tn tl|? amg of '^m fork Jirnm tiff ffithrarg of aityurrlitU (Earmalt, it. 1. f rfsfttlfh bg tlif Exttrttf (Elub of Nm lork TUMOURS INNOCENT AND MALIGNANT Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/tumoursinnocentmOOblan PLATE I.—" Fungating " Sebaceous Cyst (Sebaceous Adenoma) on the Scalp of a Woman 83 years of age. (.See paije 237.) TUMOURS INNOCENT AND MALIGNANT Stijctr ©Ixttical JFeaturj^s anh ^pprofrriatc QTrcatmcnt J. bla:^^d suttoi^ ASSISTANT SURGEON TO THE MIDDLESEX HOSPITAL LONDON JFITR TWO HUNDRED AND FIFTY ENGRAVINGS AND NINE PLATES PHILADELPHIA LEA BEOTHEES & CO 1893 PEEFAO E. Very early in the practice of my profession I became con- vinced of the great increase in diagnostic power that results from, the combination of pathological and clinical knowledge. Imbued with this belief, I formed, eight years ago, the intention of writing a book on Tumours in which their clinical and pathological features should be equally considered. In 1885 I began to collect materials, from man and other vertebrates, in order to make myself acquainted with the histological peculiarities of tumours. The great difficulty was to define the boundaries of my subject. In order to do this I determined to eliminate all those conditions, often classed with tumours, which have been demonstrated to depend on micro-organisms. This cleared the ground in a satisfactory manner. Attention was first devoted to cysts, and the results of the investigation were embodied in my Hunterian and Erasmus Wilson Lectures, delivered at the Royal College of Surgeons during the years 1886, '87, '88, '89, '90 and '91 ; they dealt particularly with the group of tumours known as Dermoids, and the genus of cysts which I have ventured to name Tubulo-cysts. During the same period I contributed to the Odontological Society of Great Britain a series of papers to show that many tumours of the jaws, vaguely classed as exostoses, are really derived from aberrant development of teeth. In describing Cancer a wide departure is made from the beaten track. The terms scirrhus, colloid, and medullary or encephaloid, have dominated the minds . of surgeons and hindered progress long enough. The term cancer is employed in a sense equivalent to malignant adenoma, the species being determined by the gland in which the cancer arises. Whenever it seemed desirable to illustrate the nature of a genus of tumours by reference to Comparative Pathology, I have not hesitated to do so. Without this aid, any attempt 374782 vi TUMOURS. to catch the deeper meaning of many tumours is as difficult as endeavours to decipher a pahmpsest in which the first characters, written in an unknown tongue, have been im- perfectly removed from the parchment and are allowed to mingle with the second inscription. In describing treatment it would obviously be out of place to give the details of operations in a work of this kind, so I have contented myself by indicating the principles. In selecting the figures every effort has been made to avoid depicting repulsive coriditions. To-day surgeons are much more interested in studying the Biology of Tumours than in recording their weight. As the Surgery of Tumours is far safer than in the first half of this century, patients, now thoroughly aware of this, submit to operations at an early date. The more this is recognised, and the more generally the impotence of drugs when employed against tumours is realised, the more successful will the Surgery of Tumours become. I have to thank Mr. T. Carwardine for kindly reading the proof-sheets, Mr. C. Berjeau for his excellent drawings, and Mr. C. Butterworth -for many admirable examples of wood- engraving. In a systematic work of this kind it follows that, in order to find descriptions of the various tumours to which an organ is liable, the reader must refer to clifterent sections of the book. To minimise this disadvantage I have made two special indexes — one showing the tumours to which an organ is liable, and the other indicating the distribution of tumours among the organs ; hence these constitute a syllabus rather than a mere Index. J. BLAND SUTTON. 48, Queen Anne Street, Cavendish Square, W. October, 1893. CO]SrTE]N"TS PAGE Classification ........ 1 CHAPTER I. Group I.— Connective Tissue Tumours . . . .3 CHAPTER II. Chondromata (Cartilage Tumours) . . . . .17 CHAPTER III. OSTEOMATA (OsSEOUS TUMOURS) . ■ . . . .23 CHAPTER IV. Odontomata (Tooth Tumours) . . . . . .31 CHAPTER V. Fibromata . . . . . . . . .49 CHAPTER VI. Myxomata ......... 59 CHAPTER VII. Gliomata ......... 63 CHAPTER VIII. Sarcomata ......... 67 CHAPTER IX. Sarcomata [continued) ....... 78 CHAPTER X. Sarcomata [continued) . . . . . . .90 CHAPTER XI. Sarcomata [continued) ....... 96 CHAPTER XII. Sarcomata [continued] . . . . . . . ■ 104 CHAPTER XIII. Sarcomata [continued] ....... 108 CHAPTER XIV. Sarcomata [concluded] ....... 117 viii TUMOURS. CHAPTER XV. PAoi: Myomata . . . . . • • .120 CHAPTER XVI. Neuromata . . . ■ • • • .147 CHAPTER XVII. Angeiomata ........ 158 CHAPTER XVIII. Group II. — Epithelial Tumours— Papillomata . . .167 CHAPTER XIX. Papillomata {concluded). ...... 177 CHAPTER XX. Cutaneous Horns . . . . • • .183 CHAPTER XXI. Epithelioma . . . . . - . .191 CHAPTER XXII. Epithelioma {concluded) ....... 207 CHAPTER XXIII. Adenoma and Carcinoma ...... 218 CHAPTER XXIV. Cysts, Adenoma, and Carcinoma of Sebaceous and Mucous Glands. ........ 233 CHAPTER XXV. Adenoma and Carcinoma of the Thyroid, Prostate, Parotid, and Pancreas . . . . . • . 240 CHAPTER XXVI. Adenoma and Carcinoma of the Liver, Kidney, Ovary, and Testicle ........ 250 CHAPTER XXVII. Adenoma and Carcinoma of the Stomach, Intestines, and Rectum . . . . . • • • 259 CHAPTER XXVIII. Adenoma and Carcinoma of the Uterus and Fallopian Tube 272 CHAPTER XXIX. Group III.— Dermoids ....... 279 CONTENTS. ix CHAPTEK XXX. page Sequestration Dermoids [contiimcd) . . . . . 287 CHAPTER XXXI. Sequestration Dermoids {concluded) ..... 299 CHAPTER XXXII. Implantation Cysts ....... 304 CHAPTER XXXIII. Tubulo-Dermoids. ....... 308 CHAPTER XXXIV. Tubulo-Dermoids [continued) ...... 318 CHAPTER XXXV. Tubulo-Dermoids {concluded) ...... 323 CHAPTER XXXVI. Dermoids ......... 330 CHAPTER XXXVII. Dermoids {concluded) . . . . . . . 339 CHAPTER XXXVIII. Peculiarities in the Distribution of Cutaneous Appendages « IN Dermoids ........ 346 CHAPTER XXXIX. Moles ......... 353 CHAPTER XL. The Treatment of Dermoids ...... 359 CHAPTER XLI. Teratomata . ....... 363 CHAPTER XLII. Group IV.— Cysts ....... 376 CHAPTER XLIII. Tubulo-Cysts ........ 389 CHAPTER XLIV. Tubulo-Cysts {conchuh:!) . . . . . .397 CHAPTER XLV. Hydrocele. . . . . . . . .411 X TUMOURS. CHAPTER XLVI. page Congenital Cysts (Hydroceles) of the Neck and Axilla . 419 CHAPTER XLVII. Cysts of the Salivary Glands— Ranul^— Pancreatic Cysts— Dacryops ........ 425 CHAPTER XLVIII. Pseudo-Cysts ........ 431 CHAPTER XLIX. Neural Cysts ........ 445 CHAPTER L. Neural Cysts {concluded) . ... . . . 459 CHAPTER LI. Hydatid Cysts ........ 472 CHAPTER LII. The Zoological Distribution of Tumours .... 487 CHAPTER LIII. The Cause of Tumours. . . ... . . 492 LIST OF ILLUSTEAT10E"S. Lipoma in the palm of the hand . Lipoma of the left axilla . Lipoma superhcial to the temporal fascia. Diffuse lipoma of the neck . Small pendulous appendices epiploicte, Avith twisted pedicles, of the ascending colon ..... Lipoma arborescens of the shoulder Enlarged sucking-cushion ..... Emaciated child crying and displaying the sucking-cushion Meningeal lipoma simulating a spina bifida in a chihl eight months old . . . Meningeal lipoma overlying the sac of a sj)ina bifida Lad twenty years of age with multiple chondromata Condyles and epiphysial line of a rickety femur, with a cartilage island 19 Osteoma of the left frontal sinus (anterior view) . . .24 Osteoma of the left frontal sinus, seen from below . . .24 Exostosis of the femur : its surface w^as clad with cartilage and sur- mounted by a bursa . . . . . . .26 Symmetrical exostoses of the nasal processes of the maxilhe . . 27 Big toe with a sub-ungual exostosis . . . . .28 Bell's specimen of Chmtodon, with its bony tumours and large occipital crest ......... 29 Epithelial odontome ....... 31 Microscopical characters of an epithelia,l odontome . . .32 Follicular odontome (dentigerous cyst) ... . . .33 Fibrous odontome from a goat . . . . . .33 Cementome from a horse . . . . . . .34 Compound follicular odontome from a Thar (Co^jrrtye»)^a{c«) . . 35 Denticles from the odontome of a Thar . . . . .36 Denticles from Tellander's, from Sims's, and from Mathias's cases . 37 Radicular odontome from human subject . . . . .38 Radicular odontome . . . . . . .39 Left lower jaw of a young marmot with a large radicular odontome connected with the incisor . . . . . .39 Lower jaAV of an adult Canadian porcupine : a radicular odontome is attached to its lower incisor . . . . . .40 Two figures of a radicular cementome from a man aged twenty-five years ......... 40 Composite odontome from a young lady aged eighteen . . .41 Composite odontomes . . . . . . 42 & 43 Odontome from the upper jaw . . . . . .43 Composite odontome from the upper jaw . . . . .44 Large odontome, which Avas spontaneously shed from the antrum . 46 Section of large odontome to show the concentric lamination . . 46 Composite odontome from the upper jaw : the left-hand figure shows tlie tumour in section . . . . . . .47 Odontome from the upper jaw . . . . . .47 Case of molluscum fibrosum . . ... . .53 Native of Sierra Leone, aged fifty, with molluscum fibrosum . . 55 Keloid in the lobule of the pinna, associated with an ear-ring puncture 56 Unusual case of keloid in a coloured woman . . . .57 6 7 9 10 12 12 14 15 18 xii TUMOURS. PAGE Pediinciilated myxoma from tlie labiuiri of a woman fifty yearn olfl . 61 Bilateral giiomatous enlargement of the pons and crura cerel)ri . 65 Spinal cord, in transverse section, from a case of glioma . . 66 Microscof)ical appearance of a lympho-sarcoma from the mediastinum 68 Small spindle-celled sarcoma from a metacarpal bone . . .68 Cells from a spindle-celled sarcoma of the neck of the uterus . . 69 Myeloid sarcoma from the acomial end of the clavicle . . .71 Periosteal sarcoma of the ilium invading the inferior vena cava . 75 Sjjina ventosa of the fibula . . . . . .80 Skeleton of an ossifying periosteal sarcoma of the femur . . 81 Spindle-celled sarcoma ot the fibula . . . . .83 Sarcoma arising in the follicle of a developing tooth . . .86 Deformity produced by a sarcoma of the nasal septum . . .87 Faciar region of the skull from the case shown in the preceding figures, seen in sagittal section . . . . . .88 Parotid sarcoma implicating the pinna in a woman thirty-five years of age ......... 91 Microscopical characters of a tumour arising in an accessory adrenal . 99 Kenal tumour originating in an accessory adrenal . . . 100 Myo-sarcoma of the testis ....... 101 Portion of a mediastinal lympho-sarcoma, to show the manner in ^^'hich the tumour extends along the bronchi and pulmonary vessels . 105 Anterior portion of a dace ; each black spot contains a central white dot representing an encysted parasite .... 109 Pigmented mole which ulcerated and infected the inguinal lymph glands ; the patient was sixty-five years of age . . .111 Melano-sarcoma of the uveal tract ..... 113 Secondary nodules of melano-sarcoma in the liver . . .114 Forearm of a woman four years after excision of the lower fourth of the ulna and the radius for a myeloid sarcoma of the radius . 118 Section of a uterus showing a small myoma .... 128 Very vascular uterine myoma seen in section .... 129 Microscojsical appearance of the mucous membrane covering a prolapsed uterine myoma, showing mutation of columnar ciliated into stratified epithelium as a result of pressure .... 130 Section of a litems with multiple myomata .... 132 Myoma of the broad ligaments ...... 140 Myoma of the Fallopian tube ...... 142 Congenital subcutaneous myoma of the occiput .... 144 Neuroma of the infra-orbital nerve invading the antrum . . 148 Neuro-fibroma of the radial nerve at the wrist, from a female nineteen years old . . ' . . . . . . 149 Plexiform neuroma from the back of a youth nineteen years of age . 152 Arm in which the musculo-spiral nerve was neuromatous . . 153 The arm represented in the jjreceding figure dissected ; the musculo- spiral nerve and its branches are. transformed into a plexiform neuroma ........ 154 Dissection of a stump of the forearm three years after amputation, to show the bulbs on the ends of nerves . . . . 155 Dissection of a plexiform angeioma of the forehead . . .163 Macroglossia in a girl aged eleven years ..... 166 Wart growing from the skin of the cheek and obscuring the eye . 169 Microscopical characters of the wart in the preceding figure . . 170 Wart-horn growing on the pinna . . . ... .172 Villous tumour of the bladder . . . . . .173 Pelvis of a kidney with a villous papilloma . . . .174 Section of a mamma with a dilated duct filled with villous papillomata 176 Microscopical appearance of a typical psammoma . . .177 Bilateral psammomata in relation with the lateral recesses of the fourth ventricle ....... 178 Psammomata in the lateral ventricle of a horse's brain . . . 180 LIST OF ILLUSTRATIONS. xili PAGE Portion of the spinal cord with a psammoma . . . . ISl Cutaneous iiorn : the widow Dinianche . . . . ; 183 Cutaneous horn from the penis . . . . . .184 Sebaceous liorn in a mouse . . . . • .185 Head of an African rhinoceros with a large wart posterior to and in a line with its nasal horns ...... 186 Head and leg of a thrush with cutaneous horns .... 187 Horn formed on the cicatrix of a burn . . . . .188 Horns growing from the scar of a burn ..... 189 Epithelioma of the upper lip (early stage) .... 191 Epithelioma of the lip, beginning in a fissure .... 192 " Warty " variety of epithelioma ...... 193 Microscopic appearance of the cells in epithelioma : the connective tissue stroma is omitted ...... 194 Epithelioma of the gall bladder ...... 216 Section of an adenoma from a child's rectum .... 219 Cancer of the breast . . . . . . . 223 Section from a mammary cancer . . .... 224 Sebaceous glands in the velvet of the antler of a stag . . . 234 Large sebaceous adenoma involving the pinna .... 236 Large unilateral bronchocele . . . . . . 241 Bronchocele of unusual size . . . . . . 242 Pulsating tumour of the skull, associated with an enlarged thyroid . 243 Microscopical appearance of the tumour of the skull in preceding figure 244 Median prostatic adenoma, sketched from -N^-ithin the bladder . . 246 Adenoma of the liver .... Congenital cystic kidney .... Congenital cystic kidney : early stage Adenoma of the kidney .... Sorcalled colloid of the mentum . Cancer of the sigmoid flexure of the colon Cancer of colon (constricting variety) Section of three thoracic ^'ertebrce, with a small dermoid situated over two stunted spinous processes. Dermoid in the lumbo-sacral region of a man tM'enty-tw Median aspect of a sheep's digit, showing the interdigital pouch . 282 Dermoid situated over the junction of the manubrium and gladiolus of the sternum : there was also a dermoid near the left corner of the hyoid bone . . . . . - . . . 283 Presternal dermoid ........ 284 Sternal dimple ........ 285 Head of an early human embryo, showing the disposition of the facial fissures. ........ 287 Mandibular tubercle associated Avith a malformed auricle . . 288 Right side of the head of a foetus, showing a large mandibular tubercle and an accessory tragus ...... 289 Pierrot's head, to show the mandibular tubercle .... 290 Median fissure of the lower lip . . . . . . 291 Congenital fistulfe in the lower lip of a child, associated with double hare-lip ......... 292 Haredip in a frog, associated with a persistent intermandibular fissure 293 Dermoid at the outer angle of the orbit ..... 294 Dermoid at the inner angle of the oi-bit ..... 295 Dermoid arising in naso-facial sulcus ..... 296 Nasal dermoid in a child ....... 297 Pedunculated dermoid tumour from the pharyngeal aspect of the soft palate ......... 298 Dermoid of the scalp connected by a pedicle with the dura mater . 299 Head of the man Lake with a large dermoid .... 300 Congenital tumour over the anterior fontanelle .... 301 Implantation cyst from the tip of the finger .... 304 250 253 254 255 261 264 265 280 o years of age . 281 xiv TUMOUBS. PACK Large implantation cyst of the cornea, following an injnry . . 306 Section of the cyst in the preceding figure, highly magnified . . 307 Large lingual dermoid, protruding from the mouth . . . 310 Diagram to show the relation of parts in a case of median cervical fistula ......... 314 Thyroid-dermoid ......... 319 Thyroid-dermoid of the coccygeal region, in section . . . 320 Rectal dermoid in section . . . . . . . 321 Rectal dermoid ........ 322 Early mammalian embryo, showing the gill-clefts . . . 323 Diagram to indicate the orifices of persistent branchial fistuke . . 324 Pharyngeal diverticulum ....... 327 Head and neck of a young woman, showing branchial fistuhe in the neck and a sinus in the helix . ..... 328 Cervical auricles in a child. ...... 330 Head and neck of a goat with cervical auricles .... 331 Horned sheep with cervical auricles ..... 332 Head of a pig with cervical auricles (the Bell-pig of Australia) . . 333 Faun and goat with cervical auricles ..... 334 Two drawings representing the development of the auricle . , 335 Congenital fistula in the helix ...... 336 Dermoid of the auricle and naevus of the palpebral conjunctiva. . 337 Auricle with an accessory trajus ...... 338 Mucous membrane from an ovarian dermoid .... 340 Ovarian dermoid detached from the uterus and hanging from the omentum ........ 342 Ovum in its follicle : from a cat ...... 345 Magnified section of an ovarian dermoid, to show the large size of the sebaceous glands ....... 346 Ovarian dermoid with a sebaceous gland, from a woman . . 347 Ovarian mamma : hair and teeth are also present . . . 348 Head of a sheep Avith a branchial fistula, cervical auricle, and tooth . 349 The germ of an ovarian tooth, from a dermoid .... 350 Epithelial pearl . . . . . . . .351 Extensive hairy mole upon the face of a boy a year old . . 353 Extensive hairy mole on the trunk of a man forty-seven years of age, which became the seat of sarcoma, from which the patient quickly died ......... 354 Conjunctival mole : common variety ..... 356 Mole on the caruncle, associated with an eccentric pupil . . 356 Conjunctival mole associated Avitli coloborna of the eyelid, a mandibular tubercle, and accessory tragus ..... 357 Conjunctival mole in a sheep ...... 358 The tAvin-sisters Radica and Doodica at the age of three and a half years ......... 363 Laloo, a Hindoo, with an acardiac parasite attached to his thorax . 364 Chick with a supernumerary pair of legs projecting from the ventral aspect of the pelvis ....... 365 Chick with a supernumerary pair of legs projecting from the dorsal aspect of the pelvis ....... 365 Frog {Rami palustris) Avith a supernumerary hind-leg . . . 366 Louise I., dame a quatre'jambes ...... 367 Sacral teratoma with a supernumerary leg .... 368 Posterior view of J. B. dos Santos at the age of six months . . 369 Cephalic extremity of a two-headed snake .... 370 Acardiac foetus . . . . . . . .371 Acardiac foetus ........ 372 Acardiac in Fig. 191 shown in section ..... 373 Young toad with a supernumerary hind-limb .... 374 Section through the tip of the vermiform appendix, to show the abundance of its glands .... . 378 LIST OF ILLUSTRATIONS. xv PAGE Hyilroneplirosis secondary to a large calculus in the bladder : two fragments of calculus occupying the prostatic portion of the urethra 379 Bilateral hydronephrosis in a new-born child .... 380 Calculus impacted in the urethra of a gelding, producing Avide dilata- tion of the vesical orifices of the ureters and double hydronephrosis 382 Unilateral (intermitting) hydronephrosis ..... 383 Pyonephrosis of one-half of a horse-shoe kidney . . . . ,384 Concretions from the guttural pouches of horses .... 388 Congenital jjedunculated tumour of the navel . . . . 389 Diagram of the alimentary canal of the embryo, showing the position of the yolk sac ........ 390 Cyst, probably of the vitello-intestinal duct, attached to the intestine of an emu ........ 392 Septate ileum ........ 393 Ileum with a persistent vitello-intestinal duct associated with a valve. 394 Imperforate ileum ........ 395 Diagram to represent the cyst regions of the ovary . . . 398 Ruptured papillomatous (paroophoritic) cysts of the ovary . . 399 Cyst of the parovarium, .showing its relation to ovary and tube . 402 Anterior portion of a cow's vagina, showing two large cysts developed in the terminal segment of Gartner's duct .... 403 Diagram to show the relation of the mesonephros and its ducts to the adult testicle ........ 404 Hydrocele of the tunica vaginalis, and an encysted hydrocele associated with the same testis ....... 405 Testicular adenoma ....... 408 Hydrocele of the tunica vaginalis testis ..... 412 Ovarian hydrocele in a rat . ...... 416 Ovarian hydrocele : the interior of the sac is bent with warts . . 417 Congenital cervical cyst extending into the axilla . . . 420 Congenital cervical cyst in a man tA\-enty years of age . . . 421 Congenital cyst of the thorax with nevoid walls. . . . 422 Imperforate pharynx ....... 433 Septate pharynx ........ 434 Pharyngeal diverticulum ....... 4.35 Tracheal opening and pouch of an emu ..... 436 Bursa under the semi-membranosus tendon communicating with the knee-joint ........ 4.38 Hydrocephalic skull, from an infant ..... 445 Hydrocephalic skull, showing Wormian bones .... 446 Sagittal section of a hydrocephalic skull from a child, with the brain in situ ......... 447 DraAving from a cast of the head of James Cardinal . . . 449 Head of a lion's whelp in section, showing great dilatation of the cerebral ventricles, due to obstruction of the interventricular passages by a thickened (rickety) tentorium . . . 4.50 Hydrocele of the fourth ventricle ...... 451 Occipital meningo-encephalocele ...... 4.52 Boy with a cephalhfematoma over the right parietal bone . . 455 Monkey (Cebns monachus) with a huge cephalhfematoma . . 456 Skull of Cehus monachus, showing the bony Avails of the cephal- ha?,matoma and a group of Wormian bones .... 457 Lumbar region of a fretus Avith spina bifida, variety myelocele . 459 Diagram to represent the microscopic characters of a transverse section of a myelocele . . . . . . . 460 Syringo-myelocele in transverse section ..... 461 Syringo-niyelocele and meningocele in longitudinal section : from the cervical region ........ 462 Diagram shoAving meningo-myelocele in transverse section . . 463 Microscopical appearances of the nerve-tissue from the Avail of a meningo-myelocele showing the central canal . . . 464 xvi TUMOURS. PAOE African child with a pedunculated tumour (an occlu'led spina bifida sac) attached to its buttock ...... 465 Tumour from the African child (.s.38 previous ligure), shown in section 466 Hair field on the loin overlying a spina bifida occulta . . . 467 Hair field overlying a spina bifida occult.i ; there is also a long tuft on the cervical region . . .... 46S ^gipan sporting with a faun [Bacchus and Silenus) . . . 469 Half- vertebra ........ 470 Echinococcus colony in the kidney . . . . . 473 Multilocular hydatids of the shaft of the humerus . . . 474 Multitude of minute hydatids on the pelvic peritoneum, probaldy secondary to the tapping of a cyst in the liver . . . 477 Cyst (implantation) of the palm ...... 498 LIST OF PLATES. "Fungating" Sebaceous Cyst (Sebaceous Adenoma) on the scalp of a woman eighty-three years of age . Froutispiece Melanosis of the Skin, secondary to Melano-sarcoma of the Uveal Tract ..... To face i^uge 114 Molhrscum Fibrosum combined with tumours on the nerves . . . . . . . ,, 150 An unusual form of Wart, growing from the skin of the Pubes ....... ,, 170 Cuirass Cancer. The right breast had been amjjutated two years. The right arm is in the condition kuo^vn as "Lymphatic" G^ldema . . . . ,, 227 Inflamed Sebaceous Cyst, situated on the inner margin , of the Left Mamma . . . . . ,, 2.35' Placenta from a case of Twins, one of Avhich was an Acardiac •- . . . • . ,, 374 Right Kidney with Two Ureters, one of which opens into the Bladder at the vesical orifice of the Urethra ; the lower half of the kidney drained by this ureter is converted into a pyonephrosis. The upper half drained by the normal m'eter is healthy. The left kidney was normal . . . . . • ,, 385 Lower two-thirds of a Femur, with the upper fourths of the Tibia and Fibula. The remnants of the Femur and Tibia are fenestrated osseous shells, in • consequence of the pressure exercised by multilocular hydatids Avhich began in the Femur, invaded the Knee-joint and involved the Tibia. There is a sequestrum in the Femur measuring 7 "5 cm. by 4 cm. ,, 482 TUMOUES INNOCENT AND MALIGNANT: Their Clinical Characters and A])pTopriate Treatment. CLASSIFICATION. Any thoughtful individual, on commencing the study of tumours, must doubtless have been struck by the confusion which prevails in oncological literature in regard to the use of such terms as classes, groups, species, varieties, etc. This confusion will be more obvious if the student be acquainted even in a moderate degree with Systematic Zoology. Not that the zoologist can in any way claim to have discovered a perfect method of classification, but he certainly uses the terms genus, species, etc., in a consistent manner. In the present work an attempt will be made to classify tumours on similar lines to those employed in Biology. The classification adopted is one which will not, in any serious way, involve the Taxonomy (if it be worth such a name) at present in fashion. It is certain that the efforts of J. Miiller (1838) to classify tumours according to their minute structure had a great in- fluence in promoting the study of Oncology. Virchow's labours on the histolog)^ of tumours, and especially his success in de- monstrating that all the tissues found in them have a physio- logical prototype, have made it plain that it is impossible, in any useful classification of tumours, to neglect to take into consideration their structural characters. To-day it must be clear to all who study Virchow's great work, "Die Krankhaften Geschwlilste" (1863), in the light of our present knowledge that he employed the term tumour in a B 2 TUMOURH. too comprehensive manner. It is highly desirable to exclude from tumours those formations known as infective granido- mata, and there can be no doubt that this group will be largely increased in the near future, as it has been in the recent past, at the expense of sarcomata and, in all probability, of the epitheliomata and carcinomata, as our knowledge of the biology of micro-organisms increases. Tumours may be arranged in four groups : — I. Connective tissue tumours. II. Epithelial tumours. III. Dermoids. IV. Cysts. Each group contains several genera ; each genus has one or more species ; of each species there may be one or more varieties. CHAPTER I. GROUP I.— CONNECTIVE TISSUE TUMOURS. The Connective Tissue Group of tumours contains the following genera : — 1. Lipomata (fatty tumours). 2. Chondromata (cartilage tumours). 3. Osteomata (osseous tumours). 4. Odontomata (tooth tumours). 5. Fibromata (fibrous tumours). 6. Myxomata. 7. Gliomata (neuroglia tumours). 8. Sarcomata. 9. Myomata (muscle tumours). 10. Neuromata (tumours on nerves). 11. Angeiomata (tumours composed of blood-vessels). 12. Lymphangeiomata (tumours of lymphatic vessels). LIPOMATA (fatty TUMOURS). A Lipoma is a tumour composed of fat. The various species of this genus, determined mainly by the situations in which they arise, are : 1, Subcutaneous ; 2, subserous ; 3, sub- synovial ; 4, submucous ; 5, intermuscular ; 6, intramuscular ; 7, parosteal ; 8, meningeal. 1. Subcutaneous Lipomata. — Beneath the skin there exists a layer of fat, which varies in thickness in different parts, but is most abundant over the trunk and trunk ends of the limbs. This subcutaneous fat is a common situation in which to find lipomata. Usually they occur as irregularly lobulated encap- suled tumours, more or less adherent to the skin. Unless they have been irritated, lipomata are movable within their cap- sules. Generally one lipoma is present, but two, ten, twenty, or more may occur concurrently on the same individual. In size they vary widely ; a lipoma weighing sixteen ounces is a tumour of fair size ; exceptional specimens have been reported to weigh fifty, eighty, and even one hundred pounds. Although subcutaneous lipomata are for the most part confined to the trunk and trunk ends of limbs, they ]nay arise on the distal 4 CONNI<:CTIVI<: TISSUE TUMOURS. parts of tlio limbs, such as the hands and feet. Many speci- mens have been observed in the pahii of the hand (Fig. 1), a situation in which they are apt to give rise to difficulty in diagnosis, more especially as they simulate compound ganglia of the flexor tendons. The lobes of fat are apt to burrow beneath the palmar fascia, and it is probable that some lipo- mata of the palm originate beneath this fascia, in the lobules Fig. 1. — Lipoma in tlie palm of the hand. of fat lying between the lumbricales. Fatty tumours are occasionally found on the fingers : Steinheil* has collected a large number of examples. A lipoma in the sole of the foot is more comprehensible than one in the palm of the hand, yet, strange to relate, they are far more frequent in the hand than in the foot ; in both situations they are apt to be congenitaLf * Bruns, Beitriige, bd. vii. 605. t Gay, Trans. Path. Soc, vol. xiv. 243, and Lockwood, ibid., vol, xxxvii. 450. LIFOMATA. 5 Subcutaneous lipomata are often symmetrical (Fig. 2) and are apt to become pedunculated, especially when growing from the thigh. Pedunculated lipomata are never very large, and when the pedicle is thin it will become twisted by the rotatory movements of the tumour, the growth of which will in con- sequence be arrested, or at least checked. Fatty tumours are rarely met with upon the head or face. Fig. 2. — Lipoma of the left axilia; a similar tumour occupied the liglit axilla. but I have on three occasions removed a lipoma from beneath the skin covering the temporal fascia : the largest specimen is depicted in Fig. 3. There is a variety known as the diffuse lipoma ; in typical cases the tumours appear as symmetrical swellings in the neck and on each side of the ligamentum nuchse. The fat has a coarsely granular appearance, due to being bound ujj in tiny lobules, which causes it to resemble omentum. In the neck these collections of fat are situated on the deep as well as the superficial aspect of the platysma muscle. Similar unencap- suled masses of fat occur in the groin, pubic region, and axillae of those who are unfortunate enough to possess them in the neck (Fig. 4). 6 CONNECTIVE TISSUE TUMOURS. There is a variety of fatty tiiiiiour sometimes called, on account of its vascularity, ncjevo-lvporaa ; some are of opinion that it is a nieviis which has undergone fatty degeneration. Possibly some of the vascular lipomata met with on the face have this origin. 2, Subserous Lipomata. — The peritoneum, like the skin, rests upon a bed of fat, the thickness of which varies consider- ably. As in the case of subcutaneous lipomata, those which Fig. 3. — Lipoma superficial to tlie temporal fascia. occur in the subserous tissue may be sessile, pedunculated, or diffuse. Surgeons have long been aware, in oj)erating for inguinal or femoral hernia, that occasionally they come across a mass of fat, and find difficulty in determining whether it be omental or a local increase of the subserous fat surrounding the hernial sac. It is now clear that in the neighbourhood of the femoral and inguinal canals an overgrowth of the subserous fat may occur and be mistaken for a hernia, and individuals have been recommended to wear, and have actually worn, trusses for fatty tumours of this character. It is also clear that as these LIPOMATA. 7 local overgrowths of fat arise and protrude in the groin, they occasionally draw with them a pouch of peritoneum unasso- ciated with a hernia. These pouches may afterwards lodge a piece of gut, and become true hernial sacs. Thus peritoneal pouches, produced mechanically by subserous lipomata, may subsequently become hernial sacs : on the other hand, lipomata may arise in relation with peritoneal pouches which were Fig. 4. — Diffuse lipoma of tlie neck. (After Morrant Baker.) originally hernial sacs. In some cases a subserous lipoma of this character will invaginate a peritoneal pouch and form a pedunculated tumour within the hernial sac. Fatty tumours sometimes arise in the scrotum^or labium without being connected with hernial pouches.* Lipomata arising in the subperitoneal tissue occasionally appear in the anterior abdominal wall, especially near the um- bilicus ; they are sometimes referred to as " fatty hernise of the * J. Hutchinson, jun., Trans. Path. Soc, vol. xxxvii. 451 and vol. xxxix., gives a good account of hernial lipomata. 8 CONNECTIVE TISSUE TUMOURH. linea alba," and arc frequently associated with peritoneal pouches. These lipomata siniulate hernia:; still further when the traction they exercise on the peritoneum causes pain. Subserous lipomata on the under surface of the diaphragm may pass upwards into the mediastinum through the space which exists behind the ensiform cartilage. A few cases are known in which lipomata have grown be- tween the layers of the broad ligament ; * in one case the tumour was so large as to simulate an ovarian tumour. f Enormous subserous lipomata, in many respects resembling the diffuse tumours of the subcutaneous tissue, have been described. Pick| recorded a case in which a mass of fat weighing thirty pounds was found posterior to the transverse colon. Meredith § successfully removed an omental lipoma weighing fifteen pounds and a half from a woman sixty-two years old ; the operation was undertaken because the tumour was thought to be ovarian. Cooper Forster|| met with a similar tumour, weighing fifty-three pounds, in a woman sixty-three years old. Hernial lipomata are interesting, for they explain the mode in which appendices epiploicas arise : they are localised pedunculated overgrowths of subserous fat, and are particu- larly large and arborescent in the neighbourhood of an old syphilitic stricture of the rectum. In well-nourished individuals the fat of the appendices epiploicse is directly continuous with the fat in the layers of the mesentery ; when wasting occurs the fat between the appendices and the mesentery is liable to atrophy and leave an adipose nodule at the bottom of a peritoneal pouch (Fig. 5). The movements of the intestine and the traction of the nodule lead to the formation of a pedicle which often becomes twisted ; sometimes the pedicle is so thin that it breaks, and the appendix is set free. Pieces of fat, not infrequently calci- fied, detached in this way, have been found in hernial sacs. Pedunculated lipomata of the colon are not uncommon in * Parono, Ann. dl Ostet. Milano, 1891, xiii. 103, pi. 1. t Treves, Trans. Clin. Soc, vol. xxvi. X Trans. Path. Soc, vol. xx. 337. § Trans. Clin. Soc, vol. xx. 206. II Trans. Patli. Soc, vol. xix. 246. LIPOMATA. ^ horses and oxen : I have known them weigh tw^o pounds ; they are apt to cause invagination of the bowel. 3. Subsynovial Lipomata. — Beneath the subserous tissue of large joints, such as the knee, there is a layer of fat of varying thickness. This fat may, as in the case of inguinal lipomata, increase m quantity and, projecting into the joint, form a fatty tumour. A common situation for this to occur is beside the patella, at the spot normally occupied by the alar ligaments. Fig. 5.— Small pendulous appendices epiploica;, with twisted pedicles, of the ascending colon. Many specimens are doubtless due to overgrowth of the fat in the alar fringes, but they may arise in other parts of the joint. The best known variety of subsynovial fatty tumour is that to which MllUer ajjplied the term " lipoma arborescens." This condition is often, but by no means always, associated with rheumatoid arthritis. A typical specimen from the shoulder-joint is represented in Fig. 6, consisting of small linger-like processes of fat projecting into the cavity of the joint ; each process is covered by synovial membrane. The lipoma arborescens bears precisely the same relation to the synovial membrane that the appendices epiploicse bear to the peritoneal investment of the colon and sigmoid flexure. 10 CONNECTIVE TISSUE TUMOUnS. 4. Submucous Lipomata. — Fat exists in the subimicous tissue in many situations and, like that in the subcutaneous tissue, is not infrequently the source of lipomata. Thus Virchow* has figured a fatty tumour situated Ijeneath the mucous membrane of the stomach, near the pylorus : it was as big as a nut. They also grow from the jejunum and hang as Lipoma arborescens of the shoulder. pedunculated tumours in the gut, and have caused intussus- ception. Laryngeal lipomata are rare. One of the most remarkable examples was described by Holt.f The patient, a man. died suddenly : hanging from the left aryteno-epiglottic fold and from the side of the epiglottis was a pedunculated tumour, which extended into the oesophagus to a distance of * " Krank. Geschwiilste," bd. i. 372. f Trans. Path. Soc, vol. xxxii. 243. LIPOMATA. ' 11 22'5 cm. (9"). It consisted of fat covered with nmcoiis membrane. Sydney Jones* removed a lipoma from the right aryteno- epiglottic fold of a man forty years old : it was 5 cm. (2") in diameter. The patient could protrude the tumour into his mouth. Bruns removed a lipoma the size of a hazel nut from the right arytenoid region. Subconjunctival lipomata occasionally occur near the point where the conjunctiva is reflected from the lower lid to the eyeball : they are almost confined to children. Sometimes lipomata arise from the orbital fat and project the conjunctiva in the neighbourhood of the lachrymal gland and near the insertions of the ocular muscles. 5. Intermuscular Lipomata. — Fatty tumours now and then arise in the connective tissue between muscles : they have been found between the greater and lesser pectorals, between the nmscles of the tongue and the intermuscular strata of the anterior abdominal wall. In the last-mentioned situation they have been known to attain prodigious pro- portions, f The most remarkable variety of this species of lipoma arises in connection with the sucking-cushion. This curious ball of fat is situated between the masseter and buccinator muscles, and comes into close relation with the buccal mucous membrane. It is believed to play an important function in connection with sucking, by distributing atmospheric pressure and preventing the buccinators from being forced between the alveolar arches when a vacuum is created in the mouth. They are relatively much larger in infants than in adults. Ranke J also points out that in emaciated children the cushions are only slightly diminished in size even when there is scarcely any subcutaneous fat. (Figs. 7 and 8.) The sucking-cushions sometimes enlarge in adults, and simulate more serious species of tumours, and it is curious that in some of the recorded cases the enlargement of the cushion has been associated with the impaction of a salivary * Trans. Path. Soc, vol. v. 123. f Sir Astley Cooper, Medico-Chir. Trans., vol. xi. 440. Eve, Trans. Path. Soc, vol. xxxix. 29.5. Abdel-Fattah Fehmy, Brit. Med. Journal, 1893, vol. i. 459. X Virchow's " Archiv," bd. xcvii. 527. 12 CONNECTIVE TISSUE TU}fC)TjnS. Fig. 7.— Enlarged sucking-eusbion. {After Raiilcc.) calculus in the duct of the parotid gland.* The association of an impacted salivary calculus and an enlarged sucking-cushion Fig. S.— Emaciated cliild crying and displaying tlie sucking-cushions. {After PuinU.) * Berger, Gaz. des Eopitaux, Nov. 15, 1883; and Owen, Lancet, 1890, vol. ii. 71. LI POM AT A. 13 is interesting in relation with an observation of Norman Moore, who found a large collection of fat around a ureter at the site of an impacted calculus. (Museum, Royal College of Surgeons, 196a.) t). Intramuscular Lipomata. — Many examples of fatty tumours occurring in the midst of muscles have been reported, and are of interest from the trouble they cause in diagnosis. They have been found in the deltoid, biceps humeri, com- plexus, and rectus abdominis ; in the muscular tissue of the heart, and in the middle of a submucous myoma of the uterus.* 7. Parosteal Lipomata. — ^This term has been applied to fatty tumours arising from the periosteum of bone. They are usually congenital, and nearly always contain tracts of striated muscle fibre. Some of these tumours are clinical puzzles. Dr. F. Taylorf reported a case in which a fatty tumour grew from the anterior surface of the bodies of the cervical vertebra3 ; it projected the posterior wall of the pharynx, and sinudated a post-pharyngeal abscess. The patient was a girl four years old. I have removed parosteal lipomata from the dorsal surface of the infra-spinous fossa of the scapula, the body of the pubes, and the frontal bone immediately above the right superciliary ridge. The appended table contains references to descriptions and accessible examples of parosteal lipomata. PAROSTEAL LIPOMATA. Seat. Reporter. Reference. Femur . D'Arcy Power Trans. Fath. Soc, xxxix. 270. Tibia and Fibula . Butlin . Traits. Path. Soc, xxviii. 221. Ischium T. Smith Trans. Path. Soc, xvii. 286. Spine of Ilium Walsham . Trans. Path. Soc, xxxi. 310. Clavicle . Gould . Museum, Middlesex Hospital. Scapula . T. W. Nunn . Museum, Middlesex Hospital. Neck of Radius T. Smith Trans. Fath. Soc, xix. 344. Coccyx . T. Smith Trans. Path. Soc, xxi. 334. Frontal . Sydney Jones Trans. Fath. Soc, xxxii. 243. * T. Smith, Trans. Path. Soc, vol. xii. 148. See also Lebert, d" Anatomic Pathologique," plate xvi., fig. 11, t. i. p. 128. t Trans. Path. Soc, vol. xxviii. 216. ■ Traite 14 CONNECTIVE TISSUE TUMOURS. 8. Meningeal Lipomata. — Fatty tumours occur within the spinal dura niator, as well as external to this membrane. When growing within the sheath they surround the cord. Gowers,* Recklinghausen,t and Obre:j: have recorded examples. In the cases described by the first two observers the tumours Fig. 9. — Meningeal lipoma simulating a spina bifida in a child eight months old, (After Timoiii.i) contained striped muscle tissue. The occurrence of an intra- dural lipoma is not surprising, as the loose connective tissue between the cord and dura mater contains fat. Fatty tumours are not uncommon in the middle line of the * Trans. Path. Soc, vol. xxvii. 19. t Virchow's " Archiv," Tbd. cv. 243. I Trans. Path. Soc, vol. iii. 248. § Arch. Froviiiciales de Chirurr/ie, 1892, p. 179. LIFOMATA. 15 back, especially in the liimbo-sacral region, overlying the sac of a spina bifida. (Figs. 9 and 10.) Clinical Features. — Although lipomata occur more fre- quently than any other genus of connective tissue tumours, and may, in most instances, be diagnosed with absolute cer- tainty, yet under sonae conditions they are very puzzling, and give rise to much difference of opinion. The subcutaneous species is rarely the source of doubtful diagnosis, unless Fig. 10.— Meningeal lipoma overlying the sac of a spina bifida. {Museum, Roycd College of Surgeons.) situated in the palm of the hand, sole of the foot, or on the scalp. The intimate relation between the tumour and the over- lying skin, the absence of definite boundaries and its dough- like consistence, are usually sufficiently trustworthy guides. When a lipoma is connected with the periosteum of a long bone it will sometimes simulate a sarcoma ; when embedded in a muscle the most divergent opinions are often expressed in regard to the nature of the tumour. 16 CONNECT fVE TISSUE TUMOURS. Ilcfei'cnce lias already been niado to those large lipoiriata which arise in the siiljperitoneal tissue and the way they mimic the signs of ovarian tumours. Lipomata in the neigh- bourhood of hernial openings have often been confounded with herniie. Especial attention must be drawn to supposed fatty tumours situated in the middle line of the back : in most cases these are abnormal masses of fat overlying the sacs of spinse bifidfe. Incautious surgeons, in operating upon such tumours, have unexpectedly opened the dura mater. Treatment. — Solitary subcutaneous lipomata should, as a general rule, be removed. When very many tumours are present (ten or twenty) it is not customary to interfere with them, for when multijDle they rarely attain uncomfortable or dangerous proportions. It occasionally happens with multiple, (and also with solitary) lipomata, that one or other becomes irritated with some part of the dress, such as petticoat bands, braces, etc., or in some jDarticular employment followed by the individual. Such tumours should invariably be removed. The removal of a subcutaneous lipoma is one of the simplest proceedings in surgery, but the extirpation of a large subperitoneal fatty tumour is often attended with difficulty and grave danger.* Diffuse lipomata do not admit of removal. It was for- merly stated that liquor potass^, taken internally, caused them to diminish in size and even disappear. So far as my observations have extended, the administration of this drug is useless in preventing the growth or reducing the size of these tumours. * Homans, International J. Med. ScL, April, 1891 ; and Spencer "Wells, " Ovarian and Uterine Tumours," 1882. CHAPTER 11. CHONDROMATA (CARTILAGE TUMOURS). Chondromata (enchondromata) are tumours composed of hyaline cartilage. Tliis genus contains three species : — 1, chondromata ; 2, ecchondroses ; 3, loose cartilages in joints. 1. Chondromata. — Cartilage tumours in their typical con- dition occur in long bones, and, as a rule, grow in relation with the epiphysial cartilages, hence they are most frequently observed in children and young adults. Often a chondroma is solitary, but very frequently many exist, especially on the long bones of the hand. A remarkable case is de- picted in Fig. 11 ; this patient was under observation at the Tubingen Clinic twenty-five years. He died at the age of fortj^-five. Most of the long bones of the limbs were occupied with cartilage tumours. Some of them were very large.'^ Kast and Recklinghausenf have described a similar case, and I have a photograph of a lad who used to be exhibited for gain at fairs in various parts of England, with cartilage tumours on his hands, feet, and legs as numerous as in Steudel's unfortunate patient. Chondromata are always encapsuled, and form deep hollows in the bones from which they grow ; they are painless, grow slowly, and are firm to the touch. Frequently they undergo mucoid softening, then the softened patches give rise to fluctuation. This often serves to distinguish them from osteomata, with which they are liable to be confounded clinically. Cartilage tumours are prone to ossify. The frequency of chondromata in those who were rickety in early life may be due, as Virchow pointed out, to the existence of untransformed pieces of cartilages acting the part of tumour-germs. Such remnants of unossilied cartilage (cartilage islands) are not difficult of demonstration in rickety bones. (Fig. 12.) It is a curious circumstance that the tissue of a chondroma * Bruns, Beitrage, bcl. viii. 503. t Virchow's "Archiv," bd. cxviii. s. i. IS CONNEC'TIVI'J TL^HUE TUMOURS. resembles, histologically, the bluish translucent epiphysial cartilage characteristic of progressive rickets. 2. Ecchondroses may be defined as small local overgrowths They are best studied in three situations — viz., of cartilages Fig. 11. — Lad twenty years of age -with multiple cliondromata. (After SteudeJ.) along the edges of articular cartilages, the laryngeal cartilages, and the triangular cartilage of the nose. Ecchondroses of articular cartilage are especially common in the knee joint, and occur in connection with the condition known as rheumatoid arthritis. They are frequent in the joints of persons past the meridian of life, and they present CHONDBOMATA. 19 themselves as small projecting prominences along the margins of the articular cartilage. Often the edge of the cartilage is produced into a raised prominent lip, the regularity of which is broken here and there by a sessile or pedunculated nodule. When these nodules are examined many of them present on their outer surface a convex outline, but on the inner aspect — that looking towards the joint — they are concave, the concavity being produced by friction during the movements of the joint, or by pressure when the parts are at rest. Occa- sionally erosion of the ecchondrosis may extend so deeply that by some extra movement of the joint the pedicle is broken, and the detached nodule either falls as a loose body into the Fig. 12.— Condyles and epiphysial line of a rickety feniur, witli a cartilage Lsland. joint-cavity, or it may be retained in position by its attachments to the fibrous structures of the articulation. Laryngeal ecchondroses are by no means common ; they grow from the thyroid, cricoid, and occasionally the arytenoid cartilages. Paul Bruns* collected fourteen cases of laryngeal chondromata ; of these, eight sprang from the cricoid, four from the thyroid, one from the arytenoid, and one from the epiglottis. Most of the ecchondroses of the cricoid cartilage sprang from the broad posterior plate. In many of the cases the inner and outer surfaces of the cricoid were involved, so that the tumour encroached upon the cavity of the larynx. Ecchondroses vary greatly in size ; some are scarcely larger than a pea, others may be as big as walnuts. Morell * Beitrcige zu Klin.-Chir., bd. iii. 347. 20 aONNKGTIVK TfSHUE TUMOURS. Mackenzie* has described an example growing from the cricoid which attained the size of a bantam's Qg^ ; in this instance the tumour extended downwards in front of the trachea. Small ecchondroses growing from the inner surfaces of the laryngeal cartilages are more dangerous than the larger examples springing from their outer surfaces. Ecchondroses, when pro- jecting into the larynx, are covered with its mucous mem- brane ; they may be smooth or tuberculatecl, round or conical. In exceptional cases the overlying mucous membrane has been found ulcerated. Chondromata, wdien they project into the larynx, produce stridor, difficulty in breathing, and sometimes interfere with the movements of the vocal cords. When the tumours only involve the outer surfaces of the laryngeal carti- lages, they do not as a rule produce any inconvenience unless they are exceptionally large. Small outgrowths from the triangular cartilage of the nose are by no means uncommon ; they never attain a large size, and are always sessile. It is difficult to imagine that ecchondroses of the nasal cartilage could be a source of ]nuch inconvenience, but some surgeons, who are enthusiastic in treating diseases of the nasal passages, view them with dis- favour. 3. Loose Cartilages. — Bodies of various kinds are found loose in the cavities of large joints, but those to be considered under the head of chondromata, in addition to detached ecchondroses, are pieces of hyahne cartilage found hanging in the joint by narrow pedicles, or occupying depressions in the bone, from which they are occasionally dislodged. Structurally they are composed of hyaline cartilage, and assume various forms. Some appear as flat discs, others are ovoid; they may be perfectly smooth, or present an irregular worm-eaten appearance, and the majority are impregnated with calcareous particles. It is a remarkable fact that in many instances in which a loose cartilage has been found in one joint, a body identical in size and shape has been found in the corresponding joint of the opposite limb.f Loose cartilages may be single or * Trans. Path. Soc, vol. xxi. 58. t Bowlby, Trans. Path. Soc, vol. xxxix. 281 ; Glutton, ihid., vol. xxxix. 284 ; American Journal of Med. Sci., vol. i. 303 ; Weichselbaum, Virchow's " Archiv," Ivii. 127. GHONDROMATA. 21 multiple : several liiindred may exist in one joint, and vary in size from a rape-seed to an almond. The origin of these cartilages is interesting. In large joints, such as the hip, knee, or shoulder, it is easy to demon- strate, in the recesses of the joint near the spot where the synovial membrane becomes continuous with the margin of the articular cartilage, villous-like processes of the synovial mem- brane projecting into the joint. Under certain conditions, especially that known as rheumatoid arthritis, these villi become greatly enlarged and increase in number until the whole synovial membrane may be so covered with them as to become quite velvety in appearance. Structurally, these synovial villi consist of a reduplication of the serous mem- brane, and contain tufts of capillaries. As they enlarge, some of them undergo chondrification, and this change may take place so extensively that a villous process is entirely con- verted into hyaline cartilage, which becomes the matrix for a deposit of lime salts. As these nodules of cartilage are merely sustained by narrow pedicles, the nodules may be de- tached either by their mere weight, undue movement of the joint, or from axial rotation, and tumbling into the joint give rise to all the inconveniences characteristic of a loose body. Specimens occasionally come to hand in which cartilaginous bodies of this description may be found sessile among the fringes, or hanging on good pedicles, or with stalks so thin that they appear to be on the eve of detachment. Occasionally these overgrown synovial villi, instead of chon- drifying, are converted into oval bodies, which, on microscopic examination, present a central cavity surrounded by a lami- nated structureless substance. To the naked eye many of these oval bodies resemble cartilage, and it is only on microscopi- cal examination that it is possible to distinguish between them ; many are infiltrated with calcareous granules. These oval bodies are present in some cases in great number. On one occasion Mr. Bentlif sent me 1,532 which he removed from the shoulder joint of a girl. Loose bodies of this character occur not only in joints, but in compound ganglia and in bursse. In concluding this account of cartilage tumours it is very necessary to point out that every tumour containing cartilage 22 CONNECTIVE TLSSUE TUMOURS. is not necessarily a chondroma. In describing sarcomata it will be pointed out that the spindle-celled species is very apt to contain cartilage, particularly when arising in the testis, parotid gland, or periosteum. Much ingenious speculation has been exercised to account for the presence of cartilage in sarcomata arising in such structures, but it appears to be an extremely easy task for connective tissue to form hyaline cartilage. Treatment. — The operative treatment of chondromata has been greatly simplified since surgeons have appreciated the fact that these tumours, when g'rowino' in relation with bones, are distinctly encapsuled. Hence, when it is necessary to interfere with a chondroma, even in cases where several tumours are present, it has become customary to incise the capsule and shell out the cartilage. In most instances this simple method is successful. Exceptionally, however, cases come under observation which demand more serious measures. When the cartilage tumours are very numerous on the bones of the hand, the fingers are so crippled and useless that amputation becomes necessary. In the patient represented in Fig. 11 the weight of the tumours caused so much fatigue that it was deemed advisable to amputate the hand. For- tunatel}^, such severe treatment is very rarely needed. In the case of loose bodies in joints it is the usual practice, when the pieces of cartilage are in the habit of getting between the opposed surfaces of the joints, to open the synovial cavity, and remove the loose body or bodies. When this manoeuvre is conducted with proper care it is highly successful. When the loose body is lodged in a sacculus, it is in a measure isolated from the general cavity of the joint, and does not call for interference. The smaller bodies, which, like mice, slip in and out of the recesses of a complex joint, are more likely to give trouble than those larger pieces of cartilage, sometimes as big as chestnuts, which the patients can grasp with their fingers, and slip in and out of the great cul-de-sac above the patella almost as readily as a marble may be manipulated under a tablecloth. Bodies of this sort rarely call for interference. 23 CHAPTER III. OSTEOMATA (OSSEOUS TUMOURS). It has been customary to describe almost all Ivincls of tumours composed of bone, or bone-like tissue, under the name of exos- toses. A critical examination of these tumours indicates that they belong to at least two genera, osteomata and odontomata. The term exostosis should be limited to irregular bony out- growths to which the term tumour is not in any sense applicable. Osteomata may be defined as ossitying chondromata, for they are found near the epiphysial lines of long bones, and when they arise in connection with flat bones it is generally in the vicinity of a tract of cartilage. Every growing osteoma has a cap of hyaline cartilage, which stands in the same relation to the growth of the tumour as an epiphysial line to the increase in lenofth of a lon