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 HEALTH SCIENCES STANDARD 
 
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 DERMOIDS. 
 
KDG77 BC( 
 
 intljeCttpofUmgork 
 
 College of ^f)v&itian^ anb burgeons 
 
 Hibrarp 
 
 Dr.W.R.B&H 
 
DERMOIDS: 
 
 OR, 
 
 TUMOURS CONTAINING SKIN, HAIR, 
 TEETH, &c. 
 
 BY 
 
 J. BLAND SUTTON, F.R.C.S, 
 
 Hunterian Professor, Royal College of Surgeons, England , 
 Assistant Surgeon, Middlesex Hospital. 
 
 LONDON: 
 BAILLIERE, TINDAL.L, 6- COX. 
 
 KING WILLIAM STREET, STRAND. 
 
 1889. 
 

 
Si 
 
 ^'^ PREFACE. 
 
 a 
 
 'T^HE facts, and opinions founded upon them, contained in 
 this book formed the substance of my Hunterian Lectures, 
 delivered at the Royal College of Surgeons, February, 1889. I 
 have ventured to publish them because dermoid cysts have not, 
 so far as I am aware, been studied from the evolutionist's point 
 of view. Much of the material utilized in my investigations 
 on ovarian dermoids was furnished me by my colleague 
 Mr. Henry Morris ; my most instructive specimens I owe to Dr. 
 Granville Bantock, who has on many occasions taken great pains 
 in order that the tumours should be in my hands before they lost 
 their tissue-Hfe ; his thoughtfulness and kindness I cannot too 
 highly appreciate. Some of the material has been the result of 
 my own operative endeavours. 
 
 I am greatly indebted to the Councils of the Pathological, 
 Obstetrical, and Gynaecological Societies for permission to obtain 
 electros of blocks illustrating my papers and reports in their 
 Transactions. Without such indulgence this work would have 
 suffered greatly, for, deprived of the free use of drawings, a work 
 on dermoids would resemble a book on geography written 
 without reference to maps 
 
 48, Queen Anne Street, W., i88q. 
 
LECTURES ON EVOLUTION IN 
 PATHOLOGY. 
 
 CHAPTER I. 
 DERMOIDS. 
 
 General Considerations. 
 
 "T^ERMOIDS are cysts, or tumours^ furnished with skin or 
 
 mucous membrane {which may or may 7ioi he acco^upanied 
 
 with the appendages peculiar to these structures), occurring in 
 
 situations where skin and ?nucotts membrane are fiot normaily 
 
 found. 
 
 In the simplest form of dermoid cyst the interior is lined with 
 skin, the epidermis of which is very thin ; from the skin sprout 
 hairs furnished with sebaceous glands, often of very large size. 
 Sweat glands may or may not be present. The cavity of such a 
 cyst is occupied by pultaceous material, composed of sebum, 
 cholesterin, and shed hairs; often these hairs are rolled into balls. 
 The sebaceous matter in such cysts is the result of the activity of 
 the glands lodged in its walls. 
 
In more complex dermoids, in addition to hair and skin, we find 
 muscle fibre, unstriped and striped (the latter is rare), teeth, and 
 even mammae. 
 
 Fig. I. 
 
 A Pedunculated Dermoid Tumour from the Rectum (after Danzel). 
 
 T, Tooth. B B, Attached Portion of Pedicle. 
 
 Dermoid tumours, on the other hand, are solid and peduncu- 
 lated. The greater proportion of the tumour is made up of con- 
 nective tissue, foetal hyaline cartilage, and fat ; nerve tissue has 
 occasionally been detected. The exterior is covered with skin 
 from which hair, often many inches in length, grows. The skin 
 is furnished with sebaceous glands 3 teeth may project on the 
 
surface or lie embedded in the midst of the tumour. The 
 pharynx and rectum are the most frequent situations for such 
 tumours. 
 
 Tumours containing formed organs other than those belonging 
 to skin or mucous membrane are not dermoids, but suppressed or 
 parasitic foetuses. 
 
 Each of the elements found in dermoids will now receive 
 separate consideration, for they present extraordinary varia- 
 tions. 
 
 1. Skin, — The cutaneous tissue found in dermoids varies within 
 very wide limits. In some specimens it is very thick, and is 
 identical with that covering the exterior of the body ; the epidermal 
 cells form a very thick layer ; papillae may be present, but this is 
 rare. In by far the greater number of dermoids occurring in the 
 ovary, and even in those found in such superficial situations as the 
 angles of the orbit, the epidermis is usually extremely thin, and in 
 some cases scarcely recognisable. The rete malpighii in some 
 cases contains pigment. So far as my reading and observation 
 extend, I know of no case in which nerves or peripheral end- 
 organs have been detected in the skin of dermoids, even when 
 papillae have been present. This may be owing to the fact that 
 such organs require special methods of preparation for their 
 demonstration. That they occasionally exist is very probable, for 
 the skin lining the cavity of a dermoid in some cases possesses 
 tactile sensibility. In the majority of specimens examined by me 
 the rete malpighii resembled the deeper layers of the stratified 
 epithelium found in the mouth, and the wavy arrangement so 
 characteristic of normal skin I have only once seen. The deeper 
 layers of the skin possess a quantity of fat, the cells of which 
 possess walls of great delicacy, and the nucleus is pushed to 
 one side. 
 
 2. Hair. — Next to skin, hair is the most constant structure 
 
found in dermoids, but it varies greatly 
 in amount. In rare cases it may be 
 entirely wanting. In a few instances only 
 one hair could be found even on the 
 most careful scrutiny ; in others five or six 
 may be seen, but more frequently they are 
 innumerable. The hairs usually resemble 
 lanugo, but they may be as coarse as those 
 on the heads of adults. In length they 
 are variable ; in some cysts they measure a 
 few lines in length, in others two feet or more. 
 When short they sprout freely into the cyst 
 cavity, and when shed they may be mixed 
 up with the sebum or rolled into oval balls. 
 The hairs now and then form a long tuft, 
 which lies coiled like a rope. When the 
 hairs are short they, as a rule, sprout from 
 all parts of the cyst wall ; when long may 
 be limited to a small area. The colour is 
 equally capricious, and usually bears little 
 relation to that on the body of the indivi- 
 dual ; in an ovarian dermoid removed from 
 a negress the hair was curly, but light brown 
 in colour. 
 
 In animals other than man dermoids con- 
 tain hair or wool, according to the nature 
 of the tegumental covering. In sheep der- 
 moids contain wool, in horses and oxen hair, 
 black in some, light brown in others. Lebert 
 refers briefly to dermoids in birds, and as 
 would be expected they contained feathers. 
 
 There is reason to believe that hair in 
 
dermoids changes in colour according to the age of the individual, 
 for when such tumours are removed from elderly individuals they 
 frequently contain grey hair ; sometimes it is quite white. 
 
 I am unaware of a case in which grey hairs were found in a 
 dermoid removed from a young subject. There is good reason to 
 believe that hair in dermoids is influenced by age in the same 
 way as that on the exterior of the body. The museum of the 
 Middlesex Hospital contains an excellent specimen of multilocular 
 cyst of the ovary removed by Mr. J. W. Hulke from an old 
 woman over sixty years of age, whose scalp was bald, and the 
 scanty hairs she possessed were quite white. On examining the 
 cyst a large ball of light brown hair was removed from one of its 
 loculi, but even the most critical examination failed to reveal the 
 spot from which it originally grew. The only explanation was 
 that as age advanced the hair in the dermoid, like that on the 
 woman's head, was shed. On examining the cyst wall I failed to 
 detect even epithelium. 
 
 We must remember that a hairy patch of skin may occur in the 
 interior of a cyst lined with mucous membrane, reminding one of 
 the cutaneous patch on the buccal aspect of a rodent's cheek, or 
 those piliferous patches of skin which occasionally appear on the 
 cornea of man, horses, oxen, dogs, and woolly patches in sheep. 
 
 3. Sebaceous Gla7ids. — As hairs are so commonly found in der- 
 moids, it necessarily follows that sebaceous glands are associated 
 with them ; but sebaceous glands in the wall of a dermoid differ 
 in some points from those normally existing in the skin. They 
 are of very large size, with wide ducts and dilated acini. Seba- 
 ceous retention cysts are not infrequent in the walls of dermoids, 
 and are often of large size. A section of the wall of a dermoid 
 rich in glands is shown in fig. 3. 
 
 On one occasion I found several sebaceous cysts in the wall of 
 an ovarian dermoid \ in two of them a mass of horny material 
 
projected, resembling the cutaneous horns occasionally seen 
 sprouting from sebaceous cysts. In the remaining cysts the horny 
 matter was lodged in the cavities, and resembled nail in texture. 
 
 ^'V i •..-iV'r./.'fi^o.'': 
 
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 M: 
 
 
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 Fig- 3- 
 Magnified Section of the Wall of a Dermoid, showing the Sebaceous 
 Glands. Two groups of sweat glands have been divided in the 
 section. 
 
 The museum of the College of Surgeons contains some similar 
 specimens, described in the catalogue as "small pieces of a sub- 
 stance like an ill-forraed horn, such as grows sometimes from a 
 
diseased hair follicle ; they were removed from an ovarian cyst. 
 (From the museum of J. Heaviside, Esq.)" 
 
 Fig. 4. 
 
 An Ovarian Dermoid, containing Teeth (T), Bone, and a Cutaneous 
 
 Process furnished with a Nail-horn (H), (after Cruveilhier). 
 
 The formation of horny matter in a sebaceous cyst of the ovary 
 is of interest because it indicates that when such horns arise in 
 connection with sebaceous cysts of the skin it depends upon 
 
8 
 
 something more than the mere exposure of the sebaceous matter 
 to the desiccating influence of the atmosphere ; there is some 
 vital process concerned in their formation.* 
 
 In rare instances the walls of a sebaceous cyst may undergo' 
 calcification. 
 
 In addition to horns originating in sebaceous cysts lodged in 
 the walls of ovarian dermoids, there is reason to believe that true 
 nails may form in them. Mr. Thornton t exhibited before the 
 Obstetrical Society in 1882 an ovarian dermoid; it contained a 
 cutaneous projection furnished with a long nail. In this case it 
 is to be regretted that the description is so very meagre and with- 
 out a drawing. 
 
 Cruveilhier i has figured an ovarian dermoid which contained 
 a finger-like process, furnished with a nail resembling the over- 
 grown nails seen in bedridden people. Thus of the four varieties 
 of cutaneous horns which occur in the human subject, two have 
 been detected in ovarian dermoids. 
 
 The Pultaceous Material contained in Dermoids. — The fluid 
 contents of dermoids vary greatly ; in most specimens they are of 
 the same greasy character as the semi-solid material found in 
 sebaceous cysts, and are composed of fat, sebum, cholesterine, and 
 shed epithelium, mixed in the case of dermoids with hairs. 
 Sometimes the material is pure sebum, and quite white. In 
 many cases it is glairy, due to free admixture with mucus derived 
 from mucous glands lodged in the wall of the cyst ; at times it 
 consists wholly of mucus ; these last conditions are found chiefly 
 in ovarian dermoids. In rare cases dermoids have been found to 
 contain a collection of rounded bodies resembling pills ; they are 
 collections of epithelial cells rolled into balls. 
 
 * Trans. Path. Soc, vol. xl. 
 
 t Trans. Obstet. Soc, London, 1882. 
 
 X Anatomic Pathologique, liv. xviii., pi. v., figs. 3 and 4. 
 
Subjoined is a detailed analysis of the contents of a pelvic 
 dermoid : — 
 
 Fig. 5- 
 An Ovarian Dermoid, containing a Fold of Skin resembling a Shrunken 
 Mamma (Museum, Koyal College of Surgeons). T T, teeth. 
 
 Berna/s Analysis of the Contents of Dr. OnVs Case. 
 
 Melting-point 
 Sp. gr. at 38^ C. 
 Fixed fatty acids 
 Volatile 
 Oleic acid 
 Glycerin 
 
 .. 0-8855. 
 
 .. 98-4. 
 
 , . o-o6, 
 
 .. 56-64. 
 
 .. 0-45. 
 
lO 
 
 Ma??i??iary Glands. — It is no uncommon event to find in the 
 interior of an ovarian dermoid one or more tags of skin resem- 
 bling a nipple, associated with teeth and hair. Not infrequently 
 these nipple-like processes of skin are attached to more or 
 
 Fig. 6. 
 
 An Ovarian Dermoid with a Spurious Mamma and Nipple growing 
 
 from its Wall (Museum, Royal College oi Surgeons). 
 
 less rounded projections of tissue, which recall in a strik- 
 ing manner the shrunken mammae of a woman who has 
 given suck to many children (fig. 5). The nipples in these 
 cases are imperforate, and beset with large sebaceous follicles. 
 In other cases the mamma may be plump and well formed (fig. 6), 
 but is composed of fat covered superficially with skin. Even in 
 
II 
 
 such a case as this no ducts or gland tissue occupy the substance 
 of the mass, although the nipple is surrounded by an areola. 
 Though the nipples of fhese pseudo-mammae have no ducts, yet 
 
 Fig. 7. 
 
 An Ovarian Dermoid nearly natvn-al size, with two Nipple-like Pro- 
 jections. At the base of the larger one is a cavity lined with 
 squamous epithelium. Sebaceous cysts with calcified walls sur- 
 round the main cavity. 
 
 it does not of necessity follow that glandular tissue is absent in 
 the substance of the mamma, for in a specimen described by 
 Shattock the nipple was imperforate, but a cyst filled with colo- 
 strum occupied the base of the mamma. 
 
12 
 
 A similar specimen has come under my notice, and is repre- 
 sented in fig. 7. In this case we have an ovarian dermoid the 
 walls of which are beset with numerous clusters of cysts and 
 isolated cavities. Many of the cysts are distended ovarian 
 follicles, but others are sebaceous cysts, and one of them has 
 calcified walls. Projecting from the wall of the chief cyst may be 
 seen two cutaneous prominences, villous-looking, and furnished with 
 tufts of hair an inch or more in length. On making a section 
 through the larger of the two prominences, we find a cyst capable 
 of containing a cherry-stone occupying its base. On examining 
 the parts under the microscope the nipple-like projections are 
 seen to be crowded with villous processes of epithelium, resem- 
 bling the filiform papillae of the tongue, whilst around them are 
 clusters of very large sebaceous glands ; the pit-like depressions on 
 the surface of the skin-covered area of the cyst wall are the orifices 
 of these glands. The cavity at the base of the nipple is lined 
 with several layers of squamous epithelium. In some of the 
 sections obtained from the "nipple" a small cluster of sweat 
 glands was detected lying among the sebaceous glands ; this is 
 not an unusual occurrence. 
 
 It is also a fact worth noting that the hairs in this cyst are 
 entirely confined to two tufts directly associated with the nipples. 
 
 The museum of the Middlesex Hospital contains an ovarian 
 dermoid presenting a mamma furnished with a nipple possessing 
 ducts communicating with glandular tissue lodged in the substance 
 of the mamma. 
 
 These three specimens illustrate a point of some importance, 
 viz., the abundance of hair with which they are surrounded, and 
 the extremely large size of the sebaceous glands lodged in the 
 skin which covers the mamma. 
 
 My most perfect specimen was obtained from an ovarian der- 
 moid removed by Dr. Granville Bantock. The cyst is of the size 
 
13 
 
 of a cocoa-nut, and was filled with the usual pultaceous material and 
 hair (fig. 9). Projecting from the wall of the cyst is a mamma 
 as large as a Tangerine orange. Passing from each side of the 
 mamma were two long slender processes covered with skin, 
 
 Fig. 8. 
 
 Mamma from an Ovarian Dermoid. The right-hand figure is shown in 
 
 section, so as to display the glandular tissue. 
 
 attached by their distal extremities to the cyst wall. The base of 
 the processes was surrounded by an areola. When divided, these 
 skin-covered processes were found to be hollow, and communicated 
 Vv^ith glandular tissue in the midst of the mamma. This glandular 
 portion was small in amount, and embedded in rich yellow fat of 
 delicate texture. The ducts and passages were filled with fluid 
 resembling very poor but viscid milk ; under the microscope this 
 
14 
 
 fluid had all the characters of milk, and contained colostrum 
 globules. 
 
 Fig. 9. 
 
 A Mammiferous Dermoid. The gland llias two tube-like nipples, one 
 
 of which has been divided. 
 
 Structurally the secreting tissue of the gland differed from the 
 
IS 
 
 normal mamma only in the character of the epithelium, which 
 instead of being cubical in shape, was spheroidal and arranged 
 several rows deep. In the midst of the secreting tissue of this 
 mamma several isolated pieces of cartilage of the hyaline variety 
 were detected. 
 
 Fig. ID. 
 
 A Mammiferous Dermoid (Von Velitsj. 
 
 The first to describe a mammary gland in an ovarian dermoid 
 seems to have been Haffter.* The mamma was rudimentary in 
 character. De Sinety t has recorded a similar observation. 
 
 Dr. Desiderius von Velitsj was the first to describe an example 
 of mammiferous dermoid which yielded milk and colostrum (fig. 
 loj ; but beyond describing an isolated specimen, no one has 
 
 * ** Ueber Dermoide," Arch, der Heilkimde^ xvi., p. 56, 1875. 
 t "Traite Prat, de Gyn.," 2nd ed., Paris, 1884, p.749 
 X Virchovjs Archiv, Bd. cvii. 
 
i6 
 
 attempted to trace the various stages from cutaneous tags to fully 
 formed glands until my communication was made to the Patho- 
 logical Society in 1887.* 
 
 Up to the present I have not succeeded in obtaining, in so far 
 
 Fig. II. 
 The Histological Characters of the Ovarian Mamma described by 
 
 Velits. 
 
 as histological details go, so perfect a specimen as the one reported 
 by Velits. In this case the glandular elements were typical of the 
 normal mamma, and are well displayed in the drawings accom- 
 panying his paper (fig. 11). 
 
 Ovarian nipples and mammas are interesting from the evolution- 
 ist's point of view. Most persons who have studied the question 
 are of opinion that a mamma ought to be regarded as a collec- 
 tion of modified sebaceous glands. As a rule, milk-glands are 
 
 * Trans. Path. Soc, vol. xxxix. 
 
furnished with a cutaneous process or nipple, in relation with which 
 the excretory ducts open. 
 
 In monotremes, as in the early human embryo, the ducts open 
 on a plane surface of skin (fig. 12, A) ; in other mammals normal 
 mammae are furnished with cutaneous processes called nipples, or 
 teats. Teats have been divided by Gegenbaur into two kinds 
 true and false. 
 
 Fig. 12. 
 
 Three Types of Mamma. 
 
 A, Monotrematous Form, without Nipple. B, True Nipple (Man). 
 
 C, The False Nipple (Cow). 
 
 The true teat (fig. 12, B) is traversed by the ducts of the gland 
 but in the false teat (fig. 12, C) the ducts open at the base of a 
 furrow formed by the uprising of the surrounding skin. 
 
 In ovarian mammae the teats, or nipples, are of the true form, for 
 the ducts traverse the nipples. In very many specimens the 
 mamma is simply represented by a nipple, everywhere beset with 
 very large sebaceous glands. 
 
 It is also of interest to remember that supernumerary mammat; 
 occurring in situations other than in the line of the epigastric 
 arteries affect most frequently regions where hairs are most abun- 
 
i8 
 
 dant, e.g.^ the axilla. When occurring in ovarian cysts they also 
 obey this rule \ the large size of the sebaceous glands in ovarian 
 dennoids has been noticed by all who have studied this department 
 of pathology. The secretion of a mamma agrees in principle with 
 that of a sebaceous gland, for milk is justly defined as " a natural 
 emulsion." Thus ovarian mammae may be regarded as something 
 more than pathological curiosities. It may be mentioned that, 
 like the normal mammary gland, they become the seat of adeno- 
 celes, and may even contain tissue resembling hyaline cartilage. 
 
 Mr. A. H. F. Cameron,* in a paper on supernumerary mammaa, 
 ascribed to Laycock the suggestion that a mamma might make its 
 appearance on any part of the body, and there seems to be a power 
 of producing this particular organ, reminding one of the develop- 
 ment of hair and teeth in ovarian cysts. 
 
 This would account for their occasional occurrence in such 
 apparently extraordinary situations as the labia majora and minora. 
 From the latter situation I removed a typical supernumerary 
 mamma ; it was as large as a cherry, furnished with a nipple, and 
 rich in glandular acini. 
 
 Sweat Glands, — These are by no means frequent in dermoids, 
 and when present they are usually seen as small isolated clusters 
 surrounded by sebaceous glands. When their ducts are detected 
 traversing the skin I have never seen them presenting the 
 characteristic twist so constant under normal conditions. A 
 cluster of sweat glands is shown in section in fig. 1 1. 
 
 Bone. — Osseous tissue is often present in dermoids, especially 
 those occurring in the ovary ; it may or may not be associated 
 with hyaline cartilage, and cartilage may occur unassociated with 
 bone, but this is rare. Bone occurs in two forms — (i) in loose, 
 porous, ill-formed, and shapeless masses, resembhng alveolus in 
 
 * Journal of Anal, ana Phys., vol. xiii., p. 152. 
 
t9 
 
 texture; or (2) as shapeless plates, exceedingly hard, and resem- 
 bling, as Doran aptly suggests, the facial bones of an osseous 
 fish. 
 
 Fig. 13. 
 An Axillary Mamma (alter Leichteiistern). 
 
 Teeth. — These are by no means constant structures in dermoids ; 
 indeed, in the majority of specimens teeth are wanting. Dermoids 
 of the ovary often possess teeth, and those connected with the 
 rectum ; in other situations they are rare. Teeth, when present, 
 may vary in number from two or three up to three hundred. 
 Such teeth may be embedded in definite bony sockets, or sprout 
 
20 
 
 from from the cyst wall. Not infrequently the bone lodging such 
 teeth resembles a superior maxilla (fig. 14). As a rule, the teeth 
 resemble in shape those of the milk dentition, and some observers 
 have described germs as of permanent teeth growing in relation 
 with them ; this, however, requires confirmation. I have never 
 succeeded in detecting them. The teeth present the usual dis- 
 position of enamel, dentine, cementum, and pulp ; nerves have 
 
 Fig. 14. 
 A Piece ol Bone from an Ovaiian Dermoid, lodging Teeth. 
 
 been described entering the pulp, but this requires more abundant 
 confirmation. It is somewhat remarkable that caries very rarely 
 attacks teeth contained in dermoids. Secondary dentine has been 
 detected in the pulp chamber of these aberrant teeth. 
 
 The resemblance of the bone supporting teeth and denticles in 
 ovarian cysts to maxillae has often been mentioned, but we must 
 not regard this likeness in any serious light, because the maxillae 
 owe their peculiar shape to the presence of teeth, and when the 
 jaws are deprived of teeth, as in old age, and in edentulous 
 mammals, the resemblance fails. We may safely attribute the 
 
31 
 
 jaw-like appearance of bone in ovarian cysts to the presence of 
 teeth. 
 
 Mucous Membrane. — Dermoid cysts containing mucous mem- 
 brane occur in two situations, viz., in connection with the post- 
 anal gut and the ovary. In the latter organ mucous membrane 
 
 Fig. 15. 
 An Ovarian Dermoid, containing Teeth, but no Hair, Skin, or Glands. 
 
 may form part of a tumour which is lined chiefly with skin, but 
 when the cyst presents only mucous membrane it is often described 
 as a multilocular glandular cyst. In some specimens the mucous 
 membrane in the cysts is furnished with locks of hairs, and it is a 
 fact of some interest that under abnormal conditions pilose mucous 
 membrane is often met with. In some ovarian dermoids, when 
 no hair, teeth, or glands are present, it is often difficult to 
 
determine whether the cyst is lined with skin or mucous 
 membrane. 
 
 As a rule, the epithelium covering the mucous membrane in 
 ovarian cysts is columnar, and arranged in the most regular 
 manner conceivable, even in the acini of the glands. At other 
 times the surface epithelium is squamous and arranged several 
 layers deep, whilst in a multilocular cyst the shape of the epi- 
 thelium varies in different cysts, as a result of pressure. The 
 mucous membrane in such cysts is soft, pink when living, and 
 velvety to the touch, resembling that found in the bowel, and the 
 fluid contents of such cysts is identical with mucus. 
 
 Mucous Glands. — These are found in cysts lined with skin, as 
 well as in those presenting undoubted mucous membrane. The 
 general characters of mucous glands occurring in ovarian cysts 
 may be studied in fig. i6. They differ from those occurring in 
 the normal mucous membrane by their greater complexity. 
 Another peculiar feature is that they are not equally distributed 
 throughout the cyst wall, but occur in patches, often producing 
 slight projections on the lining membrane of the cyst not unlike 
 the cotyledons in the uterus of a recently delivered ruminant. The 
 peculiarity in the disposition of glands in these cysts will be 
 fully considered in the chapter devoted to ovarian dermoids. 
 
 Among other structures found in ovarian dermoids, mention 
 must be made of the curious eyelike organ detected by Baum 
 garten.* In a multilocular ovarian dermoid he found in one of 
 the cavities a structure closely resembling a foetal eye. It 
 presented a transparent portion, shaped like a watch-glass, and 
 of the size of a pfenning, corresponding to the cornea. When 
 the organ was sagittally bisected a cavity of the size of a cherry- 
 stone was found, containing clear fluid. The walls of the cavity 
 
 * " Ueber eine Dermoid Cyste des Ovarium mit augenahnlichen Bildungen, 
 Virchow's Arch., Bd. cvii., s. 515. 
 
23 
 
 were lined with a delicate layer of pigmented epithelium 
 resembling the uvea of a normal eye. Nothing in any way 
 resembling a retina could be detected. 
 
 
 
 W^% ill 
 
 .»S>!W. 
 
 
 
 ^^^^vTv^^^^^^^T^j^ ^^^^^l^f;:;;- .y.;.-_.:v:-v;;;,r;,-v.-v 
 
 Fig. 1 6. 
 
 Magnified Section oi an Ovarian Cyst, containing Mucous Membrane 
 
 and Mucous Glands. 
 
24 
 
 CHAPTER II. 
 
 The Identity and Mutability of Skin and Mucous 
 
 Membrane. 
 
 "DEFORE proceeding further, it will be convenient to discuss 
 
 the relationship of skin and mucous membrane. Skin in its 
 
 most typical condition covers the exterior of the body, and 
 
 Figr 17- 
 Mucous Glands in the Skin of a Salamander, 
 
 possesses, in addition to the horny layer, a rete mucosum contain- 
 ing pigment. In many animals it furnishes protective structures, as 
 scales, horn, scutes, quills, bristles, feathers, hair, etc., all of which 
 are modifications of the papillae or the epidermis. Cellular 
 down-growths give rise to glands which may furnish sebum, 
 
25 
 
 mucus, poisonous fluids, and milk ; in some cases a shell, often 
 very complex, is formed, and in rarer instances pearl. Subject 
 as skin is to external modifying influences, we need not express 
 
 Fig. 1 8. 
 
 The Stomach of the Darter {Plotiis Anhingd), showing the Hairy 
 
 Pyloric Plug (from a specimen in Mus., R Coll. of Surgeons). 
 
 surprise at the variety of structure and modification exhibited 
 by it. 
 
26 
 
 Mucous membrane in its most typical form exists in the in- 
 testines. It is covered superficially by a single layer of columnar 
 epithelium, which may be ciliated, as in amphioxus, petromyzon, 
 ammocoetes. The epithelium dips below the surface to form 
 mucous glands. On comparing a section of skin with a typical 
 section of mucous membrane the difference is very striking. In 
 addition to structural characters, we have an embryological one ; 
 viz., cutaneous epithelium is epiblastic in origin, whilst that of 
 mucous membrane is hypoblastic. 
 
 Instead of intestinal mucous membrane, let us select a piece 
 from the buccal cavity. Here we find it lined with layers of 
 flattened epithelium surmounting papillae ; some of the papillae 
 are calcified and form teeth ; in many rodents we find hairy 
 patches on the buccal aspect of the cheek. In dogs the buccal 
 mucous membrane contains pigment ; this is occasionally the case 
 with the lingual mucous membrane in man, and the vagina some- 
 times contains tracts of blue pigment in monkeys. Sebaceous 
 glands are not peculiar to skin ; they are large and numerous in the 
 mucous membrane of the nymphae ; in rare cases a milk gland 
 may develop in this situation. Mucous glands occur in the skin 
 of batrachians, worms, and as slime glands in fish. 
 
 In snails, oysters, mussels, etc., the skin glands secrete a shell ; 
 in reptiles, and such specialised vertebrates as birds, the glands in 
 the oviducal mucous membrane perform a similar function ; cal- 
 careous formations resembling shells are constantly formed by the 
 glands in the prostate of man. 
 
 A single layer ot epithelium avails little in the argument, for 
 worms have a single layer of columnar epithelium to their skin. 
 Amphioxus is similarly provided in the gastrula stage, the cells 
 being ciliated. It has been urged that the lining membrane of 
 the mouth is practically skin, inasmuch as it is derived from the 
 epiblast, and a great deal has been said that, to render the argu- 
 
27 
 
 mcnl valid, hair should be found on such a typical mucous mem- 
 brane as that lining the stomach and bowels. This is not very 
 difficult, for that remarkable bird the darter {Plotus anhinga) has 
 its pyloric orifice guarded by a tuft of hair (fig. i8). This curious 
 pyloric plug is composed of structures which do not resemble hairs 
 merely in the external appearance, but also in their histology. We 
 should also remember that cutaneous piliferous patches occur on 
 the conjunctiva of men and dogs, and wool on the cornea of sheep. 
 For a detailed account of this remarkable structure the student 
 
 Fig. 19. 
 Dermoid Growth on the Conjunctiva (after Wardrop). 
 
 should consult the collected works of Garrod (p. 334), " The 
 Anatomy of Plotus Anhinga^ 
 
 Thus, of the various structures usually regarded as dermal, we 
 find that they exist in the mucous membrane of various vertebrata. 
 It will, perhaps, be convenient to arrange them in a summary : — 
 
 Skin. — i. Epider/nis. — Stratified cells cover the buccal aspect 
 of cheeks and lips, and form a thick pad lining the bird's 
 bizzard. 
 
 2. Pigment. — Occurs in the mouth of dogs, in the mucous 
 membrane of man's tongue occasionally, and in the vagina ot 
 monkeys. 
 
 3. SMI. — Occurs in the glandular acini of the human prostate 
 
28 
 
 after fourteen years of age. Shell is also formed by the glands in 
 the mucous membrane of the oviducts in the sauropsida and 
 monotremata. 
 
 4. Hair. — Stomach of the darter, as a pyloric plug; also on 
 caruncle of the eye, and in the mouth of rodents. 
 
 5. Mucous Glands. — Skin of batrachians, fish, and worms. 
 
 6. Sebaceous Glands. — Labia minora of the human female. 
 
 Fig. 20. 
 Dermoid Growth, with Wool, on the Conjunctiva of a Sheep, 
 
 7. Sweat Glands. — These are probably modified mucous glands 
 such as occur in the skin of frogs. 
 
 Epiblastic Origin. — The mucous membrane of the mouth, 
 pharynx, and conjunctiva is epiblastic. 
 
 Thus there is no character or set of structural characters by 
 which we can definitely mark a fundamental distinction between 
 skin and mucous membrane. The supposed embryological dis- 
 tinction that skin is of epiblastic origin, whilst mucous membrane 
 comes from the hypoblast, is often urged very strongly. Yet in 
 the case of the conjunctiva we have a typical mucous membrane 
 
29 
 
 derived from epiblastic, which not infrequently declares its 
 fundamental relation to skin by exhibiting upon its surface a 
 larger or smaller patch of true skin. A specimen from man is 
 shown in fig. 19. It was observed in a man aged fifty years. 
 The condition was congenital. Twelve very long hairs grew 
 from its middle, passed between the eyelids, and hung over the 
 cheek. The hairs did not appear until the sixteenth year, when 
 the patient's beard began to grow.* Very many such cases have 
 been placed on record in man. I have collected many examples 
 from other mammals. Thus, a specimen in the museum of the 
 Royal College of Surgeons shows a patch of skin on the cornea of 
 a sheep, from which a long tuft of wool sprouts (fig. 20). 
 Partridge t has described a case which occurred in an ox (fig. 21). 
 Indeed, they are not rare in this animal. Dermoid tracts have 
 also been seen on the conjunctivae of dogs and horses. 
 
 The most useful fact in relation with this matter is that the 
 change from mucous membrane to skin may be actually studied in 
 the human subject. On examining microscopically the covering of 
 an internal pile which has been long extruded, instead of the 
 columnar epithelium characteristic of the rectum, we meet with 
 stratified cells characteristic of the epidermis. 
 
 Similar changes occur in connection with the uterus when 
 inverted. Mr. Dickinson informed me that in a negress suffering from 
 elongation of the cervix the part projecting from the vulva was not 
 only skin-like in appearance, but intensely black, like the rest of the 
 integument. But uterine myomata offer the readiest means of 
 demonstrating the change. When a submucous myoma projects 
 into the cavity of the uterus its surface is covered with columnar 
 ciliated cells. Later, when such a tumour projects into the vagina 
 the surface cells become stratified, whilst those lining the glandular 
 
 * Wardrop, "Morbid Anatomy of the Human Eye." 
 t Trans. Path. Soc. 
 
30 
 
 recesses of the exposed part retain their columnar ciliated character. 
 This was beautifully shown in some specimens described by 
 Dr. Gervis* before the Obstetrical Society (fig. 22). These 
 cases are of great value, for they decide the unstable nature of 
 opinions as to the genesis of cysts founded merely on the character 
 
 Fig. 21. 
 
 The Eyeball oi an Ox, with a Piece of Hairy Skin growing iiom the 
 Conjunctiva (after Partridge). 
 
 of the epithelial lining ; indeed, epithelium is very variable, especially 
 when subject to pressure. 
 
 If we admit the morphological identity of skin and mucous mem- 
 brane, it necessarily follows that a cyst lined with mucous mem- 
 brane should, with as much propriety, be admitted into the 
 
 * Obstetrical Soc. Trans , vol. xxviii., 1886. 
 
31 
 
 category of dermoids as one lined with skin, provided they arise in 
 
 Fig. 22. 
 
 Appearance of the Mucous Membrane of a Prolapsed Uterine Fibroid 
 
 (after Gervis). 
 
32 
 
 situations where skin and mucous membrane do not normally 
 occur. 
 
 Dermoid Tumours. 
 
 The facts considered in the preceding section, concerning the 
 relationship of skin and mucous membrane, are of great import- 
 ance in connection with an exceptional form of skin-covered 
 tumour occasionally found in certain parts of the alimentary 
 canal. 
 
 Fig. 23. 
 A Dermoid Tumour from the Pharyngeal Aspect ol the Soft Palate (after 
 
 Arnold). 
 
 In cases of large congenital hairy naevi it is not rare to find small 
 pyriform tumours, covered with piliferous skin, hanging by narrow 
 pedicles from the naevus. A very marked instance of this occurred 
 in a child whom I saw with Mr. Wilkes, of Salisbury : nearly the 
 whole of the trunk was covered with darkly pigmented, hairy skin ; 
 in some parts the hair was as long as that on the child's scalp. 
 
Hanging from the naevus near the spine of the left scapula were two 
 of these pendulous dermoid tumours. Similar pedunculated der- 
 moid tumours occur in the pharynx and rectum. Pharyngeal dermoid 
 
 Fig. 24. 
 A Pilose Pharyngeal Dermoid (after Abraham). 
 
 tumours may be attached to the back of the soft palate or to the 
 roof of the pharynx, and it appears to be very difficult during life to 
 exactly decide to which part of the pharynx a given dermoid 
 tumour is attached. 
 
 Arnold * has published an excellent description of a dermoid 
 tumour, of the size and shape represented in fig. 23, removed by 
 Schiitz, of Mannheim, from the pharyngeal aspect of the soft 
 palate, a little to the left of the median line, of a girl aged thirteen 
 years. The tumour was congenital, and covered with skin furnished 
 with hair and sebaceous glands. The bulk of the tumour con- 
 sisted of connective tissue, containing striped muscle fibre and 
 cartilage. 
 
 Abrahamt has described a dermoid tumour removed from the 
 pharynx of a young woman, aged twenty-two ; it contained a 
 nodule of cartilage ; it grew from the basilar suture (fig. 24). 
 
 Dr. Hale White X described a similar specimen, removed 
 from the pharynx of a child, three years old. It was uncertain 
 
 * Virchow's Arch., Bd. cxL, s. 176, 1888; 
 -t Journal of Anat. and P/iysioL, vol. xv., pt 244, 
 X Path. See. Trans,, vol. xxxii., p. 201. 
 
 3 
 
34 
 
 whether the tumour grew from the back of the soft palate or roof 
 of the pharynx. 
 
 Fig. 25. 
 A Pharyngeal Dermoid Tumour in a Monstrous Pig.* 
 
 Arnold refers to a case reported by l^anibl, in which a 
 pedunculated pharyngeal dermoid occurred in a child four weeks 
 old. At the age of six months the dermoid became detached, 
 
 * The specimen is fully described in the Trans. Odont; See. of Great 
 Britain, Dec, 1888. 
 
and swallowed by the child. Next day it passed per anum. It 
 consisted of fat and pilose skin. 
 
 The pharynx, like the coccygeal region, is very frequently occu- 
 pied by teratomata, and occasionally a dermoid tumour may be 
 associated with a pharyngeal teratoma. 1 once dissected a 
 specimen of this sort in a monstrous pig. The dermoid is shown 
 
 Y\g. 26. 
 A Rectal Dermoid in Section (after Port). 
 
 in fig. 25. It was mainly composed of fibrous tissue, covered 
 with integument beset with soft bristles and glands. 
 
 Similar tumours occur in connection with the rectum, but as a 
 rule they are furnished with tufts of hair often of great length. 
 These long locks of hair protrude from the anus, and ca'jse great 
 annoyance and distress. 
 
 The case described by 1 )r. Port ' may be selected as a typical 
 
 * Trans. Path. Soc. vol; xxxit, p. 307. 
 
36 
 
 specimen of this form of dermoid ; it is composed of fat and 
 fibrous tissue, covered externally with piHferous skin, furnished 
 with sebaceous glands and a tooth (fig. 26). 
 
 I have also had an opportunity of examining a very similar case 
 exhibited by Glutton * at the Pathological Society. This also had 
 
 Fig. 27. 
 A Pedunculated Dermoid of the Rectum (after Danzel). 
 B B, its point of attachment to the bowel. T, Tooth. 
 
 some tufts of long hair. The tumour was situated near the upper 
 end of the rectum. Danzel t reported a case which occurred in a 
 woman aged twenty-five years. The tumour resembled the 
 two just mentioned, but was said to contain brain substance 
 enclosed in a bony capsule (fig. 27). Such tumours may 
 be attached to the mucous membrane of the bowel, just 
 
 * Path. Trans., vol. xxxvii., p. 
 
 I Lav^enbeck's -Archiv, 1874, Bd. xvii. 
 
within the anus, or extend as high as the sigmoid flexure. 
 Some surgeons are of opinion that such tumours originate in the 
 ovary, make their way through the gut, and project into the rectum. 
 Such an explanation has not any evidence to support it. In some 
 instances they probably arise from the transformation of the mu- 
 cous membrane of the bowel, in the same way as dermoid patches 
 on the conjunctiva, and there is no theoretical reason why a skin- 
 covered tumour should not form in any part of the alimentary 
 canal, from the mouth to the anus. Some of the rectal and 
 pharyngeal dermoids may arise in a somewhat different manner, as 
 will be explained later. 
 
 Classification of Dermoids. 
 
 Up to the present time little has been attempted towards the 
 classification of this remarkable group of tumours. In the 
 present essay we shall find it most convenient to consider them in 
 three groups, according to their mode of origin ; they may arise 
 in sequestrated portions of the surface epiblast, in connection 
 with obsolete canals, and in ovarian follicles. This will enable 
 me to form three groups : — 
 
 1. Sequestration dermoids. 
 
 2. Ovarian dermoids. 
 
 3. Tubulo-dermoids. 
 
 Each of these groups will be separately considered. Of 
 the three groups, the simplest in structure are sequestration cysts, 
 the largest, most complex, and dangerous to life are the ovarian 
 forms, whilst tubulo-dermoids occupy an intermediate position 
 in each respect. 
 
38 
 
 CHAPTER HI. 
 
 SEQUESTRATION DERMOIDS. 
 
 Dermoids belonging to this group arise in detached or 
 sequestrated portions of the surface epiblast, chiefly in situa- 
 tions where during embryonic life coalescence takes place 
 between two surfaces possessing an epiblastic covering. Under 
 this heading we may conveniently include the interesting variety 
 " dermoids by implantation." The cysts of this group are the 
 simplest dermoids, and may be considered according to the 
 situation in which they grow : — 
 
 1. In the Trunk. 
 
 2. On the Head. 
 
 3. Iritic Dermoids. 
 
 4. Implantation Dermoids. 
 
 {a) Limbs. 
 {b) Iris. 
 
 I. Dermoids of the Trunk. 
 
 Sequestration dermoids arising in connection with the trunk 
 occur strictly in the regions where the opposite halves of the body 
 wall coalesce. These lines of coalescence may be indicated in 
 the adult by a line starting from the external occipital protube- 
 rance, and extending along the mid-line of the back to the coccyx ; 
 it then passes through the perinaeum (scrotum, and penis, in the 
 male), upwards through the umbilicus, thorax, and neck, to the 
 symphysis menti. 
 
39 
 
 {a) T/ie Dorsal Group. — Dermoids associated with the spine 
 are very rare. For an opportunity of examining the following 
 specimen I am indebted to the kindness of Mr. Gilbert Barling. 
 The parts were removed from a child two years old, the subject 
 of spina bifida occulta. Beneath the hairy patch, and associated 
 with the defective spines, a small dermoid cyst was found 
 (fig. 28), containing pultaceous material and hairs. 
 
 I long had a suspicion that many tumours described as spina bifida 
 cysts may have been dermoids, for, theoretically, dermoids should 
 occur with tolerable frequency along the dorsal line. To this end 
 I made a microscopical examination of a large number of spina 
 bifida cysts which were in my possession and under the charge of 
 my friends, as well as those preserved in the museum of the Royal 
 College of Surgeons, but without success. Recently Dr. Wilde 
 described before the Pathological Society a large dermoid removed 
 by Mr. Holthouse from the lumbo-sacral region of a man aged 
 twenty-two years. The cyst was congenital, as large as a turkey's 
 egg, and lined with skin, furnished with hairs and possessing 
 tactile sensibility. This I verified by personal observation. 
 
 Faulty coalesence is by no means uncommon in the lumbo- 
 sacral region, as is attested by the occurrence in association with 
 and not infrequently without, a spina bifida cyst of small congenital 
 sinuses known as post-anal dimples, erroneously attributed by 
 Cleland to abnormal shortness of the notochord. 
 
 {b) The Ventral Group. — Scrotal Dermoids. — There are many 
 good reasons for believing that the majority of dermoids reported 
 as being testicular were really scrotal. This was clearly so in a 
 case reported by Bilton Pollard* as a dermoid of the testicle. The 
 cyst was situated on the left side of the scrotum, between the 
 testicles, and was adherent to the back of the left one, outside the 
 
 * Path. Soc. Trans., vol. xxxvii., p. 342. 
 
40 
 
 tunica vaginalis. The cyst contained putty-like material in which 
 there were a few grey hairs ; three hairs were found growing from 
 the cyst wall. The cyst was lined with stratified epithelium ; 
 papillae and sebaceous glands were detected. 
 
 It is usually stated in text-books that dermoids of the testes are 
 common. This is very improbable, for very few cases are to be 
 
 Fig. 28. 
 
 Section of a Portion of a Spine with Sp. Bif. Oc. 
 
 D, a small Dermoid (Semi-diagrammatic). 
 
 found in surgical literature, and then the details in most cases are 
 insufficient to enable me to determine whether the dermoid was 
 scrotal or testicular. For evidence as to the rarity of testicular 
 dermoids Mr. D'Arcy Power's* paper should be consulted. 
 
 This furnishes a good example of the small amount of reliance 
 to be placed on loosely recorded descriptions of specimens. In 
 records of future cases it will be necessary to pay particular 
 attention to the relation the dermoid bears to the testicle, tunica 
 vaginalis, and scrotum. 
 
 * Path. Soc. Trans., vol. xxxviii., p. 224. 
 
41 
 
 (c) Penile Dermoids. — As is well known, the penis is formed by 
 the union ot two lateral moieties, the line of confluence being 
 indicated in the adult by the prominent median raphe so con- 
 spicuous on its under aspect. Thus, we may anticipate the 
 occasional existence of dermoids in this situation ; they are never- 
 theless very rare. It is likely that some cysts occurring on the 
 under aspect of the penis near the prepuce, and described as 
 dermoids, may have been sebaceous, whilst some described »as 
 sebaceous were really dermoids. 
 
 [d) Umbilical Dermoids. — The umbilicus is not a common 
 situation in which to find dermoids. Lannelongue * has given a 
 careful description of one which hung pedunculate from the navel 
 of a child eight years old. The tumour had been noticed since 
 the age of three. The cavity of the dermoid contained pultaceous 
 matter, and the walls, when examined microscopically, exhibited 
 the characters of skin, but glands and hairs were not found. A 
 drawing of the histological features accompanies the description. 
 One of the most remarkable specimens of dermoids known 
 is described by Budin, f which was found attached to the 
 umbilical cord of a girl; it was as big as a large fist, and 
 was situated twenty centimetres from the umbilicus. The interior 
 of the cyst possessed an epithelial lining, hairs, and sebaceous 
 glands. 
 
 Dermoids in the Mid-line of the Thorax and Neck. — Along this 
 
 line dermoids are most frequently seen in relation with the 
 
 manubrium sterni, at the spot known as the angulus Lndovici. 
 
 Here they may attain goodly proportions, and dip behind the 
 
 manubrium to invade the superior mediastinum. They may occur 
 
 on the ventral (anterior) aspect of the sternum unconnected with 
 
 the angulus. An easily accessible description of a case of this 
 
 * '* Kystes Congenitaux," p. 196. 
 
 t Le Frogrls Medical ^ Dec. 31, 1887. 
 
42 
 
 nature is furnished by Glutton.* The patient was a female aged 
 thirty-nine years. She had a tumour, 13 inches in circumference^ 
 pendulous between the breasts. The tumour, when removed,, 
 contained 11 ounces of the usual pultaceous material found in 
 dermoids. The cavity was lined by skin, but no glands were 
 found. Only one hair was detected growing from its walls. When 
 the patient was six weeks old a small body the size of a pea was 
 noticed ; at nineteen it was as large as a hen's egg ; since that age 
 it increased in size rapidly. Cysts in this situation are very rare. 
 Judging from the few recorded cases, sternal dermoids are most 
 commonly situated over the interspace between the manubrium 
 and gladiolus. 
 
 Numerous examples of dermoids in the mid-line of the neck, 
 near the hyoid bone, have been reported. 
 
 II. Cranial Dermoids. 
 
 Sequestration dermoids occurring in the head are divisible into 
 two distinct groups ; viz., those arising in connection with the 
 facial fissures, and those found on the scalp or in relation with the 
 dura mater. The fissures connected with the face occasionally 
 occupied by dermoids are the orbital and palatine, and the 
 choroid cleft of the eye. 
 
 Oi'bital Dei-jHoids. — The outer and inner angles of the orbits 
 are, next to the ovary, the most frequent situations in which to 
 find dermoid cysts. Indeed, their characters are so well known as 
 to scarcely need a description. They are m.ore common at the 
 outer than the inner angle of the orbit, and as a rule they rarely 
 exceed the dimensions of a filbert. The cavity of the cyst con- 
 tains pultaceous matter and hair ; the cyst wall is co\ered with 
 epidermis, presenting hairs and large sebaceous glands, but rarely 
 sweat glands. "J'eeth, I believe, have never been found in these 
 * Path. Soc. Trans., vol. xxxviii., p. 393. 
 
43 
 
 orbital cysts. Usually they are lodged in a shallow recess in the 
 bone, and not infrequently have a pedunculated connection with 
 the dura mater. The general appearance of such a cyst is shown 
 in fig. 29. 
 
 Fig. 29. 
 An Orbital Dermoid. 
 
 This specimen is somewhat unusual, in that the patient was a 
 middle-aged man. As a rule they are removed early in life. In 
 actual practice it is necessary to avoid confounding a meningocele 
 in this situation with a dermoid, or serious consequences may 
 ensue. 
 
 Dermoids in the vicinity of the orbital angles are regarded as 
 arising from portions of the surface epiblast sequestrated during the 
 
44 
 
 process of obliteration of the orbital fissure, shown in fig. 30, which, 
 cleft is represented in the adult by a line drawn from a spot about 
 half an inch behind the external angular process ofthe frontal bone, 
 through the orbit, and following the lachrymal canal, passes through 
 
 Fig. 30. 
 Ventral View of the Mouth of a Human Embryo, showing the 
 
 Orbital Fissure. 
 
 the lip, to one side of the median line, into the mouth. The 
 nasal duct represents a persistent portion of this cleft. It is not 
 justifiable to apply the term branchial to this fissure, although 
 there are many reasons to lead us to suppose that at one time it 
 may have supported gills ; nevertheless, the arguments are not 
 altogether convincing, and at the present day no forms are known 
 in which at any time gills sprouted into the cleft. 
 
 Although many orbital dermoids may be satisfactorily regarded 
 as arising in portions of surface epiblast sequestrated during the 
 obliteration of the orbital fissure, the explanation does not satis- 
 factorily account for all dermoids in connection with the orbits. 
 
45 
 
 On several occasions I have removed dermoid cysts from the 
 eyelids unconnected with bone or periosteum, and situated in the 
 palpebral tissues. The eyelids are occasionally subject to a mal- 
 formation known as coloboma : the upper lids are affected more 
 often than the lower, and the malformation may be unilateral or 
 bilateral ; not infrequently the defect is accompanied by hare-lip, 
 cleft palate, and similar conditions. 
 
 Our knowledge of the details of the development of the eyelids 
 is not very exact, certainly not sufficient to enable us to offer a. 
 satisfactory account of the mode of origin of such a defect as 
 coloboma palpebrarum. I have little doubt that when a satisfac- 
 tory account is forthcoming we shall probably find the key to the 
 origin of many dermoid cysts lying in intimate relation with 
 the eyelids, unassociated with bone and the orbital fissure. 
 
 Cvs/s of the Choroid Cleft. — Cysts, variously described as 
 sebaceous and dermoid, growing on the iris, may arise in two 
 ways. The majority of such cysts have been associated with 
 antecedent perforating wounds of the cornea, whereby small pieces 
 of Descemet's membrane, epidermal scales, or eyelashes have been 
 accidentally transplanted on to the iris and formed the germs of 
 cysts. 
 
 Mr. Osborn * admits that many iritic dermoids and sebaceous 
 cysts arise in this way, but suggests that others may occasionally 
 be due to dilatation of some portion of the unobliterated remains 
 of the choroidal cleft, which when persistent gives rise to the 
 defect known as coloboma iridis. Such cysts look like small 
 white currants, semi-transparent and pearly, protruding into the 
 anterior chamber, occluding the pupil, and eventually inducing an 
 attack of iritis. 
 
 * St. Thomas's Hospital Rep., vol. vi., p. 69. R. Lond. Ophth. Hosp. 
 Rep., vol. vii., p. 245. 
 
46 
 
 Osborn also relates a case in confirmation of this view, where a 
 cyst of the iris was associated with a dermoid in front of the pinna, 
 a little above the tragus. 
 
 Masse * has published some evidence which strongly supports 
 Osborn's view. Iritic cysts are of rare occurrence, and are among 
 the most striking and beautiful pathological specimens when seen 
 in the living eye. 
 
 Dermoids of the Pinna. — The pinna is first indicated in the 
 human embryo by six ill-defined tubercles, which arise on each 
 side of the hyo-mandibular cleft ; their subsequent fusion gives 
 rise to the pinna. 
 
 Should any of these tubercles fail to coalesce, various defects 
 are occasioned, such as congenital fistulse and supernumerary 
 auricles ; if pieces of the surface epithelium get locked in a der- 
 moid may arise t (fig. 31). 
 
 Palatine Dermoids. — Originally the roof of the mouth is incom- 
 plete, the nasal and buccal cavity forming a common chamber. 
 Gradually the palatine processes of the maxillae and palate bones 
 converge to the middle line to form a roof to the mouth. For a 
 long time, however, the palate is occupied by a fissure, extending 
 originally through the upper lip ; it is for a time restricted to the 
 hard and soft palate, and finally closes from before backwards. 
 Cysts and tumours arising from faulty closure of this fissure or 
 cleft are of two kinds — epithelial pearls and dermoids. 
 
 When the mouth of a child at birth is examined it is not 
 unusual to find in the median raphe of the palate, and sometimes 
 hanging by thin, short pedicles, small pedunculate bodies of the 
 size of millet seeds, sometimes as large as peas, composed 
 of epithelial cells. The small bodies are known as epithelial 
 
 * '* Kystees, Tumeurs Perles, et Tumeurs Dermoides de I'lris," Paris, 18S5. 
 t For fuller details see Lancet^ Feb., 1888. 
 
47 
 
 pearls, and are to be regarded as remnants of the cells which 
 covered the opposed surfaces of the palatine elements, which 
 growing from each side, meet together in the median line to form 
 the roof of the mouth. Small collections of epitheUal cells of this 
 character have been seen in the raphe on the under aspect of the 
 penis. For references to a discussion on the nature of the 
 epithelial pearls the student may consult Leboucq's paper.* These 
 
 '''''^'''^. .r')fe:::t^^3r^'^^ 
 
 Fig. 31. 
 
 A Dermoid of the Pinna associated with one in tlie Orbital Fissnre 
 
 (after Lannelongne). 
 
 little bodies are of some interest, for they may be regarded in the 
 light of tumour germs. Neoplasms perfectly innocent in their 
 nature, but full of epithelial nests, occur in the palate, and good 
 ground exists for the behef that many palatine tumours described 
 *" Note sur les Pedes Epitheliales,'' --/nvv. de Biolo^ie^ vol. ii. , 1881, p. 400. 
 
48 
 
 as adenomata were really of the same nature as epithelial pearls. 
 For a careful account of the characters and structure of these 
 neoplasms reference should be made to the papers of Stephen 
 Paget,* who has reported some cases and collected the more 
 important in surgical literature. 
 
 Dermoids of the palate have several times been seen, and as a 
 type specimen that reported by Cleraultt may be selected: — 
 
 " A male infant was born with a tumour inside its mouth which 
 was at first mistaken for a tongue, being of the same colour and con- 
 sistence. The soft palate was partially cleft. The tumour grew 
 from the middle of the hard palate, and was lobed and covered with 
 silky hairs, especially on the left side. Its surface was covered with 
 true skin, with large sebaceous glands, but no papillae ; inside it was 
 composed of adipose tissue, with a fasciculus of striped muscular 
 fibre." 
 
 Dermoids of the Scalp and Dura Mater. — Dermoid cysts are 
 occasionally found in connection with the scalp and dura mater. 
 The usual situations are the anterior fontanelle, root of the nose^ 
 and external occipital protuberance. In these situations they 
 may be confounded with sebaceous cysts or with meningoceles. 
 Dermoids of the scalp nearly always have a thin pedunculated 
 attachment to the dura mater, the pedicle traversing a hole in the 
 underlying bone, unless the cyst is over a fontanelle. 
 
 Arnotti published the details of an instructive case of dermoid 
 situated over the anterior fontanelle in an infant a few days old. 
 The tumour exactly resembled a meningocele, " rising and falling 
 with regular pulsation, and swelling when the child coughed ; " 
 the resemblance was so strong that it was treated as a meningocele. 
 
 ♦Paget, "Tumours of the Palate," St. Barth. IIosp. Rep., vol. xxii., and 
 Path. Soc. Trans., vol. xxxviii.. p. 348. 
 t Bull. Soc. Altai., 1874, p. 380. 
 X Path. Soc. Trans., vol. xxv., p. 228. , 
 
49 
 
 A few weeks later the child died from broncho-pneumonia, and 
 the cyst was found to be a dermoid. The specimen is preserved in 
 the museum of St. Thomas's Hospital. 
 
 Fig. 32. 
 A Congenital Tumour over the Anterior Fontanelle (after Hutchinson). 
 
 Giraldes * records a case even more remarkable than this. A 
 child, three months old, had an ovoid tumour, of the size of a 
 pigeon's egg, over the anterior fontanelle. The tumour was 
 covered with fine white hair, and did not pulsate with respiration. 
 It was thought to be a meningocele, and in order to establish a 
 diagnosis it was punctured with a fine trocar, and fluid resembling 
 that found in meningoceles was withdrawn. Notwithstanding 
 numerous subsequent punctures, the tumour maintained its 
 original volume. Some months later it was removed, Giraldes 
 being still under the impression that it was a meningocele, but it 
 was found to be a typical dermoid. 
 
 The clinical characters of such tumours occurring at the 
 
 * " Maladies Chir. des Enfants," p. 342. 
 
5° 
 
 anterior fontanelle may be illustrated by the case reported by 
 Hutchinson.* As the tumour distinctly filled when the child cried, 
 it was not interfered with. At the date when the case was pub- 
 lished the patient was a fine young man of eighteen, and the cyst 
 has not shown any tendency to increase since birth (fig. 32). 
 
 Some of the most striking specimens of dermoid cysts are those 
 found associated with the dura mater, but situated on the inner 
 side of the bony covering. A frequent position for such cysts is 
 in the immediate neighbourhood of the torcular Herophili. Careful 
 descriptions of at least four cases are accessible. Professor 
 Turner t described a dermoid cyst of small size situated between 
 the layers of the dura mater beside the torcular. It contained 
 hair, and was unassociated with any defect of the occipital bone. 
 It occurred in a child aged twenty-three months. Dr. Oglej 
 observed a similar case in a child two years and a half old, asso- 
 ciated with a defect in the squamous portion of the occipital 
 bone. 
 
 Dr. Pearson § Irvine published the details of a cyst which he 
 found in a child seven years old. The cyst had invaded both 
 lobes of the cerebellum, and had injuriously affected the medulla 
 and upper part of the spinal cord. The cyst contained hair, 
 sebaceous matter, and pus ; inflammation and suppuration had 
 occurred. 
 
 Lannelongue || has figured a specimen of this nature. The 
 patient was a little girl whose head began to enlarge at the age of 
 three years ; at the age of seven her head presented all the 
 
 * "Illustrations of Clinical Surgery," vol. ii., plate xlvi. 
 t St. Earth. Hosp. Rep., vol. ii., p. 62. 
 X Brit, and For. Med. Chir. Rev., 1865. 
 § Path. Soc. Trans., vol. xxx., p. 195. 
 
 II " Kystes Congenitaux," 1886. The details of this case were communicated 
 to the Soc. Anat. by Wedal (1885). 
 
51 
 
 characters of hydrocephalus, and she suffered from vomiting, 
 giddiness, and convulsions. Paralysis, amaurosis, and coma 
 gradually supervened, and at the age of seven years and a half 
 she died. On examining the parts the ventricular cavities and 
 intercommunicating passages were found greatly distended. Pro- 
 
 Fig. 33- 
 A Dermoid of the Scalp connected with the Dura Mater by a Pedicle. 
 
 jecting into the space between the cerebellar lobes was a cyst of 
 the size of an orange, which had depressed the roof of the fourth 
 ventricle and obliterated the underlying cavity. 
 
 The cyst contained sebaceous matter and epithelial scales ; the 
 walls were lined with several layers of epithelium, and externally 
 were adherent to the tentorium cerebelli, whilst a portion passed 
 out of the skull immediately beneath the occipital protuberance, 
 and was adherent to the overlying scalp. 
 
52 
 
 Thus dermoids presenting on the scalp may or may not have 
 pedicles of attachment to the dura mater, whilst intra-cranial 
 dermoids connected with the dura mater may or may not have 
 pedicles of attachment with the scalp. 
 
 Although at first sight a dermoid cyst connected with the dura 
 mater and projecting into the brain seems to violate all embryo- 
 logical rules, nevertheless, when we view this membrane from a 
 morphological standpoint the strangeness vanishes and a satisfac- 
 tory explanation is forthcoming. 
 
 Morphologically considered, the bony framework of the skull is 
 an additional element to the primitive cranium ; this is represented 
 by the dura mater, and as I have elsewhere* endeavoured to 
 show, the term extra-cranial should strictly apply to all tissues 
 outside the dura mater. In common practice we find it convenient 
 to regard the bones as the boundary of the skull, but morpho- 
 logically this is inaccurate ; the skull-bones must be regarded as 
 secondary cranial elements. Early in embryonic life the dura 
 mater and skin are in contact ; gradually the base and portions 
 of the side-wall of the cranium chondrify, thus separating the 
 skin from the dura mater. In the vault of the skull, membrane 
 bones develop between the dura mater and its cutaneous cap, but 
 the skin and dura mater are long in contact along the various 
 sutures even for a year or more after birth. This relation of 
 the dura and skin persists longest in the region of the anterior 
 fontanelle and the neighbourhood of the torcula. Should the 
 skin be imperfectly separated, or, indeed, a portion remain per- 
 sistently adherent to the dura, it would act precisely as a tumour- 
 germ, and give rise to a dermoid cyst. Such a piece of skin may 
 retain its old attachment to the dura, and its pedicle becoming 
 
 * Journal of Anat. and Physiology, vol. xviii.,p. 28, "A Critical Study in 
 CraDial Morphology." 
 
53 
 
 surrounded by bone, the cyst resulting from it would lie outside 
 the bone, but be lodged in a depression on its surface, with an 
 aperture transmitting its pedicle. On the other hand, it may 
 become buried in by bone ; the cyst would then project exclusively 
 on the inner surface or between the layers of the dura. If this 
 view of the origin of dermoids of the scalp be admitted, we 
 must then slightly modify our teaching, and say that the de- 
 pressions in which dermoid cysts of the cranium are lodged arise 
 as imperfections in the developmental process, and are not due to 
 absorption induced by the pressure exerted by the cyst ; further, 
 the fibrous connection of such dermoids with the underlying dura 
 is primary and not secondary. 
 
 III. Dermoids of the Limbs. 
 
 These form a very interesting group, for we may regard them 
 in the light of an experiment which affords good evidence in 
 support of the view that sequestration dermoids arise in detached 
 portions of surface epiblast. 
 
 The cysts which will be here described as dermoids of the 
 limbs have in most cases been reported as sebaceous cysts ; they 
 are extremely rare, and in nearly all instances associated with 
 antecedent injury. Thus, in one of best-described cases the 
 facts were as follow * : — 
 
 A cyst, the size of a small cherry, was removed from the finger 
 of a man who some years before had injured his right middle 
 finger, the terminal phalanx of which was amputated in 
 consequence. The cyst, which lay under the skin and 
 rested upon the sheath of the flexor tendons, on the palmar 
 aspect of the proximal phalanx of the injured finger, was com- 
 posed of a layer of fibrous tissue, supporting a stratum of 
 
 * Barker, Path. Soc. Trans., vol. xxxvii., p. 478. 
 
54 
 
 irregular epithelial cells, and lastly a layer of horny epidermis, 
 lining a cavity containing sebaceous material and cholesterin. 
 
 In another case a man pricked his finger with a piece of 
 steel in the flexure of the joint ; a small nodule appeared at 
 the injured joint ; this was removed, and found to consist of 
 densely packed epithelial scales. Mr. Poland,* in reporting 
 these facts, mentions that Mr. Davies-Colley had removed two 
 similar cysts from the finger, both associated with antecedent 
 injury. Mr. Bowlby reported a cyst of this nature removed 
 from the dorsal surface of the index-finger. The patient, a 
 woman aged sixty, had frequently pricked the finger at that spot 
 with a sewing-needle. 
 
 It would seem that at the time of the accident small particles 
 of skin or epidermis are carried into the tissues by the instrument 
 which inflicts the wound, and behaving as grafts, become the 
 starting-points of dermoids. 
 
 Polaillon f has given an account of digital dermoids, and gives 
 to M. Muron the credit of first recognising the character of such 
 cysts (1868). He says the tumours are more frequent in the 
 palmar than the dorsal aspect of the digits, but he fails to associate 
 them with antecedent injury, though he distinctly points out 
 that they occur mainly on the hands of workpeople and soldiers. 
 
 A digital dermoid from the subcutaneous tissue of the finger 
 pulp is represented in fig. 34. The specimen was placed at my 
 disposal by Mr. Shattock, who described its microscopical 
 characters thus : " It appeared as if a piece of the skin covering 
 the pulp of the finger had been inverted." There was no clear 
 history of old mechanical injury, but the patient was a farrier. 
 Cysts of this character are not confined to the digits. Mr. 
 
 * Path. Soc. Trans., vol. xxxv., p. 399. 
 
 t " Die. Ency. des Sci. Med.," 1884, in an admirable article, *' Doigt." 
 
55 
 
 Targett recently exhibited at the Pathological Society a very 
 large dermoid removed from the subcutaneous tissue on the 
 outer side of the knee-joint, near the insertion of the biceps. The 
 cavity contained the usual pultaceous material peculiar to der- 
 moids. Under the microscope the lining membrane was found 
 
 Fig. 34- 
 A Dermoid from the Pulp of the Finger, natural size. 
 
 to be skin, but no cutaneous appendages were detected. In the 
 •clinical notes, which were taken six years ago, no history of 
 injury was recorded. 
 
 Dermoids by " implantation " are of interest, for they serve to 
 throw light on some cysts containing hair and wool, preserved in 
 the museum of the Royal College of Surgeons. Two of the 
 cysts are from sheep, and contain wool embedded in fatty matter. 
 Unfortunately, the catalogue affords no information as to the 
 region of the body from whence they were removed. The third 
 and fourth specimens were removed from the shoulder of a cow 
 which had six legs. The cysts contain light hair, fatty and cal- 
 careous matter. These four specimens are Hunterian, The 
 fifth specimen was removed from beneath the integuments of the 
 shoulder of an ox. It contained slender black hair, resembling 
 those on the skin of the animal, mixed with fat. These cysts 
 served for a time to puzzle me, because at the shoulder we have 
 no embryonic lines of coalescence. In the cow from which the 
 third and fourth cysts were removed we have, it is true, a mal- 
 
56 
 
 formation, viz., two supernumerary legs, in association with the 
 cysts, but the details are too meagre to allow of any safe 
 inferences being drawn ; besides, this will not explain the 
 cysts in the sheep and ox. Fortunately, these cysts can be 
 explained on the same lines as dermoid cysts of the fingers in 
 man. The sticks used by cattle-drovers are armed at the end 
 with a sharp iron spike, an inch long, with which they " prod " the 
 beasts, often very severely. It may be assumed that punctures 
 
 Fig. 35- 
 A Dermoid Cyst from the Back of a Cow (Museum, Royal College of 
 
 Surgeons). 
 
 produced with such an instrument may lead to the deposition of 
 dermal grafts beneath the skin, which may give rise to dermoids, in 
 the same way as punctured wounds in the skin of men and 
 women. Punctured wounds in sheep and oxen may be caused 
 by projecting nails, iron spikes, tenter-hooks, and the like. 
 
 The opinion that dermoids may arise in the subcutaneous 
 tissue by implantation receives the strongest possible confirmation 
 from what we know of similar cysts of the iris associated with 
 mechanical injury. Those arising in the choroidal fissure have 
 been already described. 
 
57 
 
 IV. Iritic Dermoids. 
 
 Cysts of the iris are of comparative rarity, generally appearing 
 as transparent vesicles situated on its anterior surface. As a rule, 
 they are sessile, but occasionally possess a pedicle. The con- 
 tents may be opaque, but in exceptional cases they have been 
 filled with sebaceous material, such as fills the cavities of der- 
 moids. 
 
 Mr. Hulke * has collected some valuable facts in relation to 
 such cysts, and states that in fifteen out of nineteen cases, as well 
 as in two reported by himself, there was distinct history of ante- 
 cedent mechanical injury. This, especially punctured w^ounds, 
 suggested to him that in some instances perhaps the cyst 
 originated from portions of Descemet's membrane, which may 
 have been torn from the cornea and implanted on the iris. Mr, 
 Power mentioned to me the case of a sailor who wounded his 
 cornea with a knife ; subsequently a small cyst was found on 
 the iris, with an eyelash sprouting from its middle. On 
 this head we have the accumulated experimental observations of 
 Dooremaal, Goldzieher, Schweninger, Zahn, and Masse, who 
 introduced various kinds of tissue, such as cartilage, hairs, and 
 conjunctiva, into the anterior chambers of rabbits. In very many 
 instances the transplanted tissues grew ; in others they were 
 absorbed or extruded from the globe. 
 
 * " On Cases of Cysts of the Iris." R. Lond. Ophth. Hosp. Rep., vol. vi., 
 1869; also Hosch, "Ex. Studien tiber Iriscysten," Virch, Arch., Bd. xcix., 
 s. 449. 
 
58 
 
 CHAPTER IV. 
 
 THE INTESTINAL ORIGIN OF THE CANAL OF THE 
 CENTRAL NERVOUS SYSTEM. 
 
 Last year I attempted to show from embryological and patho- 
 logical data that the central canal of the spinal cord may be re- 
 garded as a disused segment of the primitive alimentary canal. 
 
 Nearly three years ago I ventured to state, notwithstanding that 
 we were absolutely in the dark concerning the significance of the 
 central canal of the cord, it was justifiable to regard it as an 
 obsolete canal, basing this opinion on the ground that it behaved 
 itself like functionless ducts and passages in general, and at times 
 formed cysts. 
 
 It gave me considerable satisfaction to hear Dr. Gaskell express, 
 before the Anatomical Society of Great Britain (assembled at 
 Cambridge in June, 1888), the opinion that the tube which 
 primarily represents the central nervous system in the vertebrate 
 embryo must be regarded as a disused segment of the primitive 
 alimentary canal. Dr. Gaskell had arrived at this conclusion from 
 quite a different mode of working in that adopted by me : it is of 
 interest and importance that two men working independently 
 and in different directions should arrive at fundamentally the 
 same conclusion, although, as may be anticipated, there is some 
 difference in minor details. 
 
 As far as I am aware, nothing in any way approaching this 
 somewhat startling conclusion has ever been suggested ; excepting, 
 
59 
 
 perhaps, the unsatisfactory attempt of Owen,"*^ who supposed 
 that the gullet of ancestral vertebrates passed through the 
 third ventricle, and that the space from the pineal to the pituitary 
 bodies, by way of the infundibulum, represented this primitive or 
 invertebrate (cephalopodic) gullet. 
 
 Dohrn t also put forward the view that the fourth ventricle is 
 the place where the oesophagus may be supposed to have pierced 
 the nervous ring. 
 
 H-— 
 
 Fig. 36. 
 
 A Diagram representing the Gastrula. E, Ectoderm (Epiblast). 
 
 H, Endoderm (Hypoblast). G, Archenteron. B, Blastopore. 
 
 Invertebrates are distinguished embryologically from the 
 majority of vertebrates by the fact that in the early stage of 
 development they undergo a process termed invagination, where- 
 
 * " On the Conario-hypopophysial Tract," Jota-nal of the Linnean Society ^ 
 1883, p. 131. 
 
 t *' Ursprung der Wirbelthiere," etc., Leipzig, 1875, 
 
6o 
 
 by a portion of the outer wall of cells is depressed in such a way 
 as to give rise to a double-walled cup (fig. 36). This is the gas- 
 trula stage, and represents temporarily the double-layered con- 
 
 Fig. 37. 
 Transverse Section of the Embryo of Echiims Miliaris, to show the 
 origin of the Pleuro-peritoneal Cavity (Coelom) from the Primi- 
 tive Alimentary Canal. (After Selenka.) 
 
 dition permanent in many invertebrata. The hollow, A, in the 
 gastrula is the archenteron, the primitive digestive cavity ; the 
 cells lining it constitute the endoderm (hypoblast) ; the outer wall 
 is the ectoderm (epiblast) ; the two layers become continuous at 
 the edges of the blastopore. It should be mentioned that the gas- 
 trula stage occurs in amphioxus as in invertebrata, and has been 
 detected in the ova of some fish and amphibia. 
 
 Ingenious attempts have been made to identify the occurrence 
 of something which in the higher vertebrates corresponds to the 
 gastrula stage of invertebrates, for the intimate connection of the 
 
6i 
 
 •embryological processes throughout the animal kingdom strongly 
 suggests the occurrence of the gastrula in a modified form, even 
 in the highest mammals. Up to the present time nothing satis- 
 factory has been advanced in this direction. The views which I 
 «hall now endeavour to express were forced upon me whilst in- 
 vestigating the mode of origin of those singular ovarian tumours 
 known as dermoids. 
 
 It has long been customary to regard the coelom (pleuro-perito- 
 eeal cavity) as a dependency of the vascular or lympli system, 
 
 Fig. 38. Fig. 39. 
 
 Transverse Section of the Embryo of Ajuphioxus, showing the Ab- 
 
 strictions of the Primar}' Alimentary Canal which form the Coelom. 
 
 (After Kowalevsky.) 
 Transverse Section of a Polygordius Larva, to show the relation of 
 
 the Alimentary Canal and the rudiments of the Coelom, (After 
 
 Hatschek.) 
 
 C, Notochord. P, Coelomic Epithelium. H, Hypoblast. 
 
 E, Epiblast. 
 
 but the investigations of the Hertwigs* show this view of the 
 matter to be untenable ; it is, on the contrary, a derivative of the 
 archenteron ; each pleuro-paritoneal cavity, for they are at first 
 
 Die Colomtheorie," Jena, 1881. 
 
62 
 
 quite separate, arises as a diverticulum from the central cavity of 
 the archenteron, as represented in fig. 37. The central portion 
 persists as the permanent alimentary canal, whilst the lateral 
 
 Fig. 40. 
 
 Transverse Section through the Head of an Embryo Dog-fish, 
 shouting the parts representing the Gastrula Cavity. (After 
 Balfour.) 
 N, Neural Furrow. E, Epibiast. C, Notochord. P, Peritoneal 
 
 Epithelium. 
 
 diverticula converge ventrally and coalesce to form a common 
 chamber. 
 
 These relations of the coelomic diverticula are well shown in the 
 embryo of amphioxus (fig. ^S), where we find the parts represented 
 in transverse section. 
 
 A later stage is indicated in a transverse section of a Polygordius 
 larva (fig. 39) ; here the abstriction is complete. Later in Poly- 
 gordius these abstrictions converge ventrally, but remain separated 
 by a thin septum. 
 
63 
 
 In order to render the view more conclusive in its relation to 
 vertebrata, a transverse section through the head of an embryo 
 dog-fish is given in fig. 40. 
 
 This view of the nature of the ccelom is of great importance 
 from a pathological standpoint, because it clearly indicates that 
 the cells lining the peritoneum are truly epithelial and of hypo- 
 blastic origin, and this applies to the epithelium lining the recesses 
 of glands derived from the primitive pleuro-peritoneal (coelomic) 
 epithelium. Embryologically it is also important, as it tends to 
 show that the peculiar manner in which the coelom arises in most 
 mammals, viz., as a schizocoele, must be regarded as a secondary 
 or modified form of invagination, and represents only a portion of 
 the gastrula stage of invertebrata. 
 
 We may now turn our attention to the space in the gastrula 
 which lies between the blastopore and the wall of the tube 
 
 E 
 
 p 
 
 
 Fig. 41. 
 
 Transverse Section of a Three-days' Embryo of Trito7i Tceniatus, 
 
 showing the Coelom arising as a Schizocele. (After Hertwig.) 
 
 N, Medullaiy Folds. E, Notochord. E, Epiblast. Ep, Peritoneal 
 
 Epithelium. H, Hypoblast. 
 
 we have just been considering. In vertebrata one of the 
 most conspicuous structures in the early embryo is the notochord, 
 concerning which a great deal of discussion has been carried on 
 at various times as to which of the germinal layers it is derived 
 
64 
 
 from. Morphologically, its most conspicuous features are its close 
 association with the alimentary canal and relation to the spinal 
 cord.* If we glance at the gastrula of Echinus miliaris we find 
 that by approximating the edges of the archenteron at the point N 
 we should produce a thickening, and divide the cavity into a 
 
 Fig. 42. 
 Longitudinal Section oi an Embryo of Bombinator Ignens, to show 
 the relation of the Neural and Alimentary Canal. (Modified 
 from Goette.) 
 
 nc^ Neural Canal. al, Alimentary Canal. 
 
 dorsal and ventral section, the part below corresponding to the 
 bowel and ccelom, and the parts on the dorsal aspect would repre- 
 sent the medullary folds of the vertebrate ; now occlude the 
 blastopore, and we at once give rise to an arrangement of parts 
 corresponding in longitudinal section to the disposition of parts 
 seen in the early vertebrate embryo, and in longitudinal section 
 would furnish us with the fundamental U-shaped tube from which 
 
 * I omit for the present any reference to the sub-notochordal rod which 
 is more intimately connected with the gut than is the notochord. 
 
6s 
 
 the vertebrate and brain, cord and alimentary canal are derived 
 (figs. 42 and 44). Before proceeding to discuss the ontogeny of 
 these parts, it maybe mentioned that one of the advantages which 
 will follow this view of the matter is that it furnishes an evolutional 
 definition of hypoblast, viz., that the epithelium lining the cavities 
 derived from the archenteron is hypoblastic. This will include 
 the epithelium of the central canal of the nervous system from the 
 
 Fig. 43- 
 Coccygeal Body. 
 
 infundibulum of the third ventricle to the extremity of the cord, 
 that lining the neurenteric passage, the alimentary canal as far 
 upwards as the junction of oesophagus with the pharnyx, the epi- 
 thelium of the air passages from the trachea downwards, and that 
 lining the pleuro-peritoneal cavities and of the organs derived 
 therefrom. 
 
 The embryological evidence now at our disposal enables us to 
 represent the primitive alimentary canal as a U-shaped tube lined 
 with a continuous layer of columnar epithelium. Each limb ends 
 at the cephalic extremity in a cul-de-sac. The ventral limb is 
 widely open to the yolk sac ; the flexure of the tube is occupied 
 by the notochord and sub-notochordal rod (fig. 44). 
 
 5 
 
66 
 
 The subsequent events in the ontogeny of these structures is 
 interesting. The Hmb connected with the yolk sac may, for 
 convenience, be divided into two sections — the fore and hind gut. 
 
 Fig. 44. 
 The AHmentary Canal and Central Nervous System of a- Mammal at 
 
 the Date of the Closure of the Dorsal Groove. 
 
 P Infundibulum. P', Pineal Diverticulum. N' Neurenteric Passage. 
 
 X, Notochord. Y, Yolk Sac. M, Vitcllo-intestinal Duct. 
 
 The anterior end of the fore gut becomes connected with the 
 exterior by an epiblastic involution — the stomodasum, which not 
 only opens up the cephalic end of the gut, but has close rela- 
 tionship with the cephalic end of the dorsal or neural tube by a 
 
67 
 
 diverticulum, the pouch of Rathke, which comes into union with 
 the infundibular diverticulum from the primary encephalic vesicle. 
 The coalescence of the stomodaeum and fore gut results in the 
 establishment uf a communication between the pharynx and 
 oesophagus. 
 
 An involution next appears in the caudal region — the proc- 
 todaeum — which coalesces with the tube and establishes a nether 
 opening — the anus. The remaining section of the primary tube 
 on the ventral aspect of the notochord is known as the post-anal 
 gut, represented in the adult by Luschka's gland (fig. 43), whilst the 
 segment joining the ventral and dorsal portions of this primary 
 tube is the neurenteric passage. All that portion of the tube on 
 the dorsal aspect of the notochord anterior to the neurenteric pas 
 sage becomes converted into spinal cord and brain. 
 
 Not only are the dorsal and ventral segments of the tube in 
 connection by the neurenteric passage, but they are intimately 
 associated in a way that is of some importance in support of my 
 contention. 
 
 Occupying the flexure of the tubes is a chain of sympathetic 
 ganglia which distribute branches to the ventral and dorsal sections 
 of the tube. Those on the ventral portion of the tube ramify in 
 the walls of the bowel, and are provided with intrinsic ganglia. 
 These nerve plexuses are later recognised by the names of iVuer- 
 bach and Meissner. Those distributed to the dorsal tube ramify 
 in its substance, and join with groups of nerve-cells contained in 
 the thickness of its walls, which constitute the essential elements 
 of the grey matter of the cord. 
 
 These nerves, which bring the dorsal and ventral sections of the 
 tube into such intimate association, are the leukenteric nerves, or 
 splanchnic roots of Gaskell. 
 
 The opposite differentiation of the cells composing the walls of 
 the dorsal and ventral section of the tube is very instructive. In 
 
68 
 
 t^ig- 45- 
 A Diagram illustrating the Transformation of the U-shaped Tube in 
 
 fig. 43 and the principal Obsolete Canals. 
 
 I, Infundibulum. Pt., Pharyngeal Canal. T X, the Thyreo-lingual Canal. 
 
 M, Vitello-intestinal Duct. G, Post-anal Gut. C, Coccygeal Body. 
 
69 
 
 the dorsal section the elements have become nerve-cells, whilst 
 those in the ventral limb have metamorphosed into muscle-cells, 
 
 Fig. 46. 
 
 Diagram to represent the conditions of the Dorsal and Ventral Segments 
 of the U-shaped Tube and their relation to eacli other after the 
 transformation. 
 
 S, Spinal Cord. N, Notochord. I, Intestine. 
 
 L, Leukenteric Nerves. 
 
 the two being in close union by means of a leukenteric nerve. 
 Again, the epithelium lining the free surface of the tube in the 
 dorsal limb remains undeveloped ; that in the ventral limb becomes 
 highly differentiated for digestive purposes. 
 
 Some of the chief reasons in support of the intestinal origin of 
 
70 
 
 the canal of the central nervous system may be summarised 
 thus : — 
 
 1. The original continuity of the lumen of the gut and spinal 
 cord. 
 
 2. The similarity in their mode of development and correspon- 
 dence in point of time. 
 
 3. The relation of the lateral ganglia (sympathetic) to the walls 
 of the gut and its intrinsic ganglia and to the ganglia (grey matter) 
 of the cord respectively. 
 
 4. In lower vertebrate forms the spinal cord is relatively larger 
 than in man ; in batrachians it much exceeds the brain in 
 weight. 
 
 5. The association of certain malformations of the central 
 canal of the spinal cord, especially syringo-myelocele and syrmgo- 
 me7ii7igocele^ with malformations of the alimentary canal. 
 
 We may consider the effects of this extraordinary metamorphosis 
 in relation with obsolete canals and dermoids. 
 
71 
 
 CHAPTER V. 
 TUBULO-DERMOIDS. 
 
 An obsolete canal is one which was functional in the ancestors 
 of modern vertebrata, but now appears in the embryos of existing 
 forms, in obedience to heredity. In the ordinary course of de- 
 development many of these canals disappear ; some persist in a 
 rudimentary condition. All those to be considered in connection 
 with dermoids are associated with the alimentary canal. 
 
 The more important obsolete canals which exist in higher verte- 
 brates are the central canal of the nervous system, extending from 
 the infundibulum of the third ventricle to the end of the spinal 
 cord, the neurenteric passage, the post-anal gut, the thyreo-lingual 
 duct, the cranio-pharyngeal canal, the branchial clefts, and the 
 vitello-intestinal duct. 
 
 Congenital tumours connected with obsolete canals are of three 
 kinds : — 
 
 1. Dermoid cysts. 
 
 2. Dermoid tumours. 
 
 3. Thyroid-dermoids, or congenital adenomata. 
 
 The third group (thyroid-dermoids) are peculiar to obsolete 
 canals ; structurally they resemble the thyroid body in that they 
 are composed of closed vesicles lined with glandular epithelium 
 and filled with colloid or mucoid fluid. These tumours have been 
 variously described as carcinoma, congenital cystic sarcoma, adeno- 
 mata, etc. Their leading features may be enumerated thus : 
 
72 
 
 They arise in obsolete sections of the gut, resemble the thyroid 
 body in structure, frequently contain striped and unstriped muscle- 
 fibre and hyaline cartilage, and are congenital, though they may 
 
 Fig. 47. 
 ThjToid Dermoid in Cocc3'geal Region. (After Hutchinson.) 
 
 not always be recognised during infancy. As the type of this form 
 of tumour we may select those familiar to surgeons as congenital 
 sacro-coccygeal tumours. They are always congenital, lie anterior 
 to the coccyx and below the levator ani muscle, and correspond 
 to Braune's congenital cystic sarcomata; he regarded them as 
 
arising in the coccygeal body. These tumours present very defi- 
 nite characters, and are sure to attract attention on account of 
 their large size (fig. 47). Braune* has collected several cases, 
 and individual specimens have been described by Hutchinson,f 
 Wagsta ff e^t Shattock,§ and others, || and often referred to as con- 
 genital cystic sarcoma. The naked-eye characters of such tumours 
 are well shown in fig. 48. 
 
 In some cases these tumours present a large central cavity 
 filled with mucus ; such a cavity is probably due to secondary 
 changes. Microscopically these tumours are composed of cysts 
 and duct-like passages, lined with cubical epithelium, and held 
 together by richly cellular connective tissue. In many situations 
 the epithelium is columnar, set upon flatter cubical cells. The 
 cysts contained ropy mucus. The cysts varied in size from a nut- 
 shell to the smallest space visible to the naked eye ; many of the 
 cysts contained intra-cystic growths. Hyaline cartilage was also 
 present in the tumour. 
 
 Athough in the majority of cases these tumours project down- 
 wards between the legs, such is not always the case. The tumour 
 sometimes extends upwards and overlies the lower extremity of 
 the spine, and resembles a spina bifida tumour. 
 
 This form of congenital sacro-coccygeal tumour arises in con- 
 nection with the post-anal gut and neurenteric passage. 
 
 The first to associate a congenital sacro-coccygeal tumour with 
 the post-anal gut was Dr. K. Middledorpf.H His specimen was 
 
 * " Doppelmissbildung, etc." 
 t " Illustrations of Clin. Surgery," Fas. xiii. 
 X St. Thos. Hosp. Rep., vol. iv. 
 § Trans. Path. Soc, vol. xxxii., p. 197. 
 II Virck. Archiv. 
 
 ^ " Zur Kenntniss der Angebornen Sacralgeschwiilste," MrcJioiv's ArcJiiv^ 
 Bd. ci., S. 37. 
 
74 
 
 removed from the neighbourhood of the anus of a girl a year old. 
 The tumour was composed of fatty and richly cellular connective 
 tissue, and contained mucous membrane with characteristic 
 
 Fig. 48. 
 
 A Congenital Sacro-coccygeal Tumour, originating in the Post-anal 
 gut. A glass rod is passed into the rectum. (After Shattock.) 
 
 Lieberkuhn follicles, solitary follicles, sub-mucous tissue, longi- 
 tudinal and circular layers of striped muscle fibre. 
 
 I had come to the same conclusion before the publication of 
 Middledorpfs paper, but his case is the most conclusive one on 
 record. 
 
75 
 
 Dermoid cysts and tumours other than those we have just con- 
 sidered, connected with these passages, are, as a rule, situated be- 
 tween the rectum and sacrum. Occasionally, when large, they 
 make their way between the bladder and rectum in the male, or 
 rectum, vagina, and uterus in the female. 
 
 The following specimens will serve to illustrate this type of 
 
 Fig. 49. 
 A Dermoid Cyst attached to the Sacral Aspect of the Rectum. 
 
 dermoids. The first is a cyst, of the size of a walnut, containing 
 curly locks of brown hair, bony and well-formed teeth, attached to 
 the sacral aspect of the rectum (fig. 49). Mr. J. H. Targett ex- 
 hibited a dermoid at the Pathological Society,'' which was removed 
 by Mr. Bryant from between the coccyx and rectum of a lad 
 aged nineteen. The tumour was of the size of an orange, and 
 made of cysts and loculi, some of which were filled with 
 
 * Path. vSoc. Trans., vol. xxxviii., p. 395. 
 
76 
 
 pultaceous material. It also contained an irregular-shaped 
 piece of bone. The cyst walls were lined with columnar 
 epithelium, beneath which were layers of flattened and round 
 cells. 
 
 Of dermoids which present themselves as large cysts occupying 
 the space between the rectum and bladder, one of the best 
 accounts is that by Dr. Ord.* The patient was a man aged 
 twenty- eight years, and the dermoid weighed fourteen pounds and 
 a half ; it measured thirteen inches in length and ten inches in 
 breadth. The cyst contained the usual pultaceous material, mixed 
 with hairs. The cyst wall was lined with piliferous skin, contain- 
 ing sebaceous, but no sudoriparous glands. The account of this 
 specimen is rendered more valuable by a report furnished by 
 Bernays of the fluid contents of this cyst. 
 
 Several cases of dermoid occupying a similar position in the 
 pelvis of women have been recorded. 
 
 The Infundibuluin. — Several well-described specimens of der- 
 moids arising in connection with the pituitary fossa have been 
 recorded. Bowlby t has described a tumour of the pituitary body, 
 composed of vascular connective tissue, cysts lined with 
 epithelium, and bone ; the tumour was of the size of a walnut, 
 and occurred in a man aged twenty-two years. 
 
 Hale-White \ met with a similar dermoid, of the size of a nut, 
 growing from tlie pituitary body and involving the optic commis- 
 sure ; it contained connective tissue, vessels, fat cells, white nerve 
 fibres (some in bundles as large as the radial nerve), ganglionic 
 cells, and striped muscle fibre. The patient was a boy aged 
 twelve years. 
 
 * Med-Chir. Trans., vol. Ixiii., p. i. 
 t Path. Soc. Trans., vol. xxxvi., p. 35- 
 \ Path. Soc. Trans., vol. xxxvi., p. 37 
 
77 
 
 Lavvson * described a tumour which grew from the body of the 
 sphenoid, and projected into the orbit. It consisted of hyaline 
 cartilage, spindle cells, cysts lined with squamous epithelium, and 
 glandular tissue. The patient was two days old. 
 
 Thyroid Dermoids. — Among recorded cases the following may 
 be mentioned. A baboon {Anubis) which had lived in the Zoo- 
 logical Gardens presented at the base of its brain a large, ragged- 
 looking tumour over the optic commissure. The nerves and 
 other parts of the brain appeared quite healthy. Dr. Goodhartf de- 
 scribed the specimen as evidently having its origin in the pituitary 
 fossa. It was composed of large, epithelial-looking cells, arranged 
 in alveolar manner. This arrangement of cells, considered in rela- 
 tion with the epiblastic origin of the pituitary body, Dr. Good- 
 hart thought justified the tumour being regarded as a carcinoma. 
 The brain and tumour are preserved in the museum of the Royal 
 College of Surgeons. 
 
 Mr. VV. K. Sibley % has described a similar specimen from a 
 ewe. The tumour was as large as a walnut. I examined some 
 of the sections under the microscope, and found them identical 
 in structure with the thyroid body. 
 
 The Cra?iio-pharyngeal Canal. — This passage extends from the 
 floor of the cella turcica to the pharyngeal aspect of the basi- 
 sphenoid. It may be readily detected as a small canal in the 
 macerated sphenoid bone of the fcetus ; in the last months of 
 fcetal life it is filled with fibrous tissue. If the posterior wall of 
 the pharynx be carefully examined in the foetus at the time of 
 birth, a recess will be seen in the mucous membrane exactly in 
 the middle line, close up to the base of the skull. This recess, 
 
 * Path. Soc. Trans., vol. xxxv., p. 379, 
 
 t Path. Soc. Trans. 
 
 X Ibid^ vol. xxxix., p. 459. 
 
78 
 
 which is often half an inch deep, is known as the bursa pharyngea- 
 (it frequently exists in the adult), and marks the pharyngeal termina- 
 tion of the fibrous tissue lodged in the cranio-pharyngeal canal. 
 The orifice of this recess is surrounded by lymphoid tissue, and 
 is known as the pharyngeal tonsil. 
 
 The cranio-pharyngeal canal is the remains of the space origin- 
 ally enclosed by the open arms of the trabeculas cranii, whilst 
 the mucous membrane which occupies it represents the diverticu- 
 lum from the stomodseum, known as the pouch of Rathke, which 
 brings the pharynx into relation with the infundibular prolonga- 
 
 Fig. 50. 
 A Longitudinal Section through a Human Tongue, showing the Lingual 
 
 Duct. 
 
 tion of the third ventricle of the brain, the meeting-point of the 
 two funnels being accurately indicated by the pituitary body. 
 
 The precise significance of this relation of the pharynx and in- 
 fundibulum is difficult to estimate clearly, but it is probably closely 
 related to the original function of the infundibulum. From what 
 has already been stated regarding obsolete canals, it would be ex- 
 pected that the roof of the pharynx should be occasionally the 
 seat of dermoids. 
 
 Some cases of dermoid tumours hanging from the roof of the 
 pharynx have already been mentioned, and adenomata in young 
 
79 
 
 children are not uncommon in this situation, but more pre- 
 cise observations are requisite before the true relation of 
 the bursa pharyngea to these tumours can be satisfactorily 
 established. 
 
 The Thyroid Body and its Duct, — In all vertebrata the thyroid 
 body arises as one or more diverticula from the ventral wall of 
 the pharynx, or floor of the mouth ; in a few of the lowest forms 
 it retains its connection with the pharynx, but in higher forms 
 this communication becomes shut off and the duct rendered 
 obsolete. In man and other higher mammals this communication 
 is represented in the embryo, and the passage (first detected by 
 His) is known as the thyreo-hyoid duct (fig. 45). On the appear- 
 ance of the hyoid bone the duct becomes divided ; the segment 
 •in relation with the tongue is the lingual duct, whilst the portion 
 till retaining its connection with the thyroid is the thyroid duct, 
 but more commonly known as the processus pyramidalis, and as 
 it is often surrounded by muscular tissue, is frequently described in 
 anatomical text-books as the levator glandulae thyroidea. P^ach 
 duct will now be separately considered in its relation to dermoids. 
 
 This duct, according to my dissection, seems to be present about 
 once in every ten subjects examined, and is sufficiently large to 
 admit a bristle ; in some cases it is merely represented as a band of 
 fibrous tissue. The canal, when well developed, is lined with epi- 
 thehum. Its position in the tongue is somewhat diagrammatically 
 shown in fig. 50. 
 
 It is easy to understand that if this duct is persistent, but both 
 extremities become obliterated, the continual shedding of the 
 epithelium, and the accumulation of sebum from the glands which 
 occasionally exist in its walls, will in due time dilate it into a 
 cyst of fair dimensions. 
 
 Lingual Dermoids, — This will form a useful group with which 
 to begin. Lingual dermoids, like dermoids occurring on the scalp, 
 
8o 
 
 have frequently been mistaken for sebaceous cysts, and thus 
 dermoid cysts arising in the tongue have been regarded by most 
 writers as rarities. Such, however, is not the case. Mr. Barker,* 
 in his excellent paper on lingual dermoids, gives references to 
 sixteen cases, and classifies them as follows : — 
 
 1. They may be unilateral, lying between the geni-hyo-glossi 
 and the mylo-hyoid muscles, on one side or the other. 
 
 2. They may be central, lying between the genio-hyo-glossi 
 muscles. 
 
 3. They may be bilateral, lying between the mylo-hyoid and 
 genio-hyo-glossi muscles on each side. 
 
 It is the second group, dermoids occupying the space between 
 the genio-hyo-glossi muscles, that we are concerned with just 
 now. These central dermoids arise as retention cysts in the 
 lingual canal. 
 
 I once had an excellent opportunity of studying the anatomy 
 of a lingual dermoid. A man aged twenty-four years was under 
 my care for a so-called ranula. He had, during nine years, been 
 submitted to seven operations, but without success. When I saw the 
 patient I passed a thin knife into the cyst, some sebaceous material 
 escaped, and the smell settled its dermoid character. On dis- 
 secting out the cyst I found it situated between the genio-hyo- 
 glossi muscle, and extended from the mucous membrane near 
 the foramen caecum to the basi-hyoid. It was as large as a 
 bantam's egg, and contained hairs, sebum, and cholesterin. The 
 walls presented a few fine hairs, and were beset with sebaceous 
 glands. 
 
 Mr. Stephen Paget! reported a specimen of this nature which 
 was remarkable that in addition to hair, epithelium, and glands, 
 
 * Clin. Soc. Trans, vol. xvi., p. 215. 
 I Path. Trans., vol, xxxvii., p. 225. 
 
8i 
 
 a deposit of granular black pigment was found in the deeper 
 layers. The cyst was removed by Mr. Butlin from under the 
 tongue of a little girl. It lay in the middle line of the floor of 
 the mouth. 
 
 mr—F 
 
 Fig. 51. 
 
 A Tumour in the Tongue, in the position of the Lingual Duct, 
 
 structurally resembling the Thyroid Body. (After Bernays.) 
 
 Lingual dermoids are rarely sufficiently large to allow of their 
 detection in infants. Richet, however, removed one from a child a 
 few days old, in I'Hopital St. Louis. In addition to the references 
 by Barker in the paper already referred to, Jean Cusset"^ furnishes 
 
 * " Branchial FistulcC," Paris, 1877. 
 
82 
 
 a goodly list, and many of his cases are recorded in detail for 
 the first time. 
 
 The lingual duct, like the infundibulum and post-anal gut, may 
 give rise to tumours resembling in structure the thyroid body, a,s 
 in the following case, reported by A. C. Bernays.* The patient, 
 a female, aged seventeen, had a tumour, consisting of two parts, 
 on her tongue. The larger portion was of the size of a bantam's 
 egg ; the smaller equalled that of a cherry. The upper part of 
 the smaller tumour was occupied by a depression corresponding 
 to the foramen caecum. The larger tumour was situated between 
 the genio-hyo-glossi muscles. The relation of the tumours to the 
 surrounding parts is shown in fig. 51. They were easily shelled 
 out, and when examined by the microscope were found to resemble 
 the normal thyroid body. 
 
 A somewhat similar specimen was described by Dr. Hickman,t 
 which occurred at the base of the tongue in a new-born female 
 child. The tumour projected above the mucous membrane of the 
 tongue, about three-quarters of an inch, and prevented the child 
 from breathing. The infant survived its birth a few hours only. 
 The tumour was submitted to the Morbid Growths Committee. 
 The following was the substance of the report : — 
 
 The tumour not only projected above the tongue, but extended 
 deeply into its substance. The bulk of it appeared to be made 
 up apparently of glandular follicles, ducts, and vessels, embedded 
 in a matrix of nucleated connective tissue. Some of the 
 follicles contained material resembling coagulated mucus. 
 
 Rushton Parker | reported a specimen which was probably of this 
 nature. The patient was a girl aged sixteen years and a half; 
 
 * S^. Lota's Med. and Surg, lournal^ vol. Iv., p. 201. 
 t Trans. Path. Soc, vol. xx., p. 160. 
 X Trans. Path. Soc, vol. xxxii., p. 238. 
 
83 
 
 the tumour was situated under the mucous membrane at the base 
 of the tongue, and was as large as a walnut. Structurally it 
 consisted of glandular tubes lined with cubical epithelium of 
 uniform size ; some of them contained a plug of gelatinous material. 
 It was described as a tubular adenoma. 
 
 The Thvroid Duct. — In mammals it is normal that this duct 
 
 Fig. 52. 
 A Persistent Thyroid Duct. 
 
 should disappear, but in adults it may persist in three forms — 
 I. As a duct running from the isthmus of the thyroid body to the 
 posterior aspect of the hyoid bone, surrounded by muscular 
 tissue (fig. 52). This duct is often easily capable of admitting a 
 probe. 2. It may be partially obliterated, the interrupted portions 
 becoming dilated, so as to produce a moniliform condition. 3. 
 The space usually occupied by the duct is represented by a series 
 of detached bodies known as accessory thyroids. 
 
«4 
 
 The thyroid duct and the accessory thyroids derived from it 
 occasionally become the germs of cysts, sometimes of im- 
 portant size. Accessory thyroids have been known to acquire 
 large proportions in cases where the main thyroid has been 
 extirpated by the surgeon. Cysts are by no means infrequent 
 in the neighbourhood of the hyoid bone. Some of them are of 
 slow growth and contain much solid material ; others are filled 
 with fluid and grow quickly ; many of them are unilateral, and 
 often mistaken for enlargements of one lobe of the thyroid. As 
 a rule, a correct diagnosis is not made unless the surgeon 
 attempts to extirpate them ; he then finds them unconnected 
 with the thyroid. Cysts developed in accessory thyroids in some 
 instances are filled with warty masses, and occasionally are the 
 sources of malignant tumours of the neck. In rarer cases the 
 cyst walls may calcify. 
 
 The most interesting of all forms of thyroid cysts in con- 
 nection with our present study are dermoids. Shattock* has 
 described a typical form of such a cyst, which he dissected in 
 the neck of an infant. This tumour was ovoid in form, 
 measuring four and a half inches in its vertical, and three and a 
 half inches in its short axis, and occupied the position of the 
 thyroid body. On section it displayed a loculated structure ; the 
 cystic spaces contained soft material. The microscope showed it 
 to contain hyaline cartilage and acinous adenoid tissue, lying in 
 young connective tissue. The glandular epithelium was cubical. 
 
 Shattock sums up his clear account of the specimen thus : 
 " The specimen is doubtlessly related to the congenital sacral 
 tumours, and has characters indicative of an early intra-uterine 
 formation in some aberrant embryonic structure." Shattock also 
 informed me that he could not find a thyroid body distinct from 
 
 * Trans. Path. Soc, vol. xxxiii., p. 289. 
 
8s 
 
 the tumour. This is a fact of some importance, for I am of 
 opinion that the tumour originated in the thyroid diverticulum, 
 and is to be regarded as an aberration analogous to those 
 
 Fig. 53- 
 
 Congenital Tumour replacing the Thyroid Body. Thyroid Dermoid - 
 
 (Museum, St. Thomas's Hospital.) 
 
 occurring in the post-anal gut. In support of this opinion I will 
 adduce as evidence the following facts : The museum of St. 
 
86 
 
 Tliomas's Hospital contains the upper part of the trunk of a 
 mature foetus. The neck is occupied by an enormous tumour 
 replacing anatomically and resembling in shape the thyroid 
 body (fig. 53). Through the generous co-operation of Mr. 
 Shattock I am enabled to represent the appearance of the parts 
 in section (fig. 54), and the naked-eye features of the tumour 
 are strikingly in accord with the congenital sacro-coccygeal 
 tumours. 
 
 The analogy, however, does not rest here, for on examining 
 the tumour microscopically it is seen to be composed of locuh, 
 varying in size from a millet-seed to a small nut. The cavities 
 contain mucoid material, but it is only here and there that 
 evidence can be obtained of parietal epithelium. The matrix 
 of the tumour consists of richly cellular connective tissue, in 
 which tracts of well-developed hyaline cartilage occur. In 
 many places this cartilage is undergoing direct transformation 
 into bone. The cartilage in this specimen is typical of that 
 found at the end of a foetal long bone, and difters from that 
 so common in chondrifying sarcomata. In the latter case 
 the cells are stellate, and do not present the sharp contour so 
 characteristic of well-formed hyaline cartilage. Thus, in their 
 naked-eye character, in their minute structure and embryo- 
 logical associations this particular form of congenital thyroid 
 tumour corresponds so closely with the sacro-coccygeal glandular 
 tumour that they ought to be classed together. For accounts of 
 some of these tumours the following works may be consulted : 
 Von Ammon, Die Ajigeboreneti Chiriirg. Krafikeiteti^ Tab. xiii., 
 xxxiii. Holmes, Laficet^ May, 1864. T. Smith, St. Barth. Hosp. 
 Rep., vol. ii., p. 16. 
 
 TJie Viiello-intestinal Duct. — It is not uncommon to find con- 
 nected with the umbilicus of infants and young children small 
 tumours varying in size from a pea to a cherry. As a rule they 
 
87 
 
 are of a bright red colour, soft and velvety to the touch, often 
 attached to the navel by thin slender pedicles, but occasionally 
 they are sessile. When pedunculate they resemble red currants. 
 
 Fig. 54. 
 The Tumour in Section. 
 
 When examined histologically these tumours present unstriped 
 muscle-fibre, mucous membrane, Lieberkuhn's follicles, and 
 columnar epithelium, collected into a mass ; in rarer instances the 
 tumour presents as a cyst projecting externally and internally ; such 
 
88 
 
 cysts present internally mucous membrane typical of the small intes- 
 tine, with villi, columnar epithelium, and follicles. Such cases 
 are easily confounded with the sac of an umbilical hernia. A 
 very instructive case is reported by Roser. A young man came 
 under his care suffering from a sinus at the umbilicus, from 
 
 Fig. 55- 
 
 Anterior part of 
 
 Elasmobranch Embryo 
 
 with Yolk-sack. 
 
 which a slimy discharge issued. Some time before, a surgeon 
 had removed a small cyst which projected from the navel, but 
 the wound never healed. The discharge from the sinus 
 frequently corroded the surrounding skin. On introducing a 
 
89 
 
 probe, the sinus was found to lead into a cavity measuring six: 
 centimetres in diameter. The cyst was removed, and micro- 
 scopical examination showed it to present all the histological 
 characters of intestine. 
 
 Such cysts and pedunculated tumours admit of easy explana- 
 tion, for they take origin in persistent portions of the Vitello- 
 intestinal duct. This duct when persistent presents the normal 
 structure of bowel, and like the vermiform appendix, possesses an 
 abundance of adenoid tissue. For details of individual cases the 
 following references be may consulted : Kolaczek,* Roser,t 
 Gould, t Colman.§ 
 
 In some of these cysts the epithelium, instead of pre- 
 serving its columnar character, becomes squamous. Lanne- 
 longuell described a pedunculated tumour of the size of a nut 
 which he removed from the umbilicus of a child eight years 
 of age. The pedicle was short and narrow. When examined 
 after removal it was found to be a cyst. The interior was lined 
 with flattened epithelium, supported by a vascular layer of con- 
 nective tissue. 
 
 The vitello -intestinal duct cannot strictly be regarded as an 
 obsolete canal, because in some forms it fulfils the function of a 
 duct. In most vertebrates the yolk is absorbed by vessels 
 ramifying on its surface. For elasmobranchs Balfourii makes the 
 following statement : " Nutriment from the yolk-sack is brought 
 to the embryo partly through the umbilical canal and so into the 
 intestine, and partly by means of blood-vessels in the mesoblast of. 
 the sack." 
 
 * Lajigenbeck Arch., Bd. xviii., S. 349, 1S75. 
 
 t Ibidem, Bd. xx., S. 472, 1877. 
 
 X Trans. Path. Soc, vol. xxxii,, p. 204. 
 
 § Ibidem, vol. xxxix., p. no, 1888. 
 
 il " Kystes Congeiiitaux," 18S6. 
 
 ^ **Comp. Embry.," vol. ii., p. 53. 
 
go 
 
 CHAPTER VI. 
 
 BRANCHIAL CYSTS. 
 
 Since 1825, when Rathke, one of the most accurate observers 
 who has ever lived, found evidence in the embryo of a pig, 
 
 Fig. 56. 
 A Child with a Pedunculated Tumour hanging from the Navel. The 
 tumour originated in a persistent portion of the Vitello-intestinal 
 canal. 
 
9^ 
 
 horse, and chick of the branchial clefts so characteristic of fish, 
 many eminent anatomists have confirmed his observations and 
 extended the view to vertebrata generally. Rathke was also 
 fortunate enough to detect the fissures in the neck of an early 
 human embryo, and, in a letter to Yon Baer, he states that they 
 were of such distinctness that there could be no doubt about them. 
 Although congenital fistulae in the neck were not described by 
 Dzondi until 1829, under the name of tracheal fistulse, four years 
 after Rathke's discovery, he failed to connect the two conditions. 
 
 A Human Embryo, with its Branchial Clefts. 
 
 Three years later Ascherson showed that the fistulas were con- 
 nected with the pharynx and not with the trachea. After the 
 publication of Ascherson's observations numerous instances of 
 cervical fistulae were recorded, which enabled Heusinger,* in 1864, 
 to analyse forty-six examples of the malformation, in a paper 
 entitled " Hals-kiemen-fisteln von noch nicht beobachteter Form." 
 The heading of the paper clearly shows that Heusinger was well 
 aware of the relation of these fistulse with the branchial spaces. . 
 Since that date our knowledge of these fistulae has been con- 
 siderably increased by the careful reports published from time to 
 time of individual cases. It will be necessary to arrange 
 
 * Virchow's Archiv, Bd. xxix. 
 
92 
 
 branchial fistulae into two groups : i, those situated in the 
 neck; 2, those occurring in the pinna. 
 
 The following may be enumerated as the chief features of 
 
 Fig. 58. 
 
 A F, A F', Situations of Congenital Auricular Fistulee. I, II, III, IV 
 indicate the External Orifices of Brmtchial Fistulse. I is the Ex- 
 ternal Auditory Meatus, O F the Orbital Fissure, M F the Mandi- 
 bular Fissure, H H ' the Lines of Lateral Hare-lip ; C F, C F^, mark 
 the Situations of Congenital Median Cervical Fistulae. 
 
 cervical branchial fistulae : They are always congenital, and 
 appear as fine canals, capable of admitting a bristle, and in some 
 
93 
 
 cases a fine probe. The orifice usually opens in the neck, but 
 when complete into the pharynx also. There is reason to 
 believe that they may open into the pharynx, but end externally 
 as a cul-de-sac. One, two, or three fistulae may be present in the 
 same individual ; they have a great tendency to be bilateral, to 
 affect several members of the same family, and to be transmitted 
 to several generations. The canals, which may vary in length 
 from half an inch to two inches or more, are lined by mucous 
 membrane, sometimes with ciliated epithelium, or by skin contain- 
 ing sebaceous glands. The lining membrane of the canal usually 
 secretes a thin mucous fluid, which may become increased during 
 catarrhal conditions of the respiratory passages. Occasion- 
 ally the canal inflames, and an abscess results, which may give 
 rise to considerable pain and difficulty in deglutition. The 
 external orifice of a branchial fistula may be indicated by a 
 tag of skin, which often contains a piece of yellow fibro-cartilage. 
 These cutaneous processes, or cervical auricles as they are 
 called, may attain a large size. Not infrequently a cervical 
 auricle is present, and of large size, without any evidence of a 
 fistula. 
 
 I. Cervical Branchial Fistulce. — Neglecting for the present the 
 first cleft — the tympano-Eustachian passage — it may be con- 
 venient to consider the situations usually occupied by these 
 fistulae when they occur in man. 
 
 The external orifices are apt to vary, but they usually open in 
 the situations shown in fig. 58. The clefts usually represented 
 number four. The first becomes the tympano-Eustachian passage ; 
 the second opens close behind the angle of the jaw anterior to 
 the line of the sterno-mastoid muscle ; in a few cases it may 
 be seen on a level with, and slightly posterior to, the lobule of 
 the pinna. 
 
 The third is situated on a level with the thyro-hyoid space close 
 
94 
 
 to the level of the anterior border of the sterno-mastoid : this 
 situation is very constant. 
 
 The fourth opens, as a rule, immediately above the sterno-cla- 
 
 Fig. 59. 
 
 A Longitudinal Section of the Human Pharynx. E, Orifice of the 
 Eustachian Tube. R, Rosenmiiller's Fossa. P, Plica Triangularis. 
 F, Fossa Supra-tonsillaris. T, Tonsil. S indicates the Sinus 
 Pyriformis, X the Lingual Canal. (Modified from His.) 
 
 vicular articulation, but it may open an inch or an inch and a 
 half higher in the neck, but like the others, it always lies close to 
 
95 
 
 the anterior border of the sterno-mastoid. They persist in the- 
 following order of frequency : the fourth in the majority of cases^ 
 then the third, but the second very rarely. The internal orifices 
 of the branchial fissures are indicated in the following manner : 
 On bisecting the pharynx, as shown in fig. 59, we readily recognise 
 the following landmarks : E, thepharyngeal orifice of the Eustachian 
 tube ; R, the fossa of Rosenmliller ; P, plica triangularis ; F,. 
 fossa supra-tonsillaris ; T, tonsil ; S, the sinus pyriformis. Each 
 must be separately considered. It is beyond all dispute that the 
 pharyngeal orifice of the Eustachian tube indicates the inner 
 end of the first cleft. The orifice of the second corresponds to 
 the fossa of Rosenmliller and the recess containing the tonsil ; the 
 two depressions are separated from each other by a fold of 
 mucous membrane known as the plica triangularis. Rosenmiiller's 
 fossa is difficult to display in longitudinal section of the pharynx^ 
 but comes out well in transverse section of the head if made 
 close to and parallel with the Eustachian tube (fig. 60). 
 
 The fossae are relatively larger in the child than in the adult,, 
 and contain a large amount of adenoid tissue. 
 
 The third and fourth clefts in the embryo do not, according to 
 His, open directly into the pharynx, but into a blind recess,, 
 named by him the siims precervicalis, which has intimate relation 
 with the development of the thymus gland. In the adult, bran- 
 chial fistulas, due to persistence of the third and fourth cleft, 
 open into the sinus pyriformis, the cul-de-sac situated in the 
 mucous membrane on each side of the epiglottis. To reach this 
 sinus a fistula corresponding to the third cleft must pass over 
 ihQ plica nervi laryngei, or curve formed by the superior laryngeal 
 nerve. His states that when these fistulas communicate with the 
 pharynx it is artificial, and due to the passage of a probe. I have 
 satisfied myself, however, in many cases, that the communication, 
 exists independently of the probe. 
 
96 
 
 Abnormal persistence of branchial clefts occurs in four forms : — 
 I. Complete fistula. 
 
 Fig. 60. 
 Horizontal Section of the Pharynx of a Child, showing Rosenmiiller's 
 Fossa, F F. The Eustachian Tube, E. (After Symington.) 
 
 2. There is an external orifice, but the passage ends internally 
 in a cul'de-sac. 
 
97 
 
 3- The internal orifice alone persists. 
 
 4. The external and internal orifices are occluded, but an 
 intermediate segment persists. 
 
 The first form, complete fistulse, as far as my own obser- 
 vations extend, occur most frequently in connection with the 
 second cleft. In one case, a youth, aged fifteen years, the 
 communication with the phar}^nx was so complete that when 
 he swallowed milk some of the fluid occasionally passed through 
 the fistula, and appeared at the cutaneous orifice. In another 
 case, that of a little girl, aged ten, saliva issued at the cervical 
 orifice w^hen the child had been talking freely, and had thus 
 excited the parotid gland to unusual secretory exertion. 
 
 The second set of cases, those with external openings, but 
 ending blindly in the neck, are the most common examples, 
 and need no further comment. 
 
 The third class are rarely recognised ; this is not remarkable 
 when we remember that they open into the pharynx, but end 
 externally as cul-de-sacs. Heusinger was of opinion that some 
 pharyngeal diverticula are of this nature, and Sir James Paget 
 refers to the probability that some rare instances of diverticula 
 from the pharynx may be regarded as dilatations of portions 
 of branchial fistulse, closed externally, but remaining open within. 
 
 The most remarkable case, undoubtedly, of this nature that 
 has been placed on record is the specimen which occurred in the 
 body of an adult male dissected in the University of Edinburgh, 
 and described by Morrison Watson.* 
 
 A tube, terminating inferiorly in a cul-de-sac containing a large 
 quantity of grumous material, was found extending from the 
 pharynx, immediately behind the tonsils, to the interclavicular 
 notch. The tube possessed muscular walls, and in the deep part 
 
 * Journal of Anatomy and Physiology, vol. ix., p. 134. 
 
98 
 
 of its course passed between the fork of the carotids, over the 
 plica nervi laryngei^ and in the lower part was parallel with the 
 anterior border of the sterno-mastoid muscle ; internally it rested 
 on the sterno-hyoid and sterno-thyroid muscles. It communicated 
 with the pharynx by means of a slit-like opening, not more than 
 an eighth of an inch in length, the margins of which were so closely 
 in contact that the entry of solid particles into it from the mouth 
 must have been prevented. The diverticulum itself increased in 
 calibre from above downwards, so that whilst at the upper end' 
 a crow-quill could with difficulty be introduced, at its lower a 
 pencil could readily be passed along the lumen of the tube. 
 
 It is further noteworthy that the pharyngeal orifice was situated 
 between the lower jaw and the stylo-hyoid ligament. Its point of 
 departure from the pharynx corresponds to the fossa supra-tonsillaris. 
 The muscle fibres were, for the most part, red and striated, and 
 the mucous lining resembled that of the cesophagus. 
 
 Aubrey* has recorded an example of this form of diverticulum, 
 which occurred in a fowl ten months old. The bird presented a 
 tumour immediately above the sternum, of the volume of an egg. 
 It was thought to be an abscess, and a bistoury was plunged into 
 it, but instead of pus, food made its appearance. On giving the 
 bird water, it escaped from the opening. By introducing the 
 finger the gizzard could be felt. A pad of pitch was placed over 
 the orifice, and in time the wound contracted, leaving a small but 
 permanent fistula. 
 
 Diverticula from the pharynx and oesophagus are common 
 enough as herniae of the mucous coat, through weak points in the 
 muscular wall ; but some of the rarer forms, which will not admit 
 of this explanation, may safely be ascribed to persistent branchia 
 spaces. Doubtless they are of more frequent occurrence than the 
 
 * Rectieii de Medccine Ve'erina're, 1863, quoted in Heusinger's Memoir. 
 
99 
 number of recorded cases would lead us to believe ; it is almost a 
 
 Fig. 6i. 
 A Diverticulum from the Pharynx (after Morrison Watson). 
 
 matter of accident when such cases fall into the hands of observers 
 competent to deal with them. 
 
 The fourth class, or those closed at each end, leaving a portion 
 
lOO 
 
 of unobliterated canal remaining in the neck, cannot be recognised 
 except by the effects to which they give rise. 
 
 It has long been suspected that the so-called sebaceous cysts 
 which occasionally occur in the neck below the deep cervical fascia 
 take origin in unobliterated branchial spaces, and are dermoids. 
 
 In their mode of origin and the structure of the walls sebaceous 
 cysts in this situation differ very materially from those found on the 
 scalp. Commonly a sebaceous cyst arises by distension of the 
 follicles of the gland, in consequence of obstruction to the excre- 
 tory duct. In the cysts we are now considering the sebum escapes 
 from the glands, but collects in a closed cavity, viz., the unoblite- 
 rated segment of the cleft. Hence, they are exactly analogous to 
 the dermoids of the tongue, originating in the persistent portion 
 of the lingual canal. The most convincing case of this kind is 
 one by Virchow.* In this instance a woman, aged twenty-four, 
 had noticed, since the age of fourteen, a tumour between the angle 
 of the jaw and the mastoid process. When she came under obser- 
 vation it was of the size of a goose's egg. She had also a small 
 tumour immediately above the sternum, which she would not allow 
 to be removed. The larger tumour was extirpated, and found to 
 contain sebaceous matter and epidermal scales. The walls of the 
 cyst were covered with epidermis, and sebaceous glands were 
 disseminated in it. 
 
 Lingual dermoids lying between the mylo-hyoid and genio-hyo- 
 glossi muscles most probably arise in connection with a partially 
 obliterated second branchial cleft. 
 
 A retention cyst, arising in connection with partially obliterated 
 branchial cleft, need not necessarily contain sebaceous matter ; 
 cysts filled with mucus, and occasionally of large size, are to be 
 observed in the neck. This apparent contradiction is capable of 
 
 * Arckiv, Bd. xxxv., 1866. 
 
lOI 
 
 easy explanation. The internal segment of a branchial fistula is 
 lined by mucous membrane continuous with that of the pharynx, 
 whilst its external segment is a continuation of the surface epithe- 
 lium of the neck. It is to this transitional arrangement that some 
 branchial fistulae are described as presenting ciliated epithelium, 
 others squamous, and so forth. If a cystic dilatation arise in 
 
 Fig. 62. 
 
 Head and Neck of a Young Woman, showing Branchial Fistulae in the 
 
 Neck, a; and one in the Helix, A. (After Heusinger.) 
 
 connection with the inner segment, a cavity with mucous contents 
 would be the result, whilst in a similar cyst arising from the 
 external segment epidermal scales, sebaceous matter, and choles- 
 terine would be expected. As far as my own observations go, 
 
I02 
 
 mucous cysts originating in this manner attain larger dimensions 
 than the dermoid varieties. 
 
 In the copy of Heusinger's sketch (fig. 62) we find a clear space 
 indicated by the letter b, which is thus described in the original : 
 *' Immediately above the opening is a slight elevation of normal 
 coloured skin." In Knox's translation of Dzondi's paper the 
 translator remarks that in many persons, in the region where 
 fistulae have been observed, he had noticed one or more dis- 
 coloured spots, which spots are either rounded and of a pale red 
 colour, or brownish, or like subtile striae of hairs, superior in 
 whiteness to the surrounding skin, but conspicuous only to very 
 sharp sights. I have occasionally found these spots referred to 
 by Knox in persons with branchial fistulse \ they are not infrequent 
 near the angle of the jaw, and correspond to the external orifice 
 of the second cleft. 
 
 Our knowledge of branchial fistulae in mammals other than man 
 is very limited. Heusinger mentions the occurrence of congenital 
 cervical fistulae in horses immediately below the ear and near the 
 angle of the jaw. They are more frequently found in carriage 
 than in draught horses ; the secretion or discharge which issues 
 from them when inflamed soils the surrounding skin and attracts 
 the groom's attention. 
 
 There are many reasons for believing that the two remarkable 
 pouches which occupy the naso-phar}mx in the horse, into which 
 the Eustachian tubes open, represent the dilated inner ends of the 
 second branchial clefts. The cavities known as the guttural 
 pouches replace the fossae of Rosenmiiller and the tonsils in other 
 mammals.* 
 
 Congenital fistulae in the middle line of the neck must not be 
 confounded with branchial fistulae. 
 
 * Veterinarian^ 1888. 
 
lO 
 
 2. Congenital Auricular Fistulce. — Heusinger seems to have 
 been the first to describe congenital fistulse connected with the 
 auricle, and in the case already alluded to as " Von noch nicht 
 beobachteter Form " the peculiarity consisted in the existence of 
 a fistula in the helix (fig. 62). 
 
 
 Fig. 63. 
 
 Three Drawings representing the Development of the Human Pinna. 
 
 (Modified ft-om His.) 
 
 The most complete account of these auricular fistulas which 
 has yet appeared in our language is by Sir James Paget.* The 
 
 Medico-Chir. Trans., vol. Ixi, 1878, p. 41. 
 
I04 
 
 fistula usually appears as a small opening leading into a canal 
 ending blindly in the substance of the helix. Paget says of 
 them, " It might have been very hard to explain these tistulae in 
 the ears, if their meaning had not been indicated by the co- 
 existence of well-marked branchial fistul?e in the necks of the 
 same person or members of the same family." The same author 
 further writes, " So may these aural fistulae be regarded as due to 
 incomplete closure of the upper or first post-oral fissure, or 
 rather that part of it which is not utilised in the formation of the 
 Eustachian tube, tympanum, and meatus." I shall take occasion 
 to show that the last part of this sentence is the correct one. It 
 is also necessary to bear in mind that similar canals occasionally 
 occur in the lobule. 
 
 Some important additions to our knowledge of the development 
 of the pinna have been made by His,* which shed a new light 
 on the relation of branchial fistulae in the pinna, as well as afford 
 an explanation of the occurrence of supernumerary auricles. 
 
 Reference to fig. 63 will serve to show that the pinna arises 
 from the swollen edges of the first and second branchial clefts. 
 The germs appear very early as a series of sharply defined 
 elevations. In embryos, at the end of the first month, six of 
 these may be distinguished. Two belong to the mandibular, and 
 three to the hyoid arch, the remaining one to the uniting band. 
 In the drawings these elevations are indicated by figures i to 6. 
 They may, for convenience, be referred to as follows : i is the 
 tuberculum tragicum ; 2, the tuberculum anterius ; 3, tuberculum 
 intermedium ; 4, tuberculum antihelicis ; 5, tuberculum antitra- 
 gicum ; 6, the lobulus. 
 
 The subsequent fate of these tubercles may be briefly given. 
 The tuberculum tragicum unites, across the cleft, with the tuber- 
 
 * "Anatomic menschlicher Embryonem," Leipzig, 1885, Heft, iii., S. 211. 
 
I05 
 
 culum antitragicum, the space formerly separating them being 
 simply indicated by the fissure intertragicum. The tuberculum 
 intermedium is the source of the helix, whilst the tuberculum 
 antihelicis furnishes the antihelix; the nodule VI., cut off by the 
 fusion of tragus and antitragus, becomes the lobule. An exten- 
 
 Fig 64. 
 A Congenital Fistula in the Helix. (After Paget.) 
 
 si on of the helix known as the crus or spina helicis, towards the 
 antitragus, causes a segmentation of the original cavity. In cases 
 of malformation a portion of this may be isolated from the fossa, 
 and give rise to a branchial fissue in the external ear. On these 
 
io6 
 
 grounds His has come to the opinion that these so-called 
 branchial fistulae have nothing to do with the cleft from which the 
 ear passage arises. 
 
 I have had an opportunity of dissecting the parts in a foetus 
 with a malformed auricle, in which a fistula like those so well 
 described by Sir James Paget was present, and I satisfied myself 
 that in this case His's view was the correct one. Inasmuch as the 
 whole of this cavity arises from a branchial cleft, so must branchial 
 fistulae connected with the helix or tragus be regarded as origina- 
 ting in one of these fissures. It will, however, be necessary to 
 
 Fig. 65. 
 A Pinna with a Congenital Fistula in the Lobule. 
 
 divide them into two categories : (i) those originating directly 
 from the cleft, as in Virchow's case, where a probe passed directly 
 into the pharynx ; (2) those arising as secondary diverticular 
 formed in consequence of modifications of the pinna during 
 development. 
 
 This confirms Sir James Paget's view when, as I have before 
 stated, he writes that these aural fistulae may originate in that 
 portion of the cleft which is not utilised in the formation of the 
 Eustachian tube, tympanum, and meatus. 
 
I07 
 
 With regard to fistulae occurring in the lobule of the pinna 
 some remarks must be made. A case has come under my notice 
 where a girl was born with a perforation in the lobule of the left 
 ear, exactly in the situation for putting in earrings. An enthusiast 
 might at once conclude that it was an example of the trans- 
 mission of an artificial deformity, viz., frequent piercing of the 
 ears leading to an inherited defect. However, a satisfactory 
 explanation of the matter is forthcoming. 
 
 Fig. 66. 
 
 An Auricular Dermoid. (After Lannelongue.) 
 
 In fig. 63 a gap is seen to exist between the tuberculum anti- 
 tragicum and the lobulus. When the tubercules I. and V. unite 
 with each other across the intervening notch VI. becomes isolated 
 as the lobule. When this union occurs, if anything should 
 happen to prevent the free edges of V. and VI. from fusing com- 
 
io8 
 
 pletely an aperture would arise, exactly as in the case of the 
 tubercules I. and II., which are concerned in forming congenital 
 fistulae in connection with the helix. Hence, as in the case of the 
 helix, a fistula in the lobule originates in a portion of the cleft 
 •not utilised in the formation of the various parts of the auditory 
 apparatus. 
 
 As a rule, auricles with congenital fistulae are misshapen as in 
 fig. 64, but this is by no means a constant condition. I have 
 several times seen a fistula in the helix, but the pinna has been of 
 normal shape. 
 
 When discussing branchial fistulae it was pointed out that should 
 the inner and outer extremities of a cleft become closed, whilst the 
 inner segment persisted, the small cavity, by becoming gradually 
 distended by secretion from its walls, manifests itself as a cyst. A 
 similar condition may arise in connection with the pinna. Such 
 cysts are often described as sebaceous, but a more careful 
 examination will show that in some instances at least the cysts are 
 really dermoids in character. The specimen represented in fig. 
 66 was of this nature, and was associated with a dermoid con- 
 nected with the orbital fissure. 
 
I09 
 
 CHAPTER VII. 
 
 OVARIAN DERMOIDS. 
 
 The human ovary, like that of most mammals, presents three 
 parts, each giving rise to cysts presenting distinctive features. 
 The three cyst regions are — 
 
 1. The oophoron. 
 
 2. The paroophoron. 
 
 3. The parovarium. 
 
 These parts are diagramatically represented in fig. 67. The 
 oophoron is the region in which the ova are found, and is often 
 referred to as the ovarian parenchyma. The paroophoron is 
 lodged, as it were, in the concavity of the oophoron ; by some 
 writers it is termed the tissue of the hilum. It is almost entirely 
 composed of mesonephritic remains (Wolffian body), in various 
 stages of retrogression. Connected with the paroophoron is the 
 parovarium, a structure composed of a series of verticle tubules 
 the persistent remnants of the excretory ducts of the meso- 
 nephros. The parovarium consists of three parts — a distal 
 series of tubules usually attached by end only ] these are 
 Kobelt's tubes ; then follows a row of tubules connected by one 
 extremity with the paroophoron ; the opposite end joins a 
 common collecting canal, the representative of the segmental 
 duct known in the adult female as Gartner's duct. The 
 number of tubes in the parovarium varies considerably in 
 individual specimens. 
 
 In order to make my remarks comprehensible it will be con- 
 
no 
 
 venient to divide the subject into three sections, and consider 
 each separately, in the following order : — 
 
 1. The characters of the cysts which may be demonstrated 
 anatomically to arise in the oophoron. 
 
 2. The relation of such cysts to the ovarian follicles. 
 
 3. The nature of ovarian follicle. 
 
 Fig. 67. 
 A Diagram to represent the Cyst Regions of the Ovary. A, 
 Oophoron. B, Paroophoron. C, Parovarium, K, Kobelt's 
 Tubes. G, Gartner's Duct. 
 
 OoPHORiTic Cysts. 
 
 Cystomata arising in the oophoron may be arranged clinically 
 into the following groups : — 
 
 1. Unilocular cysts. 
 
 2. Multilocular cysts. 
 
 3. Cystic corpora lutea. 
 
Ill 
 
 I. Unilocular Cysts. — The term unilocular is mainly of clinical 
 significance, for it is rare to find an oophoritic cyst consisting of 
 one cavity only. A careful examination of so-called unilocular 
 cysts will nearly always reveal the existence of numerous smaller 
 loculi in their walls. Nevertheless a single-chambered cyst is 
 
 Fig. 68. 
 
 An Incipient Oophoritic Cyst. 
 
 A, Oophoron. B, Paroophoron. P, Parovarium. F, Fallopian Tube. 
 
 now and then seen, but even in some ot these a close scrutiny 
 will enable us often to detect the remains of septa in some part 
 or other of the cyst-wall, showing that the cyst was originally 
 compound. 
 An incipient oophoritic cyst is represented in fig. ^'^. The 
 
112 
 
 cyst is clearly an enlarged ovarian follicle, and its walls have a 
 well-marked membrana granulosa. 
 
 In such an early stage it is easy to demonstrate the relation of 
 such cysts to the oophoron, but as the cyst enlarges it rapidly 
 produces absorption of the ovarian tissue. This is well shown by 
 a specimen of cystic ovary in the museum of the Royal College 
 of Surgeons, prepared by Mr. Doran to demonstrate this point. 
 
 Fig. 69 
 Ovarian Cyst, Early Stage. (After Doran.) 
 
 The tumour (fig. 69) is only a few inches in diameter, yet the 
 normal relation of the parts is completely destroyed. 
 
 The lining membrane of unilocular cysts varies greatly ; in very 
 large cysts it is, as a rule, impossible to detect epithelium. This is 
 due to atrophic changes, the consequence of continual pressure 
 exerted by the slowly accumulating fluid. Similar changes and 
 
113 
 
 results may be studied in a distended vermiform appendix or in 
 the gall bladder, in the condition known as hydrops vesicae fellse. 
 The smaller loculi in the walls of a large cyst often present a lining 
 of typical columnar epithelium. Occasional flattened epithelium 
 
 Fig. 70. 
 
 A Unilocular Oophoritic Cyst, containing Skin, Hair, and 
 
 Nipple-like Tags of Skin. 
 
 may be detected on the walls of fairly large cysts. On several 
 occasions I have found a cyst containing upwards of two quarts 
 of fluid identical with mucus, and the walls lined with a soft, 
 velvety membrane, raised here and there into elevations resembling 
 the cotyledons of a pregnant ruminant's uterus. The membrane 
 
114 
 
 was beset with rich columnar epitheUum, and in many places 
 dipped beneath the surface to form complex mucous glands. The 
 lining of such cysts is, under the microscope, identical with 
 mucous membrane not unlike that of the small intestine. 
 
 Fig. 71. 
 A Human Ovary in Section, showing a Multilocular Cyst in an Early 
 
 Stage. 
 
 The credit of first recognising mucous membrane in ovarian 
 cysts belongs to Poupinel ; his observations were published in the 
 Archives de Physiologie, series iii., vol. ix.* 
 
 My observations were "made in ignorance of Poupinel's paper, 
 and were conducted along totally different lines. 
 
 In a third class of unilocular cysts we find the main cavity 
 lined with skin, furnished with hair, sebaceous glands, teeth, un- 
 striped muscle fibre, and even a nipple (fig. 70). 
 
 * For a review of this paper see the London Medical Recorder for 1888, 
 " On Mixed Tumours of the Ovary," p. 234, 
 
115 
 
 The variations in the lining membrane of the main cavity of the 
 unilocular oophoritic cyst may be summarised thus : — 
 
 1. Epithelium may be absent. 
 
 2. One or more layers of flattened' epithelial cells may be 
 detected. 
 
 Fig. 72. 
 A Simple Multilocular Ovarian Cyst with Twisted Pedicle. 
 
 3. The interior may be clothed with typical mucous membrane. 
 
 4. Skin with its various appendages may be present. 
 
 5. In size such cysts may vary from an ordinary ovarian follicle 
 to one containing gallons of fluid. 
 
 6. The contents may be a thin and colourless fluid, or thick and 
 tenacious mucus, dark and grumous from admixture with blood, 
 
ii6 
 
 or contain semi-solid pultaceous matter mixed with hair and 
 epithehal debris. 
 
 2. Mtdtiloculaj' Cysts. — In this group the various tumours are 
 for the most part made up of a congeries of cysts of varying size, 
 so that in typical specimens a section carried through the more 
 solid part of the tumour has an appearance not unlike a honey- 
 comb. For convenience of description they will be considered in 
 three sets — 
 
 {a) Simple multilocular cysts. 
 
 (^) Adenomata. 
 
 {c) Multilocular dermoids. 
 
 In each group a type form will be selected, but the three varieties 
 pass, by insensible gradations, one into the other. 
 
 The early stage of a multilocular cyst is represented in fig. 71. 
 It shows clearly the restriction of the cysts to the oophoron. 
 Under the microscope these cavities are indistinguishable from 
 ovarian follicles. In the human female as soon as these follicles 
 attain proportions sufficient to enable them to become perceptible 
 clinically it is impossible to determine in which partof the ovary 
 they had their origin, because they rapidly produce absorption of 
 the ovarian tissues, as has already been illustrated by fig. 69. 
 Nevertheless their growth from ovarian follicles may be actually 
 traced in mares, as will be presently demonstrated. From the 
 condition shown in fig. 71, which may be termed the indifferent 
 stage, the various loculi may continue to increase in size until a 
 tumour of such a size is produced that the individual's life is 
 rendered burdensome merely on account of the mechanical incon- 
 venience induced by it. As the tumour increases in size the 
 various loculi may continue to retain a simple lining of flattened 
 epithelium, which in many of the cavities may be difficult to dis- 
 tinguish, or it may be wanting entirely. Such a tumour is denomi- 
 
117 
 
 nated as multilocular (fig. 72), or the epithelium exhibits very 
 active changes, and the cysts become filled with glandular struc- 
 tures^ which in some specimens are of considerable complexity ; 
 
 Fig. 73. 
 Portion of a Multilocular Ovarian Cyst — Adenoma — showing the varie- 
 ties of Loculi, c Primary, d Secondary, Ovarian Follicles, 
 
 such are termed multilocular glandular, or better ovarian 
 adenomata. 
 
ii8 
 
 The ovarian adenoma is not only an important, but an extremely 
 interesting variety of tumour. As a rule it is invested by a 
 dense fibrous capsule, and is occasionally lobulated. These 
 
 Fig. 74- 
 
 Portion of an Ovarian Adenoma containing a Tuft of Hair. (Museum 
 
 of St. Thomas's Hospital.) 
 
 tumours attain great dimensions, and are made up of innumerable 
 cysts which vary in size from a microscopic cavity to one holding 
 a quart or more of fluid. Critical dissection of such tumours 
 enables us to recognise three varieties of cysts entering into their 
 composition. 
 
 In typical specimens we shall find projecting into some of the 
 
IT9 
 
 larger cavities a honeycomb-like mass occupying usually one-third 
 of its circumference, so that a section of the cavity resembles a 
 signet-ring. Such cysts are primary, whilst the cavities occupying 
 
 Fig. 75- 
 A Portion of a Multilocular Ovarian Dermoid. 
 
 the honeycomb portion are secondary cysts, and are as a matter 
 of fact mucous retention cysts. The third set of loculi contain 
 no honeycomb-like structures, are of small size, and histologically 
 are indistinguishable from distended ovarian follicles. The three 
 forms of cyst are represented in fig. 73. 
 
 The primary cysts in their early stage are lined wath ricl> 
 columnar epithelium, and in that portion of their circumference 
 which corresponds to the honeycomb of larger cysts mucous glands 
 are found. Indeed, the lining membrane of such cysts is 
 
I20 
 
 identical with mucous membrane. Occasionally a lock of hair may 
 be detected sprouting into one of the larger loculi. 
 
 The museum of St. Thomas's Hospital contains an excellent 
 example of this. The specimen is mounted in the teaching series 
 as a type of multilocular ovarian glandular cyst. Sprouting from 
 a small dermoid patch in one of the larger loculi is a tiny tuft of 
 hair (fig. 74). 
 
 From multilocular cysts lined with mucous membrane we pass to 
 those which possess in one loculus a small tuft of hair, to others 
 which present skin or mucous membrane furnished with hair, 
 sebaceous or sudoriparous glands, unstriated muscle fibre, fat, and 
 teeth in every loculus (fig. 75). 
 
 Occasionally tumours occur presenting three distinct types of 
 cysts ; that is, one set of cysts contain skin, hair, sebaceous 
 glands, and teeth ; others present only clusters of mucous glands 
 and mucous cysts ; and the third set are indistinguishable from 
 ovarian follicles. 
 
 Thus, as in the case of unilocular cysts, it is impossible to 
 demarcate between adenomata and dermoids. In specimens without 
 glandular contents it is often impossible to determine whether the 
 lining membrane should be classed as mucous membrane or 
 skin. This was notably the case with the tumour represented in 
 fig. 72, yet I hsve seen a specimen in every way resembling this 
 possess in one small chamber a rudimentary mamma. 
 
 We may here consider some exceptional forms of ovarian 
 cysts. The following condition has, so far as I know, been 
 observed only in connection with dermoids, and this is the distri- 
 bution of small cysts among the omentum, mesentery, and 
 intestine. In a case of this nature reported by Moore * all the 
 smaller cysts were attached to the main cyst by long pedicle?. 
 
 * Path. Soc. Trans., vol. xviii., p. 
 
121 
 
 This fact has lately been rendered more interesting by the 
 researches of Mr. Alban Doran,* who has demonstrated satis- 
 factorily enough that many abdominal dermoids described as 
 non-ovarian are, as a matter of fact, ovarian dermoids that 
 
 v\\ 
 
 Fig. 76. 
 An Ovarian Dermoid, villous with Adhesions. (After Doran.) 
 
 have separated from their pedicles, and this is especially the 
 case with cysts of the omentum. In such specimens necrosis of 
 the dermoid is prevented in virtue of vascular connections it 
 has acquired by means of adhesions to the omentum before its 
 original connections with the ovary were lost. Ovarian der- 
 moids are notorious for contracting adhesions, and the extent 
 
 * Med.-Chir. Trans., vol. Ixviii., p. 235. 
 
122 
 
 to which this occurs may be inferred from a glance at fig. 76, 
 taken from a specimen in the museum of the Royal College of 
 Surgeons. 
 
 A very good example of this kind of adhesion and subsequent 
 attachment came under my notice in 1887. The specimen was 
 
 Fig. -j-j. 
 
 All Ovarian Dermoid which has nearly detached its Pedicle, and 
 
 acquired new attachments to the Omentum. 
 
 O, Ovary. D, Dermoid. F, Fallopian Tube. A, Omentum. 
 
 exhibited at the British Gynaecological Society, by Mr. Grigg 
 Smith. The tumour was adherent to the omentum, but a thin, 
 frail band of tissue connected it with the right angle of the uterus. 
 The tumour was multilocular ; the largest cyst was as big as a 
 melon ; in one of the smaller loculi a small tuft of skin contain- 
 
12 
 
 ing hair and glands was found (fig. 77). The chief adhesions 
 were connected with this part of the cyst ; other slender bands 
 existed on other parts of the tumour, but those marked A in the 
 drawing were by far the most important. The thin ligament 
 which connected the tumour with the uterus was the attenuated 
 portion of the Fallopian tube. 
 
 Such a case as this is intermediate to the cases of completely 
 detached dermoids. Thus Doran* describes a specimen of the size 
 
 Fig. 78. 
 A Cystic Corpus Luteum from the Ovary of a Mare. 
 
 of a cricket-ball, which was found adherent to the omentum. The 
 right ovary was found at the operation to be cystic ; the left 
 Fallopian tube was obstructed and slightly dilated ; close to it, in 
 the site of the ovarian ligament, lay a short, firm tag of fatty and 
 partly calcareous tissue. This specimen is also in the College 
 museum. 
 
 The explanation of the detachment is to be found in the tendency 
 
 * " Tumours of the Ovary," p. 122. 
 
124 
 
 exhibited by ovarian cysts, especially dermoids, to undergo axial 
 rotation, whereby the pedicle becomes twisted. Should the twist- 
 ing occur rapidly gangrene of the sac may follow, but if it twists 
 gradually adhesions are acquired, whereby the vitality of the 
 tumour is maintained and its original pedicle is lost. 
 
 3. Cystic Corpora Liitea. — Cysts arising in corpora lutea are 
 interesting pathologically, but of no clinical import, as they rarely 
 attain a large size. Such cysts are occasionally found in the 
 human ovary, but they occur with great frequency in the ovary of 
 the cow, mare, and numerous other mammals. In the recent 
 state they are easily recognised, the walls of the cyst presenting 
 the characteristic yellow tissue ; the cyst-wall when examined 
 microscopically does not present a definite lining membrane or 
 epithelium. 
 
 In very rare cases cysts developed in corpora lutea have con- 
 tained solid facetted bodies resembling calculi. 
 
 2. The Relation of Odphoritic Cysts to the Ovariaji Follicles. — 
 It has always appeared to me contrary to the dictates of common 
 sense and sound reasoning when attempts are made to ascribe 
 oophoritic cysts to tissues of the ovary- other than those connected 
 with the follicles. To ignore the ovarian follicles in this matter, 
 and attribute cystomata to epithelial ingrowths and such mythical 
 structures as Pfliiger's tubes, is absurd. 
 
 We have already seen that in their early stage oophoritic cysts 
 are restricted to the egg-bearing segment of the ovary, and in 
 their early stages are indistinguishable from ovarian follicles. 
 This was well illustrated in the ovary represented in fig. 71, but 
 the connection may be traced much more completely in the 
 ovaries of mares. In mares of the age of ten years or upwards 
 the oophoron is invariably occupied by dilated follicles, cystic 
 corpora lutea, or both ; these ovaries are the more instructive 
 because they possess a very large paroophoron. It has already 
 
125 
 
 been pointed out that when the folHcles attain a moderate size in 
 the human ovary the paroophoron is absorbed and the real rela- 
 tion of the parts disturbed ; this is not so in the mare, and even 
 in a tumour which weighed eighty-four pounds the cysts remained 
 restricted to the oophoron, and were histologically identical with 
 ovarian follicles ; many of them contained mucous glands (fig. 79). 
 We will consider the anatomy of an ovarian follicle, in order to 
 
 Fig. 79. 
 Transverse Section of an Ovarian Tumour from a Mare ; it weighed 
 eighty-four pounds. A, Oophoron. B, Paroophoron. F, Fallopian 
 Fimbriae. 
 
 ascertain the relation between it and the primary cysts of a multi- 
 locular tumour or ovarian adenoma. The ova of mammals differ 
 from those of oiher vertebrata in the fact that they are enclosed 
 by a membrana granulosa. In a fully developed follicle the cells 
 are arranged two or more rows deep, the surface cells being more 
 
126 
 
 or less columnar. At one point the cells form a prominence, the 
 discus proligerus, in which the ovum is embedded. The surface 
 cells are more distinctly columnar in the neighbourhood of the 
 disc than elsewhere. The membrana granulosa secretes a fluid 
 known as the liquor folliculi. Thus, in section the ripe follicle 
 has an appearance like a signet-ring (fig. 80). 
 
 If a ripe follicle be compared with a primary cyst in an ovarian 
 adenoma (fig. 73) the comparison is very suggestive, especially 
 when we note the restriction of the glandular material to the 
 signet portion of the cyst. This is even more suggestive if we 
 examine the smaller cysts. In the accompanying drawing (fig. 81) 
 three cysts from an ovarian multilocular dermoid are represented 
 in juxtaposition. The cyst a is barren, but b is lined with a layer 
 of rich columnar epithelium, with a small cluster of glands, whereas 
 c resembles h, but has a much larger collection of mucous glands. 
 In the next stage we have obstruction to the free flow of secretion 
 from these glands, inasmuch as it passes into a closed cavity, 
 hence they are always subject to pressure ; the result of this is to 
 produce a retention cyst, the honeycomb structure of fig. 73. 
 These facts tend to show that when an ovarian follicle becomes 
 cystic there is a tendency for the surface cells of the discus pro- 
 ligerus to dip beneath the surface and form mucous glands of great 
 complexity, and as the cyst assumes greater proportions these 
 glands become mucous retention cysts. Hence the signet-like 
 mass in the primary cyst is to be regarded as an enlarged discus 
 proligerus. 
 
 These principles are applicable to multilocular dermoids also, 
 for a critical examination of the loculi will reveal the fact that in 
 most of them there is a restriction of the glandular elements to 
 one section of the cyst wall, and it is quite an exception to 
 find glands distributed evenly throughout the whole lining 
 membrane. 
 
127 
 
 The two sections of my argument which we have just considered 
 show that the division of oophoritic cysts into unilocular and 
 multilocular is merely a clinical convenience, and that we can 
 actually pass by easy stages from a unilocular cyst without an 
 epithelial lining to multilocular tumours rich in glands, containing 
 structures as elaborate as a mamma oreven a rudimentar}' eye. 
 The mystery up ta the present time has been to definitely account 
 
 Fig. So, 
 
 A Ripe Ovarian Follicle. 
 
 g^ Membrana Granulosa, d^ Discus Proligerus. 
 
 for the origin of glandular tissue in such cysts, for it is well 
 established that adenomata can arise only in connection with pre- 
 existing gland tissue. It has already been stated that the 
 membrana granulosa possesses glandular functions, inasmuch as it 
 secretes the liquor folliculi. It behoves us, therefore, to institute 
 a comparison between the ovarian follicle and glands in general, 
 in order to ascertain if any phylogenetic justification exist for their 
 extraordinary behaviour. 
 
 3. The Nature of the Ovariaji Follicle. — Having demonstrated 
 the origin of oophoritic cysts in the ovarian follicles, it remains for 
 us to inquire into the nature of the follicles, and why they furnish 
 
128 
 
 adenomata, for it is contrary to pathological reasoning that glan- 
 dular tumours should arise in situations unprovided with glands. 
 
 Fig. 8i. 
 A Drawing representing Three Stages ol an Ovarian Adenoma. 
 
 This inquiry involves the phylogeny of the ovarian follicles, and is 
 intimately bound up with the history of the peritonaeum. 
 
 The ccelom (pleuro-peritoneal cavity) in most vertebrates arises 
 as a schizocoele, due to the splitting of the side walls of the 
 embryo into somato-pleure and splanchno-pleure. This mode of 
 
129 
 
 origin is secondary, for in its simpler form the coelom is due to 
 jiortions of the gastrula becoming abstricted from a central portion 
 which persists as the alimentary canal. To put the matter briefly, 
 the coelom, according to the Hertwigs, is a diverticulum of the gut, 
 and its surface is covered with epithelium; therefore the cells 
 
 Fig. 82. 
 
 Microscopical View of the Skin of an Adult Salamander. 
 
 (After Wiedersheim.) 
 
 which dip below the surface of the genital ridge to form ova and 
 ovarian follicles are of the same nature as those which in the gut 
 dip below the surface to form mucous glands. The process is 
 well exemplified in the skin of the salamander (fig. 82), where 
 downgrowths of the surface epithelium intended to form glands 
 are at first solid, then acquire a lumen with cells arranged peri- 
 pherally ; the mucus contained in the cavity escapes externally by 
 means of an orifice. 
 
 The ovary of a frog in the breeding season is very instructive ; 
 it consists of a main cavity with numerous diverticula. These are 
 
 9 
 
130 
 
 lined with cells, but at intervals we find a cell much larger than 
 the neighbouring ones ; the large cells are ova, and on section a 
 diverticulum of a frog ovary irresistibly suggests the notion of a 
 gland secreting ova (fig. 83). 
 
 In mammals we find instead of a simple gland, a complex one, 
 the acini of the gland being represented by the follicles. Indeed, 
 ovarian follicles in their mode of origin and pathological relations 
 are glands. It may be urged that in order to make my argument 
 complete the ovarian follicle needs a duct. In many invertebrata 
 
 
 Fig. 83. 
 A Section ot the Wall of an Ovarian Diverticulum, from a Frog. 
 
 the ovary is furnished with a duct for the excretion of ova, but in 
 vertebrata the female reproductive organs have undergone such 
 profound modifications that the ova are shed into the peritonaeal 
 cavity, and in a few forms escape to the outer world by way of the 
 abdominal pores. In higher types the disused ureter or ureters, 
 which formerly served as the excretory conduits of the pronephros, 
 
become modified as egg-channels. Thus Miiller's ducts in the 
 female, like the Wolffian ducts in the male, have undergone a very 
 remarkable change of function. 
 
 If it be necessary to compare pathological conditions of the 
 follicles with diseases of other glandular acini, such as those of the 
 breast, we can compare them with adenoceles and adenomata. 
 
 Thus, on morphological, embryological, and pathological 
 grounds, the identity of ovarian follicles with the acini of glands 
 is complete, and I have no hesitation in regarding the follicles of 
 the ovary as mucous crypts. As the membrana granulosa is 
 potentially mucous membrane, and as skin and mucous membrane 
 are morphologically identical and convertible structures^ cysts 
 containing skin or mucous membrane and their appendages are 
 not more remarkable than cysts and neoplasms occurring in 
 connection with other glands. 
 
 Reprinted from The Illustrated Medical News. 
 
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