully the 
 retained milk from the glands, at the same time having 
 the nurse make gentle pressure both on the lower and 
 upper surface of the gland, rubbing the surface 
 towards the nipple; the danger is thus sometimes 
 averted by the removal of the obstruction. Then a 
 sling may be placed round the breast; this has a 
 tendency to prevent any further accumulation, for it 
 will usually be found that these accidents occur when 
 the patient has been allowed to walk around, and 
 then the weight of the gland and the accumulation of 
 milk has a tendency to produce obstructions. The 
 treatment does not differ from that of ordinary ab- 
 scess. It must be evacuated, provided the milk can- 
 not be drawn out through the natural ducts. 
 
 We now take the fourth class, or proliferation 
 tumors: 
 
 I St. Fibroma: 
 
 a. Diffuse. 
 
 I. Elephantiasis. 
 
 b. Papillary. 
 
 c. Polypoid. 
 
 d. Tuberous. 
 
 I. Epulis. 
 
 e. Bony. 
 /. Keloid. 
 
 The diffuse fibroma is a sub-variety. Then the 
 papillary and the polypoid, of which there is one 
 variety, molluscum fibrosum, and the tuberous with 
 its variety, the epulis; bony, and the keloid. Now, 
 
— 72 — 
 
 recollect that I mentioned in the beginning that the 
 proliferation tumors were the new growths, the true 
 tumors. All tumors, as I said, may be classified into 
 two general forms: Neoplasms and cysts — neoplasms 
 where there is a new. growth, and cysts where there 
 is a retention of fluid. There is another term which 
 makes clear the word proliferation, and that is vege- 
 tation tumors — tumors characterized by budding. In 
 their origin they are due to the preliminary stage of 
 the inflammatory process, the stage of irritation, pre- 
 ceding the congestion. The proliferating tumors 
 exceed in number those of any other of the four 
 classes. There are more than 56 varieties of the pro- 
 liferation tumors under the present classification. 
 They may grow from the cartilage, the bone, the peri- 
 osteum covering the bone, or from any tissue of the 
 body; and the substance of the fibrous tumors may 
 be composed of any one of these structures. So 
 much for the proliferation tumor in general. We will 
 first take up that class of tumors composed almost 
 exclusively of connective tissue; that is, fibrous tissue. 
 The word fibroid is also used to describe the fibrous 
 tumors. The term desmoid has also been proposed, 
 because of its resemblance to the ligamentous tissue. 
 The fibrous tumors are then to be considered as 
 wholly composed of connective or fibrous tissue. 
 Sometimes, however, in the interstices between the 
 fibres, we find cartilage cells and bone cells, or cells of 
 any other natural structure, but they are always natu- 
 
— 73 — 
 ral tissue cells. They may be, according to the Vir- 
 chownian classification, heterologous — that is to say, 
 a cartilage tumor developed in a muscle is a heterolo- 
 gous tumor, because it is developed and grows away 
 from its normal situation, although "the tumor itself 
 may be composed of tissue entirely normal — so there 
 is no departure from the normal type. The seat of a 
 fibroma may be anywhere in the body. The uterus 
 is a favorite seat of fibroid tumors. I will not now 
 stop to describe fibrous tumors, but will say in pass- 
 ing that they are very slow in growth, and very firm 
 in texture, owing to their structure. They are also 
 painless, except where they have developed on the 
 brain, spinal cord, or in the substance of a nerve. The 
 fibromatous neuromata are very painful, and they are 
 the only ones attended by pain. So much for the 
 general characteristics by which they may be recog- 
 nized. When a particular organ is involved, there 
 are special means of diagnosis adapted to the organ 
 in which the fibroma is seated. The first or diffuse 
 form is elephantiasis. The seat of this disease is in 
 the skin. We say it is diffuse because in the more 
 limited form it may be papillary, that is, enlarged 
 papillae, or it may be polypoid, or it may be tuberous, 
 the so-called tuberculosis of skin. We have still an- 
 other variety of the papillary form, known as the ver- 
 rucose or warty fibroma. Elephantiasis, the diffuse 
 variety of fibroma, is a comparatively rare disease. It 
 is usually congenital. Small tumors are formed all 
 
— 74 — 
 over the skin of a particular part. Sometimes it ex- 
 tends over the entire body, but it is usually confined to 
 some particular part, as the leg, arm, scrotum, vulva, 
 or neck. It is conjoined with hypertrophy of the skin, 
 and has various names, according to the country where 
 it originates. Thus we have elephantiasis Grsecorum^ 
 of the Greeks, elephantiasis Arabiim, of the Arabs, etc. 
 There are other forms of elephantiasis, which are said 
 to be endemic in certain countries; elephantiasis Grse- 
 corum and Arabum are not absolutely confined to 
 Greece and Arabia, and hence are not endemic. The 
 Barbadoes leg — Cochin China leg is similar to Barba- 
 does — for example, is found only in the tropics. The 
 form known as spedalsky is very common in Norway 
 and Sweden. All these forms of elephantiasis are 
 something like leprosy. There is, however, a very 
 distinct characteristic by which the two diseases may 
 be recognized, for in leprosy we have an exces- 
 sive tendency to ulceration. Moreover, leprosy is 
 constitutional, having a special bacillus, and therefore 
 inoculable. There is no evidence whatever that ele- 
 phantiasis is contagious in any degree. It is most 
 frequent in men. Elephantiasis commences, when it 
 appears on the scrotum or on the inferior extremities, 
 as a slow inflammation. There is pain, turgescence 
 of the skin, and a tendency to spread; generally there 
 is fever, but not always; the lymphatic glands are hot, 
 swollen, and painful, as well as the lymphatic ducts. 
 There is an exudate — a clear yellowish liquid, which. 
 
— 75 — 
 coagulates slowly, depositing a mass of fibre. If you 
 carefully examine the growth of complete elephantia- 
 sis, if the disease can ever be said to be complete, you 
 will find that it consists of layer upon layer of the 
 fibrous element of the skin, following an inflammatory 
 process. It is true in elephantiasis as in leprosy that 
 the bones become affected. Sometimes, with ele- 
 phantiasis of the leg, the disease affects the perios- 
 teum in such a degree that bony osteophytes are 
 thrust out and bone forms, so much so as to entirely 
 unite the tibia and fibula. I have seen such a specimen. 
 The bony growth had apparently commenced along 
 the interosseous membrane on both sides. In stating 
 that one of the distinctive points between leprosy and 
 elephantiasis was that in leprosy the tendency was 
 towards ulceration, I should say that in certain hot 
 countries elephantiasis ulcerates, but that ulceration 
 is almost entirely local; whereas, in leprosy there is a 
 general contamination of the system, a constitutional 
 taint — the patient has all the appearance of scrof- 
 ula, and eventually becomes worn out by the disease. 
 Again, leprosy may ulcerate at any part of the 
 body— not alone in that which is the apparent seat of 
 the disease; whereas, in elephantiasis it is confined to 
 the part affected. These diffuse forms of fibromata 
 are sometimes soft, notwithstanding on microscopic ex- 
 amination they are found to be almost entirely connec- 
 tive tissue; yet between the fibres there will be found 
 a gelatinous substance constituting the soft, as distin- 
 
- 76 - 
 
 guished from the hard, variety. In the recent investiga- 
 tions of Manson and others, the disease is believed to be 
 produced by the hgematozoon called filaria sanguinis 
 honiinis. Elephantiasis of the scrotum is an example 
 of the soft variety of this disease. This is a very 
 common form of the disease in China. Elephantiasis 
 of the scrotum occupies a very considerable amount 
 of the medical reports of the Chinese Customs medi- 
 cal reports. Sometimes the scrotum grows very large, 
 extending down to the knees —sometimes almost to 
 the feet. In such cases the penis will be entirely 
 hidden. The folds of the skin over the organ will 
 have grown and developed until the penis will be en- 
 tirely out of sight. The testicles cannot be felt. The 
 skin will feel hard and tubercular, and the patient 
 will complain of the immense weight of the tumor. A 
 notable instance occurred in this country — in Alabama, 
 I think — where the tumor was removed, and did not 
 recur after extirpation. In this disease of the scrotum 
 we find that the fibrous tissue is almost always infil- 
 trated with liquid. There does not seem to be much 
 growth in the blood-vessels, but rather in the lymphat- 
 ics. Usually there is a pigmentary discoloration due 
 to the pigmentary glands in the outer layer. They 
 become quite painful through the weight of the scro- 
 tum, and almost always require extirpation. In oper- 
 ating on these tumors it is very difficult to preserve 
 the penis. In the case of which a full report was 
 made in the New York Medical Journal for 1868, a 
 
— 77 — 
 large flap was made directly over the front of the 
 tumor, in which flap the penis was raised. The flap 
 itself was about an inch and a half or two inches long. 
 A sound was passed into the sinus through which the 
 urine had flowed, for the sinus will generally indicate 
 the direction in which the penis will be found. Of 
 course, next to the penis it is important to preserve 
 the testicles. That is a matter of extreme difficulty 
 in these cases of great enlargement. In this case, 
 however, it was successfully done, and the organ and 
 its appendages presented a very creditable appear- 
 ance. So much for elephantiasis of the male organ. 
 Elephantiasis of the female breast was known for 
 some years as " hypertrophy of the breast," but the 
 microscope showed that it was composed of this 
 fibrous structure. They grow very large sometimes, 
 so that the breast hangs down over the front of the 
 belly — sometimes entirely down to the knees. The 
 remedy is the same as for elephantiasis of the 
 scrotum — extirpation. Birkett has observed this dif- 
 ference between hypertrophy of the natural tissues 
 and a tumor, or fibrous growth. He observed that 
 true hypertrophy commenced in the glandular tissue, 
 itself, and that it was a growth of the organ in its 
 entirety, whereas in elephantiasis the growth of the 
 tumor was in the interstitial tissue, between the glands 
 and the integument. The neck is a frequent seat of 
 the soft or lymphatic form of elephantiasis. vSome 
 years ago Dr. Carnochan, of New York, ligated con- 
 
- 78 - 
 
 secutively the common carotid artery, right and left, 
 and the patient recovered. The tumor was very 
 large. It involved the neck on both sides, so that the 
 mouth was scarcely visible, and the chin entirely cov- 
 ered up by the excessive growth of skin, and the neck 
 itself existed only in name. It extended from the 
 clavicle directly upwards, the base towards the clav- 
 icle. The patient recovered. Those of the neck are 
 almost always of the soft variety; that is, where there 
 is a gelatinous infiltration of the fibrous structure of 
 the tumor. 
 
 The papillary form of fibroma is simply hyper- 
 trophy of the papilla in the beginning, but finally a 
 papilla grows out from the cutis, and grows very 
 large. It is sometimes pedunculated; that is, has a 
 foot stalk. It grows late in life. It is not confined, 
 however, to the skin, but is found sometimes in the 
 brain, in the breast, and in the bladder. This form 
 constitutes the so-called condylomata, and is generally 
 multiple. There may be on the surface of the uterus 
 loo or more. The polyoid variety is the fibrous vari- 
 ety as distinguished from the mucous variety. It ori- 
 ginates from the connective tissue lying just under- 
 neath the mucous membrane, and pushes the mucous 
 structure out with it. The mucous polypus is quite 
 soft, and liable to bleed. The fibrous polypus does 
 not bleed. Wherever accessible, the remedy is extir- 
 pation. One of the varieties of polypoid form is the 
 molluscum fibrosum; that occurs all over the body, par- 
 
— 79 — 
 ticularly on the face, neck, and trunk, and is a small 
 tumor, varying from the size of a pea to a walnut, quite 
 
 Section of Molluscum Fibrosum. 
 
— 8o — 
 
 moveable, and entirely painless. I have here a report 
 of a case made by Dr. Hamlin, of Bangor, Maine, 
 found in Marine Hospital Report, 1882. "He sent me 
 the tumor, and through the courtesy of some of my 
 friends in the Navy Medical Department, I had 
 it photographed. It is the only photograph of that 
 kind with which I am familiar. We had a very hand- 
 some heliotype made from it, which I will show you. 
 
 The photograph gives a pretty clear idea of the 
 structure of the tumors. It is not so good as the one 
 in Virchow, but perhaps it represents a different sec- 
 tion of the tumor, this being transverse, whereas that 
 of Virchow is apparently longitudinal in section. A 
 year later Dr. Hamlin reported another case. He 
 says: 
 
 In February, 1882, I had the honor to forward 
 to the Department the report of a case of molluscum, 
 which appeared in the annual report of the Marine 
 Hospital Service for the same year. On November 
 27 last, Charles M. Smith was admitted to the Marine 
 Hospital at this port, suffering from acute cystitis of 
 one week's duration. In making an examination of 
 this patient I at once recognized another case of mol- 
 luscum. Patient's age, 42; height, 5 feet ^}( inches; 
 weight, 130 pounds; figure, spare; birthplace, Boston, 
 Mass. He removed to this State (Maine) when a 
 child, and performed ordinary coarse labor until 
 about 20 years of age, since which time he has been a 
 sailor, sometimes going before the mast, at other 
 times acting as steward. His health had always been 
 good up to the recent attack of cystitis. His family 
 
record revealed no history of morbid growths of any 
 kind. Fifteen years ago he first noticed these tumors 
 on his face and neck, and since then they have from 
 time to tinie appeared on other parts of the body, 
 causing neither pain nor discomfort. These growths 
 were particularly numerous on the face, forehead, 
 neck, trunk. They were fewer in number on the ex- 
 tremities, though as a rule larger in size; several on 
 the left side of the thorax, as well as one over the left 
 patella, ranked among the largest. There were none 
 on the scalp, and, excepting one over the left instep, 
 none below the knees. These tumors were too numer- 
 ous to count accurately, but I estimated that there 
 were about three hundred. In size they varied from 
 a pin's head to that of a large marble. None were 
 pedunculated; some were oval, some dome-shaped, 
 while others were nipple-like in form. To the touch 
 they were rather soft superficially, but fibrous in their 
 interior. It would appear in this case that the ten- 
 dency of the lesions was to increase in number, and 
 to any considerable extent in size. It is interesting 
 to note that the mental powers of this individual were 
 decidedly dwarfed. This patient was unwilling to 
 part with any of the growths, and consequently none 
 could be obtained to examine microscopically. 
 
 These cases are of decided interest. I have m 
 my mind now a medical man whose face and necfc 
 are entirely covered with these fibroid tumors. There 
 is no danger to health from any of the fibromata, with 
 the single exception of the epulis. The tuberous 
 fibroma may be the starting point of epulis. It is 
 simply another form of the fibrous growths, taking its 
 origin from the skin. For the most part, all these 
 
 6 WW 
 
— 82 — 
 
 tuberous fibromata are characterized by multiplicity. 
 It is in this class of tumors that the subvariety of 
 tuberous fibroma is found in the fibrous epulis. This 
 is a small tumor situated on the gum, usually spring- 
 ing from the periosteum of the socket of the tooth. 
 If the tooth be not removed, caries follows, and it is 
 first noticed as a little warty excrescence along the 
 side of the tooth. When the surgeon is called, not 
 infrequently it is found that caustics have been ap- 
 plied, and the tumor is removed down to the gum; 
 feut its rapid recurrence has created alarm on the part 
 ■of the patient, and he thinks that perhaps the growth 
 is cancerous. But, recognizing that the tumor springs 
 from the socket of the tooth, it will be readily seen 
 that the removal to the level of the gum does not 
 prevent recurrence. The proper remedy will be to 
 remove the tooth, and scrape out the tumor from the 
 alveolus. 
 
 There are numerous forms of fibromata that are 
 called by Virchow " heteroplasia," because they have 
 a tendency to form different structures from that in 
 which they grow. For example, osseous fibromata do 
 not proceed from the connective tissue, but from the 
 medullary membrane, or from the periosteum. The 
 last form is the keloid. This usually occurs after 
 burns, or in cicatrices. Some of you may remember 
 a negro who was a patient in Providence Hospital a 
 year or more ago, with an extensive burn of the neck 
 and side of the shoulder. In every one of the scars 
 
- 83 - 
 
 that formed by contraction of the tissiies, a small 
 tumor developed. That tumor was the keloid. It is 
 very liable to recur^after extirpation. It is non-ma- 
 lignant in character, and should cause the patient no 
 annoyance except to appearance. I have seen a great 
 many of these keloid growths growing from the lobe 
 of the ears after piercing for ear-rings. 
 
)tL^ 
 
 Figs. 3-4. — Photograph of an unusual tumor of the thigh (from 
 a Marine Hospital patient). Front. — [Dr. Glennan.] 
 
The same patient. Back. 
 
LECTURE VII. 
 
 PROLIFERATION TUMORS, CONTINUED. 
 
 CLASS 4. LIPOMA, MYXOMA, CHONDROMA, ENCHON- 
 DROMA, OSTEOID ENCHONDROMA. 
 
 By the term lipoina we mean a fatty tumor, that 
 is to say, a tumor composed of normal fat. There 
 was once a term used — steatoma — to designate this 
 class of tumors, but they were confounded with seba- 
 ceous tumors, and there is a great difference between 
 them. The sebaceous cyst is, as you will remember,, 
 a retention tumor. It is due to retention of sebum. 
 There is usually no cholesterin in the fatty tumor — 
 whereas in steatoma there is cholesterin. Lipomata are 
 composed, then, of true fatty tissue. " The fat is con- 
 tained in cells with membrane surrounding it, which 
 cells are generally identical with the ordinary fatty 
 tissue and contain the fat crystals, but they are larger 
 than the fat of the adipose tissue which they join " ( Vir- 
 chow). They are always proliferation tumors; that is 
 to say, they vegetate from neoplasms. " Every lipoma. 
 is lobulated; that is, contains lobules between which are 
 formed the connective tissue and vessels " (Virchow). 
 In ordinary lipoma, a small fatty tumor, the fat greatly 
 predominates over the connective tissue lying between 
 the lobes. But we have several varieties; the fibrous- 
 
— 87 — 
 (for one), where the connective tissue predominates. 
 The lobes are smaller than in the ordinary variety. 
 We may have still another form of lipoma — teleangei- 
 ectatic— where there is an increase in the number 
 and size of the blood-vessels. Then we have the 
 " petrified " lipoma— a calcareous degeneration, and 
 an osseous form. Finally, we have the epiploic lipo- 
 ma, which is lipomatous hernia, so-called, where the 
 epiploon has passed out through the hernial opening, 
 and fatty degeneration or proliferation has com- 
 menced. Lipomata are also named from their shape. 
 Thus we have polypoid lipoma; that is where the 
 tumor has a foot stalk connected with the tissue. 
 Then we have the arborescent, arranged like leaves 
 on the branches of a tree. These tumors may 
 extend into the serous and synovial membranes. 
 So much for the normal varieties. We have also the 
 so-called sclerous form, where there is hardening and 
 induration. Sometimes cartilage cells are thrown out 
 and form one of the so-called cartilaginous tumors, 
 part fat and part cartilage. Sometimes it takes on cre- 
 taceous degeneration. The outer layer becomes almost 
 as calcareous as a calculus in the bladder. Finally,, 
 we have fatty tumors in the parenchyma of the organs. 
 We find them in the liver, in the kidneys, and in the 
 brain. Ordinarily the lipoma is a single tumor, but 
 occasionally you will find a patient who has several 
 tumors in different parts of the body, but they seem 
 to have no connection with each other. Ordinarily, 
 
©besity will possibly degenerate into fatty tumor 
 whenever it projects beyond the body so that the skin 
 is forced out and the fat is no longer in layers, or 
 there is an extra deposition of the fat and it becomes 
 encapsulated — ^^then it is a tumor. But there is tliis 
 differen(?e; let the patient be put on low diet, starva- 
 tion diet, if you please, and the fat which is connected 
 with the general circulation, and is deposited in the 
 natural places, will be taken up, and the patient will 
 become less stout, whereas in lipoma no amount of 
 starvation will diminish the size of the growth. As to 
 the progress of the tumor: Inflammation is somewhat 
 rare; it is painless, and its growth is slow. Occasion- 
 ally, however, from weight and pressure of the cloth- 
 ing, inflammation of adjacent tissues will result. It is 
 usually in mild degree, but occasionally may progress 
 to the formation of pus, ulceration, or even gangrene, 
 from obstruction of the blood-vessels going to the 
 tumor. In the ordinary lipoma, especially where it is 
 in a prominent place, you will find that the skin, if it 
 is rubbed through, causes an ulcer. I have seen a 
 lipoma over the buttock of a young man 22 years of 
 age. There was an opening into it where the skin 
 seemed to have been rubbed through, about the size 
 of a silver dollar, through which the fatty structure 
 could be distinctly seen. It was painless, and through 
 it exuded a serous exudation. That tumor would 
 weigh perhaps 25 pounds, but he was unwilling to let 
 it go, it having been his constant companion for many 
 
years; I could not persuade him to part with it at the 
 time, and I lost sight of him. The treatment of 
 lipoma is extirpation, no remedy having been found 
 that will exercise the slightest influence over its pro- 
 gress or retard its growth. The diseased skin should 
 be removed with it, and every prolongation— every 
 lobule — should be removed, otherwise there may be a 
 recurrence. The next form of tumor is the myxoma, 
 a semi-malignant tumor, to which an asterisk has 
 been affixed in the nomenclature, so that you may 
 know that tumors having that mark are either malig- 
 nant /.?/- se, or may become so from situation. 
 
 Myxomata are the mucous tumors. They differ 
 from the mucous cysts, for which you might confound 
 them if your attention were not directed to them, in 
 this: The mucous cyst is simply an obstruction of a 
 mucous gland, whereas myxoma is composed strictly 
 of mucous tissue. It is not a cyst, but a vegetative or 
 proliferative tumor. These tumors are all soft and 
 painful. They differ from the fibroma,- in that they 
 are composed less of connective tissue than of mucous 
 tissue, and they do not impart that hard feeling that is 
 found in the fibromata. Sometimes we have fluctua- 
 tion in them; that is, where the mucous glands have 
 been stimulated, secretion increased, and mucus ac- 
 cumulated. The myxomata are very frequent in the 
 eye. We have them in that situation as the "hyaline." 
 They may be seen sometimes in the aqueous humor, 
 and are harmless. I think Virchow terms them het- 
 
— 90 — 
 
 erologous; but they are true mucous tissue, although 
 technically heterologous. We term it medullary 
 myxoma where the myxoma starts from the medullary 
 membrane. When a myxoma liquefies, we term it 
 cystoid, because it is like a cyst, although not a true 
 cyst. Whenever the connective tissue predominates 
 over the mucous tissue, it is then termed fibrous myx- 
 oma; and when fat globules predominate, it is called 
 lipomatous. When the cartilaginous prevails, it is 
 called cartilaginous myxoma. So it is with the 
 increase of blood vessels, when it is termed teleangei- 
 ectatic. Then there is the myxoma peculiar to 
 females. We have a myxoma of the placenta, which 
 was formerly called cavernous mole, and hydatids of 
 the placenta, but is now known as myxoma. The 
 heterologous myxoma may be developed in any organ 
 or tissue of the body. The nerve sheaths are very 
 common sites for myxoma, the neuromatous variety. 
 I have spoken of the fibrous tumor of the nerves, the 
 neuroma, so-called. There is also a myxomatous 
 neuroma composed of mucous structure, which gives 
 rise to as much pain as the fibrous neuroma. The 
 diagnosis of myxoma is always uncertain before 
 removal. It usually requires a microscopical exami- 
 nation to determine the nature of this tumor. 
 Usually it does not recur after extirpation, but occa- 
 sionally it does, and then it generally assumes the so- 
 called malignant form. The tumor may not be mal- 
 ignant in its incipiency. It may not be malignant in 
 
— 91 — 
 
 most of its growth; but sometimes a change in the 
 cells commences and a marked departure in the type 
 of its issue, and then the tendency to destroy life is. 
 developed. 
 
 Chondroma. There are three varieties of chon- 
 droma: The ecchondroma, the enchondroma, and 
 the osteoid enchondroma. The ecchondroma is a 
 tumor arising directly from the cartilage. The 
 enchondroma rises from the connective tissue, the 
 bone, or periosteum. We have the ecchondroma 
 most frequently in the larynx and trachea, springing 
 from the cartilage; if on the internal aspect, they 
 speedily destroy life by obstruction of breathing, un- 
 less extirpated. We find it also in the symphysis 
 pubis, where it grows to a great size. Also in the 
 spheno-occipital articulation in the early period of 
 life, springing from the edges of the fontanelle. 
 Death results from perforation of the dura mater. 
 Then we have enchondroma of the intervertebral 
 cartilages, and from the occipital cartilages. We 
 have in the chondroma, as well as the myxoma and 
 lipoma, the so-called heterologous growths. Ecchon- 
 droma may also grow directly from the inter-articular 
 cartilage of the joint. In the first year of my prac- 
 tice I had a case of enchondroma on the finger of 
 the right hand of a farmer, who said the swelling was 
 caused by the plow handle. He consulted several 
 practitioners, and a great many diagnoses had been 
 given. I advised the removal of the tumor. On cut- 
 
— 92 — 
 
 ting down I found a tough, white, dense, fibro-carti- 
 laginous structure, springing from the periosteum. 
 The patient recovered, and the tumor did not recur. 
 I had recently a case of a private patient in Provi- 
 dence Hospital, where the tumor, about the size of 
 a walnut and distinctly cartilaginous, developed on 
 the right thigh, springing from the fascia lata. The 
 cartilage cells, you remember, are from ^w ^^ two 
 inch in diameter. The tumor gave him consid- 
 erable pain by rubbing against his clothing, and 
 was in the way of his hand when he put it in his 
 pocket. He said he almost invariably struck tne 
 tumor. It was removed with some difficulty, owing 
 to its fibrous connective tissue attachments. Enchon- 
 droma, or I may say chondromata in general, are 
 generally non-malignant, but they occasionally recur 
 after extirpation. Mussey reported a case some years 
 ago where ertchondroma commenced in the hand, 
 which was amputated. It followed in the arm, which 
 was amputated, and finally proceeded to the shoulder 
 of the patient, who lost his life. Syme had a case 
 where the shoulder was amputated for enchondroma 
 of the arm, and it recurred in the stump and in the 
 axilla. Virchow reports a case of enchondroma of 
 the scapula where the tumor was removed seven 
 times, and the patient finally recovered. The remedy 
 for this tumor is extirpation. The next variety is 
 osteoid chondroma. This is composed of osteoid 
 tissue, but is more properly classed as an osteo-sar- 
 
— 93 — 
 coma. There is great vascularity in these osteoid 
 enchondromata, and extirpation is the only remedy. 
 In these tumors, wherever the bone is involved, am- 
 putation is the only remedy. 
 
LECTURE VIII. 
 
 PROLIFERATION TUMORS, CONTINUED. 
 
 'OSTEOMA, PSAMMOMA, MELANOMA, MYOMA, NEUROMA, 
 ADENOMA, DERMOID CYST, ANGEIOMA. 
 
 Osteoma. — The next variety of tumor is the 
 osteoma, or bone tumor proper. We have, first, the 
 •eburnated osteoma, where the bone is harder than 
 normal; it diiTers from bone in the apparent absence 
 oi blood-vessels and cancellous tissue; the bony 
 <;anals have become obliterated by the hardening pro- 
 cess. We have in some cases the cancellous or 
 spongy osteoma, which merely differs from the other 
 bony tissue by being a hyperplasia of the normal can- 
 cellous structure, simply an increase of growth. We 
 classify into exostosis, hyperostosis, and osteophytes. 
 Exostosis of the bone is an extra deposition of osse- 
 ous particles, which grow in an irregular shape. 
 Sometimes the bone becomes one-third larger than 
 normal. Now that is entirely homologous — that is, 
 like the normal bone. We have the heterologous 
 class of osteomata in what are termed osteophytes. 
 That is where the bony structure is developed away 
 from the bone. These osteophytes usually grow 
 from the articular cartilages, cartilage cells being 
 formed with the true bony structure. Sometimes 
 •they grow from the connective tissue, but usually 
 
— 95 — 
 from the cartilage. Rarely we find them growing 
 after a fracture. There is what is termed the bony 
 or ossific diathesis; that is, a tendency to produce 
 bone anywhere. We find it occasionally in chronic 
 rheumatism of the articular variety, and in gout. 
 This form rarely falls under the observation of the 
 surgeon unless it becomes so large as to inconvenience 
 the patient. Odontoma is a term applied to an exos- 
 tosis composed of dentine growing from the cement 
 of a tooth. 
 
 Psammoma, the brain sand-tumor, so-called be- 
 cause it is apparently composed of a granular black 
 substance called brain sand, is found principally in 
 the choroid plexus, and in the dura mater. This 
 black cerebral sand is also found in the lymphatic 
 glands, or complicating other tumors by forming in 
 their substance, and it may occur in various forms. 
 It is now known that these tumors contain spindle 
 cells, and are hence classed among the sarcomata; 
 Woodhead called them "angiolithic sarcomata." 
 Sometimes when they grow very large on the choroid 
 plexus or dura mater, they produce pressure, and then 
 the usual cerebral symptoms will manifest themselves. 
 This is one of the tumors wrongly placed in our classi- 
 fication. 
 
 Melanoma. We call this the seventh variety of 
 proliferation tumor. It is the pigment tumor of the 
 meninges. It is to be carefully distinguished from 
 melanotic cancer, which is a pigment encephaloid 
 
- 96 - 
 
 (medullary cancer). Now this melanoma, more prop- 
 erly a melanotic sarcoma, occurs primarily in the pia 
 mater, and in the choroid. It occurs also in the 
 fascia, and in the membranes of the spinal cord, and 
 in the nervous centres of the body. In addition to 
 the choroid, we may find it in the iris, in the con- 
 junctiva, and the skin. In fact, melanoma occurs 
 most frequently in those tissues in which pigment is 
 the normal constituent. There is hypertrophy of the 
 pigment glands, and hyperplasia of the pigment cells. 
 When it contains spindle cells we term it melano- 
 sarcoma, and it is then the most malignant of all the 
 sarcomatous grewths. 
 
 Myoma. This tumor is composed entirely of 
 muscular structure. Both kinds of muscular fibres, 
 the striated and non-striated, enter into it, so that we 
 find it in both the voluntary and the involuntary 
 muscles. When the tumor is composed of striped 
 muscular tissue, it is termed rhabdomyoma, and when 
 of unstriped muscular tissue, it is called leiomyoma. 
 Where there is a great abundance of connective tissue 
 in the myoma, it gives rise to great difficulty in diag- 
 nosis between myoma and fibroma. Where thus mixed^ 
 the tumor is called myo-fibroma. These tumors are 
 non-malignant, and entirely homologous. They fre- 
 quently have. haemorrhage as one of their symptoms,, 
 due to a rapid growth and to the weight of the tumor. 
 It is a passive haemorrhage. It also sometimes takes 
 on cystic degeneration, where the tumor is broken 
 
— 97 — 
 down. We may have the occurrence of teleangeiectasis 
 where the tumor contains an excessive number of 
 anastomosing capillaries or blood vessels. They are 
 sometimes cavernous and sometimes varicose. Car- 
 cinoma occasionally takes the place of myoma. The 
 tumor then becomes infiltrated with epithelial cells, 
 and as the disease departs from the normal type by 
 displacement and degeneration of the muscle cells, 
 becomes true carcinoma; so it is scarcely proper 
 always to say to a patient afflicted with myoma that 
 it is non-malignant, as there is a possibility of the 
 carcinomatous substitution. The liability to this sub- 
 stitution is admitted, but on account of that liability, 
 however limited, it is better to give your prognosis 
 with exceeding care. The most common seat of 
 myoma is in the uterus, and in that situation, owing 
 to the greater abundance of connective tissue between 
 the muscle cells, it takes the form of myo-fibroma. 
 
 The diagnosis is a matter of considerable diffi- 
 culty. They are comparatively slow in growth, which 
 distinguishes them from carcinoma. They are com- 
 paratively painless; another point where they may be 
 distinguished from malignant tumors, which are gen- 
 erally painful. The diagnosis of this tumor from 
 ovarian cyst, which is also painless, and of slow 
 growth, can only be made by the history of the case, 
 the general symptoms, and conjoined manipulation. 
 In ovarian cyst the swelling will have been first 
 noticed in the iliac fossa — in the majority of cases in 
 
— 98 - 
 
 the left iliac fossa. Now, myo-fibroma of the uterus 
 is usually directly in the centre, behind the bladder. 
 Sometimes, if upon the anterior wall of the uterus, 
 there will be great difficulty in retaining the urine in 
 the bladder. A myomatous tumor sometimes be- 
 comes affected by cystic degeneration, and then we 
 have fluctuation, so that it will be almost impossible 
 during the life of the patient to make an accurate diag- 
 nosis. These tumors frequently project in the cavity 
 of the womb, springing from the tissues of the interior 
 wall (intra-mural). In such cases removal by instru- 
 ment is practicable. This is best done by enucleation, a 
 process very similar to taking an onion out of its skin. 
 Various enucleators have been invented, the number 
 of which is a very good sign that there is still room 
 for improvement. Professor Thompson has invented 
 a spoon saw. To reach the tumor, the cervix must be 
 dilated until the cavity of the womb can be reached 
 with ease. Dr. Yarrow has an enucleator which is a 
 claw-shaped spoon with a cutting edge. It is passed " 
 into the tumor, which is gradually gnawed away. 
 Emmett had one like' a thimble, and the operation 
 was done entirely by manipulation with the finger. 
 In case of uterine myoma, where there is great haem- 
 orrhage, and the recurrent periods are characterized 
 by menorrhagia and great ovarian pain, it has some- 
 times been found necessary to perform Tait's or 
 Battey's operation for removal of the ovary. It is 
 well to bear in mind that menstruation does not im- 
 
— 99 — 
 ■mediately cease on removal of the ovary, even when 
 the Fallopian tubes have been removed. 
 
 Now, when these myomata are attached to the 
 external wall of the uterus and the connective tissue 
 to such an extent that they gradually crowd out the 
 muscle-cells, and become in time a true fibromata or 
 fibroid of the uterus. The treatment has always been 
 very unsatisfactory. The treatment by electrolysis 
 according to the method of Apostoli is still sub Judice, 
 but as between that method and the more heroic one 
 of hysterectomy, prudence would indicate first a trial 
 -of the former, leaving hysterectomy for the derniei- 
 ressort. 
 
 The next class of tumor is the Neuroma. Neuro- 
 mata are composed entirely of nervous tissue. Now, 
 4on't make the mistake of calling the fibrous tumor 
 or fibroma which occurs in the nerve-shaft a neuroma. 
 You should make the broad distinction that the neur- 
 oma proper is composed of nervous tissue. In speak- 
 ing of fibroma I told you that there was a tumor 
 which developed upon the nerve itself which was very 
 painful and essentially a fibroma — that is, fibrous 
 "neuroma" in which the nerve-fibres may be seen 
 unchanged passing through the mass of hypertrophied 
 ■connective tissue — but it differs absolutely from true 
 neuroma, which is composed entirely of nerve struc- 
 ture. This neuroma occurs most commonly after 
 amputation when the nerve is cut across. The Pen- 
 sion Office records are full of cases where the pen- 
 
sioner is unable to wear an artificial limb on account 
 of the great pain or neuralgia in the stump. This is 
 usually due to enlargement of the nerve from neuritis. 
 Of course it is highly sensitive. There is usually but- 
 one available remedy, excision of the neuroma, which 
 will generally cure the patient. Sometimes it may be 
 practicable to divide the nerve above the tumor. 
 These irritable stumps may sometimes be very effec- 
 tually treated by dividing all the tissues to the end of 
 the bone-stump. Neuromata never recur after re- 
 moval. Irritable stumps may frequently be prevented;; 
 by taking care during the amputation to pull the nerve 
 and divide it as high up as practicable. 
 
 Neuroma may also be caused by bruises. Pro- 
 fessor Kleinschmidt had a case in this city a few 
 years ago in which I was called to make an opera- 
 tion, where the supra-orbital nerve had been wounded. 
 A man had been struck by a beer-glass on the supra- 
 orbital nerve, finally resulting in most agonizing recur- 
 rent attacks of neuralgia at the seat of the injury,- 
 On examination it was found that the eyebrow had 
 been badly torn. A swelling of the size of a lead, 
 pencil could be felt in the cicatrix. A longitudinal 
 incision was made at the margin of the orbit, the lid 
 drawn down, and the nerve exposed. It was flat- 
 tened and spread over a considerable surface, three- 
 times its normal size. It was removed as far as pos- 
 sible; the pain disappeared, and has never returned., 
 So far as I know, that is the general course of neuro- 
 
ma proper. Where we have facial tic, which is a dis- 
 ease of the dental nerve, sometimes of centric origin, 
 ^ue to ganglionic changes, a resection of that nerve 
 does not cure the patient, because it does not appear 
 that there has been an increase of nerve-tissue at the 
 point where the pain is most acute. It seems to be a 
 longitudinal inflammation of the entire nerve-sheath, 
 so that removal of a section of that nerve, while 
 affording temporary relief, does not cure the disease. 
 
 In tic-douloureux the removal of a section of the 
 inferior dental nerve will usually cure the patient for 
 five or six months. After that it recurs, though some 
 cases are on record where the patients have been free 
 from pain for two years — but I think the invariable 
 history is that it returns. Lately Mr. Rose, of Eng- 
 land, and Professor Andrews, of Chicago, have pro- 
 posed the excision of the Gasserian ganglion. The 
 operation was successfully performed by Mr. Rose. 
 
 Adenoma is a gland tumor — composed of glandu- 
 lar structure. We may find adenoma in any gland of 
 the body, from the pineal down to the lymphatics. It 
 is proper to say, however, that in the gland tumor, or 
 adenoma, there are a variety of mixed forms; adeno- 
 sarcoma, which is produced by the admixture of 
 sarcomatous cells with the gland structure proper; 
 adeno-myxoma, which is a gland tumor with mucous 
 cells intermixed. Under our classification the mucous 
 polypi were classed as adenomata because they were 
 supposed to be a hypertrophy of the mucous glands, 
 
but it is now taught that they are really fibromata^ 
 They originate, according to Hamilton, of Aberdeen,. 
 " in the fibrous tissues of the mucous membrane, and 
 grow in the direction of least resistance, namely, intO' 
 the cavity which the mucous membrane lines. It 
 pushes the epithelium in front of it, and insinuates 
 itself between the glands of the membrane." They 
 may grow in any part of the mucous membrane. They 
 are quite soft to the touch; sometimes translucent^ 
 sometimes pale or opalescent. This is the ordinary 
 polypus of the nares, the uterus, and the external 
 auditory meatus; as -will be seen, it is wrongly placed 
 in the classification. The diagnosis of the adenoma 
 proper is very difficult. It is especially so when the 
 adenoma is in an inguinal gland, when the question 
 whether the disease is due to syphilis or specific in- 
 fection of some kind will arise. The only means of 
 diagnosis in such cases is the history of the case, and 
 if the patient is inclined to prevaricate, you will be 
 obliged to have recourse to anatomical consideration. 
 Of course it is easy to tell bubo from an antecedent 
 gonorrhoea, or chancre from adenoma. Bubo is above 
 Poupart's ligament, and adenoma is below it. Differ- 
 ential diagnosis between adenoma and cancer is very 
 important and very difficult. So far as the patient is 
 concerned, the remedy will usually be the same — ex- 
 tirpation. But it is a great thing to be able to tell the 
 patient that the disease is non-malignant. Now, in 
 adenoma of the mammary gland you should always. 
 
— ;o3 — 
 
 treat it like cancer, for fear of carcinomatous prolif- 
 eration. 
 
 There is another variety of adenoma, known as 
 molluscutn contagiosum, so-called because it was 
 formerly believed to be contagious. It is a homolo- 
 gous epidermic growth. It is situated in the gland 
 adjacent to the hair follicle, and is sometimes called 
 epithelial molluscum, because it is situated in the 
 sebaceous glands. Virchow states that this tumor 
 does not show the fatty glands or oil globules, found 
 in sebaceous tumors. Owing to the great number and 
 variety of the mollusca, extirpation is hardly worth 
 considering, as they involve so great an extent of sur- 
 face. They are precisely like molluscum fibrosum, 
 so far as distribution over the body is concerned. It 
 is now believed that the former growth is due to a 
 micro-organism. 
 
 Dermoid Cyst. This is not a true cyst, because it 
 is not due to damming up of any duct. These cysts 
 contain sebum, the cells of epidermis — that is, pave- 
 ment epithelium — and the walls of the cyst are usually 
 like true skin. Sometimes these tumors contain hairs^ 
 sweat-glands, teeth, etc., and the products of these 
 glands are retained in the cysts, and add to their size 
 and keep the growths constantly increasing. The 
 hair found in these cysts is sometimes very long and 
 in great bunches. This is produced by the hair fol- 
 licles found in the cyst wall. Teeth are sometimes 
 found in them, encased in bone. Sometimes the 
 
— I04 — 
 
 teeth are loose. The reason why it has been classed 
 as a proliferating tumor is because of the growth of 
 these dermoid appendages. It is nearly always con- 
 genital, but it was formerly supposed that the der- 
 moid cyst was due to an undeveloped foetus. This 
 is disproved by very many things, one of which is 
 that as many as one hundred teeth have been found 
 in one cyst — enough teeth for a great many foetuses. 
 It is usually found in the ovaries, and the treatment 
 is the same as for other ovarian cysts; it has also 
 been found in the orbit of the eye, in the testicle, and 
 in the mouth. 
 
 Angeioma is a tumor composed mainly of newly- 
 formed blood-vessels, or of blood-vessels with newly- 
 formed elements in their walls. We have the simple 
 angeioma, the cavernous, venous, arterial, and mu- 
 cous. The names will give you an indication of the 
 pathology of that form of tumor. Simple angeioma 
 is an enlargement of all the blood-vessels of the part 
 constituting the tumor. Cavernous angeioma is ap- 
 plied to that form where the vessels are greatly dilated, 
 the form usually taken on by nsevus, or mother's mark. 
 The sub-varieties of cavernous are arterial, venous, 
 and mucous. The simple angeioma is a vascular 
 tumor, from which comes the term Teleangiectasis. 
 The common seat of the angeioma is the face and 
 neck. You may often see patients on the street with 
 the simple variety, the growth spreading over the en- 
 tire cheek, or any part of the skm of the face. They 
 
— I05 — 
 
 are best treated by subcutaneous ligation. They are 
 also treated by cauterization and by electrolysis. 
 Angeiomata are occasionally coexistent with sarcoma. 
 A sailor came to me Feb. 2 2d, 1877, having an immense 
 angeioma directly between the shoulders, over the 
 spine. It projected considerably beyond the surface, 
 and was congenital, but lately had given him some 
 pain by reason of its increased size. I passed a 
 needle directly through it, with a double ligature, in 
 one direction, and another at right angles, also armed 
 with a double ligature. The ends were then cut, and 
 the tumor tied in four sections. It came off in a few 
 days, the cicatrix healed, and the man apparently 
 recovered. After I left the station I was informed 
 that the man returned in a few weeks with an 
 immense sarcomatous growth in the axilla, of which 
 he finally died, so that the prognosis after removal of 
 this tumor is not always favorable. 
 
 The cutaneous naevi on the face and other parts 
 are best removed by the red-hot needle thrust into 
 them subcutaneously, cauterizing with the galvanic 
 needle from an 8- or lo-cell battery. When the eschar 
 is formed by the cautery, you must allow it to become 
 perfectly hard and dry. Electrolysis is a favorite 
 method of treatment. The operation is performed as 
 follows:* "One or more steel, platinum, or irido- 
 platinum needles are connected with the negative 
 
 * Shoemaker, Diseases of Skin, p. 48. ist ed. 
 
— io6 — 
 
 pole of the battery, and, if the iisevus be large, one 
 needle or a charcoal point with the positive pole; both 
 needles are introduced at the same time into the 
 growth, and allowed to remain in the tissue for a few 
 moments until gas bubbles ascend through the orifice, 
 a clot forms, and the spot assumes a blueish-white 
 color. The negative needle is first removed. The 
 current being reversed, the positive becomes the 
 negative needle, and is easily removed." 
 
 The still more superficial forms are often treated 
 by subcutaneous ligation, the knot known by the 
 English surgeons as Ferguson's being that usually 
 employed. 
 
 Then there is the linear scarification; done by 
 making lines of scarification in one direction, and 
 then crossing them at right angles. Then there i& 
 the puncture. A number of needle-points are thrust 
 directly into these surfaces. Sometimes vaccination 
 has been used to destroy these tumors where the pa- 
 tient has not been vaccinated. The virus is inserted 
 directly into the angeioma, and a cure is said to^ 
 result. 
 
LECTURE IX. 
 
 PROLIFERATION TUMORS, CONTINUED. 
 
 PAPILLOMA, GLIOMA. 
 
 Continuing the subject of proliferation tumors, I 
 will speak of the papilloma^ which is the 15th in order 
 of the 4th class: 
 
 a. Wart. 
 
 b. Mucous tubercle. 
 
 c. Condylomata. 
 
 d. Urethral caruncle. 
 
 The papilloma consists of hypertrophied and 
 branched papillae, and always occurs in one of the 
 three surfaces, cutaneous, mucous, or serous. The 
 first one of this variety is the common wart — the so- 
 called verruca vulgaris, which is simply an enlarge- 
 ment of the papilla. There are various forms of 
 them, such as the verruca senilis, which is the wart 
 of the old people, usually situated on the back, and 
 highly pigmented; verruca filiformis, a very small fili- 
 form wart, \\.o \ inch in length, painless, and looking 
 much like a piece of thread projecting from the skin, 
 and which can sometimes scarcely be detected except 
 by attempting to pull it off; a flat form called verruca 
 plana; moist warts, from which a constant secretion 
 is produced. The cause of the wart is not known. 
 Virchow states that anatomy bears out the statement 
 
— io8 — 
 
 that it is simply an enlargement of the papilla. 
 Sometimes they disappear spontaneously. This fact 
 is taken advantage of by charlatans and so-called 
 ''cancer doctors;" all forms of warts being called 
 cancers, and subjected to all sorts of cauterizations, 
 and among the negroes to Voudooism. The child's 
 remedy of a pencil mark around the growth, oint- 
 ments, and a variety of applications are in popular 
 repute as wart cures. Some are amusing, and a re- 
 cital of them would make an interesting chapter. 
 Warts may be treated by snipping them off with scis- 
 sors, or cauterizing with nitric acid. The mucous 
 tubercle is another form of papilloma, being an en- 
 largement of the mucous papilla. Sometimes it takes 
 on softening and general cystic degeneration, and in 
 that way the duct becomes obstructed, and we have 
 a mucous cyst resulting from an originally verrucous 
 growth. 
 
 The condyloma is a form that is deserving of con- 
 siderably more attention. There is a general predis- 
 position to the formation of papillary growths in the 
 inter-natal fold, in the groin, and in fleshy females 
 where the mammary glands hang over the chest, and 
 anywhere where mucous or cutaneous surfaces rub 
 against each other. The condyloma appears not 
 only from natural causes, but is frequently and usu- 
 ally due to a specific cause. We find it on the glans 
 penis and the corona glandis. There is a considera- 
 ble secretion flowing from them, which is highly 
 
— log — 
 
 odoriferous and disagreeable. Tliere is great irrita- 
 tion when it is situated in the glans penis, or concealed 
 beneath the prepuce, and there may be pain, not 
 directly from the condyloma itself, but from the irri- 
 tation caused to the prepuce and gland. When con- 
 cealed, it may be mistaken for gonorrhoea or a con- 
 cealed ulcer. The operation for phimosis will reveal 
 at once the cause of the difficulty; or by using a pair 
 of forceps, as a speculum, the prepuce may be sepa- 
 rated so that the growth may be seen. The treat- 
 ment is excision with the knife or cautery, or, as I 
 prefer, the actual cautery, or fuming nitric acid. The 
 next form is urethral caruncle. When this is large, it 
 constitutes a very serious affection. It consists of 
 enlarged papillae situated at the meatus urinarius of 
 the female, and sometimes entirely within the urethra. 
 Anatomically these structures are found to be very 
 richly endowed with nerve filaments and blood-vessels, 
 on account of which they are very painful and bleed 
 very freely. Not only that, but they sometimes form 
 a considerable obstruction to the flow of urine, mak- 
 ing urination painful. Cases are recorded where the 
 caruncle has attained the size of a goose-egg, though 
 ordinarily they are the size of a pea. When they are 
 found in the urethral canal, instead of the margin of 
 the meatus, they give rise to greater obstruction to 
 the flow of urine, and necessitate the passage of the 
 catheter; a very painful operation. 
 
 <• The prognosis is good if single, but if multiple 
 
they produce persistent neuralgia of the membranes, 
 so that the removal of the caruncle does not stop the 
 pain, and you must give a guarded prognosis in such 
 cases. 
 
 Treatment: To remove them, you may use the 
 ordinary polypus snare, or excise them by scissors, or 
 use the thermo-cautery. If situated in the canal, it 
 will be necessary to dilate the urethra and apply a 
 stick of nitrate of silver or fuming nitric acid, by 
 means of a glass rod, to the stump of the tumor. For 
 the persistent neuralgia following these carunculi, 
 forcible dilatation of the urethra is the best remedy. 
 
 '^Glioma. Following the nomenclature, I shall fix to 
 glioma an asterisk to denote that it is malignant. As 
 its etymology would indicate, it is a gelatinous tumor. 
 Virchow gave the name to this tumor, which comes 
 from the gelatinous substance between the nerve 
 proper and the connective tissue of the nerve; the 
 gelatinous substance of Rolando. This, you will re- 
 member, differs from the neuroglia proper (the con- 
 nective tissue of the spinal cord). The tumor is 
 found most frequently on the retina and choroid. 
 Williams states it is the only tumor of the retina; but 
 other forms of sarcomata are frequently found among 
 the intra-ocular tumors. It is highly malignant, and 
 invariably destroys life. An operation may prolong 
 but does not save life. It was formerly termed en- 
 cephaloid, but, as I shall show you in speaking of 
 encephaloid, there is a very marked and wide differ- 
 
ence between glioma and encephaloid. Occasionally 
 we have glioma of the mucous surfaces, or springing 
 from the nerve; again, we have them intermixed with 
 mucous structure — myxo-gliomata. Gliomata on the 
 serous surfaces, the arachnoid for example, are harder 
 than these, which are always soft. The former ap- 
 proach to the fibroma, and are sometimes called from 
 that circumstance fibro-glioma. It is now claimed 
 that the glioma is a variety of the round-celled sar- 
 coma^the view adopted by the most recent patholo- 
 gists. It is, I may say, a disease almost entirely of 
 early life, very seldom occurring in the adult, and in 
 this respect markedly different from ordinary sarcoma. 
 Sometimes the gliomata have branching, spider-like 
 cells, called Dieter's cells. These tumors may take 
 on calcareous or fatty degeneration. On looking into 
 the pupil of a child affected with glioma, we find a 
 white, glistening appearance, sometimes called the 
 " cat's eye." There is great tension and great pain. 
 Sometimes after the eye has been enucleated we find 
 that the disease has extended along the optic nerve 
 and into the substance of the brain; occasionally it 
 breaks out afresh, extending to the soft structures in 
 the orbit. In the American Journal of Medical Sciences 
 for October, 1884, I find a case reported by my friend 
 Dr. Dickey, of Wheeling, which is so typical that I 
 shall take up your time by reading it: 
 
 Virginia , a bright, attractive child of very 
 
 fair and beautiful complexion, when two years old 
 
was found to be entirely blind in the left eye. The 
 pupil was widely^ dilated, and through it shone a 
 satiny, lemon-colored reflex. There was some ptosis 
 and convergent strabismus. None of the vessels 
 were congested, nor had there ever been any evidence 
 of pain. The growth ^was probably congenital, for 
 shortly after birth the child's aunt had noticed some- 
 thing peculiar about the eye, and in a picture taken 
 at three months can be observed a slight degree of 
 ptosis and deflection inward and upward. 
 
 The little patient was examined by several prom- 
 inent surgeons and oculists of Philadelphia, where the 
 family then lived, and enucleation was advised. The 
 operation was performed successfully a few months 
 later, and there was never any recurrence in the left 
 eye. Six months afterward vision began to fail in the 
 right eye, and the child was taken to Philadelphia — 
 the family having removed to this city in the mean- 
 time — but an ophthalmoscopic examination revealed 
 nothing but a slightly congested condition of the 
 retina. In the following fall vision had entirely 
 failed, the ball being constantly turned upward in a 
 vain effort to see. The pupil gradually became 
 dilated, and the same salmon-colored reflex could be 
 observed that had been noticed in the other eye. The 
 tumor gradually grew until it could be easily seen in 
 a good light at the distance of several feet. It 
 appeared to be lobular in form, and tortuous vessels 
 traversed its surface. These were plainly visible as 
 the refracting media retained their transparency. 
 The pupil became dilated ad maximum^ tension 
 increased, the scleral vessels were congested, and 
 attacks of sharp pain became frequent. An operation 
 was deemed advisable, and on January 15th, with Dr. 
 R. W. Hazlett and Dr. E. L. Hoge, I removed the 
 
— 113 — 
 
 globe. We found the optic nerve considerably thick- 
 ened, and resected it as far back as possible, remov- 
 ing some of the orbital cellular tissue about the nerve. 
 We made a microscopical examination of the eye, and 
 found the sclerotic coat near the ciliary region verf 
 thin and almost ready to burst. The vitreous humor 
 had degenerated into a dirty, watery fluid full of float- 
 ing specks of caseous matter. On the back wall of 
 the eye, with the papilla as a centre, was a tumor the 
 size and shape of a Lima bean. The specimen was 
 sent to Dr. Knapp, of New York, who kindly ex- 
 amined it microscopically, and reported that it was a 
 well characterized glioma of the retina, spreading to 
 the surrounding choroid by a cake-like transition. 
 
 There was a speedy recovery from the operation, 
 but on March ist, about six weeks after the enuclea- 
 tion, the tumor reappeared in the right orbit, and 
 grew rapidly, pushing out between the lids. It 
 assumed a cylindrical form, and extended from the 
 orbit about six inches, with a circumference of about 
 nine inches. The tumor was covered with the stretched 
 integument of the lids out to the end, where it pre- 
 sented a rough, fungous, bleeding surface, which 
 eventually became quite offensive, having the heavy, 
 peculiar odor of an open cancer. The growth hung 
 downward by its own weight, projecting so far as to 
 make it difficult for the little sufferer to drink from a 
 cup, and pressing upon the nose until the right nostril 
 was occluded, and the left considerably obstructed. 
 The cervical glands became very much enlarged, 
 especially on the affected side, and the inguinal glands 
 of both sides were indurated. Several metastatic 
 tumors formed on the head, the first one, which ap-\ 
 peared in the lambdoidal portion of the occipital bone, 
 attaining the size of a hen's egg. The other tumors, 
 
 8 WW 
 
— iM — 
 
 ranging in size from a hazel nut to An English walnut, 
 were on the parietal bones. They were quite hard, 
 and were probably caused by metastases in the diploe, 
 as described in Case i, and illustrated in Figures lo, 
 II, and 12, in Knapp's work on Intra-ocular Tumors. 
 The patient gradually grew weaker, finally be- 
 coming greatly emaciated, and died of exhaustion, 
 July 25th, 1884, four years and three months old, 
 about a year and a half after the first enucleation, and 
 about six months after the second. She retained full 
 consciousness to the last. There was entire absence 
 of cerebral symptoms through the whole course of 
 disease. The child was an unusually intelligent one, 
 and at no time was there perceptible dullness of in- 
 tellect. A post-mortem examination could not be ob- 
 tained. 
 
 I read this case in detail, because it gives you a 
 better idea of the growth and progress of glioma than 
 hours of lecturing on obscure conditions of that kind. 
 
LECTURE X. 
 
 PROLIFERATION TUMORS, CONTINUED— GRAN- 
 ULATION TUMORS. 
 
 TUMORS DUE TO INFECTIVE MICRO-ORGANISMS; LUPUS, 
 
 GUMMA, LEPRA ARABUM, YAWS, GLANDERS, 
 
 LYMPHOMA. 
 
 Granulation tumors— the 15th variety of class 4 
 — are all due to micro-organisms. First there is 
 •simple granulation; then lupus; then gumma; lepra 
 Arabum; yaws; farcy or glanders; and tubercle proper 
 — that is, granulation tubercle. This form of tumor 
 is characterized by a tendency to formation of granu- 
 lations, having, however, great affinity to the sarcom- 
 atous tumors. They are by some included among 
 the round-celled sarcomata. Virchow, who gave 
 their name, admits the great difficulty in distinguish- 
 ing them from sarcomata. They are characterized 
 iby inflammatory action, and differ from the ordinary 
 products of inflammation by infectivity, and a failure 
 to complete the process of repair. They should be 
 ■classed among the microbic diseases. They are 
 wrongly placed among the proliferation tumors in our 
 nomenclature. 
 
 Lupus^ as the name would indicate, is a corrod- 
 ing tumor — an eating tumor — from "lupus," a wolf. 
 We find it, however, in two forms — '"'exedens" and 
 
— ii6 — 
 
 non-exedens. The lupus non-exedens sometimes, 
 cicatrizes and heals spontaneously, but the other 
 variety does not. Friedlander, in 1874, first suggested 
 that lupus was -a tubercular disease, and Koch subse- 
 quently (1882) demonstrated the tubercle bacilli in 
 some specimens. It is, therefore, a tuberculosis of the. 
 skin. Its frequent seat is the nose; commencing at 
 the external opening of the nasal duct, it extends 
 down the side of the nose into the interior nasal pass- 
 ages, destroying the entire nose, lips, eyelids, and 
 the soft tissues of the face. I remember an old physi- 
 sician who lived a short distance from my boyhood' 
 home. I remember how all the children ran awa5r 
 when he came on the scene. Although the disease 
 had then ceased to progress, he presented an appear- 
 ance not only disgusting, but horrifying. His lips, 
 nose, and eyelids were gone, and the mouth was- 
 simply a ghastly opening, from which the saliva 
 flowed, dribbling over the deformed chin, and the 
 lachrymal secretion went dribbling down over the 
 front of the raw face. His teeth were still left, the 
 gums sound, and by his teeth he was able to retain a 
 handkerchief to catch the salivary flow; and so he 
 walked about for many years. Finally, secondary 
 lymphatic infection of a malignant form intervened- 
 and destroyed his life. Lupus does not always de- 
 stroy life; sometimes, instead of occurring on the face,. 
 as in the case i have just described, it occurs on the 
 hand, or it may be on any portion of the skin. It 
 
— 117 — 
 
 ■closely resembles syphilis, and in the form of " Ltipus 
 syphilitica,'' which is really syphilis, the two may be 
 confused and the syphilis be treated for lupus; it is 
 very painful. It may be mistaken for epithelial can- 
 cer, and, if the disease is not recognized and properly 
 treated, will destroy life. 
 
 The treatment for lupus is the actual cautery or 
 fuming nitric acid, to destroy the granulations and 
 the specific character of the ulcer; or by any of the 
 more common forms of caustic, one of the best being 
 pure bromine, mopping it on the diseased tissue. 
 Bromine is said to almost certainly arrest the progress 
 •of the disease. Mercury as an internal remedy may 
 be administered in combination with iodide of potas- 
 sium, or in the form of protiodide of mercury, or cor- 
 rosive chloride. Treatment by injection of " tuber- 
 culin " has proved a failure. I have seen the most 
 marked changes occur in the lupus ulcer after the in- 
 jection of the "tuberculin," but at the date of revising 
 this proof I have not seen any case of recovery from 
 its use. 
 
 Gumma. This is not malignant, and is amenable 
 to treatment, so much so that medication alone usu- 
 ally suffices. It is a soft, fluctuating tumor, due to the 
 bacillus of syphilis. It is rather a circumscribed de- 
 generative change than a new growth. The gumma 
 may be found on the periosteum of the long bones, 
 and in the soft tissues. The brain, the liver, and the 
 spleen and the kidney are not infrequent seats of 
 
— ii8 — 
 
 gummata. When the gummy tumor springs from the 
 periosteum, you will generally find that the patient 
 complains of nocturnal pains, and that the generaii 
 symptoms of periostitis are present. 
 
 The treatment consists in the external use of 
 iodine ointment and " mixed " treatment internally. 
 
 Lepra Arabum. This " leprosy of the Arabs" is also* 
 called elephantiasis Grsecorum, but it differs from the 
 fibrous elephantiasis already described; first, as to its 
 inoculability; and second, as to its anatomy. Some 
 claim that it is not inoculable, but the lepra Arabum^ 
 or true leprosy, is in its nature essentially contagious,, 
 being caused by an infective organism. There is a ten- 
 dency to ulceration. From time immemorial the leper 
 has been excluded from the society of his fellows,, 
 and most recent investigators have decided that the 
 segregation of the leper is a necessary precaution. 
 The report of the health officer of the Kingdom of 
 Hawaii shows that there are two islands set apart for 
 lepers — one for leprosy which has not proceeded to 
 ulceration, and one for lepers who have reached the 
 ulcerative stage. On reading the report I was struck, in. 
 the first place, by the extreme care with which a home 
 is provided for that unfortunate class of people, and the 
 great desire to prevent, if possible, the further spread 
 of the disease. In Norway; in Maracaibo, Venezuela; 
 and in Havana, Cuba, there are special institutions for 
 the treatment of lepers; there is also a leper settlement 
 in New Brunswick. A few cases were reported in 
 
— 119 — 
 Louisiana, and some in Minnesota, mainly among the 
 Norwegians, who probably brought the disease with 
 them. It has not been known to develop or materi- 
 ally spread in this country, but in New Brunswick I 
 believe the disease is spreading; it certainly is in 
 Norway; and in the Hawaiian Islands the leper popu- 
 lation is believed to be increasing. The bacillus of 
 leprosy demonstrated by Dr.Arman Hansen, of Bergen, 
 in 1873, resembles that of tubercle; these bacilli are 
 very numerous. Unna states that an examination of 
 one of the leprous tubercle^ shows that almost the 
 larger half of the tissue consists of bacilli and their 
 products. Leprosy is incurable at present, although 
 much is hoped from the new studies in bacteriology. 
 
 Symptoms: There is sometimes pain present, and 
 in the beginning there is usually hypergesthesia of the 
 part. The swollen tubercles are quite painful, but as 
 the disease progresses, the nerves are impinged upon 
 so that they are not capable of transmitting secretion. 
 Then ansesthesia -follows. I have twice visited the 
 Leper Hospital in Havana,- and made careful inspec- 
 tions of the inmates. All varieties and stages of the 
 affection may be seen at this hospital; cases where 
 the patients are totally blind from destructive ulcera- 
 tion of the eyes, those without fingers and toes, and 
 those with tuberculated faces are most common. The 
 series of photographs sent the Marine Hospital Bureau 
 by the U. S. Consul at Maracaibo are most interest- 
 ing. Leprosy is slower in its course than syphilis. 
 
A leper may live for years, but when the disease pro- 
 gresses to ulceration, if not before, there is fever, 
 which is persistent, and daily exacerbations. 
 
 Treatment : The general treatment is most un- 
 satisfactory. The Chinese remedy is the Hoang Nan. 
 Analgesin for the febrile symptoms is said to have 
 been administered with good effect. Then we have 
 Chaulmoogra oil, and the Gurjun-wood oil. The 
 Hoang Nan is the bark of a tree of the Strychnos 
 family, and is said to owe its curative property to the 
 strychnine and brucine,* in small quantities, which it 
 contains. Of course, such patients should be promptly 
 isolated. 
 
 Yaivs, also called framboesia, is a disease of the 
 West Indies and tropical islands, and endemic in the 
 mountains of Peru. It is also known as Peruvian ver- 
 ruga. The disease has a febrile stage and an erup- 
 tive stage. When the eruption appears, the tumor 
 grows until it reaches the size of a raspberry; some 
 remain about the size of a currant. The accompany- 
 ing illustration from Dr. Nielly's Elements de Patho- 
 hgie Exotique shows very clearly the appearance of 
 these eruptive growths. Yaws also grows in the cuta- 
 neous folds, in the wrinkles of the neck, axilla, groin, 
 and in those places in which condylomata appear. It 
 first occurs in small, reddish spots, which are hsemor- 
 rhagic; they enlarge, and finally ulcerate. The dis- 
 ease is contagious, and the exudation from it inocu- 
 lable. It is, however, amenable to treatment. 
 
Treatment: In the first place the tumors should 
 be excised or cauterized, and the febrile symptoms 
 controlled by appropriate medication. In Peru de- 
 scent from the mountain is insisted upon, and general 
 tonics are administered. 
 
Glanders or Farcy. This is a disease specific in 
 character, which may be transmitted to man from the 
 lower animals, most frequently the horse, the mule, 
 or the ass. Man himself may reciprocate that favor 
 by retransmitting the disease to an animal previously 
 sound. It is one of the most contagious diseases 
 known, but Professor Senn asserts that the virus of 
 glanders can only find entrance into the organism 
 through a wounded surface. It has its most frequent 
 seat in the mucous membrane of the nose. The 
 membranes become swollen, and the Schneiderian 
 membrane becomes involved; after a while there is a 
 nodular eruption of the skin, " farcy buds," which 
 finally ulcerate; and high fever is present. There is 
 great swelling of the glands, generally the axillary 
 and those of the neck and ears. The bowels are 
 costive, and there is general malaise. The bacillus 
 peculiar to glanders is called the bacilhis Mallei. In 
 the treatment of these cases great care must be taken 
 to prevent the disease being carried to yourself and 
 attendants. The period of incubation is very short, 
 the disease setting in actively two or three days after 
 breathing the contaminated air or inoculation by the 
 virus. Pustules are seen in about ten days after the 
 beginning of the disease. When the disease is exter- 
 nal, and the internal organs are not involved, the pa- 
 tient may recover, but glanders is one of the most 
 fatal maladies. It has been noted that the glands 
 are swollen and sometimes change the same as in 
 
— 123 — 
 oriental plague, which causes a swelHng of all the 
 glands of the body, and hence has been termed 
 bubonic plague. 
 
 Treatment; The treatment of glanders has been 
 very unsatisfactory, and death generally takes place 
 in from one to three weeks. Of course, if called to 
 such a case, the most active local disinfection should 
 be practiced. From the beginning the mercuric 
 bichloride solution should be mopped upon the nasal 
 membrane, the glands themselves being injected with 
 a dilute solution of carbolic acid or bromine. The 
 attendants and surgeon should have their hands care- 
 fully oiled, and every precaution taken so far as quar- 
 antining the patient is concerned. Treat the case as 
 you would when there is an asthenic tendency requir- 
 ing quinine and tonics, basing your highest faith on 
 local disinfection. 
 
 * Lymphoma. This is the lymphatic tissue tumor, 
 and usually malignant. These are neoplasms of the 
 connective tissue. Now, this tissue is found in every 
 tissue of the lymphatic glands, and also in the Mai- ' 
 pighian corpuscles of the spleen, in Peyer's patches, 
 the glands of Lieberkiihn, the thymus gland, and the 
 glands of the pharynx. You will see, then, that the 
 lymphatic system is composed of glands and lacunae, or 
 •' lymph spaces" and fibrillae; these last are the con- 
 nective tissue of the lymphatics. The fibrillae form a 
 net-work, and between the meshes of the net-work 
 are the so-called corpuscles. Lymphoma would seem 
 
124 — 
 
 to be a hyperplasia or outgrowth, or proliferation of 
 normal lymphatic tissue. In that peculiar disease 
 known as Hodgkin's, the lymphatic glands through- 
 out the body are infected. T.ymphomata are usually 
 non-malignant, but epithelial cells are sometimes infil- 
 trated from the adjoining tissue, and the more rapidly 
 they proliferate, the more malignant the tumor. Some- 
 times they are simple hyperplasias — non-malignant. It 
 should be remembered that there is some variation in 
 lymph tissue structure in health, but when the cells 
 are atypical then they become malignant. The cells 
 are like those of small round celled sarcoma. Lym- 
 phoma of the mammary gland is as fatal as any carci- 
 noma. In Hodgkin's disease the spleen is found to 
 be diseased in four-fifths of the cases. The Hodg- 
 kin's disease has been termed by Mr. Paget lymphatic 
 adenoma; but as it is a specific disease, it is very 
 doubtful if it should be included in lymphoma proper. 
 Simple lymphoma is very difficult to diagnosticate from 
 adenoma. Owing to the character of the cells and the 
 stroma, some consider it a sarcoma of the lymphatics, 
 and others term one variety of it lymph-sarcoma. 
 
LECTURE XI. 
 
 PROLIFERATION TUMORS, CONTINUED. 
 
 SARCOMA. 
 
 Sarcoma. The disease known as sarcoma is one 
 of the most important of the tumors, whether we con- 
 sider its variety of forms, its effects on the patient, or 
 the attention that must be given by the surgeon. 
 Among the older writers, nearly all malignant and 
 fleshy tumors of whatever character were included 
 among the sarcomata, and I am not sure but you may 
 conclude, when considering the number of tumors 
 that, having separate names, are yet classed among 
 them, I am fast returning to the ancient practice. 
 This tumor is generally, but not always, malignant. 
 The initial growth of the sarcoma is from the con- 
 nective tissue, in whatever organ or tissue the tumor 
 may be found; but there is a cellular structure in the 
 sarcoma in addition to the type cell of the matrix from 
 which it sprung. The cells are infiltrated between the 
 fibrillee of the connective tissue. The starting point 
 may be normal connective tissue, or that of another 
 tumor, such as myoma, fibroma, or cyst. The sarcoma 
 springing from the connective tissue then becomes a 
 myo-sarcoma, a fibro-sarcoma, or a cysto-sarcoma; 
 and that is what is meant by the sarcomatous trans- 
 formation. The cells of a sarcoma are the formative 
 
126 
 
 cells of connective tissue, but they never complete 
 the formation; hence they are termed embryonic. 
 This holds true of all varieties of sarcomata; and 
 these embryonic cells are constantly reproduced in 
 the proliferation growth of the tumor. There are 
 three broad varieties of sarcomata. The first has a 
 simple or round cell, and is the most malignant; the 
 next has the so-called giant cell; and the remaining 
 one the spindle cell. The giant cells have also been 
 "termed myeloid, because they are like the protoplasms 
 found in the marrow of foetal bones. They are the 
 largest of all human cells. They sometimes have 
 hundreds of these nucleated cells; these may have a 
 great many nuclei. The sarcomata are very vascular. 
 There is a variety of sarcoma, characterized by an 
 excessive development of blood vessels, called angeio- 
 sarcoma, or erectile sarcoma. Sometimes fat cells 
 grow out of the other cells, producing fatty degenera- 
 tion, which is more apt to take place in spindle than 
 in round or giant-cell sarcoma. It differs in malignity 
 in the character of the cell, the round cell being 
 more, the spindle cell less, and the giant cell least 
 malignant. It has a progressive tendency and, if 
 allowed to remain, and neither fatty nor calcareous 
 degeneration occurs, it destroys life. The method 
 of recurrence of this tumor, after extirpation, con- 
 stitutes one of the observed differences between it 
 and carcinoma. A cancer, when removed, recurs, but 
 not necessarily on the site of the old tumor; whereas 
 
— 127 — 
 
 sarcoma recurs nearly always in the exact site of the 
 original tumor. In carcinoma it is more, apt to occur 
 in what is termed the secondary form, by making its 
 appearance in some of the internal organs, the nearest 
 lymphatic gland, or even some point quite removed 
 from the original infection. The lymphatic glands 
 are not always affected, except those in the path of 
 circulation from the tumor to the center of the lymph 
 system; there is no " cancer juice." The sarcomatous 
 cells also form continuous portions of tissue; whereas 
 in carcinoma the reverse of all this occurs. There is 
 
 Fig, 6. — Small round-celled sarcoma, (x 300, after Wood- 
 head). 
 
 a. Small round cells, with nuclei and nucleoli. 
 
 b. Flattened spindle cells forming walls of embryonic 
 blood vessels. 
 
 great pain; the lymphatic glands are affected; and 
 there is "cancer juice." The cells do not form part 
 
— 128 — 
 
 of the tissue. There is a difference in the malignancy 
 of sarcoma, according to its site. Sarcoma of the tes- 
 ticles, for some unknown reason, is more liable to 
 destroy life than sarcoma of the ovary; why this 
 should be, is not understood. Then we have sarcoma 
 of the hand, which will surely destroy life unless am- 
 putation is performed. A medical officer of the army 
 called upon me some years ago, having a diffuse 
 swelling or thickening of the hand. It showed more 
 
 Fig. 7. — Giant-cell sarcoma (x 400, after D. J. Hamilton.) 
 
 a. Spindle-cell basis round the giant-cell. 
 
 b. Giant cell, containing many nuclei. 
 
 c. Vacuole in a giant cell. 
 
129 — 
 
 externally than in the palm. It was discolored, but 
 painless, and I regarded it as not carcinomatous. A 
 puncture was made, and some of the fluid which flowed 
 out was submitted by the officer to the late Surgeon 
 Woodward for microscopical examination. He found 
 
 Fig. 8. — Small spindle-celled sarcoma, (x 300, after Wood- 
 head.) 
 
 a. Well formed spindle cells. 
 
 b. Elongated spindles bounding one of the blood ves- 
 
 sels. 
 
 c. Embryonic blood vessel cut transversely. 
 
 d. Transverse section of spindle cell. (This transverse 
 
 section with the section of the nucleus must nat 
 be mistaken for the round cell.) 
 
 9 WW 
 
— 13° — 
 the round-celled sarcoma. The patient was then on 
 I'eave of absence, and died about four months there- 
 after. The swelling was not at that time very great, 
 and there was no pain. 
 
 There is a melanotic or pigment sarcoma, having 
 its seat mostly in the skin, and in the choroid of the 
 eye — sometimes in the lymphatic glands, but it may 
 be found elsewhere. A case of melanotic cysto-sar- 
 eoma was under my care a few years ago, in which 
 the tumor recurred three times after extirpation. In 
 this case the mammary gland of the right side was 
 alone affected, and the tumor recurred at the site of 
 operation. The patient finally'died with all the symp- 
 toms of general anaemia accompanying the cancerous 
 cachexia. 
 
 The giant-cell sarcoma, or so-called myeloid, has 
 its common seat in the bone, although it may appear 
 in the mammary gland. There is a characteristic 
 difference between all the sarcomata and adenomata 
 ©f the mammary gland. In sarcoma, upon section 
 the cut surface will present little] pink vascular points 
 ©f different shades of color, which afford a pretty 
 ready coarse means of distinguishing sarcoma from 
 adenoma by the eye, for in adenoma, on the contrary, 
 there is only the usual appearance of glandular struc- 
 ture. 
 
 The following table from Woodhead will be useful 
 to you in making your comparison between sarcoma 
 and carcinoma: 
 
— 131 — 
 
 DIFFERENTIAL DIAGNOSIS (fROM WOODHEAD). 
 
 CARCINOMA. 
 
 SARCOMA. 
 
 s. Origin Entirely mesoblastic. Meso- and epi- or 
 
 hypo-blastastic. 
 
 2. Stroma Intercelluar. Does Forms alveoli, which 
 
 not form alveoli communicate with 
 only. one another, and 
 
 surround masses of 
 cells. 
 
 3. Cells. 
 
 .Granulation tissue or Epithelial, shape and 
 
 embryonic cells, not size various. Dis- 
 
 epithelial (shape va- tinct nuclei and nu- 
 
 rious). cleoli. 
 
 4. Intercellu- ) 
 
 lar sub- >• Present, 
 stance. ) 
 
 5. Vessels Embryonic in charac- 
 
 ter. In contact with 
 the special cells of 
 which tumor is com- 
 posed, and formed 
 by modification of 
 them. 
 
 ■6. Spread By blood-vessels. 
 
 7. Malignancy. Great. 
 
 Absent, or merely 
 fluid. 
 
 Well developed, en- 
 tirely contained in 
 the walls of the al- 
 veoli. Not in con- 
 tact with the cells, 
 except in very rare 
 cases. 
 
 By lymphatics, ex- 
 cept in the later 
 stages, when they 
 may also spread by 
 blood-vessels and 
 then very rapidly. 
 
 Greater. 
 
 Treatment: Whenever possible, it should be ex- 
 tirpated early. You must not allow your patient to 
 take any chance as to the malignancy of the disease, 
 
— 132 — 
 
 bearing in mind that unless fatty degeneration, calci- 
 fication, or ossification occurs, the disease will steadily 
 progress, and the life of the patient be destroyed. 
 When the bone is involved, constituting osseous sar- 
 coma, amputation will almost invariably be required. 
 In regard to amputation, the rule is to amputate the 
 whole bone involved, or the tumor will reappear in * 
 the stump. Careful examinations should be frequently 
 made after operation, and on the appearance of any 
 neoplasm it should be promptly extirpated, passing 
 the knife in healthy tissues. 
 
LECTURE XII. 
 
 PROLIFERATION TUMORS, CONTINUED. 
 
 CARCINOMA. 
 
 I have long been of opinion that the true origin 
 of carcinoma must be found through a study of cases 
 in their incipiency. We usually see carcinoma after 
 it is fully developed, but I firmly believe that some 
 one having leisure and opportunity will make ex- 
 amination of a sufficient number of cases to establish 
 the character and conditions of this neoplasm from 
 the first point of departure from the normal structure 
 to the completed carcinoma. 
 
 We will now take up the study of the last remain- 
 ing variety of Class 4— carcinoma, and the cancerous 
 tumors. The term cancer is one that has -been ap- 
 plied to so many different forms of tissue and so 
 many different forms of tumor as to have lost its 
 significance in a scientific sense. Sometimes adenoma 
 (which, as you know, is a simple hyperplasia of the 
 glandular tissue) is called cancer, because it occasion- 
 ally assumes cancerous degeneration. Sarcoma has 
 also been called a cancer, hence the present tendency 
 among pathologists to discard the term cancer, and 
 employ always the word carcinoma. Carcinoma pre- 
 vails in all parts of the world; there is no geographical 
 region exempt, nor can you find any particular region 
 that is specially favorable to the formation of cancer. 
 
— J34 — 
 In England alone, from 1838 to 1842, there were 
 11,662 persons who died from carcinoma. Of these, 
 8,746 were women and 2,916 men. In the U. S. 
 census of 1870 there were recorded 6,224 deaths from^ 
 carcinoma; of these, 3,923 were females and 2,301 
 males; making about one in thirt}^ in that census re- 
 port. The report of the Census Bureau for i88a 
 shows 13,068 deaths from carcinoma, of which 4,875, 
 were males and 8,195 females. 
 
 In the Marine Hospital reports, the proportion of 
 deaths from carcinoma is i in 70, occurring among 
 adult males exclusively. It is more prevalent in. 
 women than in men, because the larger number are 
 found in the mammary glands and the uterus; so 
 when you exclude carcinoma of the mammary gland 
 and of the uterus, the death-rate is reduced very 
 materially. There have been at different times great 
 disputes as to the particular cancer cell that is to be 
 found in each special variety of carcinoma. There is 
 no longer belief in any specific cancer cell; that is to 
 say, the cancer is now believed to be a growth of 
 epithelial tissue which has grown out of place. Yoa 
 will not be far wrong if you view all carcinomata as 
 one disease, the alleged subdivisions as many of them 
 arbitrary, and all of them founded on chnical 
 differences, some 01 which may be accidental. 
 Hamilton's (of Aberdeen) definition of cancer is "a 
 neoplasm formed of any tissue whose fibrous inter- 
 spaces and lymphatic vessels are infiltrated with 
 
— 135 — 
 
 actively proliferating epithelial cells." Carcinoma 
 may be developed in any part which has epithelial 
 tissues, or any organ of the body which has epithelial 
 tissue in its substance. Now, we distinguish carcino- 
 mata in general from other tumors of the body by 
 what we term the^alveolar structure, wherein the so- 
 called cavity or cell is formed. I show you here a 
 diagram from Cornil and Ranvier, which exhibits this 
 alveolar structure very clearly. We find that these 
 alveolar spaces are filled with epithelial cell infiltra- 
 
 Yic, g. — Stroma of Carcinoma, lying In which are the alveoli 
 from which the epithelial cells have been removed by 
 penciling, (x 300, after Cornil and Ranvier.) 
 
Fig. 
 
 s. I 
 r.m. 
 
 /• 
 
 lo. — Diagram to represent changes which take place 
 during the invasion of connective tissue by epithelial 
 columns. (After Woodhead.) 
 Stratum corneum, or horny layer of cuticle. 
 Stratum lucidum — s gr. — Stratum granulosum. 
 Rete Malpighii. b Superficial more flattened cells, 
 
 beneath which are the well-formed prickle cells. 
 Layer of columnar or germinal cells. 
 Epithelium at normal level. 
 
 ' e. Epithelial bands passing between the papillae. 
 Normal connective tissue papillae. 
 Cellular and vascular connective tissue. 
 Blood-vessels. 
 
— 137 — 
 tions. I say infiltrated, because they are not natur- 
 ally there; they do not belong to the part. All these 
 cells have nuclei; not, however, in the same manner 
 as the giant-celled sarcoma. There is usually a single 
 nucleus to each cell. This alveolar structure (pure 
 fibrous tissue) constitutes the stroma of the cancer. 
 It contains the blood-vessels, and grows at an equal 
 pace with the young epithelial cells. These cells 
 keep pushing on, and extending into the tissues, form- 
 ing cylinders, or what the charlatan cancer-men call 
 the " roots " of the cancer. This is simply a prolong- 
 ation. In these structures there is no capsular or 
 limiting membrane. In speaking of lipoma I told 
 you that all fatty tumors, hygromata and cysts, were 
 encapsulated by dense fibrous connective tissue, and 
 this when cut down upon would show a white shining 
 surface, and that the tumor itself does not directly 
 enter the tissue. Now in carcinomata there is no 
 capsule. These prolongations enter directly into the 
 tissue. At the outset all these growths of carcinom- 
 ata are distinctly local. That is not the case later 
 on, when we shall speak of cachexia. All the carci- 
 nomata are malignant, for they sooner or later de- 
 stroy life. The degree of malignancy is different in 
 the different forms of tumor, and of that I will speak 
 in giving the varieties. 
 
 Although I say that it is not primarily a disease 
 ■of the blood, it is a well known clinical fact that the 
 child of a cancerous parent has a predisposition to 
 
- 138 - 
 
 the formation of cancer — that in a family where one 
 brother or sister has a cancer there may be others 
 similarly affected. At first blush you will say that 
 is an evidence of blood infection; but if you recall 
 what I said in my opening lecture, about the theory 
 of Cohnheim that all tumors are congenital, you will 
 see what is now meant by the term hereditary, viz., 
 that there is some local defect causing an atypical 
 cell, which may remain dormant or latent. Our class- 
 ification recognizes seven varieties of carcinomata, 
 but at least four of them should not be so classed; 
 thus, the medullary, or encephaloid, is a carcinoma 
 like the type, except that the stroma is very slight, 
 the alveoli large, and the cells are greatly increased. 
 The melanotic carcinomata differ only in having the 
 pigment or melanine. It is doubtful if a true carci- 
 noma of bone exists. There is of course an osteoid 
 sarcoma, but as there are no bone cells in it, it is a 
 sarcoma springing from the periosteum. 
 
 The colloid carcinoma consists in distinct alveoli 
 filled with a gelatinous mucoid mass, especially com- 
 mon in the ovary and the abdominal cavity. 
 
 In epithelioma we have the true carcinoma which 
 constitutes the type— epithelial cancer. Epithelioma 
 is slower in growth than the scirrhus, and in certain 
 circumstances, when extirpated early, does not recur. 
 Indeed, it is probable that none of the carcinomata 
 would recur after extirpation if it were possible to 
 make a diagnosis and operate upon them in their 
 
— 139 — 
 
 incipiency. Epithelioma of the h'p may be taken as a 
 type of the class. It is one most amenable to treat- 
 
 FlG. II. — Case of epithelioma growing from a cicatrix. 
 From a patient at Providence Hospital. 
 
— 140 — 
 
 ment. The disease occurs in the beginning as a 
 small crack or fissure in the lip, and gradually ex- 
 tends until the whole lip, and sometimes cheek, is in- 
 volved. It is at first not very painful, but becomes 
 so as the disease progresses; haemorrhages are fre- 
 quent. After an apparently thorough extirpation it 
 may recur, but always at, or adjoining, the original 
 site; whereas in the scirrhus the recurrence may be 
 in the nearest lymphatic gland, or in some internal 
 organ. It should be an invariable rule in extirpation 
 of all the carcinomata, to keep clear of the diseased 
 structure, carrying the knife in sound tissues. Lack 
 of this precaution will render this operation unavail- 
 ing in preventing the recurrence of the disease. 
 
 Scirrhus. In this form of carcinoma the stroma 
 is very dense and firm, and the alveoli small and com- 
 pressed. I will describe a typical case: A female 
 patient will come to you complaining of sharp lan- 
 cinating pain in the breast; not infrequently she 
 will have a history of some injury, such as striking 
 the breast on a sharp corner, or being accidentally 
 struck with the elbow, etc., etc. At any rate, on exam- 
 ination of the breast, if the case be not far advanced, 
 you find a painful swelling just beneath the nipple, 
 or at one side of it. This is at first moveable, but 
 as the case progresses the nipple becomes retracted 
 more and more, the tumor rapidly grows larger and 
 firmly attached to the periosteum of the ribs; the 
 glands in the axilla become swollen, and the patient's 
 
— 141 — 
 
 sufferings greatly increase. She will then have the 
 cachectic appearance, the general appearance of 
 anaemia; and the more malignant the growth, the 
 
 Fig. 12. — Case of scirrhus of the neck. From a sailor 
 in Providence Hospital 
 
142 — 
 
 more characteristic the cachexia. When the carci- 
 noma has grown so that the entire mammary gTand 
 has become involved, the skin over the tumor usually 
 becomes infiltrated, ulceration sets in, and the patient 
 speedily dies. This is the usual course of this form 
 of carcinoma. In other organs the symptoms, of 
 course, vary according to the location and the physio- 
 logical functions of the organs involved. These will 
 all be separately considered in my forthcoming vol- 
 ume on Tumors of the Regions, in which the diag- 
 nostic points will be fully considered. It is proposed 
 to fully illustrate the work, and describe the respec- 
 tive operations necessary for their removal, in detail. "^ 
 I have only glanced at the general principles un- 
 derlying our knowledge of morbid growths, and, as 
 science never stands still, you must constantly study 
 if you would keep abreast of your fellows. 
 
INDEX. 
 
 A. Page. 
 
 Acne pancreaticus 56 
 
 Adenoma loi 
 
 Angeioma 104 
 
 Angeio-lithic sarcoma 95 
 
 Appliances for examination of tumors i 
 
 B. 
 
 Barbadoes leg 74 
 
 Barren cyst 41 
 
 Blood tumor 30 
 
 Bronchocele, cystic 51, 54 
 
 C. 
 
 Carcinoma 133 
 
 , definition of 134 
 
 , how distinguished 134 
 
 Causes of scrotal hsematoma 36 
 
 Chondroma 91 
 
 Classes of tumors, tables of 24- 29 
 
 Classification of tumors 21 
 
 , Virchow's 22 
 
 Cochin-China leg 74 
 
 Colloid carcinoma 136 
 
 Color of tumors in diagnosis 15 
 
 Comedones 55 
 
 Condyloma 107-108 
 
 Cyst, dermoid 104 
 
 Cystic bronchocele 51, 53 
 
 Cystiform haematoma 36 
 
 Cysts 46 
 
 , bony 47 
 
— 144 — 
 
 Page . 
 
 Cysis, deniigerous 48 
 
 , diagnosis of , 49 
 
 , ovarian 58 
 
 — diagnosis of 60 
 
 — treatment of 63 
 
 , parasitic 66 
 
 , parovarian 55, 63, 64 
 
 — treatment of 49 
 
 D. 
 
 Dermoid cyst 104 
 
 Desmoid tumor 72 
 
 Diagnosis, color of tumors in 15 
 
 of cysts 49 
 
 myoma 97 
 
 myxoma 90 
 
 ovarian cysts • 60 
 
 pelvic haematoma 32 
 
 scrotal haematoma 37, 38 
 
 , size of tumors in 14 
 
 of tumors .■ 14 
 
 Differential diagnosis between sarcoma and carcinoma . . . 131 
 
 Dropsy of bursae mucosae 43 
 
 E. 
 
 Ecchondroma 91 
 
 Elephantiasis 73 
 
 Arabum 74 
 
 Graecorum 74 
 
 Enchondroma 91 
 
 Epithelioma 138 
 
 Epulis 81 
 
 Exostosis 94 
 
 Extravasation tumors , 30 
 
 Exudation tumors 40 
 
— 145 — 
 
 F. Page. 
 
 Farcy 122 
 
 Fibroma 71 
 
 Fibro-neuromata 73 
 
 Fibrous epulis 81 
 
 Framboesia 120 
 
 G. 
 
 Galactocele 7° 
 
 Ganglion 43 
 
 , treatment of 44 
 
 General considerations 7 
 
 Glanders 122 
 
 , treatment of 123 
 
 Glioma no 
 
 Granulation tumors 115 
 
 Gumma ii5> ii7 
 
 , treatment of 118 
 
 H. 
 
 Haematoma 30 
 
 auris 30 
 
 , cystiform 36, 39 
 
 , parenchymatous 40 
 
 , pelvic 30 
 
 — diagnosis of 32 
 
 — symptoms of 30-34 
 
 — treatment of 34 
 
 , polypoid 40 
 
 , pudendal 35 
 
 , scrotal 37 
 
 — causes of 36 
 
 — diagnosis of 37-38 
 
 — treatment of 38 
 
 Haematometra 31, 32 
 
 Hodgkin's disease 124 
 
 10 WW 
 
— 146 — 
 
 Page. 
 
 Housemaid's knee 42 
 
 Hydrops neonatorum 56 
 
 Hygroma / 41 
 
 , proliferating 41 
 
 — treatment of 42 
 
 Hyperostosis 94 
 
 K. 
 
 Keloid 83 
 
 L. 
 
 Leiomyoma 96 
 
 Lepra Arabum 118 
 
 Leprosy 118 
 
 , differential diagnosis of, from elephantiasis 75 
 
 , symptoms of 119 
 
 , treatment of ; . . . . 120 
 
 Lipoma 86 
 
 , treatment of 89 
 
 Lupus 115 
 
 , treatment of 117 
 
 Lymphatic adenoma 124 
 
 Lymphoma , 125 
 
 M. 
 
 Medullary cancer 138 
 
 Melanoma 95 
 
 Melanotic cancer 130, 138 
 
 Meliceris 45 
 
 Molluscum contagiosum 103 
 
 fibrosum 78 
 
 Mucocele 68 
 
 Mucous polypus loi 
 
 tubercle 107 
 
 Miiller, law of 18, 19 
 
 Myofibroma 9^ 
 
— 147 — 
 
 Page. 
 
 Myoma 96 
 
 , diagnosis of 97 
 
 , treatment of 99 
 
 Myxoedena following goitre 53 
 
 Myxoma 89 
 
 , diagnosis of 90 
 
 N. 
 
 Neuroma 99 
 
 Nomenclature of tumors it 
 
 O. 
 
 Odontoma. 95 
 
 Origin of tumors. 18 
 
 Osteoid ecchondroma 92 
 
 Osteoma 94 
 
 Osteophyte 94 
 
 Ovarian cysts '. 58 
 
 , diagnosis of 60 
 
 , treatment of j 63 
 
 P. 
 
 Parasitic cysts '. 66 
 
 Parenchymatous hsematoma 40 
 
 Parovarian cysts 55, 63, 64 
 
 Papilloma 107 
 
 Pelvic hsematoma 30 
 
 , diagnosis of 32 
 
 , symptoms of 30, 34 
 
 , treatment of 34 
 
 Polypoid haematoma 40 
 
 Polypus, mucous loi 
 
 Proliferating hygroma 41 
 
 , treatment of 42 
 
 Proliferation tumors 71 
 
— i4» — 
 
 Page. 
 
 Psammoma qS 
 
 Pudendal haematoma 35 
 
 R. 
 
 Ranula 66 
 
 , origin of name 66 
 
 , treatment of 67 
 
 Retention tumors 46 
 
 Rhabdomyoma 96 
 
 S. 
 
 Sarcoma , . 1 25 
 
 , treatment of • 131 
 
 Scirrhus 140 
 
 Scrotal hasmatoma 37 
 
 , causes of 36 
 
 , diagnosis of 37-38 
 
 • , treatment of 38 
 
 Sebaceous cyst 68 
 
 Size of tumors in diagnosis 14 
 
 Spedalsky 74 
 
 Symptoms of leprosy 119 
 
 T. 
 
 Tables of classes of tumors 24- 29 
 
 Teleangeiectasis 96, 97 
 
 Thrombus of the vulva 35 
 
 Tic-douloureux .... loi 
 
 Transudation tumors 40 
 
 Treatment of cysts 49 
 
 ganglion 44 
 
 glanders 123 
 
 gumma ri8 
 
 leprosy 120 
 
 lipoma 89 
 
— 149 — 
 
 Page. 
 
 Treatment of lupus 117 
 
 ovarian cysts . . . .■ 63 
 
 pelvic haematoma 34 
 
 proliferating hygroma 42 
 
 ranula 67 
 
 sarcoma 131 
 
 scrotal haematoma 38 
 
 urethral caruncle no 
 
 yaws 121 
 
 Tumors, classification of 21 
 
 , color of in diagnosis 15 
 
 , combination 18 
 
 , definition of 7 
 
 , diagnosis of g 
 
 , extravasation 30 
 
 , exudation 40 
 
 , granulation 115 
 
 , origin of . . . 18 
 
 , proliferation 71 
 
 , rapid growth of 12 
 
 , retention 46 
 
 , size of in diagnosis 14 
 
 , tables of classes of . . .24-29 
 
 , transudation 40 
 
 U. 
 
 Urethral caruncle 107, 109 
 
 , treatment of no 
 
 V. 
 
 Verruca filiformis 107 
 
 plana 107 
 
 senilis 107 
 
 Vulva, thrombus of 35 
 
— 15° — 
 
 W. Page. 
 
 Warts .• 99-107 
 
 Watery cysts 41 
 
 Wen 68 
 
 Y. 
 
 Yaws 1 20 
 
 , treatment of 121 
 
How to Administer Iron. 
 
 It is generally conceded that the officinal tincture 
 of chloride of iron is the most valuable of the iron 
 preparations therapeutically. The practical difficulties 
 attending its administration for a length of time have 
 been its disagreeably astringent taste, its corrosive 
 action on the teeth, and its constipating action. 
 
 Dr. G. W. Weld's extensive experience in the 
 practice of dentistry led him to recognize the virtues 
 of the tincture of the chloride of iron as a stimulant 
 resource for patients after the strain of the dentist's 
 work. Repeated experiments to obtain a formula free 
 from the objectionable features resulted in the prepara- 
 tion of a highly palatable syrup, with all the therapeu- 
 tic efficacy preserved. This has been extensively tested 
 and placed in the hands of Parke, Davis & Co. for 
 manufacture, who strongly recommend it to the medi- 
 cal profession for trial. Being prepared after Dr. 
 Weld's formula, it is entitled Weld's Syrup of Iron 
 Chloride (P., D. & Co.'s). It is believed it will effect a 
 revolution in iron administration. 
 
 Samples will be sent on receipt of request to 
 physicians who indicate their willingness to pay ex- 
 press charges. 
 
 PARKE, DAVIS & CO., 
 
 Detroit, New York, and Kansas City. 
 
ByisE)CTm eFpa5ucATioN3 
 
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