COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANpARD HX64060896 )57C55 Surgical pathology; RECAP ■Hl)'bi C^^b in tl|? (Uitg of ^m fork S^f^r^nr^ ICtbrarg m vv,*:>^ c^-^: b^yy.-i ^.v ¥y^: ■;-.■■'>-■ g^^'- :"i'-'' i5?^^ :;is?s ir* SURGICAL PATHOLOGY AND PRmCIPLES. 1. SURGICAL PATHOLOGY AND PRINCIPLES BY J. JACKSON CLARKE, M.B.(Lond.), F.R.C.S. ASSISTAST-SCRGEON AT THE NORTH-WRST LONDON AND CITY ORTHOPEDIC HOSPITALS ; LATE SENIOR DEMONSTRATOR OF ANATOMY, DEMONSTRATOR OF BACTERIOLOGY, AND CURATOR OK THE MIJSBUM IN ST. MARY's HOSPITAL MEDICAL SCHOOL ; AND PATHOLOGIST TO ST. MARY's HOSPITAL. WITH ONE HUNDRED AND NINETY-FOUR ILLUSTRATIONS LONGMANS, GREEN, AND CO. 39 PATEENOSTER EOW, LONDON NEW YORK AND BOMBAY 1897 All rights reserved GLASGOW : PRINTED AT THE UNIVERSITY PRESS BY ROBERT MACLEHOSE AND CO. SIR WILLIAM HENRY BROADBENT, M.D., F.R.S. BARONET, PUYSICIAN-IN-ORDINARY TO H.R.H. THE PRINCE OF WALES, AND CONSULTING PHYSICIAN TO ST. MARY'S HOSPITAL, THIS BOOK IS nEDICATED AS A TOKEN Oi' GRATITUDE FOR HIS TEACHING AND FOR MANY ACTS OF PERSONAL KINDNESS. ^DOX, Septemler, 1897. TABLE OF CONTENTS. PAGE Introduction, -- 1 PART I. GENERAL SURGICAL PATHOLOGY. CHAPTEE I. General Considerations, 5 CHAPTER II. Eepair, 20 CHAPTER III. Factors which hinder Repair : Inflammation, - - - 53 CHAPTER IV. Infective Inflammation, ..---.-61 CHAPTER V. New Growths, -.-- 91 CHAPTER VI. Dermoids, 128 CHAPTER VII. Malformations, - - - -134 X CONTENTS. PART II. DISEASES OF SPECIAL TISSUES AND ORGANS CHAPTER VIII. PAGE Diseases of Bone, 146 CHAPTER IX. Diseases of the Jaws and Teeth, 182 CHAPTER X. Diseases of the Joints and Burs^, 188 CHAPTER XL Diseases of Muscle and Tendon, . . - . - 204 CHAPTER XII. Diseases of Nerves, 207 CHAPTER XIII. Diseases of Arteries : Aneurysm, 210 CHAPTER XIV. Diseases of Veins : Varix, 223 CHAPTER XV. Diseases of Lymphatic Vessels and Glands, - - - 230 CHAPTER XVL Diseases of the Mouth, Tongue, and Alimentary Tract, - 236 CONTENTS. CHAPTER XVII. PAGE Abdominal Hernia, - . . 254 CHAPTER XVIII. Intestinal Obstruction and Peritonitis, ... - 261 CHAPTER XIX. Diseases of the Salivary Glands, Liver, and Pancreas, - 286 CHAPTER XX. Diseases of the Respiratory Tract, 292 CHAPTER XXI. Diseases of the Thyroid Gland : Acromegaly, - - - 305 CHAPTER XXII. Diseases of the Brain, Ear, Eye, etc., - - - -311 CHAPTER XXIII. Diseases of the Spinal Column and Cord, - - - - 328 CHAPTER XXIV. Deformities of the Extremities, etc. : Club Foot, - - 345 CHAPTER XXV. Diseases of the Urinary Tract, 361 CHAPTER XXVI. Diseases of the Testis, etc., 387 xii CONTENTS. CHAPTER XXVII. PAGE Diseases of the Female Generative Organs, ... 400 CHAPTER XXVIII. Diseases or the Breast, 408 CHAPTER XXIX. Diseases of the Skin, - - - 418 LITERATURE AND REFERENCES, 434 INDEX, 435 LIST OF ILLUSTRATIONS. FIG. PAGE 1. Vertical section through a first metatarso-phalangeal joint and the skin over it, with a large corn, 10 2. A popliteal artery cut open to show laceration and retraction of the inner and middle coats and thrombosis, 13 3. Section of part of the cut end of a divided tendon, etc., 48 hours after division, -.--.------. 21 4. Section through part of the bond uniting the divided ends of a tendon after 48 hours, 23 5. Section of a portion of the uniting medium of a divided tendon on the 4th day, showing fibroblasts and vasoblasts, . - - - 24 6. Vertical section through the severed ends of a divided tendon and uniting medium on the 14th day, 25 7. Section of the medium uniting the severed ends of a tendon on the 14th day, 25 8. Section through the junction of the divided end of a tendon with the uniting scar on the 14tli day, 26 9. Section through a surgical wound of the scalp five days after operation, 29 10. Diagram representing repair in an artery after the application of a ligature, - . . - 35 11. Two veins with organized thrombi in them. From Coats's Manual of Pathology, 38 12. Longitudinal section of a fractured rib, showing callus, etc. From Coats's Manual of Pathology, - 40 13. Separation of the lower eiaiphysis of the humerus, .... 42 14. Bones of the right hind limb of a hare, showing the result of separ- ation of the lower epiphysis of the tibia, 43 15. The upper part of a femur, showing diarthrodial pseudarthrosis. (91a), - 44 16. Intracapsular fracture of the neck of the femur, . . - . 45 17. Impacted fracture at the anatomical neck of the humerus, - - 45 18. The axillary artery and nerves of the brachial plexus from the stump of an amputation through the shoulder-joint, .... 51 19. The ujjper half of a femur removed from a stump sixteen years after amputation through the thigh, 5] 20. A section at the margin of a chronic ulcer of the leg, - - . - .55 xiv SURGICAL PATHOLOGY. no. PAGE 21. Various pathogenic bacteria, and a granular wandering cell, - - 66 22. Section of tubercular synovial membrane, 80 23. Section through the marginal part of a gumma of the subcutaneous tissue, 84 24. Part of a liver containing a large gumma, 85 25. Vertical section through the iilna of a child, showing syphilitic thickening, 85 26. Section of a melanotic sarcoma of the choroid, 93 27. Section of an alveolar sarcoma of the breast, 94 28. Section of a marginal part of cancer of the colon, ... - 95 29. Diagrammatic section of a pedunculated adenoma of the rectum, - 99 30. Section at the margin of an adenoma of the thyroid, - - - . 100 31. Section at the margin of an ordinary cutaneous wart, - - - 101 32. Section at the margin of a squamous-celled cancer of the skin, - - 102 33. Section of a congenital mole which was becoming sarcomatous, - - 110 .34. Outline of a foot and lower part of a leg showing congenital hyper- trophy, 112 35. Some forms of sarcoma, II4 36. Endothelial sarcoma of the pleura, 117 37. Cell-nest of a squamous epithelioma. From "Weichselbaum, - - 120 38. Section of a rodent cancer, -------- . 121 39. Section at the margin of a patch of Paget's disease of the skin, - - 123 40. Section of a hard cancer of the breast (Weichselbaum), - - - 125 41. Section of part of a squamous-celled cancer of the penis, showing cell-inclusions, 126 42. Section through a testis containing a dermoid tumour, - - - 132 43. A kitten presenting congenital deformities. 134 44. An average case of imperforate anus, 140 45. Narrowing of the pelvic outlet in a case of undeveloped rectum, - 140 46. Shows what might result from exploring with a trochar in a case of undeveloped rectum, - 141 47. Vertical section through the upper end of a tibia in acute osteo- myelitis, . --... 150 48. Vertical section of the left tibia of a child aged 10 months, showing the effects of acute septic osteomyelitis, . - - . . 151 49. Exfoliated portion of the shaft of a femur, ---..- 152 50. The lower end of a femur showing the results of acute osteomyelitis,- 152 51. Section through the lower end of a femur showing tuberculosis of the bone extending into the knee-joint, 154 .52. Section through a tibia hypertrophied from the presence of a seques- trum at its lower extretnity, 155 53. A section showing the histological changes in tuberculosis of bone, - 155 54. Vertical section of an infant's humerus showing changes caused by syphilitic epiphysitis (osteo-chondritis) and periostitis, - - - 156 55. Section showing the histological changes at the epiphyseal line of the bone represented in Fig. 54, - - 157 56. Vertical section of a normal tibia showing the epipliyseal lines, i.e. the planes of endochondral ossification, 160 LIST OF ILLUSTRATIONS. xv ilG. PAGE 57. Vertical section through a humerus, showing marked rachitic changes, 160 58. Vertical section of a normal humerus at the margin of the epiphyseal line, X 40, partly diagrammatic, 161 59. Vertical section of a rickety humerus at the margin of the epiphyseal line, x40, 162 60. Portion of three ribs showing^'ickety beading, ----- 163 61. Vertical section of the humerus of a rickety monkey, - - - - 164 62. Schematic section showing the mode of growth of a long bone, - - 164 63. Showing normal metaplastic endochondral ossification, - - - 165 64. Section of a portion of the osteoid tissue of endochondral origin in a rickety bone, 166 65. Section of osteoid tissue of periosteal origin in a ricket}' bone, - - 167 66. The lower limbs of a girl showing rickety deformities, - - - 168 67. Vertical section though the neck of the femur of an adult showing rickety deformity of the shaft and neck of the bone, - - - 169 68. Vertical section through the radius of an infant, showing a green-stick fracture, 169 69. Multiple spongy osteomata. From Coats's Pathology, - . . I75 70. Ivory exostosis of the frontal bone. From Coats's Pathology, - - 176 71. Multiple central enchondromataofthefingers. From Coats's Pai in the tissues. The - indications for obtaining healing of an abscess are to make a free opening, and to prevent its closing by the use of the drainage-tube or by packing with iodoform gauze ; and to destroy micro-organisms by carbolic lotion, etc. Where a tubercular abscess, such as those met with in connection with the vertebrae, is of large extent, it is advisable after evacuating the contents to mop out the cavity with some strong antiseptic and then to close the external wound by sutures, the risk of re-formation of the abscess being less than that of adding pyogenic and putrefactive bacteria to the tubercular infection. Ulceration, etc. An ulcer is formed in exactly the same way as an abscess, i.e. suppurative inflammation causes a loss of tissue. Since, however, the loss is on a free surface, the result is not a cavity filled with pus, but an open breach of surface from which pus escapes. Loss of tissue caused by new growths invading a surface also forms an ulcer. When an ulcer begins to heal it is termed a granulating wound. In order that healing by granulation tissue may progress in a normal manner, the various infections and other factors which hinder repair must be absent or kept in abeyance. Where it is impossible to render a cavity or surface aseptic, free drainage and, in suitable cases, the use of iodoform, preferably in the form of a glycerine suspension, often secures rapid healing. Glycerine is hygroscopic, and hence promotes exosmosis. That iodoform is not a powerful antiseptic is shown by the fact that, in a one per cent, suspension in nutrient gelatine it does not prevent the growth of anthrax bacilli. Iodoform acts on the toxic products of bacteria, rendering them harmless, and so enabling repair to go on. In septic wounds granulations are apt to become over- developed — luxuriant, as it is termed, and the resulting scar is thick and often prominent, contrasting with the smooth scar that results in aseptic conditions. 60 SURGICAL PATHOLOGY. Wounds may be attacked by tubercle, syphilis, etc., and these diseases cause a more serious obstacle to repair than do the ordinary pyogenic bacteria. The various parts of an ulcer which are to be studied are : (1) the outline and size, (2) the floor and discharge, (3) the sur- rounding tissues. According to the characters of these and other features, ulcers may be variously designated. The edge may have a sinuous outline; if the peripheral extension of the ulcer is a marked feature, the term serpiginous is applied to it. Where the edge and base of the ulcer is thickened by the formation of much fibrous tissue, the ulcer is termed callous ; if there is much pain from irritation of nerves in the ulcer, it is termed irritable. When the granulations are large and pale from oedema, the ulcer is said to be weak ; and when the surrounding tissues are inflamed, the term inflamed ulcer may be used. In the following chapters many speciflcally diff'erent forms of ulceration will be described, e.g. leprous, cancerous, etc., etc. Scars may be "weak," that is, liable to break down into ulcers at various points. This occurs especially in fat persons with weak circulation. The prominent scar resulting from septic wounds may assume a thickened appearance so marked that the terms "hypertrophic" or "warty" may be applied to it. In some cases, instead of the scar-tissue undergoing the usual atrophic shrinking, there may be a progressive formation of fibrous tissue — in other words, the formation of a new growth, which is termed Keloid (see the section on "Diseases of the Skin "). Chronic ulcers and scars are not infrequently the starting-point for cancerous growths. Diffuse Suppuration. When the infective organisms which give rise to suj)puration are more than usually virulent, the eff"ect is not limited to a definite area, but spreads in a diff'use manner, so that instead of an abscess or an ulcer the result is a diff'use suppuration. CHAPTER IV. INFECTIVE INFLAMMATION. Bacteria or fission fungi are the best-known agents of infective inflammation. The most certain proof of a micro-organism being the cause of a disease is obtained when it is found to answer to Koch's "postulates," which are : (1) That the organism is constantly present in every instance of the disease; (2) that it has been cultivated free from other organisms on nutrient media through several generations; (3) that when, after being thus cultivated, it is inoculated in animals it reproduces the original disease, and (4) that cultures of the organism are again obtained from the inoculated animals. It would, however, be a mistake to think that this is the only mode of establishing the causal relationship between a micro-organism and a disease. Thus a protozoon has been proved to be the cause of malarial fever, though as yet no cultures of the parasite have been obtained. Its relation to the disease has been ascertained by observing the parasite in the blood of persons suffering from the disease, and noting the coincidence between the phases of the fever and those of the parasites in the blood. The conclusion has been arrived at on grounds similar to, if more refined than, those that enable us to conclude that the acarus scabiei is the cause of itch. The claims of any micro-organism to pathogenic properties must, however, be most critically examined in order to prevent false doctrine being accepted to the detriment of knowledge. The effects of bacteria are produced chiefly by poisonous substances formed by them. These substances vary in their chemical 62 SURGICAL PATHOLOGY. characters. ]\Iany of the putrefactive bacteria produce ptomaines (Gr. ptoma = coY]ise), wliich have the characters of alkaloids. Ptomaines, when they are of a poisonous character, are termed toxins (Gr. toxicon = for the bow = arrow-poison). Others pro- duce poisonous proteid bodies; when these are coagulable by heat they are termed toxalhumins, as, for instance, the poison- ous product of the diphtheria bacillus ; when not coagulable by heat the products are termed proteins. If the general symptoms of a disease are produced by the absorption into the blood of the poisonous products unaccompanied by the living organisms the condition is termed septic intoxication (Gr. sepsis = fermentation or decay). If living organisms (either by the lymphatics or the veins) gain an entry into the blood- vessels and multiply there and in the tissues, the condition is one of general infection, or septicaemia, one phase of which, marked by the formation of abscesses, is called pyaemia. Alco- holic intoxication affords an easy parallel with septic intoxication. An unicellular fungus, the saccharomyces, closely allied to the bacteria, produces by its vital action on sugar a toxic substance, ethylic alcohol. The latter, separated by various means from the fungus which generates it, is capable of producing the well- known effects on the central and peripheral nerves and other tissues and orgaus of the body. So in diphtheria, a bacillus growing on a surface where the local disease is in progress produces a toxalbumin which, absorbed into the blood, con- stitutes a septic intoxication, the evidences of which are fever, depression, albuminuria, paralysis of nerves, etc. Some bacteria produce ferments or enzymes, among which are several capable of splitting up proteids. Very minute quantities of such fer- ments absorbed into the blood may cause serious effects. A^ a marked example of septicaemia the effects of inoculating a guinea-pig with anthrax bacilli may be adduced. If living spores of this organism are placed beneath the skin in the track of a minute puncture, twenty-four hours later the animal is dead or dying. The blood in the heart and in the vessels of all parts of the body is crowded with bacilli. From a practical point of view it is of the highest im- portance to prevent the occurrence of a local septic infection, INFECTIVE INFLAMMATION. 63 and, if local infection has occurred, to prevent it becoming a general infection or septicaemia. For instance, an acute abscess, say, in a cervical gland, is a local infection producing fever and other symptoms by septic intoxication. The abscess opened and drained, the symptoms rapidly disappear. But should septicaemia have occurred before the original abscess is treated the operation may produce but little effect ; fever, rigors, etc., will continue because the organisms are distributed by the blood-stream to various parts of the body, or, in other words, the condition is one of general infection. Immunity. The rapid generalization of anthrax bacilli in the guinea-pig has been alluded to above. We may compare it with what occurs in man when some of the same spores find their way into a scratch in the skin. Local inflammation is the first effect, showing itself as a red papule which itches violently, and on which a vesicle forms. A raised and indurated area forms around the vesicle, and by the end of the second day becomes black in the centre ; meanwhile a circle of new vesicles arise around the black area, and the surrounding tissues become oedematous. There is some fever from septic intoxica- tion. If the whole of the black (necrosed) area and that bearing the vesicles is freely excised the patient recovers, if this is not done the patient dies of septicaemia within a week of the commencement, and anthrax bacilli are to be found in the blood of all parts of the body. Allowing for the slightly diff"erent conditions of the two cases, it is seen that the anthrax bacilli are less rapidly destructive to man than to the guinea-pig. This may be explained by saying that in man the connective- tissue cells and the diapedesis of leucocytes, etc., hold back for a time the bacilli from entering the general circulation by the lymphatics and veins, whilst in the guinea-pig there is little or no power on the part of the connective-tissue cells and leuco- cytes to limit the invasion of the blood by the bacilli. As compared v/ith the guinea pig, man is said to be better protected against the organisms. The amount of protection seems to be proportionate to the degree of inflammatory reaction set up. If any species of micro-organism is found to be incapable of growth in the tissues of an individual then the protection is said to be 64 SURGICAL PATHOLOGY. complete, or the individual is said to enjoy immunity against the disease. Similarly, when an individual is not affected by the chemical product of any organism, he is immune to that substance, which may be toxic as regards other individuals. Immunity may be acquired, e.g. one attack of any of the specific fevers usually protects a person from that disease, or it may be inherited. The difference between inoculated anthrax in the guinea-pig and man respectively supports Metsch- nikoff's theory to the effect that immunity depends on the capacity of the phagocytes of an individual to destroy any given organism. The view is supported by various observations, e.g. under ordinary conditions a frog is immune against anthrax. If bacilli are injected into a frog's peritoneal cavity they are seized on by leucocytes and destroyed. If, however, the frog be kept at an elevated temperature or ansesthetized with chloroform and ether mixture, the bacilli multiply and little or no phagocytosis is observed. The altered condition of the frog in relation to anthrax bacilli shows that the same individual may be at one time immune against a pathogenic organism and not at another time. This variability of the host in relation to the parasite is complicated by varying virulence of the micro- organisms. Bacteria grown under favourable conditions of nutrient medium and temperature are more active (virulent) than those grown under adverse conditions, when the organisms are of diminished pathogenic potency and are then said to be attenuated. In thinking of micro-organisms in relation to disease, the modifications due to variations of protection in the host and of virulence in the parasite must not be lost sight of. Animals may be made proof against the effects of the toxic products of bacteria. Thus a horse may be immunized against the diphtheria toxalbumin by administering gradually increasing doses by hypodermic injection. At first the animal suffers : local swelling, general fever, and malaise being observed, but afterwards even what in an unprotected animal would be a fatal dose is found to have no effect. When this stage is reached the serum of the blood of the artificially protected animal is found to neutralize the diphtheria toxalbumin when added to the latter outside the body, mixtures being inert when ad- INFECTIVE INFLAMMATION. 65 ministered to unprotected animals. This antitoxic property of the serum of animals rendered proof against diphtheria has been found to be eflfectual also when the poison has been injected alone into an unprotected animal and has given rise to symptoms. If then, after an interval, the antitoxic serum is injected, the symptoms of septic intoxication rapidly disappear. These facts have been used with some measure of success in the treatment of diphtheria. The blood-serum of protected horses, etc., injected into persons suffering from the disease has been found to diminish the symptoms of intoxication and to help in effecting a cure. A similar antitoxic serum has been found to annul the effects of snake-poison. In tetanus the results of a similar line of treatment have not been so successful. An antistreptococcic serum is now on its trial. These phenomena go to show that there are other factors besides phagocytosis in the production of immunity. Fever. The thermometer is of the greatest value in detecting the presence of septic inflammation. If the initial dose of poison is marked there is frequently a rigor, or short of this a sudden rise of temperature above the normal. The fever is probably the result of the action of the toxic material on the central nervous mechanism which regulates the temperature of the body, and on the tissues generally. There is an increased production of heat by the tissues of the body. After death the cells of the organs of the bodies of those who have died during this septic fever are found to be in a state called cloudy-swelling (see p. 16). The blood in suppurative fever is hyperinotic, that is, it clots with abnormal readiness. Thus on post-mortem examination of the bodies of those who have died from infective disease ante-mortem clots are usually present in the right ventricle of the heart. Traumatic Fever. After severe injuries when the initial de- pression of the activity of the nerve centres or shock (see p. 15) has passed away, there is frequently observed a rise of tempera- ture which may last for several days, and which is not necessarily E 66 SURGICAL PATHOLOGY, connected with sepsis. The two chief factors in the production of simple traumatic fever are reflex nerve irritation, and the reabsorption of the products of aseptic inflammation — leucocytes, serum, etc., into the blood. The sharp rise of temperature, which may be accompanied by a rigor, often observed after the passage of a catheter through a stricture of the urethra, is attributed to reflex nerve influence. This is one form of Urethral fever. Suppuration. Suppuration when not the result of artificial irritants like croton oil, etc., is due to infection by pyogenic organisms. 1 2 6 4 5 Fig. 21. — 1 Staph3'cocci and marrow cells from a cover-grlass preparation of Inflamed marrow from a case of acute osteomj-elitis. 2, Gonococci and leuco- cytes, from a cover-glass preparation of iirethral discharge. 3, Streptococci and tubercle bacilli with pus cells, from a cover-glass preparation from the discharge in a case of tubercular inflammation of the middle ear. 4, A bunch of the clubs of actinomyces, from an unstained scraping from a nodule in the skin of the face of a woman. 5, Anthrax bacilli and red blood-cells. 6, A granular wandering cell simulating a collection of micrococci, from a case of erysipelas. The preparations were drawn under a j^s-in. oil- immersion lens. X 1000 diams. Several difi"erent bacteria are pyogenic, e.g. streptococcus pyo- genes, staphylococcus pyogenes aureus, diplococcus pneumoniae, INFECTIVE INFLAMMATION. 67 gonococcus, bacterium coli, etc. The first two are the most commonly met with in pus. The streptococcus pyogenes as it occurs in ordinary acute abscesses is indistinguishable from the streptococcus erysipelatis in its morphological and biological properties. It is thus doubtful whether erysipelas is more than a special phase of the same infection that gives rise to cellulitis, etc. Pyogenic organisms are frequently accompanied by the ordinary putrefactive or other bacteria, such as the bacillus which gives a blue or green colour to the matter in some abscesses. Diseases caused by Streptococci. Cutaneous Erysipelas com- monly starts from a small scratch or abrasion of the skin or mucous membrane, occasionally in a wound or ulcer that has been suppurating for some days, and frequently in chronic syphilitic lesions. Sometimes it begins in apparently sound skin. The rash begins as a bright red discoloration of a patch of skin bounded by a definite margin slightly raised from oedema, which is most marked in lax tissues such as the eye- lids. The patch extends by advance of the margin, so that it may cover an extensive area of skin and extend to mucous membranes. Vesicles may form at first with clear then with turbid contents. There is smarting and burning pain. The corresponding lymphatic vessels and glands become tender. In children the skin may undergo necrosis. There is marked fever with chills, and sometimes a rigor. Headache, nausea with disturbed digestion, and in bad cases delirium are also among the general symptoms. The disease lasts from a few days to two or three weeks, and may relapse. During recover}'- the colour fades, the cuticle desquamates, and the hairs fall out of- the area affected. In new-born infants the disease often starts at the navel and involves the whole body, and is usually fatal. Sections of the skin at the advancing margin show the lymphatic vessels to be crowded with streptococci. In the central part of the area the tissues are crowded with leucocytes, but there are no micrococci. Gellulo-cutaneous Erysipelas begins in the same conditions as cutaneous erysipelaSj but is marked by a greater amount of 68 SURGICAL PATHOLOGY. oedema, causing the aflfected skin to be at first puffy and, later, tense. Vesications may appear. The condition may begin to subside at the end of the first week, or diffuse suppuration and sloughing of the subcutaneous tissue and general infection may result. The general symptoms are the same as those of cutaneous erysipelas. The microscope shows that streptococci are present in all parts of the affected area, and are not confined to the advancing edge as in cutaneous erysipelas. Cellular Erysipelas or Cellulitis is due to the inoculation of the subcutaneous tissue, as in septic wounds, or from punctures such as the stings of insects. The condition differs from cellulo- cutaneous erysipelas only in that the tissue affected is more lax, the suppurative effusion being more free to travel, and the corium being only secondarily affected, so that the redden- ing of the skin is not so marked as it is in erysipelas, where the corium is primarily invaded by streptococci. The general condition of the patient is the same as in other streptococcic inflammations. Sloughing, pysemia, etc., are common events. Paronychia or Whitlow is a phase of streptococcic cellulitis of the skin at the side of the nail. The suppuration may be limited to a small area, matter collecting beneath the thick epidermis or the nail (sub-epithelial whitlow); or it may extend more widely in the subcutaneous tissue of the finger (sub- cutaneous whitlow) ; or it may extend to the periosteum of the terminal phalanx, causing the intense throbbing pain which is due to the tension caused by inflammatory exudation taking place in an inelastic tissue (periosteal whitlow). The suppura- tion may extend to the synovial cavity of the sheath of the flexor tendons, causing thecal abscess, which in the case of the thumb and little finger is likely to extend to the palmar bursa. Some Diseases due to Staphylococci. — Boils, A boil begins as a small red papule formed round the root of a hair with itching and smarting. The papule increases in size, and its base extends into the subcutaneous tissue, causing much throbbing pain. The boil may abort at this stage, in which case it is termed blind. More usually a vesicle forms on its apex. The vesicle becomes a pustule, and suppuration extends INFECTIVE INFLAMMATION. 69 to the whole of the affected part, which includes the entire thickness of the corium with some of the subcutaneous tissue. The pustule ruptures, exposing a slough which becomes detached, leaving a small cavity which heals and leaves a scar. The neighbouring lymphatic glands are swollen, but rarely suppurate. Fresh boils are apt to appear owing to local infection from the original lesion. Carbuncle. This lesion begins as a raised flat or slightly conical inflamed area of skin with a clearly defined border. The lesion varies in extent from that of a halfpenny piece to that of the palm. There is much burning and throbbing pain as the infiltration extends from the corium to the subcutaneous tissue and the swelling increases in size. The colour becomes purplish, and vesicles which are converted to pustules form and open, the discharging orifices, revealing a tough slough of skin and subcutaneous tissue which slowly separates. Car- buncles are commonest on the thick skin at the back of the neck and trunk. There is fever with depression, and fatal general infection is not an uncommon event, especially in diabetic subjects who are prone to this aff'ection. Contagious Impetigo is one of the commonest staphylococcic infections. Small superficial pustules form between the layers of the epidermis often at the site of punctures of the pediculits capitis in unhealthy children. Scabs are formed by the rupture of the pustules. Secondary inflammation of glands, accompanied by slight fever, is common ; secondary glandular abscesses are not uncommon. Other Suppurative Affections. The Pneumococcus (diplococcus of Frankel), the micro-organism which is the immediate cause of acute pneumonia, pleurisy, etc., sometimes determines acute suppuration in the middle ear, and also purulent meningitis, but in neither of these conditions is it as commonly the casual agent as is the staphy- lococcus or streptococcus. Pneumococci sometimes cause ulcerative endocarditis, which will be discussed farther under Septicaemia. 70 . SURGICAL PATHOLOGY. Gonorrhoea. The organism which causes the purulent dis- charge of gonorrhoea is a diplococcus which is found in clusters in the leucocytes and epithelial cells of the discharge, as well as free in the liquid portion of the discharge. Non-pathogenic diplococci exist in the normal urethra, but clusters of paired cocci within leucocytes and epithelial cells are characteristic of the gonococcus, which moreover is decolorized by Gram's method of staining. An attack of gonorrhoea in the male urethra if left to itself lasts about seven weeks if no com- plications arise. For two or three days after infection there are no symptoms, then for another day or two a little itching and slight excess of mucus is noticed about the meatus urinarius. The acute inflammatory stage follows, and lasts two weeks or so. It is marked by a profuse discharge accompanied by pain and swelling in the urethra, first at the anterior part, and extending afterwards to the bulbous part. Sometimes the prostatic portion becomes involved, deep-seated pain and frequent painful micturition being the result. There is usually a certain amount of fever and general disturbance during this stage, which passes gradually into the third or subacute stage in which the pain and discharge gradually diminish, and in favourable cases cease in about the seventh week from infection. Septic Intoxication, due to the absorption of the poisonous products of bacteria from wounds or cavities such as the peritoneum, only differs from the effects of infection in the mode of entry of the poison into the blood and not in the nature of the poison, so that there is no reason why the symptoms of septic intoxication should differ essentially from those of septic infection. The term aade septic intoxication used to be reserved for a group of cases in which dangerous and usually rapidly fatal symptoms supervened about the third or fourth day after a surgical operation. High fever, flushed, hot skin, dry, brown tongue, vomiting, delirium, dyspnoea, and death, were among the symptoms, and doubtless by the time death occurred septic infection had in manj'' cases super- vened. Such cases have been all but abolished by antiseptics; they may still occur from neglected wounds or septic processes in the peritoneum. This is the only condition which is known INFECTIVE INFLAMMATION. 71 .clinically as acute septic intoxication. Septic intoxication, in the broader sense of the word, occurs in every acute local suppuration, and a variety of other conditions. For instance, the fever and disturbance observed in a case of a local abscess, or of tonsillitis, etc., is due to the absorption of septic products into the lymphatics, and so into the blood. General Septic Infection or Acute Septicsemia. A severe rigor marks the onset of fever, and is followed by the symptoms already enumerated under the head of acute septic intoxication. Death may occur in a day or two, usually before a week. After death, besides the changes usual in fever, small hsemorrhages (petechise) are found on the serous membranes, sometimes on the skin and in the substance of the solid organs ; and intense broncho-pneumonic changes in the lungs. Bacterio- logical and microscopic examination generally shows streptococci or staphylococci in the blood, and blocking of the capillaries and the small veins with micrococci at the seat of the small haemorrhages. Pyaemia, originally signifying a disease due to the entry of pus into the blood, designates a phase of general septic infection of less virulence than that which leads to acute septicsemia as just described. The pyococci are distributed by the blood- stream (embolic distribution), which they enter via veins or lymphatics, but the duration of the disease allows time for the formation of abscesses at the points where they lodge. If there is an external suppurating wound, the condition which suggested the original idea of pus-infection is present. Since the exact nature of the infection has been known, the number of conditions which are classed under the head of pyaemia has been extended. Ulcerative endocarditis has been termed internal pysemia. Here pyococci are present on the lesions in the heart, and are in the position which renders their embolic distribution most easy. The Symptoms of Pycemia. The infection of the blood is marked by a rigor which is generally repeated at intervals as new abscesses develop. There is continued fever, which is intensified as each rigor occurs, giving rise to a characteristic temperature chart. Sweating, wasting of muscles, pallor, diges- 72 SURGICAL PATHOLOGY. tive disturbance, and other common effects of fever follow. There is frequently delirium at night, and the heart's action is accelerated. In a few days after the initial rigor, evidence of abscess formation in the joints, subcutaneous tissue, etc., is generally forthcoming. The distribution of these abscesses, which are termed " second- ary" or metastatic, is not difficult to follow. Since the organisms enter as a rule by the lymphatics or veins, they pass to the right heart and thence to the lungs, where many of them are arrested in the pulmonary capillaries, setting up intense in- flammation and suppuration in the lobules in which they are arrested. Thus lobular or broncho-pneumonia is usually a pro- nounced feature in cases of pyaemia, just as it is in the more rapid infection, septicaemia. If the febrile condition or the presence of micro-organisms should cause clotting in the blood of the right heart, and fragments of this clot lodge in the branches of the pulmonary artery, the circulation ceases in the areas to which the occluded branches are distributed, because these branches form only capillary anastomoses, and the blood-pressure being removed from the branches of the occluded artery, blood flows into the area from the neighbouring capillaries until an equilibrium is attained; blood-stasis, and then, from the breaking down of the capillary walls, blood- extravasation follow. This is a hcBmmrhagic infarct, and from the presence of micro-organisms it is soon converted into an abscess. Such abscesses frequently open into the pleural cavities, and there cause suppuration (empysema). Many of the pyococci find their way by the pulmonary veins to the left side of the heart, whence they are distributed to all parts of the body. After the lungs the most common situa- tions for secondary suppuration are the joints, serous cavities like the pericardium and peritoneum, liver, kidneys, spleen, subcutaneous and intermuscular areolar tissue ; but no vascular part of the body is exempt. In the corium, patches of reddening (erythema) called "wandering erysipelas" may form and disappear. Streptococci and staphylococci are commonly the cause of the affection, but the other pyogenic organisms are capable, though to a slighter extent, of giving rise to secondary abscesses. Thus INFECTIVE INFLAMMATION. 73 after gonorrhcea has lasted for some three weeks or a month in the urethra, one or two large joints, especially the knee, or a fascia, may become painful and surrounded by oedema. This condition is termed gonorrhoeal rheumatism. Sometimes the oedema (serous effusion) is followed by suppuration within the joint, constituting gonorrhoeal pygemia. This pus contains gonococci. The general resemblance of ordinary pyaemia to acute rheu- matism is striking. Fever, sweating, affections of the joints, subcutaneous tissue, and skin, occur in both, only in rheumatism the effusions are serous without any tendency to become puru- lent, in pyaemia they are purulent from the first. In general gonorrhoeal infection as shown above, the affection may assume at first a serous, afterwards a purulent form. The general indications for treatment in suppurative conditions may be briefly referred to. The supreme importance of preventive, i.e. antiseptic, measures has already been dwelt upon. The value of drainage, irrigation, and continuous baths, where local sup puration has occurred, has also been mentioned. These measures act by removing toxic materials and in relieving tension, and so allowing healthy protecting granulations to form. Granu- lation tissue, consisting as it docs of rapidly-multiplying cells and blood-vessels, is a tissue of considerable vitality. From its possessing no lymphatic vessels it has but little absorbent power. In the treatment of ulcers and other suppurating surfaces, the application should be of sufficient antiseptic power to repress bacterial growth and yet so mild that the growth of granulations is not interfered with. Thus, for ordinary chronic ulcers, an ointment made by dissolving carbolic acid crystals in a little olive oil, and mixing this solution well with vaseline, so that an ointment of 1 in 40 is obtained, is suffi- ciently strong. When general infection has occurred, the patient's strength must, as far as possible, be kept up by plenty of air, nourishing and stimulating liquid food, as well as by drainage of abscesses, etc., wherever they may form. Iron appears to be of value in many cases of erysipelas. In bad cases anti- streptococcic serum may be tried. Watson Cheyne^ has used ^ Practitioner, April, 1895. 74 SURGICAL PATHOLOGY. it as a prophylactic before severe operations on the mouth and pharynx. Other Infective Diseases. Malignant pustule due to infection of the skin by anthrax bacilli has already been described (p. 63); it is important for diagnosis to examine the exudation in the vesicles of a suspected case for bacilli, by making and staining a cover-glass preparation. The large size (5 to 10 x 1 to 1*5 /x) of the bacilli and their square or concave ends, together with their immobility, are characteristic and serve to distinguish them from the thinner, round-ended, motile bacilli of malignant oedema. Infection by anthrax occurs in the lungs (woolsorter's disease) and in the intestine as well as in the skin. Tetanus is caused by a slender rod-shaped bacillus which occurs in garden earth, manure, etc. It forms terminal spores which give the sporing bacillus a drum-stick form. In persons suffering from wounds infected by the bacillus it has been found in the discharge and in the tissues in the immediate vicinity of the wound, but as yet not in the central nervous system or in the body generally. Tetanus has been found to follow contusions and other injuries which do not entail a breach of the integument. In some cases of tetanus no injury of any kind has been observed. These cases are called idiopathic, but since the infection of tetanus has been found in so slight a lesion as an acne pustule, it is easy to overlook such a source of infection, and thus it is probable that idiopathic is due to the same cause as traumatic tetanus. Cultures of the bacillus can only be made in the absence of free oxygen, for the organism is anaerobic. The culture contains a poison, tetano-toxin, which, when freed from bacilli and injected into an animal, produces the symptoms of the disease. The symptoms set in from the fourth to the tenth day after infection, which is generally received in a septic wound or the breach of surface left at the umbilicus by separation of the Cord in infants. The spasm like the contraction of rigor mortis begins in the muscles of mastication, whence the common name for the disease, "lock-jaw." Thence the spasm spreads to the face, trunk, and limbs, and differs from that caused by strychnia in that the continuous spasm is more severe whilst the paroxysmal INFECTIVE INFLAMMATION. 75 increase of spasm is, perhaps, not so marked. There is pain from the violent muscular contractions, sweating, and generally fever ; acute cases end fatally within four or five days. If the patient survives the tenth day there is some chance of recovery. An antitoxic serum obtained from horses and other animals rendered proof against the disease by gradually increased doses of pure culture of the bacillus has been found to neutralize tetano- toxin when added to it outside the body, and in a few cases the same serum has seemed to influence cases of tetanus for good when injected under the skin of persons suflfering from the disease. From a practical point of view the important reflection is that vigorous antisepsis is the best preventive of the disease. It has indeed been found that apart from other organisms, e.g. pyococci, pure cultures of the bacillus have little eff'ect when introduced under the skin of animals. Diphtheria. The membrane characteristic of this disease is formed of coagulated fibrinous exudation infiltrated by leucocytes, and of the necrosed superficial layers of cells belonging to the surface on which it has formed. The specific bacilli are found in the superficial part of the membrane, whilst strepto- cocci are generally present in the deeper part. After tracheotomy has been performed for diphtheria it is often observed that the membrane spreads from the larynx and covers the surface of the wound. Occasionally a wound of the skin becomes the original seat of diphtheritic infection. Doubtless many of the cases described as diphtheria of wounds before the exact nature of the affection was made clear were only sloughy wounds, but in some cases of wound-diphtheria a typical attack of diphtheritic paralysis follows the appearance of membrane in the wound, and proves the nature of the aff'ection. Diphtheria in wounds yields readily to strong antiseptics. For diagnosis, examination of cover-glass preparations and of cultures made on boiled white of egg or other suitable media is helpful. The liquid filtrate from cultures of diphtheria bacilli contains a toxalbumin which, injected into animals, reproduces the general symptoms of the disease. The blood of horses and other animals rendered proof against this poison by repeated injections of 76 SURGICAL PATHOLOGY. gradually increasing doses furnishes the antitoxic serum which, though it cannot be said to be curative, in many cases has been found to ameliorate the condition of the patient and help towards recovery. Emphysematous or Spreading G-angrene begins in a wound very soon (second or third day) after its infliction. There is pain and swelling in the wound, around which the skin becomes first red then purple, and finally black, with bubbles of stinking gas in the meshes of the tissues which have undergone necrosis or gangrene. The inflammation and necrosis spread rapidly, so that a whole limb may soon become gangrenous. Speedy amputation gives the only chance of recovery, and after amputation the process usually recommences in the stump. The cause is a bacillus which occurs naturally in earth. It is motile and gives out a putrid smell and forms gas bubbles. It is distinguished from anthrax bacilli by having rounded or pointed ends and possessing flagella, whence its motility. Malignant oedema is due to a bacillus which closely resembles the foregoing both in appearance and in pathological effects. Hydrophohia or Rabies is an infective disease usually acquired by the bite of an animal. It follows in about 16 per cent, of bites received from dogs suffering from the disease. When the bite is made through clothing the risk of infection is not so great as when a naked part receives the injury. Clinically the chief features of the disease are: (1) A remarkably long period of incubation, usually about six weeks, but some- times longer. (2) A premonitory stage of two or three days, attended by chills, mental depression, and irritability with exaggerated reflexes. Final stage — (3) repeated violent reflex spasms of the muscles of respiration and deglutition. The spasms are started by noises, lights, etc., or by attempting to drink. There is a condition of extreme mental tension. There is an excessive secretion of viscid saliva. Occasionally in man and dogs, and usually in rabbits, the disease assumes the form of an ascending paralysis. Dogs may be suspected of rabies when they show a marked change of temper, a sullen and unobservant bearing, an unusual snappish- ness, especially to other dogs, an alteration in the tone of the INFECTIVE INFLAMMATION. 77 voice, and a tendency to eat their own dung and other filth. The addition of a flow of viscid saliva, a dropping of the lower jaw, an inability to swallow, and repeated paroxysms of excite- ment with snappishness, makes the diagnosis certain. The pathological changes are most marked in the medulla, where, though little is visible to the naked eye, the microscope shows changes due to acute inflammation : ante-mortem thrombosis in the small blood-vessels, and extravasation of leucocytes around them. There is also inflammatory infiltration of the salivary glands. The virus has not been isolated. Pasteur found that it is present in the spinal cord of animals that have died of the disease; and, further, that by drying such spinal cords under a bell-jar containing caustic potash the virus is attenuated and, after a fortnight or so, destroyed. By injecting triturations of dried cords of gradually increasing potency under the skin he rendered dogs immune to the disease, and by applying the same principle to human subjects who had been bitten by mad dogs he considerably diminished the rate of mortality. The treatment should be begun as soon as possible after the bite. If delayed after a fortnight it appears to have little efi"ect. Glanders occurs both as an acute and as a chronic afiection in man and animals, and so constitutes a link between the acute infective diseases and the chronic or infective granulomata. In acute glanders malaise, headache, pains in the limbs, and diarrhoea are succeeded by an eruption of papules, which become flat vesicles and then pustules. Abscesses form in the muscles 3,nd subcutaneous tissues. Inflammation in the mucous mem- brane of the nasal fossee, accompanied by swelling of lymphatic glands and vessels, usually follows, and the death occurs in the second or third week from extension to the lungs. In man the disease is usually acute, and is often mistaken for typhoid or rheumatism. The post-mortem appearances are very like those of pysemia. Chronic Glanders is marked by the formation of indolent ulcers with indurated edges like tertiary syphilitic lesions. The hands and face are common sites. The joints may be affected, giving rise to abscesses and fistulse. The nasal fossae may suff"er, ulcers forming in them. Cough, with sanguineous expectoration and 78 SURGICAL PATHOLOGY. hoarseness, may occur and are apt to be mistaken for syphilis. In horses the lymphatic vessels and glands of the head and neck, groin and axillae, swell, become indurated and, frequently, ulcerate. Half the cases recover in about four months, the average duration of the disease. Diagnosis is best established by inoculating a guinea-pig, in which animal a local nodule forms and suppurates : glands then swell, and internal metastases- form. Cultures are successful only at incubation-temperature. Stained with alkaline methyl blue or carbolic methyl blue, bacilli as long as. and a little wider than those of tubercle are found. Chronic glanders, which is also called Farcy, is the form the disease usually takes in horses. The Infective Granulomata. This is the name given by Virchow to a group of infective diseases characterized by chronic inflammatory processes which lead to the formation of granulation tissue, and often tumour- like swellings. The group includes tubercle, leprosy, actino- mycosis, and syphilis. Tuberculosis is a disease widespread among birds and animals It is due to the bacillus discovered by E,. Koch in 1880. The tubercle bacillus is a slightly curved rod about 4 /a (a little more than one-half the diameter of a red blood-corpuscle) in length. It is difiicult to stain, and grows slowly on suitable media at warm temperatures. The commonest anatomical element produced by the growth of the bacilli in the tissues is familiar as the grey miliary tubercle seen in general tuberculosis. Each such element or lesion ( = injury) comprises several "giant- celled systems." The bacilli enter the body in inhaled dust, in unboiled milk from tubercular cows, and by inoculation in openings in the skin, accidental or due to pediculi, or in abrasions, etc., of mucous membranes. Thus tuberculosis of the lungs, intestine, and skin is common. From the surface of the skin, etc., the bacilli pass along the lymphatics to the lymphatic glands, where tubercle is one of the most common affections. THE INFECTIVE GRANULOMATA. 79 From the lymphatic glands the bacilli frequently pass to the large veins, and thence to the heart, thence again to the lungs; such as are not arrested there return to the left heart to be distributed to any vascular parts of the body. If sufficient niimbers of bacilli enter the circulation, general tuberculosis is the result. If they are but few they may remain in the lungs, which are thus seen to be exposed to a second mode of infection, or pass through to be sent from the left ventricle of the heart to set up local tuberculosis in various parts of the body. Doubt- less in fairly resistant individuals many of the bacilli are destroyed by the phagocytic action of leucocytes or connective- tissue cells. In rare cases general tuberculosis is recovered from. But a local tuberculosis, which remains as the only survival of a general infection, may again become generalized by lymphatic infection, or by the escape of bacilli into a vein, the wall of which has become invaded by the micro-organisms. To follow the process of tissue-change under the influence of tubercular infection a little more closely, we may imagine a living bacillus which has penetrated between two or into one of the endothelial cells of a capillary blood-vessel. If the subject of the infection is protected, the cells destroy the bacilli, and the process ends. If protection is wanting, the bacilli multiply, growing into the connective tissue beyond the capillary. The effect of the poisonous material (tuberculin) formed by the bacilli is to cause the connective-tissue cells to enlarire and become amoeboid, surround some of the bacilli, and coalesce to greater or lesser extent, as at the beginning of the formation of granulation tissue (see p. 22). The enlarged connective- tissue cells are termed endo- or epi-thelioid on account of their size. At this stage each group of enlarged connective-tissue cells is said to constitute an epithelioid tubercle. It must be remembered that the smallest tubercular lesion visible to the naked eye, the "miliary tubercle," comprises several histological tubercles. An additional effect of the tuberculin is the attraction of leucocytes from the neighbouring blood-vessels. The leuco- cytes, which are chiefly of the uninucleated sort (lymphoid cells), collect outside the epithelioid cells, forming a zone of lymphoid cells. If the growth of bacilli is rapid, the lymphoid cells 80 SURGICAL PATHOLOGY. constitute the chief part of the lesion, in these circumstances called a lymphoid tuherde. If the irritation is only of moderate degree, the central epithelioid cells fuse together, forming a multinucleated cell-aggregate or giant cell,^ and the giant-celled tubercle is formed, which consists of the giant cell, outside this epithelioid cells, and again outside them the lymphoid cells. Bacilli are found in the giant cell and in and between the endothelial cells. 3 Fig. 22. — Section of a piece of synovial membrane, showing 1, tubercle commencing in the interior of a small vein ; 2, a tubercle with two giant cells, endotheljoid cells and leucocytes ; 3, a tubercle with necrotic centre or caseous focus resulting from disintegration of the giant cell. From the knee- joint of a middle-aged man who suffered from tuberculosis of the suprarenal capsules (Addison's disease), and one of whose knee-joints rapidly swelled. The man died of heart failure. After death a considerable quantity of fluid was found in the joint, and every part of the synovial membrane was thickened and warty from the presence of recent tubercles, x 160. The part of the giant cell in immediate contact with the bacilli undergoes necrosis, the protoplasm coagulating in fine granules. When the disease progresses, this necrotic change involves the whole of the giant cell, and afterwards the whole tubercle ; new tubercles then form from the extension of bacilli from the caseous focus into the surrounding tissues. In this way large caseous masses may be formed. ^ Giant cells are also formed by the subdivision of the nucleus of a connective-tissue cell. In sarcomata they are frequently multinucleated buds of capillaries. Giant cells occur in healthj' granulation tissue as well as in many chronic inflammatory conditions. THE INFECTIVE GRANULOMATA. 81 ■ When the growth of the bacilli is rapid, and the inflammatory reaction is the more marked, there is no time for the formation of giant cells and caseous matter, and the tubercular process then closely resembles suppuration, but is unattended with the heat and pain of an acute inflammatory process — hence the term ^^ cold abscess." Thus a gland may swell, rapidly undergo colliquative change (necrosis), and, on being incised, give exit to pus which on examination is found to contain bacilli. The earlier stages of tubercle often, and the later ones sometimes, are accompanied by the exudation of much serum. Thus at the early stage of tubercular peritonitis there may be much ascites, a condition which marks the right moment for surgical inter- ference. In joints, too, there is sometimes a considerable degree of serous eff'usion. The thin pus found in many abscesses secondary to old spinal disease may be taken as an example of serous exudation in tuberculosis of old standing. Similarly, tuberculosis of the testis and other organs may be very rapid. On the other hand, when the bacilli multiply slowly, some of the enlarged connective-tissue cells of the tubercles are free to assume their fibroblastic function, and from the parts sur- rounding the tubercles ordinary granulation tissue is formed ; hence scar-tissue is produced, which off"ers a barrier to rapid extension of the disease, and in many cases brings it to a close : the bacilli perish, and their remains, embedded in caseous material, are left surrounded by scar-tissue. The caseous material may then become calcified by the deposit of lime salts. When the reparative process is going on in bone aff'ected by tubercle, new bone may be formed. Wherever tuberculosis is going on in the body there is danger of its extension along lymphatics, or ulceration into veins, and hence of general infection, with the formation of metastatic foci of disease by embolism, just as in pyaemia, etc. Hence in any given case the surgeon has to balance the probability of a natural cure being obtained with the desirability of attempting to remove a possible source of general infection. When there is a fair balance of power between the tissue elements and the bacilli, the protecting barrier assumes the form of granulation tissue. Thus a joint may be distended with 82 SURGICAL PATHOLOGY. granulation tissue which covers the synovial' membrane and the cartilage, which is gradually removed : multiplication of the cartilage cells having loosened its structure, granulation tissue springing from synovial membrane and from the bone replaces the cartilage at first in patches and, later, entirely, unless the cells of the granulation tissue defeat the bacilli, and the process is so brought to an end before all the cartilage has disappeared. Syphilis. Syphilis is a disease caused by the introduction of a specific virus into the body. The nature of the virus is unknown. It is conveyed either by direct inoculation (acquired syphilis), or is contracted by the embryo before birth, ^ — con- genital syphilis. Acquired Syphilis. For a period of about twenty-five days after the inoculation there are no signs of the disease. This is termed the incubation period. Usually the abrasion or other slight injury through which the poison enters heals during this time, or it may be the seat of suppuration from the entry of other organisms along with the virus of syphilis. Primary Syphilis. At the end of the period of incubation, -a local thickening in the skin forms slowly at the seat of inoculation. The thickening is characterized by a definite in- duration. The surface over it may remain unbroken, a few scales only forming over a brownish red papule, but commonly an ulcer with an indurated base develops ; the primary sore also known as the hard or Hunterian Chancre. It is usually painless. As the induration at the seat of inoculation is ad- vancing, the lymphatic glands which first receive the lymph from the seat of inoculation become enlarged and hard. The ^If a woman, previously free from the disease, contracts it during pregnancy, tlie virus passes from the maternal to the fcetal blood by the placenta. More commonly the disease is transmitted to her offspring by a mother infected before conception. It is not impossible that the virus may pass with the spermatozoa, and so infect the ovum from the commencement. Colles observed that the mother of a syphilitic child never contracted a primary sore on her nipple, though she had shown no symptoms of the disease ; whilst wet nurses who had not had syphilis were frequently affected by chancres of the nipple, due to infection from the mouth of syphilitic sucklings. Thus Collet' s law is to the effeo that the mother of a syphilitic infant is inmiune to the disease. THE, INFECTIVE GRANULOMATA. 83 lymphatic vessels, which pass from the sore to the glands, may also be thickened. The sore is generally healed before the eighth week from the commencement of induration. At the margin of a primary sore the epidermis extends by elongation of its inter-papillary processes into the subjacent tissue. The latter is increased in amount by a multiplication of the con- nective-tissue and endothelial cells, and infiltration of leucocytes. Induration, which is usually a marked feature of the primary manifestation of inoculated syphilis, recalls the firm character of some cancerous and other growths. To account for it there is, besides the cell-infiltration and cell-proliferation described above, evidence of proliferation of the lining cells of lymphatic vessels. Even when the induration is limited to the tissues immediately beneath the floor of the ulcer, it is still a marked feature, and is known as "parchment induration." When once the primary lesion has formed, the individual is insusceptible to inoculation with syphilis. This, together with the induration of the syphilitic sore, serves to distinguish the true chancre (Lat. cancrum) from the chancroid or soft sore. Secondary Syphilis. This stage of the disease sets in from five to seven weeks after the commencement of induration in the primary sore. It is ushered in by slight fever, headache, and neuralgic pains, phenomena which correspond to what is termed the invasion of an ordinary exanthem such as measles, etc. The invasion marks the general infection or dissemination of the virus by the blood. To these symptoms soon follow an eruption of brownish-red spots on the trunk and the limbs, and sore throat with swelling of the tonsils, and (sometimes) of the lymphatic glands throughout the body. Some of the spots or syphilides, as the skin lesions are termed, may become raised above the surface (papules) ; on the papules scales of thickened horny epidermis often develop. The papules may become vesicles, and then change to pustules. In moist parts, as in the mouth, anus, and vulva, the papules become swollen, pale, or sodden from oedema, constituting imicous tubercles. The secondary stage may continue for eighteen months or more, different lesions appearing all the time; or the eruption may be slight and, after the first few weeks, no other symptoms 84 SURGICAL PATHOLOGY. may be observed. During this period the hair usually falls out, and the tonsils may become ulcerated ; there may be pains in the bones, and towards the end of the period, inflammation of the retina, of the internal ear, or of the iris. The secondary eruption is symmetrical, i.e. affects equally both sides of the body ; it often exhibits a variety of different anatomical lesions — polj'morphism. The great variety exhibited by syphilitic lesions often results in a close simulation of other eruptions; thus there are psoriasiform, lupoid, and other syphilides, as will be pointed out more fully under " Diseases of the Skin." In severe attacks the successive crops of secondary lesions become deeper, and the latest may undergo central necrosis and ulceration, having, in fact, the characters of gum- mata. When ulcerated secondary lesions become covered by crusts, and con- tinue to enlarge, the crusts assume the appearance of limpet-shells, and the eruption is termed rupia. In these cases the secondary gradually merge into the tertiary lesions, and leave the impression that same virus as the earlier ..S!Sj?S^ai,,-^s:i Fig. 23. — Section through the marginal part of a gumma of the subcutaneous tissue invading skin, seen under a low power. 1, Normal epidermis and papil- lary layer of corium. 2, Part of the corium showing enlargement of the nuclei of connective-tissue cells. 3, Deeper part of the corium altered by proliferation of connective-tissue cells and immigration of leucocytes. 4, Layer of granulation tissue. 5, Necrosed tissue witli thrombosed capillaries. the latter are caused by the phenomena, though the virus is so altered that in the tertiary stage the disease is, as a rule, neither contagious nor trans- mitted to offspring. Tertiary Stage.'^ After the first eighteen months or so, the 1 Though the division of the periods of syphilis into stages is convenient and in harmony with the phenomena observed, it is to be remembered that symmetrical eruptions may appear as long as a year or more after the average time (eighteen months) for the secondary period to come to an end. THE INFECTIVE GRANULOMATA. 85 secondary lesions may gradually merge into the tertiary, i.e. they tend to acquire a more destructive character, shown by ulceration, etc., and to lose their symmetrical distribution. There may, however, be no tertiary symptoms at all, or years may separate the last secondary from the first tertiary symptoms. The most characteristic anatomical lesion in tertiary syphilis is the gumma, which is a focus of inflammatory change. If the process is rapid, colliquative necrosis occurs, and the some- what sticky semi-transparent fluid from which the name " gumma " is derived is formed. The minute anatomy of rapid gummatous inflammation is shown in Fig. 23. Fig. 24. tJJ Fig. 25. Fig. 24.— Part of a liver containing a large gumma cut open. The central portion of the tumour has become cicatrized. From a child aged six years, who died from the effects of congenital syphilis. Nodular swellings were felt in the liver during life. Nat. size. Fio. 2.5.— The ulna of a child, vertical section. The shaft is greatly thickened by the formation of new bone (node) from the periosteum Nat size. Gummatous inflammation of a degree of intensity, insuflBcient to cause liquefaction of the tissues results in the formation of 86 • SURGICAL PATHOLOGY. caseous foci surrounded by granulation tissue. A still less rapid process results in tumour-like growths which are most frequently observed in soft organs like muscles or the liver (Fig. 24). When the inflammatory reaction to the virus of syphilis is least intense the process results in hyperplasia. The best examples of this are to be seen in the case of bones such as the one shown in Fig. 25. The late or tertiary symptoms of syphilis differ from those of the secondary period only in being more local. The virus appears to have left the blood and to have lodged in various parts of the body where it is capable of local extension and is amenable to local treatment. Thus, whilst the secondary lesions appear equally on the two sides of the body, the tertiary phenomena tend to be more isolated or asymmetrical. Some- times syphilis is a mild affection. The secondary stage may be very short, and there may be no tertiary lesions at all. The primary lesion may be so slight that it is overlooked. On the other hand, in individuals weakened by intemperance, etc., the disease may prove fatal, either by the supervention of lardaceous disease or by lesions of the brain or other important organs, or by the syphilitic lesions opening up a way for suppurative infection. In congenital syijhilis the early stages are passed through before birth. There is no primary stage, because infection occurs from the blood of the mother to that of the foetus, and possibly sometimes by the spermatozoa at the moment of fertilization of the ovum. The foetus is often destroyed by the disease, and abortion results. The secondary phenomena in congenital syphilis may be extremely severe and often prove fatal. Though essentially the same as the inoculated disease congenital syphilis has certain peculiarities owing to the period of life of the victims. In the bodies of new-born infants that have died of syphilis it is common to find small gummata in the liver and evidence of inflammation at the juxta-epiphyseal regions of long bones, etc. Among the early eruptions are nasal catarrh (" snuffles "), and bullous or pemphigoid syphilides : large blebs filled with pus THE INFECTIVE GRANULOMATA. 87 which form in the skin and mucous membranes. Mucous tubercles are common at the angles of the mouth (where they leave radiating fissures) and about the anus and vulva. The alteration in the shape of the second set of the upper incisor and canine teeth was first noticed by Hutchinson. These teeth may be notched, pegged, and inclined towards the middle line. This is probably the result of inflammation of the tooth-sacs at an early stage of the development of the teeth. Among the tertiary phenomena a chronic inflammation of the cornea (interstitial keratitis) is common. It results in a hazy opacity of the cornea, and if the newly formed tissue becomes vascular the opaque areas become pink (salnion patch). Pliagedcena is a rapid spreading of either a primary, secondary, or tertiary lesion accompanied by sloughing. It is due to the addition of pyogenic or other organisms to the syphilitic virus and is observed in non-syphilitic lesions also. The nature of Syphilis. If syphilis be compared with inoculated small-pox, a close analogy is apparent. On the second day after inoculation with small-pox lymph discoloration of the site of inoculation was observed, and by the fifth day inflam- matory infiltration and the formation of a vesicle occurred. This became pustular, and fever set in by the ninth day, and three or four days later the general eruption appeared. Thus there were "primary" and "secondary" stages. And farther, if a woman contracts small-pox during pregnancy abortion occurs and a dead fretus, which may be covered with a typical small-pox eruption, is produced. Here is an approach to "con- genital " small-pox. Moxon's aphorism to the effect that syphilis is specific fever "diluted by time" is very just. Second attacks of syphilis occasionally occur as in the other specific fevers. A vital question in syphilis is how soon after contracting the disease may a person marry without danger of transmitting the disease to his or her children. Though under suitable treatment a person appears as a rule to be free from symptoms six months after the appearance of the primary sore, Hutchin- son's rule {Syphilis, 1887, p. 494) is that two full years should elapse between the beginning of the disease and marriage, 88 SURGICAL PATHOLOGY. and that the patient should be under treatment the whole of this time.^ The good eflfect of mercury on eavly and iodide of potassium on late syphilis is rery striking. Soft Chancre or Chancroid. This is an ulcer due to a local infective inflammation which is marked bj^ profuse suppuration. It commences in a small excoriation caused by coitus. A small pustule forms and ruptures, so that in from three to five days the commencement of the ulcer is present. The ulcer is usually round in form, the edge is well-defined, its floor is uneven, and is covered with a grey sloughy coat ; beyond the edge there is an areola bright red in colour; this is due to an inflammatory infiltration, which also causes a slight induration which fades off into the surrounding tissues and is not sharply defined as is the primary syphilitic sore. The discharge is purulent. If the discharge is pent up beneath a tight foreskin, more widespread sloughing may occur. Occasionally the ulcer may spread rapidly and widely with much sloughing, becoming " phagedsenic " as it is termed. Soft sores are frequently followed by suppuration in the inguinal glands. The exact nature of the virus is not known. It diflfers from that of syphilis. The virus can be inoculated in the aflfected person and thus differs from that of syphilis, but it is to be remem- bered that the infection may be a double one, and what begins as a chancroid may after two or three weeks become a chancre. Actinomycosis is due to the growth of a fungus which assumes in cultures the form of jointed branched filaments. Such forms are usually classed with the bacteria in a group 1 The impress of syphilis on the offspring may be transmitted during a much longer period. Thus in a boy aged ten years, brought to hospital for pain and swelling in a knee-joint, I foimd a node on the corresponding tibia and radiating fissures at the angles of the mouth — positive signs of syphilis. The mother said she had " as good as" twelve children. The first born dead, the second and third died at the age of three months — one of "wasting," another of "swellings of bones and joints" — the fourth died at nine months, the patient was the fifth, the sixth, seventh, and eighth were living but had "snuffled" in infancy, ninth and tenth miscarried, eleventh and twelfth were ali^'e and healthy. THE INFECTIVE GRAND LOMATA. 89 termed cladotrichese, from the club-like termination of some of the filaments. When growing parasitically in living tissues the clubbed ends of the filaments radiate from a common centre, forming a globular mass which in section has a radiated appear- ance, whence the name actinomyces (ray-fungus) of the parasite. The most common situation for the infection is on the tongue of calves. It is probably acquired from wheat and straw. In man it is met with in the jaw-bone (into which it finds its way through a hollow tooth), in the intestine and liver, and also in the skin either primarily or by extension. It forms indolent inflammatory tissue like that caused by tubercle. On the skin raised red nodules very like some forms of tubercular lesions are observed. They tend to soften centrally and to ulcerate. The diagnosis is made certain by the examination of a scraping under a moderately high power of the microscope (see Fig. 21, 4). The administration of iodide of potassium has sometimes almost as marked an influence on actinomycosis as in late syphilis. The action is probably due to the drug altering the tissue cells or the fungus in such a way as to increase the power of the phagocytes in relation to the parasite. Madura foot w Mycetoma, a disease met with in India and North Africa, is caused by a fungus which somewhat resembles actinomyces. The disease manifests itself by swelling of a hand or foot. Raised nodules appear in the skin and ulcerate, leaving suppurating apertures which communicate with large cavities in the soft tissues and the bones. These cavities are lined with granulation tissue containing pellets of the size of hemp-seed, composed of agglomerations of the fungus of which there are two varieties, one having a yellow the other a black colour. The disease is slowly progressive, and usually requires amputation. Leprosy is a disease marked by a long period of in- cubation. This is always over two, and sometimes as long as ten years. A prodromal period follows, and is marked by slight illness, languor, headache, etc. At the end of this time there is a marked increase in the evidence of infection. This is termed the period of invasion. High fever with pains in the back and limbs characterize this period of the affection, 90 SURGICAL PATHOLOGY. and have caused it to be mistaken for rheumatism. Some weeks or months after the commencement of invasion successive crops of red and slightly raised spots and patches appear on the face, trunk, and limbs. Sensation may be lost over the areas covered by the spots. The later phenomena of leprosy ma}' affect the skin more pronouncedly than the other parts of the body, inflammatory nodules forming in the skin of the face, limbs, etc., and in the mucous membranes. It is then termed shin leprosy; or the eff'ects of the disease may show- principally by the formation of nodular enlargements of the large nerve trunks ; in this case it is termed nerve leprosy. The result of leprous inflammation of nerve is pain and muscular paralysis together with inflammatory changes in the skin and wasting in the muscles supplied by the aff'ected nerve. In other cases, termed mixed leprosy, the skin and nerve trunks sufi'er equally. A section made through a leprous nodule of the skin and stained with carbol-fuchsin, decolorized and restained with methyl blue, shows the corium and more or less of the sub- cutaneous tissue to be crowded with bacilli which resemble those of tubercle save in that they stain much more readily. The bacilli lie for the most part in round or oval clumps, and careful examination shows that many of the larger or epithelioid cells of the inflammatory or granulation tissue in which they lie are packed with bacilli, and that the clumps of bacilli are formed within cells which afterwards undergo disintegration. In other words, the phagocytes are for the most part incapable of destroying the bacilli of leprosy. Examination of the body of a person who has died of leprosy reveals the fact that organs such as the liver, testes, etc., are crowded with bacilli lying in inflammatory foci. The thickenings in nerves aff'ected by leprosy also contain bacilli in inflammatory tissue. Leprosy nodules difi'er from those of tubercle and syphilis in showing no tendency to undergo caseation. That the bacillus is the cause of the disease is highly probable, but it is hard to cultivate, and no animal has yet been found to be susceptible to leprosy ; therefore the causal relationship of bacillus .to the disease has not been proved by inoculation of pure cultures. . CHAPTER V. NEW GEOWTHS. A NEW growth^ or neoplasm is a formation of tissue that subserves no physiological function and obeys no physiological control. A fatty tumour (lipoma), such as is commonly seen in the subcutaneous tissue, may be taken as a familiar example of a simple new growth. It consists of cells similar to normal fat cells, and is surrounded by a thin capsule of fibrous tissue, which at one point is perforated by the blood-vessels of the growth. The chief feature which distinguishes it from normal fat is its coarsely lobulated form. Its independence of physio- logical control is seen when the person in whom it occurs becomes thin from illness or otherwise. The fatty growth remains undiminished in size, whilst the rest of the fat of the body is being absorbed. This independence of physiological control is a marked feature in new growths. A lipoma does not affect surrounding tissues, except by the pressure it exerts upon them, nor does it give rise to other similar growths in its neighbourhood or in distant parts of the body. In other words, it is an innocent growth. The innocent tumours are also termed " histioid " (Gr. histos = warp, web), because they resemble in structure certain fully differentiated normal tissues of the body, e.g. fat, fibrous tissue, etc. ^ The word "tumour," which, strictly speaking, means nothing more definite than a swelling, has been applied to a number of conditions such as cysts, and errors of development, such as spina bifida, etc. , so that it seemed better to use the term " new growths " as the title for the present chapter. 92 SURGICAL PATHOLOGY. The ne\r growths which in their habits most closely resemble the infective grannlomata are the sarcomata and carcinomata. They differ from the innocent growths in that they infiltrate and destroy the tissues around them, and tend to form secondary growths in different parts of the body. Take for example a cancer of the tongue. If left to itself the growth invades the tissue of the tongue, and, when it comes to the surface, forms ulcers by its older parts breaking down from necrosis. By and by the glands which receive lymph from the tongue enlarge, and cancerous tissue exactly resembling the original growth in the tongue forms in them, and the same process of infiltration of surrounding tissues takes place around the cancerous glands as in the tongue itself. Thus, from invasion of the skin, cancerous ulcers may form under the jaw and at the sides of the neck. Finally, if the patient escapes death from septic broncho-pneu- monia, other secondary growths may form in distant parts of the body. The dissemination of a sarcoma by secondary growths is similar to that observed in cancer, save that in the case of sarcoma the infective material is conveyed by veins more readily than by lymphatics, the reverse holding good for cancer. Thus cancer and sarcoma are malignant growths, and since in some particulars they resemble the infective granulomata, their chief characters may be considered a little more in detail. The sarcomata resemble inflammatory growths, such as syphilitic gummata, more closely than do the cancers, because the cells of sarcomata are of connective-tissue type, whereas the pre- dominating element in cancers is epithelial. The Sarcomata. These growths present a wide range of structure, and a correspondingly wide range of rapidity of growth and destructive power. Their common character is malignancy. The characters that are designated by this term will be made clear in the following description of sarcoma. The cells of some sarcomata (melanotic sarcomata — Gr. meJas = \>\dick) are filled with granules of brown or black pigment. In such growths the pigmentation of the cells renders it an easy matter to follow in unstained sections under the microscope the first essential feature of malignancy, namely, the property of infiltrating and destro3'ing the neighbouring normal tissues. As an example, a NEW GROWTHS. 93 melanotic sarcoma of the choroid coat of the eye may be taken. The choroid contains normally many pigmented connective-tissue cells, and the cells of the sarcoma may be regarded as being of the same descent as the normal cells of the part. If a section of such a growth is made where it abuts on the fibrous sclerotic coat of the eye, the manner in which the pigmented cells infiltrate the fibres of the healthy tissue is readily seen (Fig. 26). «^^/r,^;»/,^ Fig. 26. — A section of a melanotic sarcoma of the choroid with part of the sclerotic. 1, Pigmented sarcoma cells which, at 2, have forced their way between the fibrous bundles of the sclerotic. 3, Normal sclerotic. The pig- ment obscures the nuclei of the cells of the sarcoma, x 200. In this case of melanotic sarcoma it would appear that the cells which infiltrate and destroy the neighbouring tissues are derived from the original cells of the tumour. If, however, such a section is bleached and then stained in the usual way, the margin of the growth may show, besides the large cells of the growth, a number of leucocytes and connective-tissue cells similar to those seen in inflammatory conditions. The close relation that exists between veins and sarcomata 94 SURGICAL PATHOLOGY. is Sometimes evidenced by the presence in large veins of ingrowths which project, often for a considerable distance, into the lumen of the vessel. In this way the inferior vena cava, in the whole of its . course, has been found to be occupied by a plug of sarcoma. In persons who have died of melanotic sarcoma pigmented cells have been found in the blood-vessels of the lungs and other organs, having been conveyed along the veins from a distant growth. Haemorrhage is a frequent accident in sarcoma, and depends on the tendency of the sarcoma cells to replace those of the blood- vessel (see Fig. 27). Fia. 27.— Section of an alveolar sarcoma of the breast. 1 and 2, Parts of a capillary which has been ruptured. 3, A space containing- red and white blood cells which have escaped from the capillary. 4, A projection of sar- coma cells capped by fibrin towards the space (3). x 200. If, as according to present knowledge is believed, it is the .cells of the sarcoma that constitute the infection, there is an evident difference between the infiltration of a tissue by sarcoma and of an inflammatory formation such as tubercle. In the lattfer it is the bacilli and their products which, by acting on the connective-tissue cells and blood-vessels of the invaded tissue, NEW GROWTHS. 95 produce the lesions. Though in infective inflanamatory lesions wandering leucocytes and connective-tissue cells invade neigh- bouring tissues, it is not these cells but the infective organisms which cause the spread of inflammation. It must be confessed, however, that when the margin of a sarcoma is examined under a high power, it is often impossible to say that some of the Fig 28 — A section of a maiginal put of a cancer of the colon 1, Junction of the normal and the proliferating epithelium. 2, Muscularis mucosse. 3, The cancerous down-growth piercing the muscularis mucosas. There is small- celled inflammatory infiltration in various parts of the section. Near the edge of the growth (1) the adjoining mucous membrane is hyperplastic. The sub- mucous tissue is everywhere infiltrated by tubular cancerous growth, x 30. connective-tissue cells of the invaded part are not converted into sarcoma cells. The difference between the mode of extension of the infective granulomata and malignant growths is more easily made out in cancers than in sarcomas. Cancer. In malignant epithelial growths or cancers the in- filtration of surrounding structures is more easily traced because the invading tissue is epithelial. This can be well 96 SURGICAL PATHOLOGY. seen at the edge of a cancerous growth on the surface of the skin or some mucous membrane. In Fig. 28, which repre- sents a section made through the edge of a cancer of the large intestine, the normal mucous membrane is seen on the left, the cancerous on the right of the figure. The tubular glands, on becoming cancerous, grow unrestrainedly, pass through the basement membrane, and, continuing to ramify, infiltrate the deeper tissues by irregular branching processes. Whilst retain- ing the general characters of the original epithelium, that that has undergone the cancerous change is marked by a less definite arrangement of the cells, which are in parts two and three deep instead of lining the tubules in an even single layer as in the normal state. The individual cells also have larger and more active nuclei, and their protoplasm stains more deeply than is the case in the normal cells. In the connective tissue in the neighbourhood of the cancerous growth, evidences of inflammatory changes are present in the form of collections of leucocytes and proliferation of connective-tissue cells. Thus in the sarcoma probably, and in cancer almost certainly, there is an element not present in the infective granulomata, e.g. tubercle. It may be repeated that it is only necessary for tubercle bacilli or other organisms to pass from one part to another to produce secondary lesions. In cancer, however, and in sarcoma, it appears to be necessary for some of the cells of the malignant growth to be transferred from the primary seat of disease to some other part before a secondary growth can arise. It would thus, according to present knowledge, appear that for the dissemination of malignant growth a transplantation of tissue cells is required, whilst in infective inflammation transplantation of virus is all that is necessary to produce the same eff"ect. The growths secondary to a melanotic sarcoma, for instaiice, possess the same peculiarities of cell and pigment as does the primary growth. In cancer the likeness of the secondary to the primary growth is still more striking. Thus a nodule of cancer in the liver, secondary to a cancer of the intestine, had broadly the same characters as the primary growth. In the same way a cancer in NEW GROWTHS. 97 bone s'econdary, say, to a growth in the breast is similar in character to the original growth. Resemblances between Malignant Growths and the Infective Granu- lomata. At the margin of a cancerous surface, the conversion of previously healthy into cancerous cells may be observed. Thus in the cancer shown in Fig. 28, more and more of the epithelium at the margin of the growth becomes involved. Again, where a cancer involving a surface of skin lies against healthy skin, as in cancer of one of the labia majora, a second cancer may form exactly opposite to the first. The gross aspect of secondary or metastatic growth, whether cancer or sarcoma, may strongly remind the observer of the infective granulomata. Thus a sarcoma of the vertebrae, secondary to a growth of some other part of the body, may present much the same appearance as the same part in tuber- cular caries. There may be absorption of one or more vertebral bodies by what might be termed "sarcomatous caries," and in- filtration of the cancellous tissue in the neighbourhood of the area of destruction. In the sarcoma, however, there will be more extensive formation of soft tissue on the periosteal aspect of the bone, and probably less extensive caseation than in a case of tuberculosis. The dissemination of sarcoma more com- monly occurs by way of the veins, but it also takes place by way of the lymphatics. In cancer lymphatic infection is the rule, and hence in cancer the likeness to tubercular infection is often very close. In many cases of tubercular ulcer of the small intestine the secondary tubercles may be seen following the course of the lymphatics beneath the serous coat of the bowel. The nearest mesenteric glands may be found to be infected, and also the whole of the peritoneum, which is studded with firm raised grey or caseous nodules. It frequently happens also in cancer of the stomach or intestine that the lymphatics and the whole of the peritoneum become studded with nodules of secondary growth. In such cases the close general resemblance of the cancerous peritoneum to cases of tubercular peritonitis has given rise to the term " cancerous peritonitis." In the pleura and the meninges a similar resem- blance between cancerous and tubercular lesions is frequently 98 SURGICAL PATHOLOGY. observed. And it may be added tbat certain sarcomatous in- filtrations present also to the naked eye a close resemblance to tubercular infiltrations. Other features common to cancer and sarcoma and inflammatory formations may be mentioned. Thus the older parts of malignant growths may undergo necrosis and caseation as do the infective granulomata. When necrosis occurs in a growth involving skin or mucous membrane ulcer- ation results. The edge of a cancerous ulcer is usually firm and raised, because the tissues beyond the edge of the ulcer are infiltrated with growth. On another point malignant growths may be compared with the infective granulomata. That is in the variations of rate of growth shown by the same kind of neoplasm in diff'erent individuals, or at different periods in the same individual. Taking the common hard cancer of the breast as an example two extremes may be noted : one of these growths ma}^ require years to attain the size of a walnut (atrophic scirrhus), whilst another cancer of the same kind may in a few months not only attain a large size, but also widely infiltrate the skin of a considerable part of the trunk (cuirass scirrhus). Slow-growing cancers present a tendency to cicatrization, as is well seen in the atrophic hard cancer of the breast. The blood-vessels of malignant growths like those of granulation tissue are derived from the tissue in which the growth arises and the tissues which it invades. Innocent Growths. The contrast between a simple fatty tumour and a sarcoma has already been made. Innocent tumours, such as lipomata, fibromata, myomata, etc., may attain a large size, and may even produce fatal symptoms by pressure on important organs. When they are superficially placed and have skin or mucous membrane stretched over them, they frequently cause ulceration by pressure, and thus open a way to pyogenic and other organisms, which may cause sloughing of the tumour, septic infection, etc. The tendency of a simple connective-tissue growth to become malignant will be noticed later. Innocent Epithelial GrovMs — Papillomata and Adenomata. The difference between the histology of an adenoma and that of a NEW GROWTHS. 99 cancer may be illustrated by comparing a cancer, such as that shown in Fig. 28, with an adenoma of the rectum as shown diagrammatically in Fig 29. _ ^^^M^^^^^ummg^ Pig. 29. —A diagram illustrating the nature of an adenoma of the rectum. 1, Normal bowel-wall. 2, 2, Muscularis mucosae which is nowhere penetrated by the epithelial proliferation which constitutes the chief part of the growth. The pedicle consists of normal mucous membrane and submucous tissue. In the adenoma, as in the cancer, there is an excessive pro- liferation of epithelial structures; but in the adenoma the latter are limited to the mucous membrane, at no point passing through the muscularis mucosce. The histological structure of the adenoma shows a slighter deviation from the character of the normal epithelium of the part than is the case in cancer. Adenomata are devoid of the special characters of cancer, that is, they do not infiltrate and destroy neighbouring tissues, nor do they form metastases. Now and again an adenoma changes its character and becomes a cancer. When an adenoma develops in the interior of a gland, such as the breast or the thyroid, the process is similar to that Avhich leads to the formation of 100 SURGICAL PATHOLOGY. adenomata of mucous surfaces. For example, the margin of a commencing adenoma of the thyroid gland may be studied as shown in Fig. 30. Papilloma. If in an area of the skin and of such mucous membranes as that of the mouth or of the urinary bladder, or in the fibrous walls of ducts fSjil of glands such as the breast, the small blood-vessels im- mediately beneath the epi- thelium may elongate and project from the surface as simple or branched pro- cesses covered by a greater or lesser thickness of epi- thelium. This constitutes a papilloma, a growth closely allied in nature to adenoma. As an illustra- tion a section of an ordin- ary cutaneous wart^ may be taken (see Fig. 31). Many papillomata are of inflammatory origin, for instance, gonorrhoeal warts. An ordinary corn has many of the features of a papil- loma. Comparing a section of a squamouscelled cancer (squamous epithelioma) with a papilloma, it is observed that in the former the most marked feature is a down-growth of the interpapillary processes of epidermis. Many of the down- growing processes contain "epithelial pearls" or "cellnests," i.e. collections of flattened horny cells arranged concentrically (see Fig. 32). A section of part of a papilloma cut obliquely ^An ordinary cutaneous papilloma is sometimes called a "hard wart," to distinguish it from the so-called soft wart, which is a kind of mole (see below) and is due to overformation of the connective-tissue cells of the corium, the epidermis being thinned. Fig. 30. — The margin of a commencing adenoma of the thyroid gland. 1, The adenoma consisting of acini, the mucous membrane of which is thrown into folds from overgrowth. 2, The adjoining normal gland-tissue. There is as yet no capsule to the growth, which was one of many similar tumours met with in a large goitre in a child. Various members of the same family were similarly affected. x200. NEW GROWTHS. 101 may very closely resemble a cancerous growth, and this fact necessitates extreme caution in basing a pathological diagnosis on the histological character of a growth. In every case the clinical characters should be carefully weighed before a diag- nosis is made. The same may be said of small-celled sarcomatous growths which closel}'' approach some inflammatory tissues. Granulation tissue will usually show formation of cicatricial tissue from fibroblasts, which will enable a practised eye to draw a distinction. Fig. 31. — Vertical sectloa through the margin of an ordinary cutaneous wart, with the adjoining part of normal skin, in which 1= horny layer; 2, granular layer ; 3, mucous layer of the epidermis ; 4, papillary layer of the corium. All these layers are exaggerated in the papilloma, and the papillse and their blood-vessels have undergone branching. x25. Malignant Metaplasia of Innocent Growths. Wherever connective tissue is present, whether in normal tissue or in neoplasms, there is a possibility of the development of sarcoma; and cancer may begin in any part where there is epithelium, whether this is in normal skin, mucous membrane, or glands, in embryonic ' rests ' such as those of the Wollfian body in the broad liga- 102 SURGICAL PATHOLOGY. ments, or the hilus of the testis, or in dermoid and other tumours. Adenomata may also undergo cancerous metaplasia. 3- FiG. 32. — Section at the margin of a squamous-celled cancer. 1, Noi-mal epidermis ; 2, normal cerium ; 3, cancerous growth consisting of epithelial processes which contain cell-nests and are supported by cellular granulation- tissue ; 4, advancing margin marked by inflammatory cell-infiltration. X 40 diams. CLASSIFICATION OF NEW GEOWTHS. Since the causation of new growths is, in most cases, unknown, the only classification available is based upon their histological structure.^ A large class of new growths are developed in tissues derived from the mesoblast of the embryo. This may be called Class I. It includes : Fibroma, Chondroma, Osteoma, Lipoma resemble normal con- nective tissues. Myxoma is a growth consisting of mucous tissues, i.e. resembling the connective tissue of the umbilical cord. ^ This was tirst taken as a basis of classification by Johannes Miiller in 1838. CLASSIFICATION OF NEW GROWTHS. 103 Angioma consists of blood-vessels with supporting connective tissue. Lymphangioma consists of lymph-vessels with supporting connective tissue. Myoma. Tumours consisting of unstriped muscle (leiomyo- mata) are common. Rhabdomyomata, or tumours con- sisting wholly of striped muscle, are rare, only occurring as congenital tumours of the heart. Transversely- striped spindle cells (young muscle cells) or striped muscle cells also occur in some sarcomata of the kidney and testis. Neuroma. This term is used somewhat loosely to designate not only growths consisting of nerve elements which are rare, but also the more common fibrous, myxo- matous, and myxosarcomatous tumours that spring from nerve trunks. Lymphoma is a term used vaguely to signify both in- flammatory and neoplastic formations of which the tissue resembles lymphoid tissue, i.e. which consists of a reticulum of cells containing lymphocytes in its meshes. Glioma is a growth resembling neuroglia. Sarcoma consists chiefly of cells which tend to multiply without producing formed elements to any marked degree. The cells resemble more or less closely those of embryonic mesoblastic tissues. Frequently in sarcoma the cells are combined with more highly differentiated connective tissues, e.g. fibro-sarcoma, glio-sarcoma, etc. Class II. A second large class is characterized by the presence of epithelial tissue as an integral part of the growth. Such are : Papilloma, Adenoma, Carcinoimi. Class III. In a third group the new growths assume the form of cysts which are lined by epithelium which usually has the characters of the epidermis and produces hair and sebaceous secretion. These tumours may be grouped together as dermoids. For surgical purposes it is more instructive to consider tumours in connection with the organs in which they most commonly 104 SURGICAL PATHOLOGY. occur. Thus many adenomatous and cancerous growths will be noticed in dealing with the surgical pathology of the breast and other organs. It will, however, be convenient to give a brief summary of the chief varieties and favourite localities of the commoner forms of new growth. Fibromata may arise in almost any part of the bodj^ They are divisible into two classes according as they are dense and firm (hard fibromata) or soft and loose (soft fibromata). The tumours are composed of fibrous tissue and blood-vessels. Some growths, such as epulis and naso-pharyngeal fibroma, which are composed chiefly of fibrous tissue, show a marked tendency to recur locally after removal, and also to form the starting-point of sarcomatous growth. Many fibromata form in the connective tissue of nerves and are generally termed neuromata, under which heading they will be considered. This applies to the remarkable multiple fibroma of the skin, or fibroma moUuscum. The qualification moUuscum refers to the softness of the growth which may assume various forms. More commonly the skin is studded with projecting rounded pendulous growths varying in size from a walnut or larger to a pin's head. They show no tendency either to disappear or to cause metastasis, and may last forty years or more without undergoing much change. Careful microscopical examination of these growths reveals the presence of a small bundle of medullated nerve fibres in the centre of the pedicle, so that it is probable the growths arise in the sheaths of small nerves, and thus these fibromata may also be classified with neuromata. Another phase of fibroma moUuscum takes the form of a diffuse hypertrophy of some area of the skin which is thrown into loose folds, in which the sebaceous glands may be over active, producing an excessive secretion which undergoes decom- position, and causes a rancid odour. This second form is again allied to a more general hypertrophy of the sub- cutaneous tissue, or dermatolysis, in which the skin can be drawn up from the deeper tissues of any part of the body. In this condition there may be general dilatation of the sub- cutaneous veins and lymphatics as well as overgrowth of the nerve-sheaths. Persons afl'ected in a marked degree by this NEW GROWTHS OF CONNECTIVE TISSUE. 105 malformation of the skin have been shown at fairs as "elephant men." The condition is allied to congenital hypertrophy of limbs (see below). Hard fibromata arise most commonly in periosteum (jaw, etc.), fasciae, skin, ovary, etc. They do not form metastases : if they endanger life it is from their position and size. Some growths, such as epulis and naso-pharyngeal tumour, which consist chiefly of fibrous tissue, show a marked tendency to recur locally after incomplete removal, and not infrequently they become sarcomatous (see " Fibro-sarcoma "). (Edematous Fibroma. Active or passive congestion of a fibrous tumour causes separation of fibrils and swelling of cells. Under the microscope such a condition may be indistinguishable from myxoma. It is sometimes difiicult to distinguish between a fibroma and a myoma when the fusiform cells of the latter are very long and slender. The same applies in less degree to some spindle-celled sarcomata. Myxomata, or tumours consisting of mucous tissue, are soft translucent growths. On section they exude a sticky colourless fluid which constitutes the chief part of their intercellular sub- stance and contains mucin. Delicate connective tissue is usually also present supporting the branched cells of the growth. Mucous polypi of the nasal fossae are the commonest examples of myxomata. Patches of mucous tissue are common in growths of other kinds, chondroma, sarcoma, etc. Lipomata, or fatty tumours, are composed of fat which has usually a more markedly lobular character than normal fat. They are commonest in the subcutaneous tissue, especially that of the dorsal aspect of the trunk and limbs. The axillae are also a common site. By drawing up the skin that covers them between the fingers, the lobulation is made apparent. Not infrequently subcutaneous lipomata become pedunculated, and pressure on the skin of such a pedunculated lipoma often causes ulceration. When a lipoma is composed of large lobules loosely joined together it may be mistaken for a cystic growth. Ordinary lipomata are surrounded by a fibrous capsule which is adherent to the surrounding tissues, and but slightly con- nected with the growth. This fact is important in practical 106 SURGICAL PATHOLOGY. surgery, because for the removal of these growths it is only necessary to open the capsule freely and shell out the contents. The subperitoneal tissue is not infrequently the seat of fatty tumours. Sometimes they lead to the formation of or compli cate a hernia. Lipomata are also met with in the spermatic cord. Further, fatty growths may form wherever there is connective tissue. When a lipoma forms beneath a strong fascia it may occasion a tense swelling of the limb, and be mistaken for a malignant growth. Rarely, lipomata form in the submucous tissue of the bowel, and project into the lumen, where they may start an intussusception. Parosteal lipoma has been observed in the periosteum of the long bones, pelvis, scapula, vertebrae, and skull. Besides fat such growths usually contain striped muscle. They are nearly always congenital. Fat is sometimes deposited in the synovial fringes in osteo-arthritis, giving rise to a condition known as " arborescent lipoma." Mixed Fatty Tumours, such are fibro-lipoma and nsevo-lipoma. In old-standing lipomata calcification is sometimes observed. Diffuse Lipoma. Two distinct conditions have been described under this designation. Most frequently it is applied to an increase of fat in the occipital and submental regions of drunkards : a condition which differs from the growths described above, and is rather a hyperplastic than a neoplastic process. Some true lipomata are ill-defined and widespread. Such growths cause great deformity of the fingers when they occur in that situation. Chondromata are composed either of hyaline or fibro-cartilage. Tumours of the former variety are the more common, and usually are lobulated from being intersected by fibrous tissue which carries blood-vessels. Hyaline chondromata are bluish on section and translucent, like rapidly proliferating cartilage at the epiphyseal line. Fibro-chondromata are white and glistening. Some cartilaginous tumours have soft patches of myxoma tissue alternating with the cartilage. Like mucous tissue, cartilage is a common constituent of mixed growths, especially some forms of sarcoma. Chondromata occur most frequently in connection with bone. NEW GROWTHS OF CONNECTIVE TISSUE. 107 Towards the ends of the diaphysis groups of ossified cartilage cells are present in normal subjects, and in young adults who have been rickety in childhood islands of hyaline cartilage are sometimes visible to the naked eye when a section of the bone is made. Such remnants of cartilage in the shafts of bones probably form the starting-points of chondromata, such as those that are not uncommon in the bones of the hand and foot, and which arise within the medullary cavity of the bones. In rickets and other conditions {e.g. syphilis), cartilage may be formed de novo from the periosteum ; and the perichondro- mata, such as those of the femur and other long bones, probably arise in the periosteum. Small outgrowths of cartilage are not uncommon in the laryngeal and costal cartilages. They are usually termed ecchondroses, and are classed with the formation of cartilage at the margin of the articular cartilages in osteo-arthritis ; that is to say, they are classed with inflam- matory hyperplasias rather than with new growths. Here, as elsewhere, the boundary between inflammatory and neoplastic processes is hard to draw. Secondary changes in chondromata, such as ossification, etc., are common, and are more fully noticed elsewhere. Osteomata. These tumours are fully described in the section on "Diseases of Bone." Some of them, the spongy osteomata, are closely related to the chondromata, since they are covered by a layer of hyaline cartilage. Hard osteomata, resembling the compact tissue of the long bones, or being of even greater hardness, are chiefly met with in connection with the skull bones, but they may occur in any bone. Both hard and can- cellous osteomata occur in the bony part of the external auditory meatus. The formation of bone is sometimes observed in the lungs and muscles, and other tissues quite unconnected with the bones. Odontomata are a varied group of tumours, etc., which arise in connection with the teeth and the embryonic structures of developing teeth. Myomata are growths composed of long slender, spindle- shaped cells, resembling unstriped muscle, with more or less supporting fibrous tissue in which their blood-vessels lie. They 108 SURGICAL PATHOLOGY. are most commonly observed in the uterus and broad ligament; they occur also in the ovary and vagina and in the skin. Uterine myomata may undergo calcification. Cells resembling striped muscle fibres occur in certain sarcomata connected with embryonic remains at the hilus of the kidney and in the testis. These sarcomata are called Ehabdomyomata. Neuroma. New growths composed of nerve elements are very rare. The bulbous enlargements that form on divided nerves in amputation-stumps (see p. 51), and elsewhere, can hardly be termed new growths in the sense of the term adopted here. They are the results of the processes which constitute the normal repair of nerves (see p. 47). Neuromata, consisting of non-medullated fibres, and sometimes of ganglion cells, have been observed in connection with the brain and the suprarenal capsules. The tumours connected with nerves that most frequently come to the surgeon's notice are fibromata, fibro-myxomata, or fibro-myxo-sarcomata that have their origin in the connective tissue of the sheath of the nerve trunks. Such growths may form at the peripheral extremity of the nerves. They are liable to be mistaken for rheumatic nodules and other subcutaneous formations. Occasionally all the branches of a large nerve may be thickened and nodular to such an extent that considerable deformity may result. This has been termed a plexiform neuroma. They are generally of congenital origin, and painless. The more common neuro- fibromata or neuro-myxomata usually form solitary growths, and may occasion much pain. When they occur on the roots of the nerves within the spinal canal they first cause pain, then paraplegia. Angiomata, or Hsematangiomata, are tumours, which consist of a new formation of blood-vessels. Three divisions of these tumours are made (Bland Sutton) : Capillar!/ angioma or simple nmvus vascularis, cavernous ncevus, and plexiform angioma. The last is also known as "cirsoid aneurysm," or "aneurysm by anastomosis." Vascular Ncevi (commonly but erroneously called nsevi without the qualification — Lat. naivus = 3i. mole) are due to a growth of capillary blood-vessels. When they occupy the corium alone NEW GROWTHS OF CONNECTIVE TISSUE. 109 they are known as port-wine marks, such as are common on the face. If they affect the subcutaneous tissue alone, the skin is slightly raised and bluish. When both the corium and the subcutaneous tissue are occupied by the over-numerous, dilated, and often pouched capillaries, there is both elevation of the skin and discoloration. The exact tint of the noevus is probably determined by the degree of dilatation of the newly formed vessels. If they are wide the blood current is slow, and the blood becomes venous; hence the colour is darker than if they are narrow. The arteries which subdivide to form a capillary nsevus are usually few in number. Present at birth, or de- veloping soon after, nsevi often increase considerably in size during the early years of life; sometimes they undergo involu- tion, probably from thrombosis and organization of clot. The clots not infrequently calcify, forming phleboliths. Care must be taken to distinguish telangiectasis, or acquired dilatation of blood-vessels, from congenital angiomata. Cavernous angiomata, or venous neevi, are tumours composed of tissue resembling that of the corpora cavernosa and spongiosa of the penis : a fibrous meshwork containing cavities lined with endothelium. What appears to be a capillary nsevus at birth may develop into a cavernous angioma, thus showing that there is no sharp boundary between these forms of vascular tumour. Cavernous angioma, like the capillary angioma, is most frequently formed in the skin. When large they may ulcerate, causing severe and even fatal haemorrhage. They have also been found in the tongue. It is this form of nsevus which is often combined with fatty growth — nsevo -lipoma. Sometimes when their arterial supply is abundant these tumours pulsate, and so approach in character the plexiform angioma. Plexiform angioma is a somewhat rare condition. It is also known as " cirsoid aneurysm " and "aneurysm by anastomosis." It is most frequently encountered in adolescents and young adults, though its beginnings are probably present at birth. The growth is either composed solely of arteries or of arteries and veins. In the former an artery and its main branches, or a set of contiguous arteries and their branches, become enlarged, thinned, and tortuous, forming a pulsating tumour. In the 110 SURGICAL PATHOLOGY. arteriovenous tumour the veins as well as the arteries are enlarged. The danger of the condition lies in the liability of the dilated vessels to rupture. When they occur in the head and face they cause great disfigurement. Ligature of the main arteries Avhich supply these tumours has little or no effect on them. Excision presents great difficulties. Congenital Moles, or Nmvi Pigmentosi, and "Soft ^Tarts." Moles are congenital tumours of the skin. If they are not visible at birth they become so soon afterwards. They are usually pigmented, but occasionally the pigment is wanting ; they are then termed "white moles." They may consist of a pigmented area not raised above the level of the skin; more commonly they are raised, and then are either devoid of hair (ncevus pig- mentosus spilusj or covered with coarse hair. Soft warts are of the same nature as moles, only they project above the surface and thus resemble warts, hence their name, "naevus verrucosus." It is important to remember, however, that they are essen- tially different from warts. In the latter the epithelium is increased in amount as well as the connective tissue and vessels; in the naevus verrucosus, the epidermis is thinned, the projections from the surface being due to accumulations of cells of embryonic connective-tissue type in the papillse and corium. Hairy moles may be of vast extent, covering large portions of the surface of the body. Their proneness to become sarcomatous has already been alluded to. This same proneness to become sarcomatous is observed in soft warts. The latter, when they Fig. 33. — Section through part of a con- genital mole. The papillary processes of the corium are the seat of sraall-celled growth over which the epidermis is thinned and stretched. In the deeper part of the section the cells have proliferated into the sub- cutaneous tissue, showing that the growth had become sarcomatous, x 20. NEW GROWTHS OF CONNECTIVE TISSUE. HI assume malignant character, extend rapidly, maintaining, how- ever, their warty type. Another very interesting feature of warty moles is their tendency to extend in one direction — thus are formed the "streaks" of dermatologists. One of these streaks may start in a patch of congenital warty moles, say, at the neck, and extend in a linear manner the whole length of the body, or along one of the limbs. Sometimes the direction they take is across the long axis of the body. The only difference between a soft wart and a mole is that in the wart the accumulation of cells in the papillae is sufficient to push up the epidermis into processes which project from the surface. In both conditions the epidermis is thinned. A nsevoid condition of the l3'mphatic3 is sometimes present in papillated moles. Lymphangiomata may be divided into three groups : Lymphatic nsevi, cavernous lymphangioma, lymphatic cysts (Bland Sutton). Lym])liatic Ncevi. The commonest example of this condition is to be found in the sago-tongue, which shows itself at or soon after birth as little bluish-grey smooth projections which are noticed in clusters on the dorsum of the tongue. Micro- scopically they are found to consist of dilated lymph capillaries with supporting fibrous tissue in which are a few blood capillaries. Cavernous Lymphangioma bears a similar relation to the neevus lymphaticus that a capillary vascular nsevus bears to a cavernous angioma. The lymph spaces are larger, and the condition is apt to be more widespread. In the condition known as macro- glossia the anterior two-thirds of the tongue are greatly enlarged, the organ projecting from the mouth. On section the enlargement is found to be due to cavernous lymphangioma diffused through the affected part of the organ. A similar condition sometimes co-exists in the lips and is termed macrocheilia. Tissues affected by cavernous lymphangioma are peculiarly liable to inflammation. In cavernous and other lymphangiomata of the skin crops of tense vesicles {Lymphangioma circumscriptum cutis) appear during the attacks of inflammation, to which these growths are prone. Lymphatic Cysts, or Cystic Hygromata, are analogous to the cavernous angiomata. They usually lie beneath the deep fascia of the neck or axillae, but have been observed in other 112 SURGICAL PATHOLOGY. regions. They are of congenital origin. They consist of one or more cysts surrounded by a wall of delicate fibrous tissue and lined by endothelium. They contain a clear serous fluid. The fibrous tissue round them is often oedematous and may resemble a myxoma in aspect. Clinically they form fluctuating swellings which vary in tension. They are subject to attacks of inflammation which are sometimes followed by spontaneous shrinking. They may or may not increase in size. They are peculiarly liable to become the seat of infective processes after operation for drainage or excision ; the latter is usually difficult, often impossible. Congenital Hypertrophy of the Limbs. The consideration of vascular nsevi and lymphatic nsevi brings to the mind a con- dition in which they are both sometimes found. The con- dition referred to is congenital hypertrophy of the limbs. Not infrequently one or two toes are the seat of a marked enlargement of all the con- stituent elements. Sometimes all the component elements of the parts are normal in structure save for their ex- cessive development. At other times wide angiomatous tracts occur, or again cavernous lymphangioma may be present and, as in a case seen by the author, during inflammatory attacks may give rise to crops of vesicles on the surface. Or the skin of the part may be dermatolytic. In one case seen by the author there was an extensive hairy mole covering the thigh of a hypertrophied lower limb in a boy aged thirteen who died of sarcoma of the lumbar glands. The simpler forms of congenital hypertrophy may be termed localized giantism. Fig. 34. — A foot, etc., showing congenital hypertrophy of the two inner toes and the inner half of the foot. After S. Horn- stein NEW GROWTHS OF CONNECTIVE TISSUE. 113 Sometimes one half of the body is affected ; the toes are a favourite seat of the condition (see Fig. 34). Sarcoma. The general features of sarcomata have already been dealt with. They present a wide range of structure. Both the cellular elements and the intercellular substance differ widely in character. In rapidly growing sarcomata the intercellular substance may be practically absent, what there is being structureless and granular. When the rate of growth is less rapid fibrous tissue may be formed. Sarcomata rarely show any cicatricial contraction and so differ from granulation tissue. In periosteal sarcoma the base of the growth may ossify and cartilage may be formed in the growth. The blood-vessels of sarcomata vary in their structure and numbers, etc. In the more slowly growing tumours they resemble the vessels of the surrounding parts from which they spring. In other cases the walls of the blood-vessels are not developed beyond the single layer of endothelium. In such sarcomata haemorrhage is common. When the proportion of thin-walled blood-vessels in a sarcoma is very great the growth pulsates. Such a growth is termed an angiosarcoma. Clinically, sarcomata form rounded lobular tumours. In consistence they vary from extreme soft- ness to cartilaginous hardness. Many of them appear to be encapsuled, but when examined by the microscope the tissues beyond the growth are seen to be the seat of some inflammatory and sarcomatous infiltration, and the capsule is found to be merely a condensation of the adjacent structures. The relation of the blood-vessels to the development of the growth has already been considered. Here a few words may be said of the chief types of sarcoma (see Fig. 35). Round-celled Sarcoma. There are two varieties : Small round- celled and large round-celled sarcoma. The former is a rapidly growing tumour which consists of round cells a little larger than leucocytes, with well-defined nuclei and ill-defined protoplasm. These tumours have little or no intercellular substance, they rapidly infiltrate surrounding tissues, and may arise in almost any organ : brain, testis, mamma, skin, periosteum, etc. The small round-celled sarcoma is one of the commonest of malignant growths. Large round-celled sarcoma is also a common growth H 114 SURGICAL PATHOLOGY. and has frequently an alveolar structure. Its cells may be pigmented. Spindle-celled Sarcoma. As in round-celled sarcoma so in the spindle-celled growth there is a wide range of dimensions ex- hibited by the constituent cells. The growths with long slender cells are common in skin, breast, brain, and many other tissues. On section to the naked eye they may be hard to distinguish from fibromata or myomata, and even under the microscope they may be indistinguishable from some myomata. Their cells tend to be arranged in intersecting bundles formed around the blood-vessels of the growth. This arrangement is particularly conspicuous in spindle-celled sarcoma of the pia mater, and justifies the designation of some of these growths as plexi- form sarcomata. Large spindle-celled growths without being rare are not so common as the small-celled growth. In a few cases some of the large cells show cross-atriation, in which case they are called rliabdomyomata. Lymphadenoma and Lymphosarcoma. No sharp line can be drawn between these conditions. The growths appear primarily in lymphatic glands or in structures such as the tonsils which contain lymphoid tissue. In the former position the glands enlarge and, after remaining separate for a variable time, the growth passes beyond the limits of the glands and invades neighbouring structures. Large lobulated tumours are thus formed, in which areas of caseous degeneration are usually present. Sooner or later secondary growths appear in the lymph glands of the body generallj', liver, spleen, kidneys, and bones. This condition is accompanied by great anaemia, and attacks of pyrexia, and is known clinically as Hodgkin's Disease. They may appear in any organ, including the brain and the skin. A common site of lymphosarcoma is in the bronchial glands. The structure of the growth recalls that of lymphoid tissue : small round cells supported by a fine cell- reticulum. When the gi'owth is invading structures such as the bronchi, sections at the advancing margin show a very vascular small-celled sarcomatous growth passing between and replacing the tissues of the invaded part. Other forms of sarcoma may originate in lymph glands. The surgical indi- NEW GROWTHS OF CONNECTIVE TISSUE. 115 cation in lymphosarcoma is removal before the growth has become generalized. Alveolar Sarcoma. Sarcomata when examined in sections present an appearance of subdivisions into cell groups by means of the blood-vessels and their supporting tissues. The term alveolar sarcoma is restricted to those in which this subdivision is a marked feature. The most typical alveolar sarcomata are large-celled tumours of which the dividing septa are capillary blood-vessels. An alveolar sarcoma may be melanotic (see Fig. 35, 5), or from the abundance of blood-vessels it may be pulsatile and so deserve the name of angiosarcoma. Fibro-Sarcoma. A good example of this growth is an ordinary epulis. The superficial part of this growth is rich in small round cells supported by fibrous tissue and spindle cells, the deeper part is more fibrous in character. Myeloid Sarcoma. This is one of the best characterized forms of sarcoma, and generally has its origin in the medulla of bones; some periosteal sarcomata have also the same character. The leading histological feature of these growths is the presence of numerous large multinucleated cells, which are surrounded by spindle cells and some fibrous tissue. The blood-vessels of these tumours are usually well formed. When they are con- fined within the medullary cavity of a bone their growth is usually slow and their tendency to form metastases small. Occasionally, however, they are widely disseminated in the various bones of the body. When cut into in the fresh state they have a fleshy appearance and a reddish-purple colour. Endothelioma. Most tissues of the body contain lymphatic vessels and these contain endothelial cells. In some cases the structure of a sarcoma suggests that the cell-proliferation com- menced in these endothelial cells. When these tumours form in fibrous membranes, such as the dura mater or the pleura, sections show under the microscope hollow or solid masses of cells surrounded by fairly thick septa of fibrous tissue, so that it is sometimes impossible to say whether the growth is sarcoma or cancer until its origin and distribution have been carefully considered. Probably it is in the endothelial cells of lymphatics that the cells of many different forms of sarcoma arise, but it 116 SURGICAL PATHOLOGY. NEW GROWTHS OF CONNECTIVE TISSUE. 117 is only when a structure such as that described above is met with that the term endothelioma is employed. In endothelioma of the dura mater the central cells of the groups form concentric whorls like the normal concentric cells of the thymus. In sarcoma of the dura mater these cell-clusters may become calcified. The growth is then termed a sand-grain sarcoma or psammoma. Fig. 36. — Alveolar endothelial sarcoma of the pleura, starting from the endothelium of the lymphatics, a, Endothelioid sarcoma cells, seen laterally ; 6, sarcoma cells, seen on the flat ; c, conuective-tissue stroma, x 285. Stained with alum cochineal. From Weichselbaum's Pathological Histology. Cylindroma. The origin of sarcoma in the budding of the blood-vessels and proliferation of the cells which cover the new vascular offshoots has been observed. When the coats of the vessels of such tumours undergo hyaline degeneration the term cylindroma is applied to them. 118 SURGICAL PATHOLOGY. Melanotic Sarcoma. Some of or all the cells of any kind of sarcoma may be pigmented from the presence of particles of black or brown pigment in the cell-protoplasm. Such growths are termed melanotic. They may occur in very various kinds of tissue, but their favourite sites of origin are the choroid coat of the eyes and the skin. In the latter situation they sometimes begin as a bluish streak at the side of the nail : "melanotic whitlow" it has been called. This form of sarcoma is rapidly fatal from dissemination. Mixed Sarcomata. This term signifies two distinct conditions : (1) Where different kinds of cells, say, round- and spindle- celled, occur in the same growth; (2) where tissues like bone, cartilage, raucous tissue, etc., alternate with the less highly difi'erentiated parts of a sarcoma. Glioma is a tumour composed of tissue resembling neuroglia. It occurs in the brain, spinal cord, and the retina. Sometimes the growth proceeds slowly, and then its structure is much like that of normal neuroglia. In other cases the growth is more rapid and, histologically, the tissue is found to contain numerous round cells in the meshes of the finely reticular neuroglia-tissue. These cellular gliomata are designated glio-sarcomata. In the brain they may form large tumours replacing considerable tracts of brain tissue. Not infrequently their central parts break down, forming a cyst which is lined by gliomatous tissue. These tumours are generally of about the same consistence as the brain tissue into which they merge. They are not so common in the spinal cord as in the brain. In about 2000 autopsies I have met with one case of spinal glioma. The growth occupied the central part of the cervical cord, the tissue of which was stretched over the growth. The latter was nearly as thick as the original spinal cord and extended for four inches vertically. Glioma of the retina is not a very unusual occurrence. EPITHELIAL NEW GROWTHS. Papillomata are commonest in parts covered by squamous epithelium — skin, mouth, vocal cords, etc., etc. On the skin EPITHELIAL NEW GROWTHS. 119 they are familiar as warts. They consist of a core of fibrous tissue, composed of the hyperplastic papillse of the part and their enlarged blood-vessels. This is covered with an equally increased amount of epithelium. In this category come many inflammatory formations to remind the student of the close proximity of new growths to inflammatory new formations, of which syphilitic condylomata, gonorrhoeal warts, and the warty condition of the skin around some chronic ulcers will serve as illustrations. Sometimes numerous warts form on the vocal cords and cause hoarseness and other symptoms. In mucous membranes, especially that of the urinary tract, papillomata also form — thus the villous tumours of the bladder belong to this category. Corns and some cutaneous horns also approach this group. Horns form on a base of hyper- trophied papillae. They are sometimes associated with cancer. Adenomata are tumours composed of gland-like elements. Thus an adenoma of the rectum or uterus is composed of tubular glands ; an adenoma of the breast, of ducts and acini which resemble broadly those of the normal breast. A greater or less amount of supporting connective-tissue always surrounds the epithelial parts of adenomata, and in some cases this sup- porting tissue assumes the character of one or other form of sarcoma. The growth is then termed an adeno-sarcovia. Carcinoma. The characters of a malignant epithelial growth have been sketched on page 95. It has in this country become customary to speak of a few cancerous growths as epitheliomata and the rest as cancers. Thus the terms squamous epithelioma and cylindrical epithelioma refer to cancers of the squamous epithelial and the columnar-celled types. In this work these growths will be termed squamous-celled cancer and columnar- celled cancer respectively. This not only gives a more uniform designation to the cancerous growths, but will not clash with the terminology in use abroad, where all epithelial growths, benign and malignant alike, are termed epitheliomata. The subdivision of cancer has yet to be made on a logical basis. At present no more can be done than describe the best known varieties, and leave the description of other forms to be con- sidered with the organs in which they arise. 120 SURGICAL PATHOLOGY. In general the epithelial parts of cancer tend to reproduce the type of epithelium in which they have their origin. The variations of hardness, softness, etc., have already been dealt with. Squamous-celled Cancer. The lip, tongue, pharynx and gullet, larynx, skin, and glans penis are the commonest sites Fig. 37. — Cone of cancer cells in an epithelial carcinoma, a, Short cylindri- cal cancer cells at the circumference of the cone ; b, spiny cells ; c, concen- trically stratified epidermic globnle. x 200. I3iematoxylin and eosin. Weichselbaum. of this growth. Two clinical types are recognizable according as (1) the growth forms papillated projections from the surface — warty or proliferating type; or (2) the surface becomes excavated by ulceration — ulcerative type. The two types are frequently combined in the same growth. In both forms an indurated base and a border raised up by firm subjacent cancerous growth are present. Thus to the eye a glans penis thickly covered by gonorrhceal papillomata sometimes closely resembles the EPITHELIAL NEW GROWTHS. 121 same part when it is the seat of an epithelioma of the warty type. Palpation of the part will at once reveal the presence of induration in the case of cancer and the absence of it in the case of warts. A section made through a squamous-celled cancer shows to the naked eye the solid white growth. Under the microscope sections show the epithelial down-growth in the shape of solid columns of cells separated by vascular connective-tissue. The larger of the epithelial columns present the cell-nests, which are composed of compressed epithelial cells (see Fig. 37). Scrapings show similar structures. Fig. 38. — Section through a rodent cancer of the face, at an early stage. 1, ulcerated spot ; 2, sweat-gland, x 30. When a squamous-celled cancer is growing in succulent tissue, cystic spaces may take the place of these cell-nests. These cysts are due partly to the immigration of leucocytes, partly to changes in the epithelial cells themselves. Squamous-celled cancers not infrequently originate in chronic ulcers, simple or syphilitic. They are also met with commencing in scars. Rodent Cancer begins as a small nodule placed beneath the epidermis. Next it forms either a wart-like lesion or a shallow ulcer. It is most common on the side of the face, but may be 122 SURGICAL PATHOLOGY. developed on any part of the skin. The cancerous nature of the growth is shown by its progressive and persistent, though slow, invasion and destruction of the parts on which it rests. The formation of new tissue is usually very slight, but the edge of the ulcer can usually be observed to be slightly raised by firm growth. Sometimes the formation of new tissue is more abundant, and the edge of the ulcer correspondingly elevated. This constitutes the "crateriform ulcer." Histologically the ingrowing processes are composed of smaller cells than those of squamous-celled cancer, and cell-nests are usually absent (see Fig. 38). The lymph-glands may be affected, though this is not common. Paget's Disease of the Skin. This disease was first described by Paget on the nipple. It occurs also on the scrotum and at the margin of the anus. Though regarded by some writers as an eczema, it has more associations with cancer. It begins as a red patch in the skin, generally at the summit of the nipple. This may becom^e covered with scales. When the scales are absent, the bright rose colour and slightly irregular surface of the patch are noteworthy. It extends progressively in all directions, and is characterized by a definite, often slightly raised and indurated edge. Slight excoriations form from time to time. After lasting from two to twenty years on the nipple, epithelial proliferation extends down the ducts to the breast, where it assumes the form of ordinary breast cancer. Two cases have come under my notice. In the first the disease had existed seven years, and the patch was as large as the palm of the hand. There was no cancer of the breast. In the second the disease had existed for thirteen years, and the patch covered the nipple and areola, and a little of the skin beyond the latter. There was cancer in the breast and axillary glands. In the second patient there was also a rodent ulcer at the upper part of one thigh. Removal of the breast is the only satisfactory treatment of the disease. In the corium both the main features of inflammatory change — enlargement of connective-tissue cells and diapedesis of leucocytes — are present. Columnar-celled Cancer. This kind of cancer arises in the stomach and intestine. Hard and soft varieties similar to EPITHELIAL NEW GROWTHS. 123 those described under squamous cancer occur. The ulcerative type is commonest, and is often combined with proliferation. Further particulars will be given below. 4 3 — ^^^ > ^^^^"^^^^ Fig. 39. — Section through the edge of a patch of Paget's disease. 1, Normal eiJidermis ; 2, vacuolated epidermal cell ; 3, swollen epidermal cell lyin^ in a cavity ; 4, a cavity containing a leucocyte and some granular bodies ; 5, dense bodies in the horny epidermis, x 250. Grlandular Cancer. Cancer of organs such as the breast or testis only differ from those commencing on a surface in that the epithelial growth begins in the midst of a solid gland instead of on a mucous membrane. Taking cancer of the breast as an example, hard and soft^ cancers may be distinguished. The former are the more common. If left to themselves they generally cause death from glandular and general infection in two or three years. But the more slowly-growing or atrophic 1 The terms scirrhus (=lump of stucco) and encephaloid (== brain-like) only refer to the hardness or softness of the growth. 124 SURGICAL PATHOLOGY. tumours may last for six or more years without producing ulceration. The hardness of these growths depends on the amount of fibrous (cicatricial) tissue present in them (see Fig. 40). The softer and more rapid growths contain a smaller pro- portion of stroma, and undergo a central caseation instead of the cicatrization which occurs in the older parts of atrophic cancer. In one form of breast cancer — duct cancer — the microscope shows that the growth consists of papillated processes covered by cubical or cylindrical epithelium. Duct cancer may be taken as comparable with proliferous cancers of the skin and intestines. Colloid Cancer. The epithelial cells in the middle of the lobules of the growth undergo colloid degeneration. On section such growths present gelatinous areas. See also " Diseases of the Breast." Colloid cancer is also met with in the stomach and intestine, in the epididymis and spermatic cord, peritoneum, etc. A mucous degeneration of the stroma often accompanies colloid degenera- tion of the epithelial parts of cancers. It is in glandular cancers, such as that shown in Fig. 40, that the alveolar character is most marked. This feature they hold in common with certain sarcomata. The character of the epithelial cells of cancer is more distinctive than their alveolar arrangement. The outlines of cancer cells are usually more definite and sharp than those of sarcomata. This observation is of value in diagnosis. Thus in cancer of the ovary, or peritoneum, accompanied by ascites, groups of large cells with definite outlines may be found in the fluid withdrawn by aspiration. Cancer may arise in any part where epithelium exists, and may be carried to any vascular part of the body. The Causes of New Growths. But little is known of the general etiology of new growths. Reviewing for a moment the varied array of new growths just described, they are found to present as wide a range of rate of increase and of habits as they do of histological structure. One of the features they have in common is " autonomy," i.e. their independence of physiological control. Even this is not absolute, as is shown by the fact that in women sufi"ering from inoperable EPITHELIAL NEW GROWTHS. 125 cancer removal of both ovaries has been found to check the growth of tlie cancer, thus showing that the cells of the neoplasm are atfected to some extent by the general nutrition of the body. Many growths such as nsevi are congenital. Congenital moles form a striking group of new growths. They have the structure of sarcomata, yet in the majority of persons they do not assume the life-habit of a sarcoma. Some formations classed among Fig. 40.— Section of a hard cancer of the breast, a, Small cancerous alveoli ; h, empty alveoli ; c, greatly developed connective -tissue stroma. X 240. Weichselbaum, Pathological Histology. tumours are clearly simple deviations from normal development. Such are cervical auricles, etc. Certain congenital tumours, which occur most frequently at the back of the sacrum, are found on dissection to be really abortive embryos, which under more favourable conditions might have developed into separate individuals instead of forming a tumour-like mass (teratoma). In. view of these teratomata, and of congenital tumours of other kinds, the "inclusion" theory formulated by Cohnheim, to the 126 SURGICAL PATHOLOGY. few® ^-^^4 effect that tumours arise from embryonic cells produced in excess of what is required for the building up of the body, appears to have a very great probability. Yet, as has been shown above, the malignant growths present close resemblances to the inflammatory processes, and many attempts have been made to prove a parasitic origin of cancer and sarcoma. One of J the latest of these was based on the view, first advanced in this country by RuflFer, that parasitic protozoa were present in malig- nant growths. In this view I shared and went even further. The evidence was based on his- tological appearances, some of which are shown in Fig 41. The cell-inclusions shown in this figure were described by Virchow as " cells of endogenous origin." Ruffer, D'Arcy Power, and others have pointed out that leucocytes and other bodies are often present in epithelial cells. I may at once admit that in many points I have modified the views I formerly expressed. The parasitic origin of malignant growths is not proven. A traumatic or irritative origin has been suggested for some cancers and other growths. Thus, when a sarcoma appears at the site of a previous fracture of a bone, the growth has been attri- buted to the injury. In many such instances the growth was doubtless present before the fracture, which indeed it deter- mined. Even when the events are really consecutive the evidence warrants no conclusion beyond that the injury may Fig. 41.— Section of a cancer of the penis. 1, Cluster of round slightly granular bodies ; 2, an epithelial cell containing two similar granular bodies ; 3, a large collection of small gi'anular bodies within what maybe a real capsule or only an optical appearance (see the Report of a Moi'bid Growths Committee, Transactions of the Pathological Society, 1894, p. 248) ; 4, 5, other granular bodies within cells ; 6, granular body ; 7, a dense body i-eticulated in the centre ; opposite 8, in the middle of the section, an epi- thelial cell containing five small clear bodies. In the spaces between the cells are eucocytes. x about 400. EPITHELIAL NEW GROWTHS. 127 be contributive, as it is in certain abscesses and tubercular lesions. Sweeps, workers in tar, petroleum, etc., are subject to epithelial growths, but the same objection may be taken against there being a causal relationship between the irritation and the growth as holds in the case of traumata just mentioned. Where papillo- matous growths are evidently connected with gonorrhoeal or other suppurations it is presumable that these growths are due to a slight degree of inflammatory action lasting for a long time. Hutchinson has shown that the long-continued internal administration of arsenic may be followed by horny and even cancerous growths of the skin. In exactly what way this is brought is not known. It will be seen that but little is established regarding the etiology of new growths. It must, however, be remembered that not many years ago tuber- cular and other now well-understood formations were included with new growths, and it is to be expected that with the increase of knowledge other members of this group of patho- logical formations will be explained. Cysts. A cyst (Gr. hjstis = bladder) is a closed sac Avitli fluid or semifluid contents. Cysts originate in various ways: — (1) By the distension of cavities or tubes. (2) By the formation of a fibrous capsule around effusions of blood or degenerated and liquefied tissue. This occurs frequently in new growths. (3) By the growth of parasites. Many cysts are of developmental origin, and will be described in the next section. Examples of glandular or " retention " cysts are the common sebaceous cysts of the skin, mucous cysts of the mouth and of the cervix uteri. The epithelial-lined cavities of new growths very commonly become converted into cysts. Of parasitic cysts, those due to the complex colonies or brood-capsules of the taenia echinococcus are best known. CHAPTER YI. DERMOID TUMOUES AND CYSTS, AND OTHER CONGENITAL PATHOLOGICAL FORMATIONS. Dermoid tumours are generally in the form of cysts, which are lined with skin with the epidermis inwards. The epidermal lining produces sebaceous matter, and so sometimes a dermoid closely resembles a sebaceous cyst. Besides sebaceous matter, hairs, teeth, etc. are sometimes found in the larger and more complicated dermoids, such as those of the ovary and the testis. The tumours are of congenital origin, though frequently they do not show themselves till puberty or later. It is an easy matter to account for many dermoid cysts. They form from distension of relics of embryonic passages, such as the gill clefts, and of lines of coalescence, such as the lips of the medullary groove, etc. These have been termed "sequestration dermoids."^ The position of such dermoids can be readily surmised from a consideration of the manner in which the body is built up from the three-layered blastoderm. Along the middle line of the back, perinaeum, in the scrotum, the middle line of the abdomen, thorax, and neck up to the middle of the lower lip is such a line of coalescence. Dermoid cysts are not common in the dorsal part of this line, and when they occur there they are apt to be mistaken for spina bifida. In the scrotum they have been mistaken for dermoids of the testis (see p. 132). Cysts or dimples resulting from a still greater failure of coalescence are occasionally observed in the skin of the middle line of the thorax and neck. Rarely dermoids have been found within the ^J. Bland Sutton, Tumours, p. 279. DERMOID TUMOURS AND OTHER FORMATIONS. 129 thorax. Sometimes they are connected with the hmg, and then hairs may be coughed up from the cyst opening into a bronchus. Others have been found in connection with the pericardium. On the face dermoid cysts are common in certain situations, and they may occur in the lines of any of the embryonic facial fissures. Thus about the angles of the eye where the orbito- nasal fissure lies in the embryo, dermoids are common whether beneath the skin or the conjunctiva. A defect of development greater than that which leaves an epithelium-lined cavity results in the persistence of these fissures or parts of them in conditions such as hare-lip, macrostoma, etc. A defect between these two in degree leads to the formation of a congenital fistula. The branchial fistulse are the most important of these. Of the four branchial clefts of the embryo, the first is utilized to form the tympano-Eustachian passage ; the other three normally disappear, but in certain families they tend to persist, either as passages blind internally and opening externally at the anterior border of the sterno-mastoid, or joining the pharynx with the surface. More rarely they open into the pharynx but are closed externally. Their external openings when present are, approximately : the second opposite the angle of the jaw, the third below the level of the hyoid bone, and the fourth near the sterno-clavicular articulation. Their internal orifices are in the neighbourhood of the tonsil. If the lower fissures remain and open into the pharynx the upper end of the passage is directed between the two carotid arteries and above the superior laryngeal nerve. When the passage is closed externally but open internally a pharipigeal diverticulum^ is formed. Unless this malformation becomes the seat of abscess from the entry of food into it, it is not likely to be discovered during life. It has been mentioned above that the first pharyngeal cleft is utilized as the tympano-Eustachian passage. In connection with its outer opening the pinna of the ear is developed by the fusion of six tubercles. In a similar manner abortive auricles are not infrequently developed at the points at which the remaining pharyngeal clefts open on the surface. Such ^See a case by M. Watson, Journal of Anat. and Phys., 1874. I 130 SURGICAL PATHOLOGY. auricles consist of skin and cartilage. In the union of the six or more tubercles to form the pinna, fistulee may be left or dermoid cysts arise in included portions of epiblast. Dermoids of the Palate. These are solid tumours covered externally with skin. They form in the line of union of the two halves of the palate, and may project either into the mouth or naso-pharynx. They may be compared with rectal dermoids. Adenomata and epithelial pearls are met with in the same situation. Dermoids of the Pituitary Grland. Dermoid tumours and adenoma have been found within the skull growing from the pituitary gland. Dermoids of the Scalp are important because they may be attached to the dura mater by a pedicle which passes through a hole in the bone. They are commonly met with in the middle line, especially at the site of the anterior fontanelle or at the occiput. In infants they are liable to be mistaken for meningoceles, in adults for sebaceous cysts. The skin covering them may become ulcerated through and then suppuration may extend to the meninges along the pedicle of the cyst, causing fatal meningitis. Cysts and tumours may develop in connection with the original duct of the thyroid gland (see below). Dermoids of the Rectum and Congenital Sacro-Coccygeal Cysts. — Post-rectal dermoids may be formed between the hollow of the sacrum and the rectum. They are rare and may contain teeth. If they remain small they will probably give rise to no symptoms, and so be overlooked. They may attain a large size, bulging into the pelvis and pushing before them the peritoneum. Rectal dermoids form pedunculated tumours within the rectum. Their presence may be made known by a wisp of hair which covers their surface protruding through the anus. They are covered externally with skin, like the palatine dermoids. They are to be distinguished from ovarian dermoids which have ulcerated into the rectum and discharged their contents per anum. Sacro-coccygeal Cysts and Adenomata. These develop from DERMOID TUMOURS AND OTHER FORMATIONS. 131 the post-anal gut or the neurenteric canal of the embryo. They consist of a fibrous wall connected with the lower part of the coccyx or sacrum. They resemble somewhat the thyroid gland in structure, and may contain cysts filled with ropy mucus. They usually project on the surface of the body, forming con- spicuous tumours between the buttocks. Dermoids of the Ovary and Testis. It is not difficult to understand the development of dermoid cysts at the site of embryonic lines of coalescence, etc., but it is less easy to under- stand how they come to form in the interior of the ovary and the testis. These organs are developed at the back of the abdomen near the middle line, and the explanation usually given of the formation of dermoids within them is that during development in some way portions of the outer layers of the blastoderm become included within their rudiments. Neither this nor other theories can be regarded as wholly satisfactory. Ovarian Dermoids are among the commonest examples of the condition. They may remain of small size, and cause no symptoms during life. Frequently, however, they attain con- siderable dimensions, and then project beyond the organ in which they are developed. They may become pedunculated and their pedicles may then be twisted, causing them to undergo first congestion and then necrosis, causing pain and other symptoms. Sometimes they contract adhesions to the omentum, and in that case, by the intestinal movements, they may be pushed away from the ovary, and be found at some distance firmly connected with the omentum^ their attachment to the ovary having first been stretched and then caused to give way. Anatomically they consist of a fibrous wall lined with skin. They often present a massive intracystic projection in which may be embedded complicated pieces of bone and cartilage. The skin which lines them frequently bears teeth, and sometimes even mammary glands. They usually contain hair and sebaceous matter. Now and again adenomata lined by mucous membrane are developed from their lining of skin. Dermoids of the Testis must be distinguished from the some- what similar tumours which arise in the raphe of the scrotum. They resemble the dermoids of the ovary, but they are much less 132 SURGICAL PATHOLOGY. common. Since they offer a good example of the more compli- cated kind of dermoid tumour, an illustration of one of them is given in Fig. 42. Between the tunica albuginea and the wall of the dermoid was a little fibrous tissue, but sections examined under the microscope failed to reveal any testicular tubules. Fig. 42. — Section through a testis distended by a relatively large dermoid. Prom a one-year-old Hindu child. In the right half of the section the layers have been dissected. 1, Tunica vaginalis; 2, tunica albuginea; 3, wall of dermoid consisting of skin ; 4, sebaceous matter and hair free in the cavity of the cyst ; 5, cartilage ; 6, bone in a large fibrous intracystic projection, which is covered by hairy skin. Nat. size. Implantation Cysts. If a blunt instrument is pushed through the skin into the deeper tissues, it may carry with it a separated fragment of epidermis which may remain alive and produce a small mass of epidermis surrounded by vascular tissue. The epidermal cells then tend to form a cj^st, those cells nearest the vascular tissue keeping to the type of the deeper layer of the epidermis, while those that lie in the centre become horny and are shed from time to time, and constitute the contents of what might be termed an artificial dermoid cyst. Similar implantation cysts have been observed in the cornea as the result of a portion of conjunctival epithelium being carried in by accidental injury or in operating. Teratomata. A teratoma is a tumour which represents an abortive and suppressed foetus attached to an otherwise normal individual. Though apparently a shapeless mass it proves on investigation to contain anatomical parts, skeletal, DERMOID TUMOURS AND OTHER FORMATIONS. 133 visceral, etc., which show that it really belongs to the same category as double monsters. Their production is due to the same process that results in the formation of twins attached to a single placenta. The single ovum produces a blastoderm on which two embryonic areas appear. If the two embryos develop equally and fully, homologous twins result. If the two remain joined together at one part a twin monster is produced. If one foetus develops vigorously, and in the other development is arrested at an early stage in the whole or part of the body, the weaker foetus remains attached as an excrescence on the stronger. Teratomata are commonest at the back of the sacrum. They seldom admit of removal. Tails. In the region of the coccyx tail-like appendages are sometimes observed. Many are dermoids, teratomata, etc. In one such caudal appendage I found a central core of muscle terminating in a tendon. The investment consisted of skin and subcutaneous tissue. It was caused by an adhesion of the amnion which had drawn out the superficial embryonic layers — an "amniotic band" in fact. True tails containing vertebrae have not been found in man (Sutton). CHAPTER VII. MALFORMATIONS. Congenital malformations are so varied in kind that Teratology, the part of pathology which deals with their origin, is a wide science in itself. Here only conditions of surgical importance will be dealt with. It may be observed that the same deformities which occur in man are met with in animals. In Fig. 43 is represented one of a litter of five kittens which were born all gravely deformed. It is still believed by many that the quickened emotions of women during pregnancy have the power of producing structural changes in the embryo. Though many strange coincidences occur no case that the author has examined has presented even a possibility of maternal mental im- pressions having any part in the production of deformitj^ Many deformities are due to simple mechanical conditions, others are readily understood in reference to the normal processes of development. Other malforma- tions are the result of reduplication of normal parts, as in cases of supranumerary talipes equino- varus of rlirrifc- man. This kitten had CllgltS. In the consideration of the origin of dermoid cysts it is found that many can be traced to defective coalescence of parts that either arise in Fig. 43. — A kitten pre- senting a double hare- lip, club hands with some digits suppressed, and a condition of the lower extremities akin to also a cleft-palate. The left eye was open at birth. From a photograph. MALFORMATIONS. 135 the embryo as paired processes, which in the normal condition form single median structures by fusing one to the other, or by similar want of complete obliteration of fissures, ducts, or passages that are present at certain stages of embryonic life but which disappear in the course of development. It will be found also that most of the congenital deformities which are of surgical interest arise by a still greater defect in the same developmental processes. It will be less fatiguing to study the majority of these defects in the same chapter instead of placing them in the sections dealing with special organs. They should be studied with the aid of a simple account of the normal development of the body. Congenital Defects of the Cerebro-spinal Axis. Congenital Hydrocephalus is due to distension of the ventricles of the brain with fluid, and is frequently associated with spina bifida. The distension of the brain entails great enlargement of the skull. In pronounced cases the greater part of the skull is membranous at birth. In such cases the foetus perishes during birth from compression and rupture of the brain. In more moderate cases the child may be born alive and then for years the head may continue to enlarge until it reaches a very great size, or, on the contrary, the condition may remain of moderate degree. If we compare congenital with acquired chronic hydrocephalus it might be expected that the former, like the latter, would be due to blockage of the foramen of Magendie, or of the iter, etc., that is, a stoppage in the drain- way from the lateral ventricles. Cerebral Meningocele is a protrusion of the meninges of the brain through an aperture in the skull. This condition is a possibility, but on dissection of congenital cysts of the cranium that in life are diagnosed as meningoceles, it is nearly always found that their cavity is continuous with that of one or more of the cerebral ventricles, and that they are lined with ependyma resting on pia mater, with a little brain matter intervening near the aperture in the skull. They are thus for the most part 136 SURGICAL PATHOLOaY. syringo-encephaloceles/ comparable to the syringomyeloceles about to be described in the spinal region, and may be regarded as cases of partial hydrocephalus. They are covered externally with skin, which may be extremely thin over the convexity of the cyst, and under this by a layer of fibrous tissue continuous with the pericranium and dura mater. Internal to this, as stated above, is a lining of pia mater and ependyma. The favourite sites for these cysts are the foramen magnum, the posterior fontanelle, and the root of the nose. When they are small they are compatible with survival to adult life, when large they usually cause death from ulceration and meningitis. They are to be distinguished from cephalhsematomata and from hydrencephalocele. Spina Bifida is a congenital defect consisting in the failure of union of the laminae of one or more vertebrae associated with defective formation of part of the spinal cord or its membranes. Six grades of the deformity may be recognized. Myelocele. The medullary groove remains open in the region affected. What should be the epithelial lining of the central canal of the cord covers a more or less oval area which, in the living child, looks like a capillary nscvus in the middle line of the back. The central canal opens at the upper end of the area, and from the opening the cerebro-spinal fluid drains away and thus causes death in a short time. This form of spina bifida is not so rare as once was thought. Syringo-myelocele. The central canal is dilated in the affected region, the dilated cord is thinned and adherent to the skin in the middle line. This condition is not amenable to treatment. If the meninges are distended with fluid around a syringo- myelocele, the condition is termed syringo-meningocele. Meningo-myelocele. The spinal cord is formed without marked dilatation of the central canal, but remains attached to the surface epiblast in the middle line. The meningeal space is dilated, and thus a tumour is formed. This variety of the spina bifida may often be diagnosed by a median depression which marks the adherence of the spinal cord. In meningo-myelocele some cures have been effected by injection of a fluid ^ containing ^Gr. fiyrinx -tnhe, encepJialon -hreim, ^wYo.s = hollow. -Morton's. - MALFORMATIONS. 137 iodine (gr. x.), iodide of potassium (gr. xxx.), and glycerine (^j.). Plastic operations have been successfully performed. Frequently there is congenital angular or lateral deformity of the spine associated with this and other forms of spina bifida. Patients who suffer from spina bifida are frequently partly or wholly paraplegic owing to inflammatory changes in, or defective structure of, the part of the cord or the nerves involved in a spina bifida. Meningocele is a protrusion of the spinal membranes without the cord or nerves through the defective part of the spine. A meningocele may protrude through the normal aperture at the back of the sacrum. They are commonest in the sacral region. Sometimes they have been observed to form pedunculated cystic tumours. Spina Bifida Occulta is the slightest degree of the malforma- tion. The vertebral arches are defective, but there is no tumour because there is no protrusion of cord or meninges, but usually a small scar marks the site of the defect. On the skin around this scar a growth of hair like that of the head occurs, and often it is this striking phenomenon that causes parents to bring their child to the doctor. Even in spina bifida occulta changes in the cord and nerves may show themselves by the formation of a perforating ulcer of the foot, paralysis of the sphincters of the anus and bladder, spastic paraplegia, etc. Congenital Defects of the Alimentary Tract. Hare-lip and Cleft Palate. These deformities arise from arrest of development of parts of the embryo which go to form the face and buccal cavity. In order to understand them, a little study of development is required. It will be remembered that in the early stage of the folding of the embryo from the rest of the ovum, the head forms a blunt elevation (head -fold), and is without mouth or nose. The formation of the mouth begins before any of the parts of the face appear, as a depression {stomodceum) at the under aspect of the head-fold, and deepens until it meets the upper end of the intestine which constitutes the pharynx. About the eighth week the tissues at the line of 138 SURGICAL PATHOLOGY. meeting disappear as if by pressure-absorption, in the form of a vertical slit, which constitutes the aperture of the fauces. The formation of the nasal fossae begins about the same time as the mouth. The nasal fossae are at first widely separated, and do not communicate with the mouth. The building up of the face begins by the formation of one median (fronto-nasal) and two lateral (maxillary) processes which grow out from the embryonic head around the stomodseum. The single median process arises on the dorsal aspect of the mouth, grows down- wards and forwards, putting out two lateral processes which pass between the rudimentary eye and the outer side of the nasal pit on each side; meantime, from the outer angles of the median part of the frontonasal process grow out to form and deepen the inner part of the nasal pits, which are thus converted into deep grooves which open behind into the mouth. The middle part continues to grow and forms the upper lip, and more deeply, the premaxillary processes from which the upper central incisors are subsequently developed. At the same time that the nose and the middle part of the upper lip, etc., have been forming, the two maxillary processes grow forward from the sides of the mouth, closing in the floor of the nasal fossse, and fusing with the lower end of the fronto-nasal process, thus completing the formation of the upper lip superficially and deeply, joining the premaxillary processes, and completing the ■ rudimentary upper jaw. If tlie front of the maxillary process fails to unite with the middle part of the upper lip (derived from the fronto-nasal process), hare-lip is the result, and is single or double according as the failure is present on one or on both sides. If the deeper part of the maxillary process fails to unite with the premaxillary process, a complicated hare lip results, as described below. The roof of the mouth, or palatine arch, which separates the mouth from the nasal passages, is derived from two horizontal processes which spring from the deeper and inner part of the maxillary process. If these palatine plates, from which the hard and soft palates and the uvula are formed, fail to unite, cleft palate results. The cleft may b6 partial, e.g. there may be only a bifid uvula, or a bifid uvula MALFORMATIONS. 139 and cleft of the soft palate, or the whole palate may be cleft. With complete cleft palate, maxillo-interraaxillary clefts and hare-lip on one or both sides frequently co-exist. The forma- tion of the septum between the nasal fossae occurs as an outgrowth from the premaxillary processes. In this outgrowth the vomer is developed, and hence in cleft palate with a double intermaxillary cleft, the central incisors ajjpear at the extremity of the nasal septum. Imperforate Pharynx. This term is applied to a condition in which the pharynx, instead of being continuous with the oesophagus, ends blindly about the level of the cricoid cartilage, and is connected with the oesophagus only by a solid fibrous cord. The oesophagus in such cases opens into the trachea. This defect is incompatible with life, though the infant has been known to live for thirteen days without any food entering the stomach. 1 The origin of this deformity has some connection with the formation of the pulmonary diverticulum from the part of the alimentary canal that becomes the oesophagus. Instead of the pharynx being imperforate, there may be a narrowing opposite the cricoid. In such cases a pouch forms from the pharynx between the oesophagus and the spinal column. Such a pouch may fill with food, and cause difficulty in swallowing by pressing on the oesophagus. In some patients severe symptoms have not shown themselves until mature or even advanced age has been reached. Meckel's Diverticulum. The formation of the alimentary canal takes place by the closing of the edges of a groove on the under surface of the embryo. The last part of this groove to close is at the umbilicus, where the vitello-intestinal duct joins the intestine. This duct normally disappears by absorp- tion right up to the intestine. The atrophic process is sometimes excessive, extending to the bowel, and producing at the site of the junction of duct and intestine a narrowing or an oblitera- tion of the gut. In the latter case there is a congenital intestinal obstruction. If the disappearance of the duct only occurs at the navel, there is produced a congenital pouch communicating ^ C. Kessick Bower, British Medical Journal, March 6, 1897, p. 586. 140 SURGICAL PATHOLOGY. with the intestine — this pouch is termed a Meckel's Diverticulum. It may either lose its connection with the navel or remain attached there. If it remains attached it may either he closed^ or remain open on the surface as a congenital fsecal fistula. Or, again, the middle part of the duct may disappear, and the outer part remain open at the umbilicus as a blind fistula. From the latter adenomatous tumours may develop. Fig. 44. Fig. 45. Fig. 44.— An average case of imperforate anus. The rectum ends blindly opposite the tip of the coccyx. There was no anal depression in this case. Fig. 45. — The pelvic outlet from a case in which the rectum ceased opposite the upper end of the uterus to which it was attached. The ischial tuberosities are close to one another and to the tip of the coccyx. Imperforate Anus. Just as the mouth becomes continuous with the anterior (or upper) extremity of the alimentary canal by the oval depression becoming continuous with the pharynx at the fauces, so the lower end of the canal at first closed is opened by its meeting a depression of the surface of the body, and the subsequent disappearance of the tissues which separate the depression of the surface from the lumen of the bowel. The depression (p-ododceum) is at first common to the bowel and uro-genital passages, but later by the meeting of lateral pro- cesses across the middle line the perineum is formed. Various degrees of the imperfection occur at the lower ex- tremity of the bowel, and may be tabulated. ^For some possible effects of a Meckel's diverticulum, see the sectioii OQ "Intestinal Obstruction." MALFORMATIONS. 141 1. The rectum and anus are continuous, but there is a narrowing at their junction. 2. The margins of the anal depression may become coherent, forming a membrane continuous with the surface of the skin. 3. In some cases only the anterior and posterior lips of the anal depression become coherent, so that the anus is divided into two lateral openings. 4. The anal depression and the lower end of the bowel are both developed, but the tissues between them (proctodeal mem- brane) fail to undergo absorption. The septum can be seen bulged downwards by pressure of meconium. 6. The anal depression may either be as in (4) or altogether absent, and then the lower part of the bowel may open in an abnormal direction — (a) into the vagina, (b) into the bladder,^ (c) into the urethi'a, (d) at the raphe of the scrotum or elsewhere. 6. The anal depression may be present or absent, but the lower part of the rectum may be un- developed, as shown in Figs. 45 and 46. Formerly it was the practice in these cases to seek for the blind end of the rectum by passing in a trochar in front of the coccyx. The effect in cases where the lower part of the rectum is undeveloped is shown in Fig. 46. The trochar traverses a part of the peritoneal cavity. When the trochar is removed meconium escapes into the peritoneum, and fatal peritonitis results. There is an important indication by which the surgeon may surmise the graver defect of development, viz. in cases where 1 In this condition cystitis occurs soon after birth, i.e. when bacteria have gained access to the intestine. Fig. 46.— The rectum, bladder, etc. in a case in which there was no development of the lower part of the rectum. The anal depression was present and a trochar is represented to show what would have been the effect of exploring with this instru- ment. 142 SURGICAL PATHOLOGY. the lower part of the rectum is absent the parts at the pelvis outlet are crowded together as shown in Fig. 45. In an average case of imperforate anus, such as that shown in Fig. 44, the ischial tuberosities and the pubic symphysis and coccyx have the normal degree of separation. Congenital Defects of the Penis and Bladder. Epispadias and Hypospadias. After the division of the common cloaca into two parts by the formation of the perineum the anterior division or uro-genital aperture is for a time alike in both sexes, and has the form of a narrow vertical slit bounded in front by a prominence, the rudimentary penis or clitoris. The lips of the slit which in the female remain as the nymphae, in the male unite to complete the formation of the urethra. If this union fails completely the urethra opens at the back of the scrotum, and the two halves of the scrotum remain separate. This is complete hypospadias. Partial is more common than complete failure. Thus the part of the urethra that perforates the glans frequently remains open below, and not infrequently the urethra opens just in front of the scrotum, all the rest of the urethra remaining open. Epispadias is a condition in which the urethra remains open on its anterior or ventral aspect (named " dorsum " of the penis in surgical works). The defect seems to be of similar origin to that about to be described. Extroversion of the Bladder is a condition in which the bladder is open on the anterior aspect of the abdomen, the wall of which is deficient from the pubes to the umbilicus. The pressure of the intestines may push the bladder forwards so that its red mucous surface resembles a growth. The orifices of the ureters can be detected by their giving vent to jets of urine at intervals. In this condition the pubic bones and the insertions of the recti are separated by an interval. In the male epispadias is also present. The testes are usually retained. An explanation of the deformity has been suggested by Shattock, who believes it to arise from an excessive extension of the depression which forms the cloaca from which the anus and uro-genital sinus are MALFORMATIONS. 1 4 3 formed. If this depression extended up to the umbilicus and deeply into the base of the allantois which becomes the bladder, this grave defect would be accounted for. Congenital Malformations of the Female Genital Organs, Congenital Hypertrophy of the Clitoris. The clitoris may be as large as the corresponding organ in the male, and in such a case it may be difficult to decide whether a child is a female or a male with complete hypospadias. If in the latter condition the testes have descended into the halves of the split scrotum the distinction is readily made. If not, it may be necessary to make a closer examination to prove the presence or absence of the vagina and uterus. Atresia of the Vulva. The depression in the surface of the embryo for the formation of the anus and vulva may fail to form, or the anal part may be formed whilst the anterior part (tiro-genital sinus) is wanting. In the latter case the vulva ndll be absent. This condition has only been found in monsters. Persistence of Cloaca. Among the forms of imperforate anus (see p. 141) is one in which the rectum opens into the vagina. This is really due to incompletion of the recto-vaginal septum. Absence of the Urethra. This is due to a failure of forma- tion of the urethra, so that the bladder leads directly into a long narrow vestibule which opens into the vagina. In other words, there is a persistence of the uro-genital sinus. Imperforate Hymen. The hymen, which is placed at the entrance of the vagina in the normal virgin condition, may have the form of a crescentic fold with its free edge in front, or it may be a diaphragm attached all round just above the level of the meatus of the urethra. The latter condition is normal when there is a central perforation or slit, pathological when it is imperforate. Imperforate hymen results from the excessive formation of the hymen, which appears in the fifth month of intra-uterine life. An imperforate hymen is abnormally thick and tough. The condition may be overlooked until menstruation appears ; after this event at each period menstrual blood accumulates in the vagina above the hymen. Sometimes 144 SURGICAL PATHOLOGY. the latter gives way and the fluid escapes. More frequently the vagina becomes more and more dilated until it may fill the whole pelvis. Later, first the cervix uhen the body of the uterus becomes filled with blood. Eupture of the uterus or tube into the abdominal cavity, or septic inflammation following spontaneous rupture or operation may cause death. Atresia of the Vagina, etc. The vagina may be occluded by adhesion of its opposed walls in intra-uterine life, or there may be a complete absence of the vagina owing to the non-formation of the whole or the lower parts of the Mullerian ducts from which the Fallopian tubes, uterus, and vagina are developed. The vagina may be divided throughout by a vertical antero- posterior septum, the remains of the division between the two Mullerian ducts which normally coalesce in their lower parts to form the uterus and vagina. In the same way the not infrequent occurrence of a double uterus, or of a two-horned uterus, is explained. In the former condition the parts of the Miillerian ducts which should fuse together to form the uterus remain separate. In such cases the vagina may be divided by a septum, or it may be normal. In the uterus bicornis the failure of fusion aff"ects the parts of the ducts Avhich go to form the upper part of the uterus. Hermapliroditism.^ True hermaphroditism means the co- existence of testis and ovary in the same individual. This condition is a very rare one. Only two authentic cases of bilateral hermaphroditism (ovary and testis present on each side) have been recorded. Unilateral hermaphroditism (ovary and testis present on one side, the other side having one form of the gland) has been mentioned in one case. Lateral hermaphroditism (ovary on one side and testicle on the other) has been more frequently met with. Pseudo-hermaphroditism is a condition of the external organs so that they simulate those of the opposite sex. Congenital hypertrophy of the clitoris and complete hypospadias are ex- amples. Misplacement of the Testis. One or both testes may be found out of their proper place. If the organ is arrested at some ^ See Hart and Barbour, Manual of Gyncecology, 1886, p. 513. MALFORMATIONS. 145 point between its origin at the side of the lumbar spine in the abdomen and its normal destination, the scrotum, the condition is termed Retention (abdominal, inguinal, etc.). If the organ is found in some abnormal position away from the normal line of descent the condition is termed ectopia (Gr. e^ = out, ^opas = place). Various causes are given for retention and ectopia of the testis, and doubtless the condition may be brought about in several different ways. Thus arrest of growth of the spermatic blood- vessels or the peritoneum covering the testis would prevent its proper descent. The part attributed to the gubernaculum in drawing doAvn the testis is problematical. In a deformed child, which died shortly after birth, I found the thighs so doubled on the abdomen that the left inguinal canal was practically closed; the left testis was retained within the abdomen and suspended by a long mesorchium. In the same subject the left thigh had been so tightly pressed against the upper part of the right that the right testis after emerging from the external ring had passed outwards in the superficial fascia of the abdomen and lay close to the right anterior superior spine. The most important form of retention is that in which the gland remains within the inguinal canal (retentio inguinalis). Here it is often associated with a congenital hernia. On examining such testes in young adults with the microscope they are found not to contain spermatozoa, and hence to be functionally sterile. A retained testis may become inflamed from forcible action of the abdominal muscles, or the cord may undergo torsion or axial rotation, and the testis then swells from congestion, oedema, and finally undergoes gangrene. The symptoms of this condition may closely resemble those of strangulated hernia in the inguinal canal. The more important forms of ectopia testis are constituted (a) by the gland passing through the crural ring into the femoral canal, or [h) after passing through the inguinal canal, instead of entering the scrotum, going into the perineum. K PART II. DISEASES OF SPECIAL TISSUES AND ORGANS. CHAPTER VIII. DISEASES OF BONE. Some of the peculiarities of pathological processes in bone depend upon its hardness. Bone may be regarded as a vascular fibrous tissue, having a calcified matrix in which the bone cells and fibres are embedded. The vascular channels contain arteries, veins, and lymphatics supported by connective tissue. The effect of this peculiarity of structure may be readily imagined when compact bony tissue becomes the seat of septic inflam- mation. The tissue cannot swell to accommodate the eff'used cells and fluid which serve to dilute the solution of septic matter in inflamed areas of more lax tissues. The tension thus becomes greater, and the inflammatory process is less likely to subside, and necrosis of tissue is likely to be more extensive than in soft parts. When necrosis has occurred, the dead tissue being hard and almost mineral in character, the process of separation of the dead part of the bone from the neighbouring living part is more difficult than when necrosed parts are composed of soft tissue. In the case of the long bones it is not only the histological structure, but also the mode of growth that influences pathological processes. The most active parts of a long bone during the period of growth are the deeper layer of the periosteum and the extremity of the shaft where it abuts DISEASES OF BONE. 147 upon the epiphyseal cartilage, the "juxta-epiphyseal region" of Oilier, In both these situations new blood capillaries and new bone are being formed. We are therefore not surprised to find that these are the two parts of a long bone in which the struc- tural alterations are most marked in rickets, and that these are the more common situations for pyogenic organisms to lodge and set up acute inflammation in bone. The vascular marrow of bone is also of great importance from a pathological as from a physiological point of view. Strictly speaking, the contents of all the Haversian canals, as well as the soft tissue in the central cavity and spongy parts of bones, come under this designation. The more active or red marrow is one of the sources of red-blood cells which are formed from its connective-tissue cells. The marrow of the older (central) parts of bones, and in later life, the whole of the marrow of the spongy tissue becomes the seat of fat formation by the deposit of oil globules within the connective- tissue cells. Absorption as well as growth, is active in bone. When the conditions are suitable, the cells (osteoblasts) which line the marrow spaces fuse together^ forming multinuclear cells (osteoclasts), which digest the bone against which they lie, and form spdces with sinuous outlines. In this way bone becomes absorbed. The process occurs in chronic inflammatory processes of moderate intensity, which thus constitute rarefying ostitis, as it is termed. In old age, when all tissues of the body tend to atrophy, the absorption of bone often results in its becoming thin and porous. This condition is termed senile osteoporosis. In the case of the jaw and some other bones certain ^ This is Kolliker's view. It is also possible that single osteoblasts perform the same function (compare Fig. 53) ; just as in inflammation connective-tissue cells, whether they remain single or fuse together to form giant cells, may digest the pre-formed fibrous tissue, so bone cells, whether they form osteoclasts or remain single, may digest pre-formed bone. When a portion of bone has perished it is thus separated from the living bone, the part of the latter adjoining the dead bone being absorbed. Some of the dead bone itself, unless it is charged with septic matter, is also removed, just as are ligatures of catgut, etc., and in time even ivory pegs, though the latter have sometimes been found encapsuled in fibrous tissue long after insertion. 148 SURGICAL PATHOLOGY. anatomical relations render them liable to affections which do not originate in the bones themselves. Thus the teeth, from their diseases and errors of development, lead to many- abnormal conditions which demand separate consideration. Acute Suppuration in Bones. In considering the repair of fractures the liability of the fragments to be forced through the skin (compound fracture), and so exposed to contamination with pyogenic organisms was mentioned. Besides delaying union, such infection may be the starting-point of septic inflammation. Before antiseptic surgery was established it was common for septic inflammation of bone to follow amputations. Both in a compound fracture and after an unclean amputation all parts of the bone are exposed to infection. If in an amputation a long bone, such as the femur, has been divided, say, in the middle of the shaft, and pyococci have gained access to the wound, suppuration may occur (a) in the medullary cavity (osteomyelitis), (b) in and beneath the periosteum, and (c) in the compa,ct tissue which is attacked from below by the inflammation due to the original infection, and from within and without by inflammation spreading from the medulla and the periosteum respectively— the result being a more or less extensive necrosis, accompanied by the formation of new bone from the periosteum by "plastic periostitis." The patient is exposed to the risk of pyaemia, and suffers from pain in the limb during the months which are occupied in the separation of the sequestrum, as dead bone when shut in by living bone is termed. Spontaneous Acute Suppuration in Bone. The frequency with which slight suppurative affections of the skin, throat, and other parts occur renders it highly probable that micrococci frequently find their way into the blood and to various parts of the body including the bones. That this occurrence usually produces no marked disturbance of the general health is owing to the fact that in persons of average vitality the organisms are destroyed by the white blood cells, and the endothelial and connective-tissue cells. In less resistant individuals they may set up suppuration. Suppurative processes are more readily set up in children than in adults, and in accordance with this is the fact that acute infective inflammation of DISEASES OF BONE. 149 bones is more common in children than in adults, though by no means unknown in the latter. There is another important reason for the frequent occurrence of suppurative disease of bone in children. It is in early life that the common infective fevers or exanthemata usually occur. Whatever the unknown agents of these fevers may be they are probably living organisms. The inflammation of the throat which occurs in scarlet fever, measles, small-pox, etc., the vesicles, etc , of syphihs and chicken- pox, and the ulcers of typhoid fever may be given as examples of breaches of the surface observed in fevers which account for the entry of pyococci into lymphatics and so into the blood. The effect of the poisons of the specific fevers is to weaken the resistance of the cells of the tissues, and so to render it more likely that pyococci once in the blood should escape destruction and start suppurative processes. So common is acute suppuration in bones after specific fevers that such cases have been grouped together as examples of "exanthematous necrosis." Frequently only a single bone is affected, but too often the condition is but part of a general pyogenic infection — a pysemia — which affects the body generally. Staphylococci or streptococci are commonly the offending organisms. The Parts of the Bones Affected. As has been stated above, the most vulnerable parts of a growing bone are the extremities of the diaphysis and the deepest part of the periosteum. If suppuration starts in the former place it is usually termed acute epiphysitis, a term which is erroneous.^ The process begins close to the epiphysis, and, if the latter is ossified, soon extends to it. The central part of the medulla or even the compact tissue may be the original seat of infection. In reality it is often impossible to learn from clinical evidence exactly where the inflammation began, so rapidly may inflammation beginning in one part of a bone spread to another. In the flat bones especially is this the case. In Fig. 47 are represented the chief anatomical characters of a case of infective so-called epiphysitis. A brief consideration of the illustration just given is sufficient to show that in acute epiphysitis prompt measures are called ^ OUier's term is " juxta-epiphysitis." 150 SURGICAL PATHOLOGY. for if the infiltration of the whole shaft of a bone with pus, and consequent necrosis and possibly general pyaemic infection, are to be averted. With the trephine or gouge the medullary cavity of the bone must be freely opened. Fig. 47. — Vertical section through, the upper end of a tibia. The central part of the epiphyseal cartilage has been destroyed by suppuration. 1, A sequestrum surrounded by (2) pus which infiltrates the spongy bone of the shaft and which has destroyed the middle part of the epiphyseal cartilage, and at (3) has extended to the periosteum and formed a subperiosteal abscess. The most imjjortant Complication. When the epiphyseal line is within the cavity of a joint as at the upper end of the femur, the pus rapidly finds its way into the joint cavity and suppurative arthritis supervenes on epiphysitis. In such cases free opening of the joint and removal of the upper end of the femur can alone save the patient from death. Joints are also frequently infected by pus escaping into them from the epiphysis, through a perforation in the articular cartilaare. DISEASES OF BONE. 151 In some cases the extremities of the diaphysis are perfectly sound, and it is evident that the process either began in the central part of the medulla and extended to the periosteum or vice versa. In the case from which Fig. 48 was taken it is probable that the process began in the medulla. The bone lesion is frequently one of many pyaemic lesions, and the case may be hopeless from the outset. The Results of Septic Inflam- mation. The occurrence of ne- crosis has already been sketched. This event is so commonly observed in infective suppura- tion of bone that the older surgeons gave the disease the name of acute necrosis. Since necrosis is here an effect of septic infection, the terms in- fective ostitis or, when the distinction can be made, infective osteomyelitis or periostitis had better be adhered to. If the suppuration is limited to the deep layer of the periosteum, the process may end without pus be If the spreads necrosis, should the promptly evacuated. infective inflammation to the contiguous superficial part of the compact tissue and extends no farther, a superficial necrosis follows and the dead bone separates as a thin shell (see Fig. 49). This is exfoliation. When a portion of the shaft of a bone has undergone necrosis owing to acute osteomyelitis, new bone is formed from the Pig. 48.— Vertical section througli the left tibia of a child aged 10 months. 1, Upper end of ; 2, middle of the me- dullary cavity which was full of pus ; 3 and 4, extremities of the diaphysis which are normal ; 5, cavity of a sub- periosteal abscess. Note that the periosteum still remains attached at the posterior aspect of the bone. The patient died of pysemic abscesses of the lungs. (229 B.) 152 SURGICAL PATHOLOGY. periosteum, as described above under septic ostitis from trau- matism. This results in the formation of a sheath of new bone (involucrum) perforated by apertures (cloacce = drains), where pus has escaped, as shown in Fig. 50. The operation of chiselhng away sufficient of the sheath to allow of the removal of a secjues- trum either entire or after sub- division is termed seqiiestrotomy. When the whole of the shaft of a bone rapidly undergoes necrosis from septic inflamma- tion the periosteum is separated from the bone by pus save where strong muscles are attached and Fig. 49. — A thin super- ficial portion of the shaft of a femur exfoliated as the result of suppurative periostitis. Fig. 50. — The lower end of the femur of an adult (1). 2, Sequestrum, the upper end of which is tapering and presents the "worm-eaten" appearance of dead bone after natural separation from living bone ; the lower end includes the whole thickness of the original bone, and it has been chiselled away in an attempt to remove the sequestrum (probably before the introduction of anjesthetics). 3, Sheath of new bone formed from the periosteum, with two cloacse. (226) ligamentous fibres enter the bone as "perforating fibres." In such circumstances it may be necessary for the safety of the patient to remove the shaft of the bone at once before any DISEASES OF BONE. 153 new bone has had time to form from the periosteum. This operation is termed " sub-periosteal resection." After both sequestrotomy and sub-periosteal resection the new bone formed from the periosteum has been found to be sufficiently strong to perform the functions of the original bone, and in some cases the new shaft has even been stronger than the original. Acute septic inflammation of bone is by no means limited to the long bones. It is not infrequent in flat bones, such as the ileum and scapula, and it has been observed in the vertebrae. See also "Diseases of the Jaws." Tuberculosis of Bone. Bone is frequently the seat of tuber- cular infection which usually occurs in the cancellous tissue. The histological changes are the same as those of tuberculosis in other tissues with the addition of the effect of the tubercular granulation tissue upon the special tissue. If the process is of moderate severity the bone is absorbed by osteoclasts as the tubercular infection extends peripherally on all sides from the original point of infection. Thus the bone is rarefied, and the process is termed rarefying ostitis or caries (L. = decay). The older part of the tubercular focus either breaks down into pus forming a chronic abscess or undergoes caseation. If the necrotic material is insignificant in amount, it may be removed by phagocytosis as fast as it is formed ; in this case the process has been termed dry caries {caries sicca). The deposit of tubercle may be either spread over a wide area of the medulla {diffuse infiltration), or it may be limited to a small area {circumscribed infiltration). Tuberculosis in the interior of a bone, apart from the destruction eff"ected in the tissues occupied by the tubercles themselves, causes the formation of more or less vascular granulation tissue, which has the result of rarefying the bone. While this "rarefying ostitis" is in pro- gress in the interior of the bone a new formation of bone may occur from the periosteum. In this way a swelling of the bone will arise, and may simulate the effects of a central sarcoma, etc. If the bacilli increase too rapidly for the bone to be absorbed pari passu with the extension of the tubercular tissue, then that part of the bone which is contained within the hollow sphere of tubercular tissue undergoes necrosis from thrombosis of 154 SUEGICAL PATHOLOGY. its vessels, the walls of which are attacked by the bacilli. If the disease, either from improved health on the part of the person affected or from diminished activity on the part of the bacilli, should become less rapid, then the portion of bone that has perished in the more rapid period of the disease may become separated by rarefaction taking place outside it when the disease has slowed down. It is then termed a tubercular sequestrum (see Figs. 51 and 52). The condition shown in Fig. 51 has been termed "caries necrotica." The term is not a very good one since most tuber- cular processes are associated with more or less necrosis, but it serves to recall the fact that formerly the terms caries and necrosis were used in contrast, the former referring to the slow absorption of bone without the formation of sequestra, and the latter designating any process which led to the formation of sequestra of dimensions not readily overlooked by the naked eye. The importance of recogniz- ing the presence of a sequestrum in tubercle of bone may be as great as it is in acute suppurative conditions : this is shown in Fig. 52, which also shows condensa- tion or sclerosis of bone (Gr. skleros = h&rd}. Sclerosis may re- sult from any form of chronic ostitis that is too slight to cause rarefaction. In sclerosed bone the Haversian canals and other marrow-spaces are narrowed. The extremity of the diaphysis has been indicated as a common situation for infection by ordinary pyogenic organisms, and it is also for tubercle bacilli. In the hip-joint and in other situations where the epiphyseal cartilage is situated within a joint-cavity this often leads to the infection of the synovial Fig. 51. — Vertical antero-posterior section through the lower end of a femur. 1, A tubercular sequestrum still covered by part of the articular cartilage aud lying in a cavity lined by tubei-cular granulation tissue ; 2, articular surface of the femur, from which much of the cartilage has been removeii by granula- tion tissue which has invaded the joint cavity from the bone. DISEASES OF BONE. 155 membrane and the rest of the joint surfaces. Such cases will be referred to again in connection with the diseases of joints. vvi m /^r \y Fig. 52. Fig. 53. Fig. 52. — Section through a tibia showing a sequestrum surrounded by sclerosed bone. The cavity in which the sequestrum lies is lined by granulation tissue. It communicated by a sinus with the exterior. The shaft of the tibia is thickened in the lower half and elongated so that it is curved forwards and had forced the foot into the position of equino- varus. ;j nat. Fig. 53. — 1, One of two tubercles ; 2, surroimding- granulation tissue ; 3, one of two spicules of bone undergoing resorption. In this spicule the osteoblasts appear to be removing the bone ; in the other below and to the left of it erosion by osteoclasts is ia progress. 4, Part of the epiphyseal cartilage becoming absorbed by granulation tissue, x 150. Cuboidal bones, such as the bodies of vertebrae, the carpal and tarsal bones, are all common situations for tuberculosis. Tuberculosis of the spine will be dealt with separately in the 156 SURGICAL PATHOLOGY. section on "Diseases of the Spine." Fig 53 shows the histo- logical structure of tubercular osteomyelitis. Syphilis of Bones. Syphilis affects the periosteal aspect of bone more commonly than the spongy tissue, thus affording a contrast with tubercle. It is in the late period of the acquired disease that serious syphilitic bone lesions are apt to occur, though transient pains may be present in the secondary period. Bone-lesions are common in the early months of life in congenital syphilis, and late lesions also occur. In the earlier syphilitic inflamma- tions of bone in congenital syphilis, not only the periosteum, but also the diaphysis in the region of the epiphyseal cartilage and this cartilage itself are prone to suffer. An admirable example of both periostitis and epiphysitis is shown in Fig. 54. The chief symptoms of syphilitic epi- physitis (or osteo -chondritis) are helpless- ness and wasting of the limb, and they have gained for the affection the name of " pseudo-paralysis." The child from which the specimen shown in Fig. 54 was obtained by H. S. Collier, died from " marasmus " at the age of eight weeks ; it had been treated with mercury, and the condition of the bones had somewhat improved. The histological appearances of the same humerus are shown in Fig. 55. The slighter degrees of syphilitic osteo-chondritis may occasion little pain or interference with movement, but are evidenced by the formation of ring-like thickenings at the epiphyseal regions of the femur, tibia, humerus, clavicles, ribs, and other long bones. The swellings are usually symmetrical, but are not so widespread as those of rickets. Fig. 54.— Vertical antero- posterior section through the humerus of an infant aged eight weeks. The lower half of the shaft is thickened by (1) a deposit of new bone (ossified node) from the periosteum. The proliferat- ing zone of the epiphysenl cartilage has been destroyed t>y (2) granulation tissue which springs from the lower extremity of the diaphysis and extends through the synovial mem- brane into the elbow joint. (290 A.) DISEASES OF BONE. 157 In this case the periostitis led to bone hyperplasia, while the osteo- chondritis resulted in the destruction of bone and cartilage by granulation tissue, and extension of inflammation into 2 1 Fig. 55. — A part of a section of the bone shown in Fig. 53. 1, Remains of the old compact tissue of the sliaft ; 2, newly formed periosteal bone con- stituting the thickening or node on the shaft ; 3, granulation tissue replac- ing the bone marrow and the proliferating layer of cartilage ; 4, marrow with dilated blood-vessels and inflammatory infiltration ; 5, cavity of the elbow joint ; 6, cartilage of the epiphysis ; 7, part of a newly formed marrow space in the cartilage; '8,' is placed between the fibrous capsule of the joint and the synovial membrane which is converted into granulation tissue ; 9, one of three islands of cartilage newly formed from the periosteum ; 10, island of epiphyseal cartilage that has escaped destruction by the granulation tissue ; 11, cells of the cartilaginous epiphysis proliferating towards the shaft. X 30 diams. the joint. Thus the changes are, like other syphilitic lesions, of varying degree. The slighter grades of syphilitic osteo-chon- dritis are very commonly met with in the bodies of syphilitic 158 SURGICAL PATHOLOGY. infants who are either born dead or die soon after birth. The lower end of the femur is a frequent site for the disease. A section in a case of slight severity will reveal an irregularity at the epiphyseal line owing to irregular and excessive develop- ment of the advancing blood-vessels at the extremities of the shaft into the epiphyseal cartilage. The latter also shows an excessive proliferation of its cells towards the shaft. Both these changes occur in rickets, as will be more fully discussed in the next section. An increase and irregularity in the calcification of the proliferating layer of the epiphyseal cartilages is also observed. The most severe cases present foci of gummatous softening in the medulla. The skull bones are apt to be affected by syphilis. If of moderate degree of intensity the disease causes diffuse nodes on the bones. In congenital syphilis this occurs most commonly in the neighbourhood of the anterior fontanelle where the sagittal, frontal, and coronal sutures make four right-angles, and when syphilitic nodes form in this situation the appearance of a hot- cross bun is roughly simulated. The condition is known as " Parrot's Nodes." If the process is more rapid in infants instead of thickening absorption of bone occurs; areas of the vault of the skull may become so thin that they can be pressed iu by the fingers. This condition is termed craniotabes. In the acquired disease diffuse thickening of the frontal bones occurs on the inner surface, sometimes causing persistent headache. Periosteal lesions of more rapid formation constitute at first fibrous nodes which either ossify or break down into gummata. Such gummata may extend and involve the skin, causing ulcers in the base of which bone is exposed to the ordinary pyogenic and putrefactive organisms. Thus a double pathological pro- cess is initiated, and suppuration supervenes on syphilitic ostitis. This double infection is of the highest importance in the case of the bones of the skull, since suppuration is liable to spread to the meninges and the brain. After syphilitic necrosis the process of separation of the dead bone is extremely tardy, years sometimes being required before the dead bone is completely free. This is partly accounted for by the progressive spreading of the disease to new areas before there is time for separation to occur. DISEASES OF BONE. 159 Or again, whilst in some part of the area of bone which is the seat of the disease the process is sufficiently active to determine absorption by osteoclasts {rarefying ostitis), at another part there is less pathological activity, so that only osteoplastic changes occur. In this way an area of bone may be separated at one part, and at another remain attached by an isthmus of living bone which serves to transmit blood to, and to keep alive more or less of the partially separated segment, which is then termed a "living sequestrum." Thus syphilis, like tubercle, produces in bone anatomical changes which vary according to the intensity of the reaction of the tissues to the virus of the disease. No- where is this shown better than in the skull-bones. Occasionally nearly the whole skull-cap is removed by what may be termed a dry syphilitic caries, and that without any implication of the skin. Any bone may become the seat of syphilitic inflammation. Destruction of the vomer and other bones of the nasal fossa leads to the sunken nose. Tubercular disease of bone frequently, as has been shown above, leads to joint disease; so occasionally does syphilis. An example of this has been given in Fig. 54. And now and again in adults gummata form in the bone and lead to syphilitic joint disease. This will be discussed more fully in treating of joints. Rickets of Bone. Before considering the changes produced in bone by rickets it is to be remembered that this disease affects the alimentary tract and the whole organism as well as the bones. The abdomen is distended, the liver and spleen enlarged, muscles are weak, and there is often marked nervous irritability. Before the bones become altered sufficiently for the most prominent sign of rickets — the enlargement about the epiphyseal regions — to be produced, there is a condition of hyperemia or congestion which has been observed on post-mortem examination, and of which there is sometimes evidence during life in tenderness of bones. When the extremities of the bones have become enlarged the malady has existed for some time. To appreciate the kind of change that exists in rickets a normal bone may be com- 160 SURGICAL PATHOLOGY. Fig. 56. Fig. .57. Fig. 56. — Vertical section of a normal tibia. 1, Diaphysis of the tibia ; 2, translucent zone of proliferating cartilage— below it is a narrow white zone, that of calcification of cartilage matrix, and below this zone of calcification again is the uppermost part of the diaphyseal ossification. The three zones together make a layer not more than ^t in. in depth. Fig. 57. — Vertical section of a rickety humerus. 1, Zone of proliferating cartilage s:reatly increased in depth and prolonged below into processes, some of which have been cut off from the original layer to form islands of cartilage ; 2, a layer corresponding to the layer of calcification of cartilage in normal bone and in rickets consisting of vascular marrow, uncalcified cartilage, and uncalcified bone or osteoid tissue ; 3, the uppermost part of the diaphyseal ossification much increased in vertical depth. The surface of the shaft shows changes in the greater porosity and vascularity of the superficial part of the compact tissue. Macerated specimens of bones removed during the active period of rickets show a rough surface. When the disease has come to an end the smooth hard surface returns. Nat. size. (244 a.) DISEASES OF BONE. 161 pared with one that presents marked rickety enlargement, as shown in Figs. 56 and 57 respectively. The enlargement at the ends of the long bones is fully accounted for by the increase in amount of tissue at the epiphyseal line, and in a severe case Fig. 58. — Vertical section of a normal humerus at the epiphyseal lino. 1, Fibrous layer of periosteum ; 2, cellular layer of the same ; 3, cartilage of the epiphysis ; 4, zone of calcification of the cartilage matrix ; 5, cartilage cell-groups at the layer of commencing vertical proliferation ; 6, scalariform groups of cartilage cells ; 7, dilated capillary in one of the uppermost pro- longations of the marrow-spaces of the diaphysis ; 8, bone of the diaphysis. Undecalcifled and unstained preparation, x 40. like that from which the humerus (Fig. 57) was taken the greater part of the enlargement is found to consist of soft tissue; fine bony spicules can however be felt in the layer (3) by drawing the finger over the cut surface. On pressing upon L Fig. 59. — Vertical section of a rickety humerus at the upper epiphyseal line. 1, Fibrous layer of periosteum ; 2, cellular layer of periosteum : 3, cartil- age of epiphysis ; 4, maiTow fomied from the cellular layer of periosteum, increased in amount and containing an increased number of blood-vessels which are dilated and full of blood (congestion) ; 5 (as in Fig 58), cartilage cell-groups at the layer of commencing vertical proliferation. From this layer to the lowest part of the figure irregular and large groups of cartilage cells are present. They represent the limited scalariform groups In the normal bone, and show that the whole of this Fig. below the line marked 5 represents the part of Fig. 58 between the lines 5 and 7. 6, Irregular marrow- spaces containing many tortuous vessels ; V, bone of the shaft corresponding to the uppermost part of zone 3 in Fig. 57. Above, 7 passes into osteoid tissue, and the latter again into calcified cartilage ; the matrix of the cartilage is not represented save where it is calcified, and then it is shown by dark lines. Unstained section of an undecalcified bone, x 40. DISEASES OF BONE. 163 the head of this humerus the soft tissue of the surface of the enlargement bulged outwards. Examined under the microscope the appearances of the normal and of the rickety bone are shown in Figs. 58 and 59. The histological changes which lead to the formation of swellings at the junction of the ribs with the rib- cartilages (Fig. 60) are precisely similar to those described above. 12 3 Fig. 60. — Portions of three ribs at tlie junction of shaft and costal cartilages. The " beading " is more marked on the pleural than on the superficial surface, owing to the sinking in at the junction of cartilage and bone. A section has been made through one of the ribs, and it shows zones 1, 2, 3 similar to those shown in the humerus in Fig. 57. In severe rickets marked changes occur in the bone of periosteal formation. This is more porous than the normal bone in texture. In Fig. 57 the superficial layer of periosteal bone is somewhat more porous than is normal. Sometimes the change in the periosteal bone is more marked than at the epiphyseal line. When this is the case there is a great de- ficiency of lime in the periosteal bone. Much of it is osteoid tissue. Occasionally in rickets islands of hyaline cartilage are formed from the periosteum. In rickety animals the formation of subperiosteal osteoid tissue is often very marked (see Fig. Gl). In membrane bones, such as those of the skull, changes similar to those described above occur in periosteal bone. This is especially noticeable at the sutures of the skull, where distinct thickenings from the formation of porous bone and osteoid tissue may occur. When this formation of bone occurs over a con- siderable area of the skull, the latter has a resemblance to the " hot-cross bun " nodes of congenital syphilis. 164 SURGICAL PATHOLOGY. Fig. 62. Fro. 61. — Section through the humerus of a rickety monkey. The peri- osteal osteoid tissue (1) is very abundant, and its yielding character is shown by the depressions (2) made where the bone had been surrounded by a loop of thread used to suspend the jsreparation. The head of the bone is bent on the shaft, and there is a sharp bend in the shaft. Nat. size. Fig. 62. — Represents, on an enlarged scale, a metacarpal bone at birth. The part of the shaft of endochrondral formation is shaded. The bone formed from periosteum is white. The ingoing arrow points to the medullary canal which traverses the part of the shaft formed from peri- osteum, and is directed towards a star which marks the centre of growth in the bone. The outgoing arrows mark the directions of gi-owth. The small figure within the larger one shows the same bone at an earlier period of life. It will be seen that any irregularities of outline in the smaller bone might readily be overcome by variations of the rate of growth in any particular direction. Modified from Kassowitz. DISEASES OF BONE. 165 The practical bearings of the pathological anatomy of rickets are simple. Whilst the disease is in progress and the bones are soft, deformities are to be treated by splints. When the disease has ceased and the bones have become hard, osteotomy is necessary for the correction of deformity. Slight deformities have frequently been ob- served to disappear during the growth of a child. This at first puzzling phenomenon is readily understood when the nature of the growth of a long bone is remembered, as is shown in Fig. 62. In order to make clear the exact meaning of the term "osteoid tissue" it is necessary to refer to some points in the normal ossifi- cation. The processes which take place at the epiphyseal line in normal conditions may be con- sidered first, as shown in Fig. 63, which shows a combination of metaplasia and neoplasia in the ossi- fication of remains of the epiphyseal cartilage and in the formation of new bone on each side of them. Metaplasia is the trans- formation of one kind of tissue into another by a modification of the cells and intercellular substance of the pre-existing tissue, e.g. the ossification of cartilage in Fig. 63. Neoplasia is the replacing of one tissue by another that invades and destroys the pre-existing tissue, as does the vascular marrow by sending processes of new blood capillaries and cells which Fig. 63. — Represents on a larger scale the capillary marked 7 in Fig. 58, and at 1 the adjoining bone and remains of the cartilage. The latter contains seven cartilage cells, one of which (2) has formed around it a thick new- capsule. This capsule becomes ossified by the deposit of grariLiles of lime salts, similar to those in the cartUago matrix on its left, whilst the cartilage cell remains as a bone-corpuscle. Thus some of the cartilage becomes directly trans- formed into bone. This is tei-med metaplastic ossification. It has but little part in the forma- tion of the shaft of the permanent bone. On the outer surface of the remains of the cartilage new bone (3) is deposited from the marrow. This has been tenued neoplastic ossification, x 200. 166 SURGICAL PATHOLOGY. replace the greater part of the epiphyseal cartilage at its pro- liferating zone, in endochondral ossification. In rickets, instead of the regular scalariform groups of cartilage cells arranged in a definite zone, there are large collections of cartilage cells irregularly scattered over a wide area, and intersected by irregular marrow spaces. The formation of osteoid tissue from this hyperplastic cartilage is shown in Fig. 64. Fig. 64.— At the upper part of the section are distorted cartilage cells lying in large spaces of the matrix. Below these are cartilage cells surrounded by matrix altered in appearance from its taking the stain more deeply than the normal matrix of hyaline cartiLage. This change would, in ordinary circumstances, he accompanied by the deposit of lime salts, and the cartilage cells it contains would be transformed to bone- corpuscles (metaplasia), as described in normal bone, and shown in Fig. 63. It is, in fact, unossified bone (osteoid tissue) of metaplastic origin. In the lower part of the figure at 1 is a space contaming a blood capillary and some marrow cells. Some of the latter are embedded in the matrix that suiTounds the space. This, in normal conditions, would be bone of neo- plastic formation ; here it is osteoid tissue, x 200. Formation of osteoid tissue from the periosteum is not infrequently observed in rickets, as shown in Fig. 65. When recovery from rickets takes place the osteoid tissue calcifies and becomes hard bone. Osteoid tissue then is simply uncalcified bone. It is found in the callus of fractures, in osteo-chondromata and other conditions as well as in rickets. DISEASES OF BONE. 167 Excessive resorption of bone is observed in the active stages of rickets, rendering the bones unusually porous. When this rarefying process is pronounced the compact tissue may come to resemble the cancellous tissue. This also predisposes the bones to fracture. Fig. 65. — 1, Fibrous layer of periosteum ; 2, cellular layer of the same. 1 and 2 are, for convenience, represented as being much narrower than they are in reality. 3, Osteoid tissue formed from the periosteum ; 4, bone formed from the periosteum. Figs. 63 and 64 are taken from sections of an undecal- cifled rickety bone, stained with picro-carmine. x 250. The Gross Effects of Rickets are usually most marked in the bones of the lower extremity owing to their having to sustain the weight of the body when the child begins to walk. Some of the commoner curves are shown in Fig. 66. Outward bending of the knee, genu-varura, is much less common than genu-valgum. In severe cases all the long bones may become curved. On making sections of such curved bones it is noticed that the shaft is thickest in the concavity of the bend (Fig. 67). This may be accounted for by remembering that the gradual bending of a bone may be regarded as the result of a series of minute green-stick fractures; and just as 168 SURGICAL PATHOLOGY. the callus of a green-stick fracture is more marked in the receding angle (see Fig. 68), so in rickets, as the bone bends Fin. 66.— The luwcr limbs of a girl aged seven, sLuwing, oil the left side, marked curving of the tibia, flat-foot, and curving of tlie femur ; and on the right the deformity known as knock-knee or "genu-valgum." From a photograph. the periosteum becomes relaxed on the concave side, and thus the formation of new tissue is more abundant there ; for the DISEASES OF BONE. 169 blood-vessels are less stretched than on the convex side, and hence the nutrition is better. Serious deformity is caused by the yielding of the soft bones in rickets. In this way rickety knock-knee and bow- legs are produced. Again the weight of the body may cause the soft tissue in the neck of the femur to give way, allowing the head of the femur to be Fig. 67. — A section of a rickety femur. The head is dei^ressed one inch and a half below the level of the top of the great trochanter, instead of being well above it. J nat. (247.) Fig. 68. — Section through the radius of an infant. There is a greenstick fracture. In the concavity of the bend there is a forma- tion of callus, part of which is a translucent bar of hyaline cartilage. (83.) depressed and giving rise to the deformity known as coxa vara (see Fig 67). The spine is often deformed. A C-shaped backward curve involving the whole spine is the commonest, but sometimes 170 SURGICAL PATHOLOGY, lateral curvature occurs. The skull may become flattened on the crown and the frontal and parietal eminences bulge out. This gives the face a dwarfed appearance. The thorax sinks in at the junction of ribs and costal cartilages, thus producing pigeon-breast. The pelvis may become flattened. The Nature of Rickets. The changes in the bones may be briefly summed up as follows : a stage of congestion is followed by hyperplasia of cartilage, vascular marrow, and often of periosteal bone. This hyperplasia is accompanied by defective calcification. These changes are best described as inflammatory in character. Comparing this hyperplastic osteo- chondritis, as the process which results in the thickenings at the epiphyseal regions may be called, with the slighter degrees of osteochondritis of congenital syphilis (see p. 156), a close histological resemblance is seen. There is the same hyperplasia of the proliferating layer of the epiphyseal cartilage and of the vascular marrow, but there is a diff'erence in that the calcification of cartilage is increased in syphilis, whilst it is diminished in rickets. Another disease, osteo-arthritis, that aff"ects bones and gives rise to inflammatory hyperplasia will be described in considering the joints. That the morbid processes of rickets is due to disorder of nutrition is hardly to be doubted. The symptoms of gastro-intestinal disturbance that accompany the disease, and the capacity of improper feeding — an insufficient supply of albuminous material and an excess of starch in the diet — to produce the disease both in animals and in children testify to this fact ; as also do the good results of proper diet and hygiene combined with the administration of cod-liver oil and iron in the treatment. Whether the disease is brought about by some poison secreted by bacteria in the alimentarj' canal or by abnormal products of the cells of the body is not known. The Differential Diagnosis of Syphilis and Rickets. The gross effects of syphilis may be compared with those of rickets by reference to Figs. 25 and 54 as examples of syphilis of bones, and Fig. 57 as a marked example of rickets. In rickets the changes affect both extremities of the bone, though, as in Fig. 57, one end may be more extensively altered than the other. If DISEASES OF BONE. 171 the periosteal bone is affected the thickening occupies the whole of the shaft. In syphilitic bone shown in Fig. 54, the thickening of the bone and the changes at the epiphyseal line affect only one end of the bone. In rickets the whole of the skeleton may be affected whilst in syphilis, though the lesions of osteo-chondritis are often symmetrical, they are not as a rule so widespread as those of rickets. It is to be remembered, however, that syphilis and rickets often co-exist in the same individual. Kassowitz suggests that congenital syphilis, by disturbing the nutrition of the body generally, may cause rickets. In the skull there may be a very close resemblance between changes produced by these two affections. In a few cases rickets has been found by Barlow and Lees to cause " craniotabes." The period of life at which rickets becomes pronounced is usually the first few months after birth, and not many cases develop after the age of two years. In a few instances the onset of the disease has appeared to be as late as seven or eight years. Another period of life at which skeletal deformities frequently arise is at the approach of puberty. These deformities are attributable in part to muscular weakness, but there may be also a weakness of bone, a condition termed rickets of adolescence. Congenital Rickets. Belief in the occurrence of intrauterine rickets has to a large extent been lost in this country, owing to the fact that at least two other conditions — cretinism and achondroplasia — quite distinct from rickets, had been mistaken for this disease. Yet Kassowitz, in one of the most recent (1881) and thorough investigations of the subject, says: "But still it is not, I believe, sufficiently known that in the great majority of cases rickets begins in a very early period of intra- uterine development. Most authors still make the error of believing congenital rickets to be a rare condition, whilst according to my experience this is by no means the case.''^ This opinion is based on the careful histological examination of new-born children, and hence is not to be disregarded. Sporadic Cretinism, which has also been called "foetal rickets," is described later with the diseases of the thyroid gland. The changes in the bones in this condition are due to a cessation ^ Kassowitz, Rickets, 1881, p. 35. 172 SURGICAL PATHOLOGY. of cartilage proliferation at the epiphyseal lines, where an ingrowth of fibrous tissue is found separating epiphysis from diaphysis. Hence the bones are greatly shortened. The con- dition is the converse of that of rickets, in which the epiphyseal cartilage proliferates in excess. Fragilitas Ossium, or symptomatic osteopsathyrosis (Gr. ^sa^%ros = friable), is a state observed in infants, and is marked by fractures occurring in the bones from slight causes and without there being any obvious condition, such as scurvy, to account for the condition. An instance recently came under my notice in a male child aged ten months. When he was five days old the mother noticed that there was inability to move the right thigh and arm and the left ankle. Soon afterwards rings of callus about united fractures were found in the middle of the right femur, the lower third right humerus, and lower third of the left fibula. Fractures continued to occur from the slightest cause. The bones re-united readily. The child had congenital syphilis and craniotabes associated with rickets. Achondroplasia, a condition in which the bones are stunted, but which is not associated with the atrophy of the thyroid gland that characterizes sporadic cretinism. To it the name "achondroplasia" has been applied. The bones of the limbs and other cartilage bones, such as the base of the skull, which begin to ossify early in foetal life, are stunted and thickened. The spinal column and the bones of the hands and feet remain of normal size, as do the scapulae and clavicles. The defects in the development of the bones, like those of sporadic cretinism, appear to depend upon an arrest of the proliferation of the epiphyseal cartilages. In most cases the foetus are born dead, in others death occurs in infancy. The few subjects of the disease who have survived are dwarfs, but they show none of the mental and other defects that characterize sporadic cretinism. Scurvy Rickets. Infantile scurvy is not uncommonly associ- ated with rickets, and when this occurs Cheadle and Barlow have pointed out that sudden swellings about the bones are liable to occur from eff'usion of blood beneath the periosteum. Spontaneous fractures at the extremities of the shafts of the long bones are also met with. The condition occurs in the DISEASES OF BONE. 173 children of both poor and rich : from neglect or want of proper food in the first class, and from rigid adherence to artificial and sterilized foods in the latter. MoUities Ossium, or Osteomalacia. This disease is marked by a softening and bending of bones. It is commonest in middle-aged women, and frequently commences during preg- nancy ; but it occurs also in men, and has been observed in children. It is usually progressive and fatal, but in a few cases recovery has occurred. Extreme deformities of the ribs, pelvis, vertebrae, and limbs are produced. The deformity of the thorax is the usual cause of death. After death the bones may be readily cut with a knife, and they may be so light that they float in water. The histological change in the bone is exactly like the effect of decalcification by acids. This process begins in the parts of the bony trabeculse that border on the Haversian canals and other marrow spaces. The decalcified parts are progressively absorbed so that the marrow spaces enlarge. The spaces are filled with cellular fatty marrow, which varies in colour from yellow to deep crimson. It should be remembered that a diff"use, cancerous, or sarcomatous infiltration of bone sometimes produces a softening similar to that of osteomalacia. Osteitis Deformans is a disease of old age, and is marked by a peculiar inflammatory affection of the bones. It occurs in both sexes. The bones of the limbs are thickened, softened, and curved. There may be tenderness over the bones. The bones of the skull are thickened so that a person's attention has been drawn to his condition by his requiring from time to time a larger sized hat than he had previously worn. The forehead becomes prominent, the clavicles thickened and curved. The femora curve outwards and forwards, the tibiae curve forwards. The upper part of the spine also bends forwards. The thorax falls in from softening of the ribs, and the patients may die from the effects of impaired respiratory movements. On examining a bone affected by osteitis deformans after removal from the body, the surface is found to be rough. The articular extremities of the bone are not enlarged. On making a section the compact tissue of the bone will be found to be thicker 174 SURGICAL PATHOLOGY. on the convex than on the concave side, and to be more porous than normal. Comparing a curved bone of an old person who suffered from rickets in childhood with one deformed by osteitis deformans, it Avill be found that in the rickety bone there is a smooth surface, that the compact tissue is as hard as, or harder than, normal, and thicker on the concave than on the convex side. Hyperostosis and Leontiasis Ossea. Diffuse thickening of the bones of the face, especially about the antrum of Highmore and the frontal sinuses, is not uncommon. Sometimes the process, starting in some of the bones of the face, slowly increases, and extends until all the bones of the face, and the supraciliary ridges and frontal bones are greatly thickened by the formation of hard coarse bone. Such cases usually commence in early life. The prominent eyebrows and cheek bones give a leonine aspect to the countenance, hence the term " Leontiasis Ossea," suggested by Virchow. In the course of years the orbits, the nasal fossse, and the auditory meatus may be greatly narrowed, so that the functions of the chief sensory organs are destroyed. The disease appears to hold a place between inflammatory formations and new growths. NEW GROWTHS OF BONE. The complex structure of bone, comprising fibrous, osseous, cartilaginous, and other tissue, offers wide possibilities in the way of morbid growths. Those which occur most fre- quently are bony and cartilaginous among the non-malignant, and the sarcomata among the malignant tumours. Since bone contains no epithelial tissue primary cancer cannot occur, but secondary cancer is common. The more important growths of bone raa}^ now be considered in detail. Osteoma. Adventitious processes of bone resulting from inflammation, such as may form from the callus of a fracture, or in a tendon, e.g. rider's bone in the tendon of the adductor longus, syphilitic or other ossifying inflammation may be dis- tinguished as osteophytes, ossified nodes, etc., from new growths of bone or osteomata. The commonest form of growth is the NEW GROWTHS OF BONE. 175 spongy osteoma which usually springs from the periosteal aspect of a cartilage-formed bone such as the long bones of the limbs, the scapula, and the OS innominatum, etc. They most frequently arise from the shaft near the epiphyseal line, and are covered on the surface by a layer of cartilage which is usually thin, but may be as much as a quarter of an inch in thickness. Their cartilaginous covering suggests their origin in some of the isolated remains of the epiphyseal cartilage which are to be found even in normal and more frequently in rickety bones towards the ends of the diaphysis. They are sometimes multiple, and affect nearly all the bones of cartilage origin. In this case they may be hereditary in some members of a family. Fig. 69, from Coats's Pathology, shows bones which are the seat of multiple spongy osteomata. Such tumours are not uncommonly solitary. Save for the inconvenience they may cause by producing de- formity about joints, disturbing the attachments of muscles, or causing pain by pressure on nerves, they are not dangerous. When they are exposed to friction bursae are some- times developed over them. When it is desirable to remove them care must be taken to gouge freely the site of their attachment so that all trace of the investing cartilage is taken away. In one instance spongy ^■