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Full text of "Tumors, innocent and malignant; their clinical characters and appropriate treatment"

TUMOURS 
INNOCENT AND MALIGNANT 



MP 

TUMOURS 

INNOCENT AND MALIGNANT 

THEIR CLINICAL CHARACTERS AND 
APPROPRIATE TREATMENT 



BY 



SIR JOHN BLAND-SUTTON, LL.D., F.R.G.S. 

Consulting Surgeon to the Middlesex Hospital, etc. 



ILLUSTRATED WITH THREE HUNDRED AND 
EIGHTY-THREE WOOD ENGRAVINGS 



SEVENTH EDITION 




GASSELL AND COMPANY, LTD 

London, New York, Toronto and Melbourne 

1922 



First Edition February 1893. Reprinted April 1894. 
Second Edition June 1901. 
Third Edition June 1903. 

Fourth Edition November 1906. Reprinted 1907. 
Fifth Edition Febmary 1911. 

Sixth Edition May 1917. 
Seventh Edition February 1922. 



ALL RIGHTS RESERVED 



PREFACE TO THE SEVENTH EDITION 

WHILST men have been keenly endeavouring to detect the 
cause of Cancer, investigations into the nature of ductless 
glands have discovered many new facts in regard to their 
influence on such conditions as obesity, multiple exostoses, 
and chondromas ; neuromas and uterine fibroids ; and 
giantism. 

Knowledge of such apparently simple things as warts 
and moles is in a state of flux, and it is startling to realize 
that delicate structures like chorionic villi, choroid plexuses, 
and arachnoid vilii can, and do, behave malignantly. We 
know now that the surface of the alimentary canal, like 
the skin, is liable to warts, abrasions, and chronic ulcers, 
which are the starting-places of cancer. These facts suggest 
that a better knowledge of symbiosis may help to explain 
how chronic sepsis tills the soil in man's body to make it 
receptive of the germs of cancer. 

Experimental Embryology has proved that tadpoles 
change into frogs precociously if fed on ox- thyroid, and 
the transformation of axolotls into salamanders may be 
quickened by the same trick. 

More astounding is the discovery that segmentation may 
be started in the eggs of frogs by tickling them with an 
exceedingly fine stylet, and the production of "fatherless 
frogs " has become a common experiment in biological 
laboratories. 

This new matter has been incorporated, with twenty new 
illustrations, in this edition, without altering the size or 

character of the book. 

J. B.-S. 

January, 1922. 



CONTENTS 



PAGE 



INTRODUCTION .... ... 1 

Group I. Tumour-Diseases of the Connective Tissues 

CHAPTER 

1. LIPOMAS (FATTY TUMOURS) 14 

2. SARCOMAS: THEIR HISTOLOGIC CHARACTERS . . 31 

3. SARCOMAS (concluded) : THEIR GENERAL CHAR- 

ACTERS AND DISTRIBUTION . . . .39 

4. TUMOURS OF BONE ... . .53 

5. TUMOURS OF BONE (continued) . . 68 

6. TUMOURS OF BONE (continued) . .75 

7. TUMOURS OF BONE (continued) . . .84 

8. TUMOURS OF BONE (concluded) .... 97 

9. SARCOMAS OF GLANDULAR ORGANS . . . .105 

10. PlGMENTED TUMOURS . . . . .115 

11. MOLES . 133 

12. NEUROMAS AND ALLIED CONDITIONS OF THE 

NERVOUS SYSTEM . . . ... 141 

13. NEUROMAS AND ALLIED CONDITIONS OF THE 

NERVOUS SYSTEM (continued) . . . .152 

14. NEUROMAS AND ALLIED CONDITIONS OF THE 

NERVOUS SYSTEM (concluded) . . . .159 

15. ANGIOMA AND LYMPHANGIOMA . . . .. 167 

16. UTERINE FIBROIDS 179 

vii 



viii CONTENTS 



PAGE 



17. UTERINE FIBROIDS (continued] . . .191 

18. UTERINE FIBROIDS (continued) . . .198 

19. UTERINE FIBROIDS (continued) . 211 

20. UTERINE FIBROIDS (concluded) . , . .219 

21. FIBROIDS OF THE GASTROINTESTINAL TRACT . . 230 

Group II. Tumour-Diseases of Teeth 

22. ODONTOMES AND DENTAL CYSTS . . 236 

Group III. Epithelial Tumours 

23. PAPILLOMAS (WARTS) ; ADENOMAS ; CARCINOMA 

(CANCER) .255 

24. THE CAUSE AND TREATMENT OF CANCER . . 273 

25. EPITHELIAL TUMOURS OF THE SKIN . . . 284 

26. EPITHELIAL TUMOURS OF THE SKIN (concluded) . 299 

27. EPITHELIAL TUMOURS OF THE BREAST . . 305 

28. EPITHELIAL TUMOURS OF THE BREAST (concluded) 314 

29. EPITHELIAL TUMOURS OF THE ALIMENTARY CANAL, 

LARYNX, AND LUNG 327 

30. EPITHELIAL TUMOURS OF THE GASTRO- INTESTINAL 

TRACT . ...... .344 

31. EPITHELIAL TUMOURS OF THE GASTRO- INTESTINAL 

TRACT (continued) . . . . . . 353 

32. EPITHELIAL TUMOURS OF THE GASTROINTESTINAL 

TRACT (continued) . . ... . .361 

33. SYMPTOMS AND TREATMENT OF CANCER OF THE 

GASTRO- INTESTINAL TRACT . . . .376 

34. EPITHELIAL TUMOURS OF THE LIVER . . . 387 

35. EPITHELIAL TUMOURS OF THE GALL-BLADDER, BILE- 

DUCT, AND AMPULLA . 395 



CONTENTS ix 

CHAPTER PAGE 

36. EPITHELTAL TUMOURS OF THE PANCREAS AND 

SALIVARY GLANDS . . . . . . 409 

37. EPITHELIAL TUMOURS OF THE URINARY TRACT .419 

38. EPITHELIAL TUMOURS OF THE GENITAL ORGANS . 434 

39. EPITHELIAL TUMOURS OF THE UTERUS . . . 440 

40. EPITHELIAL TUMOURS OF THE UTERUS (concluded) 451 

41. EPITHELIAL TUMOURS OF THE FALLOPIAN TUBE . 467 

42. EPITHELIAL TUMOURS OF THE MENINGES . 474 

43. CHORIONIC CARCINOMA ; LUTEIN CYSTS ; ANGIO- 

CHORIOMA 481 



Group IV. Teratomas and Dermoids 

44. TERATOMAS .490 

45. TERATOMAS (continued) ...... 500 

46. TERATOMAS (continued) 511 

47. TERATOMAS (continued) .... . 523 

48. SEQUESTRATION DERMOIDS 530 

49. SEQUESTRATION DERMOIDS (concluded) . . . 543 

50. TUBULO-DERMOIDS 554 

51. TUBULO-DERMOIDS (concluded) . . . 564 

52. TUMOURS OF THE DUCTLESS GLANDS . . . 572 

53. TUMOURS OF THE DUCTLESS GLANDS (concluded) . 587 

54. TUMOURS OF THE FEMALE GENITAL GLAND (OVARY) 601 

55. TUMOURS OF THE OVARY (continued) . . . 607 

56. TUMOURS OF THE OVARY (continued) . . . 622 

57. TUMOURS OF THE OVARY (continued) . . . 631 

58. TUMOURS OF THE OVARY (concluded) . . ,. 641 

59. TUMOURS OF THE MALE GENITAL GLAND (TESTICLE) 650 



x CONTENTS 

Group V. Cysts 

CHAPTER PAGE 

60. RETENTION-CYSTS . . . . . ... 666 

61. RETENTION-CYSTS (concluded) . . . . 675 

62. TUBULO-CYSTS 696 

63. HYDROCELE . . 707 

64. PSEUDO-CYSTS 717 

65. PSEUDO-CYSTS (continued) . . . - . 725 

66. PSEUDO-CYSTS (continued) 734 

67. PSEUDO-CYSTS (concluded) .... 743 

68. ECHINOCOCCUS DISEASE (HYDATID CYSTS) . . 758 

INDEX 785 



TUMOURS: INNOCENT AND 
MALIGNANT 

INTRODUCTION 

IT has long been customary in surgical writings to group 
together a very heterogeneous assembly of morbid con- 
ditions under the term Tumours. This is a very ancient- 
name, and merely means a swelling, but the careful micro- 
scopic investigations of morbid anatomists, and the study 
of the relationship of micro-organisms to many swellings 
called tumours, have led to a revolution in our knowledge, 
so that the term has been stripped of its former wide 
significance. In clinical work, the word tumour is not 
likely to disappear, although it has lost its importance to 
the pathologist. 

Formerly, the term tumour was applied to the abnor- 
mal swellings which characterize the gummatous stage of 
syphilis, the lesions of actinomycosis, leprosy, and similar 
infective diseases, the excessive formation of callus around 
the fragments of broken bones, and the exuberant produc- 
tion of cicatricial tissue known as cheloid. It is noteworthy 
that almost every increase in our knowledge regarding the 
cause of tumour-diseases reduces the list of morbid con- 
ditions known as tumours, either by removing some from 
this category, or by combining under one term a number 
of apparently diverse conditions which were formerly 
regarded as independent. Tumour-diseases of the nervous 
system illustrate this. Among recent evictions from 
tumours is the big prostate of advanced life, which is 
usually classed among adenomas ; but some excellent 
observations indicate that this disease, the bane of elders, 

B 



2 INTRODUCTION 

is caused by micro-organisms infecting the glandular recesses 
of the prostate ; and some big prostates are cancerous. 

In ignorance of the cause of tumours (pathogenesis), we 
fall back on their minute structure (histology) as a basis 
of classification (taxonomy). This is the natural outcome 
of the careful investigation of the histology of tumours, 
because it led investigators to realize that they consist of 
the same tissues which compose the normal organs of the 
body. This was a great step. Anatomic observations taught 
men that animal bodies are -made up of diverse structures, 
such as fat, suet, bone, gristle, muscle, tendon, and the 
like, but the microscope revealed that they are composed 
of fundamental tissues, which enter into the construction 
of organs of the most diverse form and function. The 
base is the connective tissues, comprising bone, fat, car- 
tilage, etc., and two remarkable structures known as muscle 
and nerve. There is also a peculiar material which per- 
meates the body and enters into the composition of every 
organ; it is called areolar tissue, a ubiquitous web which 
is stout and strong as fascia and periosteum, extremely 
delicate in the nervous system, and so fine in the retina 
as to need careful preparation to render it perceptible to 
the microscope. The connective tissues form the frame- 
work of the body, constitute a sort of sustentaculum in 
compound organs, such as the liver, intestine, kidney, and 
the like, for the support of epithelium, and serve as a 
mesh in which blood-vessels and lymphatics can ramify to 
supply the liquid tissue blood, from which the epithelial 
cell can obtain material to form the secretion which it is 
the function of particular glands to elaborate. 

The careful and critical study of the minute (micro- 
scopic) structure of tumours having revealed that they were 
composed of tissues normally existing in the animal body, 
pathologists realized that the histology and embryology of 
an organ enable an experienced oncologist to predict the 
various genera of tumours and cysts to which it may be 
liable. Thus the tibia of a child contains cartilage, bone, 
fibrous tissue, young connective tissue, fat, and red marrow. 
The epiphyseal cartilages are the source of chondromas ; 
the bone furnishes osteomas, the periosteum sarcomas. 



LIABILITY OF ORGANS 3 

and very rarely lipomas, and myelomas arise in the red 
marrow. Cancers do not arise primarily in bone, as it 
lacks epithelium, but they often occur in bone as secondary 
deposits. 

Although our knowledge of the histology of tumours, 
thanks to differential staining methods, is now sufficient 
to enable us to indicate from the structure of an organ 
the genera of tumours to which it may be liable, never- 
theless the most careful study of the minute structure of 
such organs as the salivary glands would not lead us to 
suspect their liability to tumours containing cartilage ; and 
it is strange that they should occur in the parotid, sub- 
maxillary, and lachrymal glands, and yet be unknown in 
the pancreas. What oncologist, merely from studying the 
histology of a normal ovary, would suspect that it would 
be the point of origin of a dermoid ? It is like studying 
the fauna of a country. For instance, who imagined, until 
Australia was discovered, the existence of extraordinary 
mammals like kangaroos and duck moles ? But knowledge 
gained from observation enables us to state that gliomas 
do not arise in bones, nor myomas in the brain, with as 
much certainty as we assert that at the present period of 
our planet's history lions do not sport about the ice-fields 
of Greenland, nor humming-birds flit about the flower-beds 
of Hyde Park. 

Although the tissues of an organ determine the genera 
of tumours to which it may be liable, their relative frequency 
can only be gathered from observation. There are great 
variations in the liability of the organs of the body to 
tumours. The heart is very rarely occupied by a tumour ; 
on the other hand, the uterus, also a muscular organ, is 
with extreme frequency the seat of fibroids. The liability 
of bones to sarcomas is proverbial, yet a sarcoma of a 
voluntary muscle is uncommon. A primary tumour is a 
rarity in the lung, but it is common enough in the brain 
or the eyeball. Sarcomas are frequent in the kidneys, but 
a primary sarcoma in the liver or spleen is extremely rare. 
These and many kindred questions indicate profound irnper 
fections in our knowledge concerning the cause of tumours. 
It may be stated, without fear of contradiction, that no one 



4 PLAN OF THE WORK 

has succeeded in framing a satisfactory classification of 
tumours. In this work the subjoined plan will be followed : 

Group I. Tumour-diseases of the connective tissues. 
Lipomas, Sarcomas, Osteomas, Chondromas, 
Myelomas, Myomas, Neuromas, Angiomas, 
and Fibroids. 

II. Tumour-diseases of teeth. Odontomes. 
III. Epithelial tumours. Papillomas (warts), Ade- 
nomas, and Carcinomas. 

IV. Teratomas. Dermoids and Embryomas. 
V. Cysts. 

Tumours, from very early times, have been arranged 
into a malignant and an innocent or benign division, based 
on the knowledge gained from observation that some of 
them inevitably destroy life, whilst others do not display 
such destructive propensities. 

Environment in relation to tumours. It is important 
to remember that benign tumours may, and often do, de- 
stroy life. The essential difference between an innocent and 
a malignant tumour may be expressed thus: The baneful 
effects of innocent tumours depend entirely on their 
I environment, but malignant tumours destroy life what- 
ever their situation. 

Some of the most tragic deaths due to tumours, struc- 
turally benign, occur in connexion with the air-passages. 
A man aged 76 entered a restaurant and made an inco- 
herent noise and a motion of his hand, which were taken to 
be a request for water. Death took place quite suddenly. 
At the post-mortem examination an ovoid lipoma was found 
growing from the left glosso-epiglottic fold. Shattock sug- 
gests that, from some unusual act on the part of the patient 
it was grasped by the pharyngeal constrictors and suffocated 
him as he involuntarily attempted to swallow his own 
tumour. (Fig. 1.) 

Death sometimes occurs with great suddenness when 
tumours interfere with the mechanism of the heart. A 
woman aged 54, acutely maniacal, was admitted into the 
Denbigh Asylum ; two months later she was found by a 
nurse in a state of collapse that soon ended in death. At 



ENVIRONMENT 5 

the autopsy all the organs appeared healthy, except the 
heart. On the wall of the right auricle a tumour, as big 
as a walnut, grew from the fossa ovalis, and was sufficiently 
movable to drop into the orifice of the mitral valve. Mani- 
fold, who made the examination and reported the case, is 
of opinion that this was the cause of death. The tumour 
was a cavernous angioma. 




Fig. 1. Lower part of pharynx open and showing the larynx, and a 
lipoma growing from the left glosso-epiglottic fold. From a man 
76 who died suddenly. (Museum of the Royal College of Surgeons.'} 



Tumours of nerves illustrate the effects of environment. 
A neuroma on a peripheral nerve like the median is painless 
unless squeezed, but a neuroma on the trigeminal nerve 
within the skull causes pain that baffles description (see p. 156). 
These examples show that tumours classed as innocent are 
only dangerous when, from their position, they mechanically 
interfere with vital organs or obstruct functions necessary 
for the maintenance of life. Malignant tumours, on the 
other hand, destroy life in whatever situation they arise. 



6 ENVIRONMENT 

Melanomas illustrate this. A man aged 50 had a tumour 
the size of a cherry-stone growing from the choroid coat 
of his eye. The eyeball was promptly excised. Within 
two years this man died with secondary deposits in the 
liver and other organs, each nodule being as black as the 
primary tumour, The skin became black ; melanin appeared 
in the urine, and in the ascitic fluid that accumulated in 
his belly. 

Although it is true that malignant tumours destroy 
life in whatever situation they arise, nevertheless environ- 
ment exercises great influence on the rapidity as well as on 
the mode in which they kill. For instance, cancer of the 
larynx may cause death from suffocation, but it is more 
frequently fatal by setting up septic pneumonia in con- 
sequence of the inhalation of septic matter from the 
sloughing surface of the growth. Cancer of the gastric^ 
orifices usually entails death from starvation. When a 
malignant tumour implicates a vital organ it sometimes 
destroys life before there has been time for dissemination. 
In the case of non-vital organs, death is usually induced 
by secondary nodules occupying important organs, such as 
the lung, liver, and brain. It is a fact that a periosteal 
sarcoma of the femur is a most deadly tumour, but a 
sarcoma of the tibia with the same histologic characters 
will, with precisely the same treatment (amputation), take 
as many years to destroy life as the tumour of the femur 
requires months. This would appear to indicate that the 
two tumours, though structurally alike, really have different 
causes, yet there are facts which lead us to suspect that 
variations in tissue actually constitute an altered environ- 
ment. The only condition which supports this view in 
a positive way is echinococcus-disease. The final chapter 
of this book contains abundant evidence as to the effects 
of environment on the character of echinococcus colonies, 
besides illustrating the varied manner in which the sur- 
roundings determine the mode by which these parasites 
often induce the death of human beings, their involuntary 
intermediate hosts. 

Some of the most terrible examples illustrating danger- 
ous environment are solid ovarian tumours and dermoids 



AGE-DISTRIBUTION 7 

incarcerated in the pelvis by a gravid uterus. In many 
instances the presence of a tumour is unsuspected even 
when the woman has been hours in labour. Obstruction 
of this kind is very fatal to the child, and frequently to 
the mother, and the injuries which women sustain in such 
circumstances are often of an appalling character, as works 
on midwifery testify. Even when ovarian tumours do not 
obstruct delivery, their coexistence with pregnancy is an 
inimical condition, and may bring about the death of the 
mother either in the progress of the pregnancy, during 
labour, or in puerpery. There are some anatomical con- 
ditions which distinguish innocent from malignant tumours : 
those that are benign usually possess an investing mem- 
brane, or capsule, by which they are isolated from the 
tissues in which they grow ; they do not infect lymphatics, 
nor recur after complete removal, and rarely imperil life 
save when they are growing in connexion with, or in the 
immediate vicinity of, vital organs. Malignant tumours, 
on the other hand, are rarely encapsuled, and tend to 
infiltrate the surrounding tissues ; they infect lymphatics, 
are exceedingly liable to recur after removal, tend to be- 
come disseminated by the blood-stream, and they inevitably 
destroy life. 

Age - distribution. Although some tumours occur at 
any period of life e.g. fatty tumours and sarcomas the 
majority of the genera has a fairly well-defined, and occa- 
sionally a very strict age-limit. For example, glioma of 
the retina has rarely been observed after the twelfth year; X 
it is peculiarly limited to children, and this is also the 
case with the remarkable condition known as "gliomatous 
disease" of the pons and medulla. Myelomas are tumours 
of adolescence ; and this is true of odontomes, for they 
only arise in connexion with the germs of the permanent 
teeth. Uterine fibroids are produced during menstrual 
life, and careful inquiry demonstrates that the dread 
disease chorionic carcinoma is a by-product of concep- 
tion, and therefore restricted to the child-bearing period 
of life. Parovarian cysts do not occur before the fifteenth 
year, and papilloniatous cysts of the ovary are fairly well 
distributed among the three decades bounded by the twenty- 



MULTIPLICITY 

fifth and fifty-fifth years. Angiomas and sequestration 
dermoids are essentially congenital tumours, whilst malignant 
melanomas are almost confined to adults. Age constitutes an 
environing condition when we reflect that sarcoma in in- 
fancy tends to be bilateral e.g. when it attacks the kidneys, 1 
eyes, adrenals, or ovaries. In adult life sarcoma of these 
same organs is invariably unilateral ; but, apart from this 
peculiarity, as many of the subsequent chapters will show, 
the tumours at these diverse periods of life exhibit obvious 
and unmistakable differences in their minute structure. 

Multiplicity. Innocent tumours are often multiple : five, 
ten, or twenty lipomas on an individual are not un- 
common numbers. A thousand neuromas have been counted 
on one patient ; a hundred fibroids may grow concurrently 
in the tissues of the uterus, and ten adenomas occasion- 
ally occupy a single thyroid gland ; but the occurrence of 
two primary cancers in the same patient is excessively 
rare, with the exception of the peculiar variety known as 
rodent cancer. 

The coexistence in the same person of two genera of 
innocent tumours is well known indeed, is almost a matter 
of daily observation uterine fibroids and ovarian dermoids, 
lipomas and sequestration dermoids, chondromas and osteo- 
mas being frequent combinations. 

The natural history of tumours. The opinion is deeply 
ingrained in the minds of physicians and surgeons that 
tumours grow continuously, and that their growth only 
ends with the life of the individual in whom they grow. 
This is not universally true. The autonomy of tumours is 
no mere figure of speech. A common comparison is a 
fatty tumour and a camel's hump: the latter wanes on a 
toilsome journey when food and water are scanty, but the 
former retains its size in men and women dying from a 
wasting disease. Clinical experience teaches that the ten- 
dency of many diseases is towards spontaneous cure. This 
is true of tumours. Glioma of the retina sometimes 
shrinks spontaneously (p. 164). Osteomas when thoroughly 
ossified cease to grow. The most familiar examples of the 
disappearance of tumours occur among angiomas or nsevi; 
many disappear during infancy. The best examples among 



NATURAL HISTORY 9 

tumours of a limited period of origin, growth, and obsoles- 
cence are found among uterine fibroids. They also illus- 
trate another phase of tumour-life, the influence of the 
function of the organ in which they grow. A submucous 
fibroid will so deceive (he uterus that it acts as if the 
fibroid growing in its endometrium were a normal concep- 
tion ; it will attempt, and often succeed, in extruding the 
tumour. The curious and often disastrous consequences 
associated with age - changes in fibroids, the influence of 
these tumours on the uterus, and the influence of uterine 
action and reaction on them, are set forth in Chap. xvi. 

Red marrow fills the shafts of the long bones in all 
children ; gradually it is replaced in the middle of the 
shaft by fat or yellow marrow. Its importance as a tissue 
in which the red corpuscles of blood are prefigured is now 
one of the simplest facts of physiology. Red marrow is 
the essential tissue of the tumours called myelomas. Such 
tumours produce remarkable effects on the bones in which 
they grow. The tissue of a myeloma, like red marrow 
from which it arises, is liable to spontaneous atrophy, 
and the cavity left by its disappearance is called a " cyst 
of bone." All bone-cysts do not arise from the atrophy 
of myelomas ; some may be due to the disappearance of 
normal red marrow. Other blood-forming organs, such as 
the spleen and lymph - nodes, are liable to enlargement 
caused by an abnormal but uniform increase in the tissue 
special to such organs. Cysts and irregular-shaped spaces 
filled with fluid are common in such enlarged organs : 
these spaces are probably due to the spontaneous atrophy 
of their intrinsic tissue. 

Splenic tissue, like red marrow, is relatively abundant 
in infancy and adolescence. In a child the spleen weighs 
5 oz. ; in an old person, half an ounce. The atrophy of 
overgrown spleen pulp is a probable mode of origin of 
splenic cysts, some of which contain a pint or more of pink 
fluid. A splenic cyst may also be the sequel of an infarct. 

The history of many odontomes illustrates well the 
principle that the life-history of a tumour is influenced 
by the organ in which it grows. An odontome lies con- 
cealed beneath the gum until it begins, like a tooth, to 



io NATURAL HISTORY 

erupt. Then it sets up Severe disturbance and sometimes 
places the patient's life in the greatest danger. When 
"cut" it may take its place with the normal teeth and 
be used in mastication. In many instances, like a tooth, 
it drops out (Chap. xxn). 

Nothing so forcibly illustrates persistent tissue-changes 
as superficial cutaneous structures such as hair, wool, 
feathers, horns, nails, and claws. The moulting of feathers, 
the shedding of the surface layers of the skin of snakes, 
and the ecdysis of crayfishes arrest attention. The epi- 
dermis of man comes away, as a rule, as an almost imper- 
ceptible powder, unless he gets badly sunburnt, blistered, 
or suffers from scarlet fever. The skin then peels freely. 
Epithelial pathological productions are often shed in the 
same way. Cutaneous warts, especially in children, dis- 
appear spontaneously, and a " wart charmer " exists in most 
villages. Cutaneous horns developed from warts, or the 
scars of chronic ulcers left by burns, are shed at irregular 
intervals ; but cutaneous horns on the legs or beaks of 
birds are shed with each moult. (Fig. 2.) 

The functions of epithelium are many and various, but 
one of the most remarkable is that exercised by the 
cellular covering of the chorionic villi. These singular 
structures, in their early condition, consist of a core of 
delicate tissue covered by a regular layer of cells called 
the cellular trophoblast and capped by a peculiar multi- 
nuclear mantle known as the plasmodial trophoblast. 
When the chorionic villi come in contact with the thick 
and succulent endometrium, the trophoblast erodes it and 
the villi embed themselves and anchor the oosperm firmly 
in the maternal tissues. 

The villi are liable to a morbid change known as hyda- 
tidiforrn degeneration. This is accompanied by abnormal 
growth and excessive erosive action ; in these circumstances 
the villi have been known to perforate the uterine walls 
and project into the peritoneal cavity. They are also liable 
to behave like cancer, and the plasmodial trophoblast will 
perforate the walls of veins ; detached fragments of such 
disorganized villi are transported by the blood-stream and 
set up secondary tumours in the lungs. This form of malig- 



MALIGNANT TRANSFORMATION 



ii 



nant disease is remarkable from the fact that the placenta, 
formed of chorionic villi, only exists for eight months. Yet 
fragments detached from the delicate structures which 
compose the placenta will, under certain conditions, give 
rise to chorionic carcinoma, one of the most destructive 
forms of malignant disease. 




Fig. 2. Head and leg of a thrush with cutaneous horns. The horns were 
cast each time the bird moulted. 

This disease is instructive because the erosive action of 
the trophoblast is the physiological type of the invasive- 
ness so characteristic of many varieties of cancer. The 
manner in which cancer erodes vascular tissue, the hardest 
as well as the softest, is very remarkable. 

Other examples illustrating the principles enunciated in 
the preceding paragraphs will be indicated in the special 
chapters. 

The transformation of innocent into malignant tum- 
ours. A long study of the histogenesis of tumours has 






12 MALIGNANCY 

convinced the writer that the clearly innocent and the 
decidedly malignant tumours present distinct histologic 
features, but there are intermediate varieties which cannot 
be sharply defined in relation to these points, and this 
comes out in a striking and suggestive way when an in- 
dividual possesses tumours of a supposed innocent genus in 
multiples : for example, from uterine fibroids, when they are 
multiple, a tumour may be selected which sometimes re- 
quires a saw to divide it ; another may be as soft as a 
ripe fig, and a third will be as viscous as jelly and almost 
diffluent : a soft fibroid of this character will sometimes 
recur after enucleation. Careful records are accessible in 
which fibroids of apparently simple structure have dissemi- 
nated and destroyed life; it should be borne in mind that 
the uterus is liable to be the seat of a sarcoma which, in 
the early stages, mimics a fibroid in its naked-eye characters. 

It is so difficult to decide between the slow-growing 
spindle-cell sarcoma, the fibrifying sarcoma, and the gela- 
tinous fibroid (myxoma), that it is unwise to argue from our 
present knowledge that innocent connective-tissue tumours 
may undergo transformation into sarcomas, until distinctive 
methods have been introduced by the histologist, chemist, 
biologist, or bacteriologist. 

Multiple chondromas, exostoses, neuromas and uterine 
fibroids are probably connected with disordered action of the , 
ductless glands. It is not uncommon for a sarcoma to arise 
in one of the tumours and destroy the patient (see p. 62). 

It may be stated that every genus of the connective- 
tissue group, with the exception of the lipomas, presents 
varieties which shade away indefinitely from the typical 
species towards the sarcomas, and display malignancy. It 
is also clear, from a careful study of the histology of 
tumours, that the more perfectly they approach in type 
normal tissues, the more benign is their clinical con- 
duct ; and the more widely the tissues of a tumour 
depart from the normal elements in which they arise, so 
much more likely is such a tumour to be malignant. A 
wide departure from the normal type of tissue in a given 
tumour expresses the degree of malignancy. Certainly, the 
more widely the cells of a tumour deviate from those 



MALIGNANCY 13 

normal to the matrix in which it grows, the more rapidly 
do they multiply ; and this persistent cell- proliferation is J 
one of the most obvious features of malignancy. The 
more carefully the histology of tumours is investigated, 
the more obvious is it that the borderland between 
innocent and malignant species becomes less easily 
definable. This has been very definitely revealed in the 
case of ovarian dermoids : few tumours had a better 
reputation for innocency, yet we now know that the less 
typical forms are liable to infect the peritoneum and even 
disseminate, and some varieties of testicular embryomas are 
among the most malign tumours that attack mankind. 
Realizing the uncertainty attending the diagnosis and prog- 
nosis of tumours and tumour-diseases, pathology confirms 
the practice advocated by surgeons in dealing with them, 
namely, removal, wherever practicable, at the earliest 
possible moment. 

Shattock, S. G., "A Large Laryngeal Lipoma," etc. Proc. Roy. Soc. of 
Med., 1909, Path. Sect., ii. 285. 



GROUP L TUMOUR-DISEASES OF THE 
CONNECTIVE TISSUES 

CHAPTER I 
LIPOMAS (FATTY TUMOURS) 

A LIPOMA is a tumour composed of fat; the genus consists 
of a single species. With the exception of sarcoma it is 
the most generalized tumour that occurs in man. It there- 
fore will be convenient to consider lipomas according to 
the situations in which they arise, such as in the sub- 
cutaneous and subserous tissues ; synovial or mucous mem- 
branes ; between or even in muscles ; or in connexion with 
periosteum, and the meninges of the brain and spinal cord. 

The distribution of fat in the animal body is comparable 
to that of starch in the vegetable kingdom, where it also takes 
on a tumour-like form, as in conns and tubers (Shattock). 

1. Subcutaneous lipomas. 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 fatty tumours. Usually they occur 
as irregularly lobulated encapsuled tumours, more or less 
adherent to the skin : unless they have been irritated, 
lipomas are movable within their capsules. Generally one 
liporna is present, but two, ten, twenty, or more may occur 
concurrently on the same individual. In size they vary 
widely: a lipoma weighing 16 oz. is a tumour of fair size; 
exceptional specimens have been reported to weigh 50, 80, 
and even 100 Ib. Although subcutaneous lipomas are for 
the most part confined to the trunk and trunk-ends of 
limbs, they may arise on the distal parts of the limbs, 
such as the hands and feet (Figs. 3 and 4). Many speci- 

14 



SUBCUTANEOUS LIPOMAS 15 

mens have been observed in the palm of the hand, 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 prone 
to burrow beneath the palmar fascia, and it is probable 
that some lipomas of the palm originate beneath this 
fascia, in the lobules of fat lying between the lumbricales. 




Fig. 3. Lipoma of the sole which had existed for thirty years. The foot was 
amputated by Percivall Pott. (Museum of St. Bartholomew's Hospital.} 

A lipoma has been observed on the back of the hand of 
a boy aged 8, and a process of the tumour passed between 
the third and fourth metacarpals into the palm (Pnpovac). 
Fatty tumours are occasionally found on the fingers ; 
Steinheil has collected many examples. A lipoma in the 
sole is more comprehensible than one in the palm, yet, 
strange to relate, these tumours are far more frequent in 
the hand than in the foot ; in both situations they are 
apt to be congenital, and nearly always cause doubt in 
diagnosis (Gay, Lockwood). 



16 LIPOMAS 

Fatty tumours are rarely met with upon the head or 
face, but I have on three occasions removed a lipoma from 
beneath the skin covering the temporal fascia. There is 
a variety of fatty tumour sometimes called, on account of 
its vascularity, ncevolipoma : this may be a nsevus which 
has undergone fatty degeneration. Probably some of the 
vascular lipomas which occasionally occur on the face are 
of this nature. 




Fig. 4. Lipoma in the palm. 

Fatty tumours which have existed many years some- 
times calcify, the earthy matter being deposited in the 
fibrous septa of the tumours. A partially calcined lipoma, 
preserved in the museum of St. Bartholomew's Hospital, 
came from the arm of an Arab sheikh, where it had existed 
fifty years. 

The subcutaneous fat in the neck, axilla, and groin 
sometimes forms irregularly lobulated masses which are 



SUBSEROUS LIPOMAS 17 

called diffuse lipomas, but they are not strictly tumours 
(Fig. 6). 

2. Subserous lipomas, The peritoneum, like the skin, 
rests upon a bed of fat, the thickness of which varies. 
Lipomas occurring in subserous tissue are sessile, or pedun- 
culated. 

Surgeons have long been aware, in operating for in- 
guinal or femoral hernia, that occasionally they come across 




Fig. 5. Fatty tumour on the arm of a Chinaman at Ningpo. 

a mass of fat and find difficulty in determining whether 
it be omental or a local increase of the subserous fat sur- 
rounding the hernial sac. In the neighbourhood of the 
femoral and inguinal canals an overgrowth of the sub- 
serous fat may occur and be mistaken for a hernia, and 
individuals have been recommended to wear, and have 
actually worn, trusses for fatty masses of this character. 
Local overgrowths of fat may arise and protrude in the 
groin, drawing with them a pouch of peritoneum un- 
c 



i8 SUBSEROUS LIPOMAS 

associated with a hernia. These pouches may afterwards 
lodge a piece of gut, and become true hernial sacs. Thus 
peritoneal pouches, produced mechanically by subserous lobes 
of ' fat, may subsequently become hernial sacs ; on the 
other hand, pedunculated lobes of fat may arise in relation 
with peritoneal pouches which were originally hernial sacs. In 
some cases a subserous lipoma of this character will invagi- 
nate a peritoneal pouch and form a pedunculated tumour 




Fig. 6. Diffuse lipoma of the neck. (Morrant aker.) 

within the hernial sac. More rarely a fatty tumour will 
arise in connexion with the spermatic cord. Gabryszewski 
has collected the more important cases, and discussed the 
difficulty such tumours cause in diagnosis. Fatty tumours 
arise in the scrotum or labium without being connected 
with hernial pouches. 

Lipomas arising in the subperitoneal tissue occasionally 
appear in the anterior abdominal wall, especially near the 
umbilicus; they are known as "fatty hernise of the linea 



LIPOMAS 19 

alba," and are not infrequently associated with peritoneal 
pouches. 

Fatty tumours sometimes grow between the layers of the 
mesometrium, and in some instances are so large as to 
simulate ovarian tumours (Parona, Treves). 

Masses of fat, in many respects resembling the so-called 
" diffuse lipoma " of the subcutaneous tissue, have been re- 
moved from the abdomen, weighing 30 and even 50 Ib. 
(Pick, Cooper Forster). A prolongation from a large subserous 
tumour of this kind appeared on the inner side of the right 
buttock of a woman aged 35, and simulated a perineal 
hernia. An operation was performed and a part of the 
tumour removed through an incision in the abdomen; the 
perineal portion was removed externally. The whole tumour 
weighed 14 Ib. (McGavin). 

Appendices epiploicse are localized pedunculated over- 
growths of subserous fat, and are particularly 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 to leave 
an adipose nodule at the end of a peritoneal pouch. 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 infre- 
quently calcified, detached in this way, have been found in 
hernial sacs. 

A fatty tumour may arise in the fat behind the ensiforrn 
cartilage, and, extending through the gap in the diaphragm 
in this situation, occupy the lower end of the anterior 
mediastinum. A lipoma weighing 17 Ib. occupied the 
anterior mediastinum of a man aged 37. It caused cough, 
dyspnoea, and symptoms usually associated with mediastinal 
obstruction. (Leopold.) 

Rokitansky pointed out that the subpleural fat in the 
intercostal region sometimes forms a lobulated mass which 
prolapses into the sac of the pleura, C. Gussenbauer has 



20 SUBMUGOUS LIPOMAS 

described and figured <i subpleural lipoma which made its 
way on each side of the ribs. The two lobes were joined 
by a narrow isthmus so as to form an intra- and an extra- 
thoracic portion; the latter bulged under the pectoralis 
major and simulated a sarcoma. A similar case is reported 
by Fitzwilliams : A boy aged 6 had a swelling in the right 
side of the neck, just above the clavicle and behind the 
sterno-mastoid muscle. It so resembled a hernia of the 
lung that a truss was devised and worn. As the swelling 
increased it was exposed by operation, and proved to be a 
fatty tumour, shaped like a dumb - bell and 5 in. long. 
The portion in the neck joined, by a narrow isthmus (which 
passed behind the subclavian artery), a much larger portion 
that lay within the thorax but outside the pleura. 

3. Submucous lipomas. Fat exists in submucous tissue 
in many situations, and, like fat in the subcutaneous tissue, 
is not infrequently the source of lipomas. 

(a) Subconjunctival lipomas. These occur near the 
line where the conjunctiva is reflected from the lower lid 
to the eyeball ; they are almost entirely confined to chil- 
dren. Fatty tumours sometimes arise from the orbital fat 
and cause the conjunctiva to protrude in the neighbour- 
hood of the lachrymal gland and near the insertions of the 
ocular muscles. 

(6) The lips and tongue. Lipomas in these situations 
are very rare and never large (Edmunds). I removed one 
from the submucous tissue at the side of the tongue. It 
was as large as a coffee-bean ; the patient was a woman 
aged 54. (See p. 24.) 

(c) Laryngeal lipomas. A few remarkable examples 
have been reported. Holt>- met with a pedunculated lipoma 
22-5 cm. in length, which grew from the side of the left 
aryteno-epiglottic fold and extended into the oesophagus. 
Sidney Jones removed a lipoma from the right aryteno- 
epiglottic fold of a man aged 40. The patient could pro- 
trude the tumour into his mouth. A similar tumour became 
impacted in the pharynx of an old man and choked him. 
(Fig. 1, p. 5.) 

(d) Lipomas of the gastro-intestinal tract. The stomach 
is a rare situation for fatty tumours ; as a rule, they 



SUBSYNOVIAL LIPOMAS 21 

are small, and mainly pathological curiosities. In the 
intestine they are not uncommon, but dangerous, for they 
cause obstruction. Fatty tumours have been found in the 
duodenum, jejunum, and ileum, but they occur more 
frequently in the caecum and colon. In all parts of the 
intestinal tract they are liable to cause invagination and 
obstruction, occasionally with fatal consequences. In the 
case of the colon a funnel-shaped dimple is usually present 
in the serous coat overlying the pedicle of the tumour ; 
this suggests that the lipoma, though projecting into the 
gut, arises in the substratum of fat under the peritoneum, 
and that the dimpling is due to traction. A lipoma of 
the duodenum in the Birmingham Museum has a stalk 
5 cm. long, and over the site of the attachment of the stalk 
there is a dimple in the serous covering. The presence 
of a dimple in the peritoneum overlying a tumour of the 
colon should lead a surgeon to suspect a lipoma, and 
induce him to enucleate it in preference to resecting a 
length of the intestine. I carried this out in a man aged 
44, and successfully removed a submucous lipoma of the 
ascending colon situated 5 cm. beyond the ileo-csecal 
valve. Greenwood excised the caecum and ascending colon 
of a woman aged 31, for a submucous lipoma (Fig. 7). 
Compton performed a similar operation on a woman aged 
50, and found a lipoma within the folds of the ileo-csecal 
valve. The passage from the ileum to the caecum is 
through a ring of fat covered with attenuated mucous 
membrane. This remarkable specimen, Greenwood's, and 
mine are preserved in the museum of the Royal College 
of Surgeons. In all the specimens I have seen, in which 
intestinal lipomas have caused attacks of obstruction, the 
mucous membrane covering the tumour has been ulcerated. 
The literature of such lipomas has been collected by 
Langemak and Shattock. 

4. Subsynovial lipomas. 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 
lipomas, increase in 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 occu- 



22 



LIPOMA ARBORESGENS 



pied by the alar ligaments. 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 Miiller applied the term "liporna arbor- 
escens." This condition is often, but by no means always, 
associated with rheumatoid arthritis. A typical specimen 




Fig. 7. Lipoma of ascending colon, in section. The stalk of the tumour is 
connected with the subserous fat, and the overlying serous coat is deeply 
dimpled. (Natural size. ) (Museum of the Royal College of Surgeons.} 

(Fig. 8) consists of small finger-like processes of fat pro- 
jecting into the cavity of the joint ; each process is covered 
with synovial membrane. The lipoma arborescens bears pre- 
cisely the same relation to the synovial membrane that 
the appendices epiploicse bear to the peritoneal investment 
of the colon and its sigmoid flexure. 

5. Intermuscular lipomas. Fatty tumours now and 
then arise in the connective tissue between muscles ; they 
have been found between the greater and lesser pectorals, 



INTERMUSGULAR LIPOMAg n 

the muscles of the tongue, and in the intermuscular strata 
of the anterior abdominal wall. In the last-mentioned 
situation they have been known to attain prodigious pro- 
portions. Exceptional examples have been described by 
Astley Cooper, Eve, and others. 

The sucking-pad. This ball of fat lies between the 
masseter and buccinator muscles, and comes into close rela- 




Fig. 8. Lipoma arborescens of the shoulder-joint. 
(Museum of the Middlesex Hospital.} 

tion with the buccal mucous membrane. It is believed to 
play an important function in connexion with sucking, by 
distributing atmospheric pressure and preventing the buc- 
cinators from being forced between the alveolar arches when 
a vacuum is created in the mouth. These cushions are 
relatively much larger in infants than in adults, and in 
emaciated children they are only slightly diminished in size, 
even when there is scarcely any subcutaneous fat (Fig. 9). 



24 SUCKING-PADS 

A lipoma may arise in connexion with the sucking- 
pad and bulge into the mouth. The museum of the 
Middlesex Hospital contains one removed from an edentulous 
septuagenarian. It is as big as a golf-ball and bulged into 
his mouth. Cameron has collected the literature of such 
rare occurrences. 

The hibernating gland. In animals which pass the winter 
in sleep, such as the hedgehog, dormouse, and marmot, 
masses of fat accumulate in the neck and under the 
scapula as winter approaches ; this fat dwindles during 




Fig. 9. Emaciated child crying and displaying the sucking-pads. 
(Ranke.) 

hibernation, and disappears at the advent of spring. Hatai 
and Shattock have come independently to the conclusion 
that the fat of this hibernating gland differs in some of its 
microscopic characters from common fat. In the human 
subject they find that some of the deeply seated fat in the 
neck corresponds in disposition and structure to that of the 
hibernating or interscapular gland. This layer of fat exists 
in the normal human foetus before term (Fig. 10). 

6. Intramuscular lipomas. Many examples of fatty 
tumours occurring in the middle of muscles have been 
reported, and are of interest from the trouble they cause 



PAROSTEAL LIPOMAS 25 

in diagnosis. They have been found in the deltoid, biceps 
humeri, complexus, and rectus abdominis. A lipoma, as 
big as a duck's egg, lodged in the substance of the brachialis 
anticus muscle, unconnected with the periosteum of the 
humerus, is preserved in the Museum of the Royal College 
of Surgeons. It was obtained from an old woman, a 
dissecting-room subject. The rarest of all places for a fatty 




Fig. 10. A foetus of 



months dissected to show the hibernating gland. 
(Bonnot.) 



tumour is in the middle of a submucous fibroid of the 
uterus (T. Smith, Lebert, Ellis, and others; see p. 184). 
The condition described as fatty tumour of the heart is an 
overgrowth of the fat occupying the auriculo-ventricular 
groove. 

7. Parosteal lipomas. This term has been applied to 
fatty tumours arising from the periosteum of bone. When 
congenital, they nearly always contain tracts of striated 
muscle-fibre. Some of these tumours are clinical puzzles. 



26 



LIPOMAS ON NERVES 



Fatty tumours have been found growing from the peri- 
osteum of vertebrae, the femur, tibia, fibula, clavicle, scapula, 
radius, coccyx, ischium, spine of ilium, and body of pubes. 
Czerny removed a lipoma from the neck of a girl aged 14. 
This tumour weighed 1 kg. ; it grew from a rudimentary 
cervical rib connected with the fifth cervical vertebra (see 
Voelcker). 

8. Lipomas on nerves. Occasionally a fatty tumour 
arises from the sheath of a peripheral nerve ; this is a 
neurolipoma. There is a specimen in the museum of 
the Middlesex Hospital, removed from the sheath of the 




Fig. 11. Large lipoma growing from the sheath of the great sciatic nerve 
of an infant. (Vickery.) 

median nerve as it escaped from the anterior annular liga- 
ment into the palm. Vickery succeeded in removing a lipoma 
weighing 12^ oz. from the thigh of an infant aged 9 months 
(Fig. 11;; it grew from the sheath of the great sciatic 
nerve : and I have had a similar experience. 

9. Meningeal lipomas. Fatty tumours occur within the 
spinal dura mater, as well as externally to this membrane. 
When growing within the sheath they surround the cord: 
Gowers, Recklinghausen, and Obre have recorded examples. 
In the cases described by the first two observers the tumours 
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. 



LIPOMAS: CLINICAL FEATURES 27 

A lipoma has been observed encapsuled between the layers 
of the dura mater lining the sella turcica ; it extended into 
the middle fossa of the skull on the left side. The patient, 
a woman aged 44, suffered from periodical pain in the 
head, and eventually from ptosis (two years). The tumour 
was as big as a hen's egg. 

Clinical features. Although lipomas occur more fre- 
quently than any other genus of connective-tissue tumours, 
and may, in most instances, be diagnosed with absolute 
certainty, yet under some conditions they are very puzzling, 
and give rise to much difference of opinion. The sub- 
cutaneous species is rarely the source of doubtful diag- 
nosis, unless situated in the palm, the sole, or on the 
scalp. The intimate relation between the tumour and 
the overlying skin, the absence of definite boundaries, 
and its dough-like consistence are usually sufficiently trust- 
worthy guides. When a lipoma is connected with the 
periosteum of the femur, the tibia, or the fibula, it simulates 
a sarcoma ; when embedded in a muscle the most divergent 
opinions are often expressed in regard to the nature of the 
tumour ; and a lipoma in the posterior triangle of the neck 
has been mistaken for an aneurysm of the subclavian artery : 
this vessel was tied, with a fatal result. A man under my care 
had a tumour below the clavicle and beneath the lesser 
pectoral muscle, simulating an aneurysm of the subclavian. 
It was a lipoma as big as a duck's egg, growing from the 
coracoid process. 

Small painful subcutaneous tumours, especially on the 
forearms, resembling lipomas are in reality neuromas contain- 
ing fat. A lipoma in the groin is occasionally mistaken 
for an irreducible epiplocele. 

Especial attention must be drawn to supposed fatty 
tumours situated in the middle line of the back: in most 
cases these are abnormal masses of fat overlying the sacs of 
spinse bifidse. (Fig. 12.) Incautious surgeons, in operating 
upon such tumours, have unexpectedly opened the dura 
mater. 

Treatment. Solitary subcutaneous lipomas should, as a 
general rule, be removed. When very many tumours are 
present (ten or twenty) it is not customary to interfere with 



28 



LIPOMAS: TREATMENT 



them, for when multiple they rarely attain uncomfortable or 
Dangerous proportions. It occasionally happens with multiple 
(and also with solitary) lipomas that one or other becomes 
irritated by some part of the dress, such as petticoat bands, 
braces, etc., or in some particular employment followed 
by the individual. Such tumours should invariably be 
removed. 




Fig. 12. Meningeal lipoma overlying the sac of a spina oifida. 
(Museum of the Royal College of Surgeons.} 



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. 

The occurrence of multiple fatty tumours and excessive 
fatness (obesity), of which Daniel Lambert, who weighed 
739 lb., is a classic example, is often an expression of 
disturbance connected with the endocrine glands. 



REFERENCES 29 

Berger, " Calcul salivaire et Hypertrophie de la Boule graisseuse de Bichat." 

Gaz. des H6p. t 1883, Ivi. 1041. 
Bland-Sutton, J., " On a Fatty Tumour of the Ascending Colon ; Enterectoray ; 

Recovery." Lancet, 1900, i. 1437. 

Bonnot, E., "The Interscapular Gland." Journ. of Anat. and Phys., xliii. 43. 
Cameron, A. L,, " Lipoma of the Corpus Adiposum Buccse." Journ. Amer. 

Med. Assoc., 1921, Ixxvi. 778. 
Cooper, Astley, " Case of a Large Adipose Tumour successfully extirpated." 

Med.- Chir. Trans., 1821, xi. 440. 
Edmunds, W., " Fatty Tumour from the Lip." Trans. Path. Soc., 1893, xliv. 

151. 

Ellis, A. G., "Lipoma of the Uterus." Proc. Path. Soc. of Philadelphia, 

1906, No. 8. 
Fitzwilliams, D. C. L., " Extrapleural Lipoma from a Child aged six years." 

Proc. Roy. Soc. of Med., 1913, vii., Sect, for Dis. of Children, p. 19. 
Forster, J. Cooper, " Fibro-Fatty Tumour of the Abdomen, weighing fifty-five 

pounds." Trans. Path. Soc., 1868, xix. 246. 
Gabryszewski, A., "Ueber Lipome des Samenstranges." Dcut. Zeitschr. f. 

Chir., 1898, xlvii. 317. 

Gay, J., " Fatty Tumour on Sole of Foot." Trans. Path. Soc., 1863, xiv. 243. 
Gowers, W. R., "Myo- Lipoma of Spinal Cord." Ibid., 1876, xxvii. 19. 
Gussenbauer, C., "Bin Beitrag zur Kenntniss der subpleuralen Lipome." 

Arch.f. lilin. Chir., 1892, xliii. 322. 
Hatai, S., " On the Presence in Human Embryos of an Interscapular Gland 

corresponding to the so-called Hibernating Gland of Lower Mammals." 

Anat. Anzeiger, xxi. 369. 
Holt, B., "Fatty Pendulous Tumour of the Pharynx and Larynx." Trans. 

Path. Soc., 1854, v. 123. 

Hutchinson, J., " Lipomata in Hernial Regions." Ibid., 1886, xxxvii. 451. 
Hutchinson, J., " Fatty Herniaj in Linea Alba." Ibid., 1888, xxxix. 451. 
Knaggs, E. Lawford, "Enteric Intussusception caused by an Intestinal 

Lipoma ; Laparotomy ; Eeduction ; Removal of Tumour ; Recovery. 

[Two unusual cases of Intussusception.] " Lancet, 1900, ii. 1573. 
Langemak, "Zur Kasuistik der Darmlipome." Bruns' Beit. z. klin. Chir., 

1900, xxviii. 247. 

Lebert, " Traite d' Anatomic pathologique," Plate xvi., Fig. 11, t. i., p. 128. 
Leopold, R. S., " Mediastinal Lipoma." Arch, oflnternat. Med., 1920, xxvi. 274. 
Lockwood, C. B., " Congenital Fatty Tumours of Sole of the Foot, and Fatty 

Tumour from Palm of Hand." Trans. Path. Soc., 1886, xxxvii. 450. 
McGavin, L., " Reducible Swelling of the Right Buttock." Clin. Journ., 

1914, xliii. 673. 
Obre, H., "Deposit of Fat within the Cervical Portion of the Vertebral 

Canal." Trans. Path. Soc., 1850-51, iii. 248. 
Parona, F., " Caso di Lipoma all' Ovaia ed Ovidotto di Destra." Ann. di 

Ostet., Milano, 1891, xiii. 103, pi. 1. 
Pick, T. Pickering, "Enormous Fatty Tumour of the Abdomen." Trans. 

Path. Soc., 1869, xx. 337. 



30 REFERENCES 

Pupovac, D., " Ueber seltene Localisationen von Fettgeschwiilsten." Wien. 

klin. WooJi., 1899, xii. 41. 
Banke, H., " Ein Saugpolster in der menschlichen Backe." Virchow's Arch. 

/.path. Anat., 1884, xcvii. 527. 
Shattock, S. G., " On Normal Tumour-like Formations of Fat in Man and the 

Lower Animals." Proc. Roy. Soc. of Med., 1909, ii., Path. Sect., p. 207. 
Shattock, S. G., " A Large Laryngeal Lipoma of the Epiglottis and Base of the 

Tongue, with a collection of examples of Submucous Lipomata of the 

Intestines and Larynx." Ibid., p. 285. 

Smith, T., "A Fibro- Muscular Polypus growing from the Uterus, and contain- 
ing a Cyst and a Small Fatty Tumour." 'hems. Path. Soc. t 1861, 

xii. 148. 
Steinheil, "Ueber Lipome der Hand und Finger. "Beit. z. klin. Chir. t 1891, 

vii. 605. 
Treves, F., "A Case of Lipoma of the Broad Ligament." Trans. Clin. Soc., 

1893, xxvi. 101. 
Voelcker, Fr., "Beitrag zur Kenntniss der tiefen Lipome des Halses." Beit. 

z. klin. Chir. t 1898, xxi. 201. 



CHAPTER II 
SARCOMAS: THEIR HISTOLOGIC CHARACTERS 

THE term sarcoma is applied to any connective-tissue tumour 
that exhibits malignant characters. As a matter of fact 
almost any kind of connective tissue fat, bone, cartilage, and 
even striated muscle- tissue may occur in sarcomas, but, 
as a rule, the greater part of the tumour consists of imma- 
ture connective tissue in which cells preponderate over the 
intercellular tissue. The species is determined according to 
the prevailing type of cell: thus we have round-celled and 
spindle- celled sarcomas ; some contain pigment, and are 
known as melanosarcomas. Of each there are one or more 
varieties, which have received qualifying names, such as 
lymphosarcoma, myosarcoma, chondrosarcoma, and the like. 

1. Round -celled sarcomas. This species is of very 
simple construction, and consists of round cells with very 
little intercellular substance. Each cell contains a large round 
vesicular nucleus, and a small proportion of protoplasm ; the 
nuclei are always conspicuous objects in stained sections. 
Blood-vessels are abundant, often appearing as mere channels 
between the cells. Lymphatics are absent. Round-celled 
sarcomas grow very rapidly, infiltrate surrounding tissues, 
recur quickly after removal, and give rise to secondary deposits, 
especially in the lungs. 

The round- celled sarcoma is the most generalized tumour 
that affects the human body ; it may occur in any tissue, 
osseous, muscular, nervous, thymic, ovarian, or testicular. It 
attacks the body at all periods of life, from the foetus in utero 
and the child just born, up to the extreme limits of age ; and 
arises in vestigial organs, as well as in those in the full 
exercise of their functions, such as the kidney or the 
parotid gland. 

Lymphosarcomas consist of cells identical with those 

31 



32 SPINDLE-GELLED SARCOMAS 

of the round-celled species, but the cells are contained in 
delicate meshes: the tissue resembles that of lymph-nodes 
(Fig. 13), hence the origin of the term lymphosarcoma. These 
tumours must not be confounded with simple (irritative) en- 
largement of lymph-nodes, nor with the general overgrowth 
of lymphadenoid tissue associated with leukaemia or lymph- 
adenoma (Hodgkin's disease). Lymphosar comas exhibit a 
characteristic structure, occur as a rule in very definite situ- 
ations, and present special clinical features. These tumours 
occur in the superior mediastinum, in the subpleural and sub- 
peritoneal connective tissue, at the base of the tongue, in the 




Fig. 13. Microscopic characters of a lymphosarcoma from the 
mediastinum. 

larynx, in the tonsil, and in the testicle. Fortunately, sarcomas 
of this species are rare, for they are excessively malignant. 

2. Spindle-celled sarcomas. The cells in this species 
vary much in size, but they all agree in being oat-shaped or 
fusiform (Figs. 14, 16). The cells tend to run in bundles, 
which take different directions, so that in sections of the 
tumour seen under the microscope some bundles will have 
the cells cut in the direction of their length, and others at 
right angles. This must be borne in mind, or an incorrect 
opinion will be formed of the nature of the tumour. In 
some sarcomas the cells are slender and contain very little 
protoplasm; in others they are large, fusiform, rich in 
protoplasm, and resemble the cells of unstriped muscle. 
Occasionally these spindle cells are transversely striped like 
young striated muscle-fibre. 



SPINDLE-CELLED SARCOMAS 



33 



Another peculiarity of spindle-celled sarcomas is the 
frequent presence of tracts of immature hyaline cartilage ; 
indeed, in many instances this tissue constitutes so large a 
proportion of the tumours that they are described as chondro- 
mas ; the cartilage is sometimes calcified, and even ossified. 
It may seem strange to associate tumours containing striped 
cells and cartilage with sarcomas, but the correctness of the 
classification is proved by the fact that such tumours are 




Fig. 14. Section of a spindle-celled sarcoma from the first phalanx of 
the thumb. (Highly magnified.) 

apt to recur after removal, and in some of the cases in 
which the primary and recurrent tumours have been carefully 
examined the primary tumour has contained cartilage, or 
muscle, whilst the recurrent mass has shown no evidence 
of these tissues, but has conformed to the structure of a 
pure spindle - celled or a round-celled sarcoma. In order, 
therefore, to indicate the nature of such composite sarcomas, 
they will be referred to as myosarcomas (rhabdomyomas) 
arid chondrosarcornas. Spindle-celled sarcomas often contain 
round cells. 
D 



34 



MYOSARCOMAS 



Myosarcomas. It is a remarkable fact, considering the 
large amount of striped muscle- tissue existing in the body, 
that tumours composed of or containing this tissue do not 
arise in connexion with the voluntary muscles, but make 
their appearance in such unexpected situations as the kid- 
ney, testicle, uterus, parotid gland, and periosteum, organs 




Fig. 15. Kacemose sarcoma of the neck of the uterus. (Pernice.) 

and tissues which, under normal conditions, do not contain 
muscle-cells of the striped variety. 

Myosarcomas occur in children, and they have been 
found in the bladder (Shattock), where they assume the 
polypoid form so common with sarcomas arising in the 
mucous membranes of children. They show preference for 
young periosteum, and have been observed growing from 
the mandible of a boy aged 7 (Prudden), the scapula of a 
child aged 6 months (Targett), and the ischium of a boy 



SARCOMAS 



35 



aged 4 (Marchand). Myosarcomas of the testicle occur 
mainly in children (Hulke, Neumann, Ribbert). 

Myosarcomas occur in all parts of the uterus. Pernice 
described, with great care and detail, a remarkable example 
that grew in the cervix uteri of a woman : its removal was 
followed by quick recurrence and speedy death. Myosarcoma 
of the uterus is considered in Chap. xvi. 

Grape-like (racemose) sarcoma of the neck of the uterus. 
Pernice's specimen, to which reference has already 




Fig. 16. Microscopic characters of the uterine sarcoma shown 
in Fig. 15, containing striated spindles. (Pernice.) 

been made, belongs to a rare variety of sarcoma described 
by Spiegelberg (1879). In some of the specimens the 
grape-like bodies are covered with columnar epithelium, 
the bulk of the grape consisting of oedematous spindle- 
and round-celled sarcomatous tissue. Some of these grape- 
like bodies are hollow, and the inner walls are lined with 
columnar epithelium : this suggests that they are dilated 
glands, belonging to the cervical endometrium. 

This form of tumour occurs in infants, girls, and young 



36 MYXOMAS 

women; it is very malignant, recurs locally, invades the 
uterus in the late stages, and gives rise to metastases. 

Sarcomas of the subperitoneal tissue. Very large 
spindle-celled sarcomas are occasionally found in the 
belly and pelvis, arising in the subperitoneal connective 
tissue. These tumours present some peculiar features. In 
the first place, they are nearly always globular, and not 
infrequently resemble a football in shape and in size. 
They have been observed in the neighbourhood of the 
kidney, and in some instances this organ occupies a recess 
in the tumour. Retroperitoneal sarcomas of this kind 
often have the adjective perirenal applied to them. I 
enucleated a tumour of this character as big as a coco-nut 
from between the layers of the mesentery in 1909. The 
patient, a woman aged 25, was in good health a year after- 
wards. The museum of McGill College contains a large 
globular tumour of this kind, weighing 8 lb., removed by 
Shepherd in 1897 from the mesentery of a man aged 28 ; 
8 ft. of small intestine was removed at the same time. 
The man was alive in 1900. Greer removed a solid tumour 
weighing 3J lb. from the mesentery of a man aged 54. The 
report of the case is valuable because a collection of 32 
records of similar tumours is added to it. 

All solid tumours of the mesentery should be examined 
microscopically ; sortie of these large tumours are ganglionic 
neuromas (see p. 142). 

Many of the tumours reported as "myorna of the broad 
ligament " are probably large, slowly growing spindle- celled 
tumours. They appear to be the least malignant of all the 
varieties of sarcoma. 

The genus sarcoma is certainly very heterogeneous and 
unsatisfactory, and will continue so until the cause of 
malignant connective - tissue tumours is discovered. The 
difficulty in regard to fibromas, inyxomas, and myomas 
has long been recognized ; for example, fibromas, or 
tumours composed of fibrous tissue, were regarded as 
common, but careful histologic research has shown them 
to be very rare. 

Myxomas. These are tumours composed of tissue 
identical with the jelly-like substance which exists in the 



MYOMAS 37 

umbilical cord. Here we have to deal with a difficulty, 
because there is a very great tendency in many connec- 
tive-tissue tumours to degenerate into this soft gelatinous 
or myxomatous tissue. The common nasal polypus fur- 
nishes an excellent example of this tissue ; it consists of 
cells with long, slender processes interlacing with those of 
adjacent cells and ramifying in a structureless, unstainable, 
diffluent mass, the whole being bounded by a thin layer 
of mucous membrane covered with columnar ciliated 
epithelium. Nasal polypi may be regarded as pendulous 
processes of cedematous mucous membrane. It would be 
convenient and justifiable to deprive myxomas of even the 
rank of species among tumours. 

The heart is of all the organs of the body the least 
liable to tumours, primary or secondary, yet the few 
examples of primary tumours ivhich have been observed 
in it are described as fibromas, myxomas, or fibromyxomas. 
In this organ the same histological difficulty occurs as else- 
where. A man aged 72 died suddenly. An ovoid tumour 
was found on a cusp of the pulmonary artery. It was 
roughly ovoid, 5 cm. in the long and 3 cm. in the trans- 
verse axis. This tumour was examined by experts, who 
could not decide whether the tumour was an organized 
thrombus or a sarcoma (Crawfurd). The common source 
for secondary sarcoma in the heart is bone (Pavlowsky). 

Myomas, or tumours composed of unstriped muscle- 
fibre, occur exclusively in organs containing this tissue, e.g. 
the oesophagus, stomach, duodenum, bladder, and uterus. 

Attention has already been directed to the difficulty 
of determining between the fusiform cells of sarcomas 
and unstriped muscle-fibre. This difficulty is increased 
by the fact that many malignant tumours composed of 
spindle cells (sarcomas) contain tracts of cells which pre- 
sent a transverse striation such as is seen in voluntary 
muscle in its embryonic stage ; but it is remarkable 
that cells with the transverse striation occur in situations 
where voluntary muscle is not found normally. It is also 
a fact that tumours consisting of mature striated (volun- 
tary) muscle-fibre have not been observed. Much caution 
needs to be exercised before deciding that a tumour is 



38 , MYOMAS 

a myoma; formerly many of the spindle-celled sarcomas 
of the choroid were regarded as myoinas arising in the 
ciliary muscle. It is also extremely probable that many 
of the tumours described as myomas from the oesophagus, 
stomach, duodenum, bladder, and vagina were sarcomas. 

Dermatologists are familiar with small tumours of the 
skin which are occasionally multiple and consist of smooth 
muscle-fibres. Such myomas may arise from the arrectores 
pili. Marc found one on the skin of the occiput of an 
infant, which had a diameter of 3'5 cm., and I removed 
one from the scrotum of a boy a few months old. 

Common situations for tumours containing unstriped 
muscle-fibres are the uterus and the gastro-intestinal tract. 
(See Chaps, xvi to xxi.) 

Crawfurd, R., Trans. Path. Soc. y 1898, xlix. 37. 

Greer, W. J., "Fibromatous Tumours of the Mesentery." Brit. Med. Jottrn., 

1911, ii. 1085. 
Hulke, J. W. , and Adams, W., "Tumour of the Testicle from a Young Child." 

Trans. Path. Soc., 1860, xi. 162. 
Marc, Serg., " Ein Fall von Leiomyoma subcutaneum congenitum nebst 

einigen Notizen zur Statistik der Geschwulste bei Kindern." Virchow's 

Arch. f. path. Anat., cxxv. 543. 

Pavlowsky, " Beitrag zum Studium der Symptornatologie der Neubildungen 

des Herzens. Polypose Neubildungen des linken Vorhofs." Berl. klin. 

Woch., 1895, xxxii. 393. 
Pernice, L. , " Ueber ein traubiges Myosarcoma striocellulare Uteri." 

Virchow's Arch. f. path. Anat., 1888, cxiii. 46. 
Prudden, T. M., " Khabdo-Myoma of the Parotid Gland." Amer. Journ. Mad. 

Sci., 1883, Ixxxv. 438. 



CHAPTER III 

SARCOMAS (continued): THEIR GENERAL 
CHARACTERS AND DISTRIBUTION 

SARCOMAS rarely possess capsules, and when they do it is 
generally a spurious encapsulation depending on environment, 
as when they occur in the kidney, the eyeball, or the centre 
of a bone. It is the lack of a capsule that permits them 
to infiltrate surrounding tissues and disseminate. It will 
be convenient in this chapter to consider the way in which 
sarcomas display malignancy. 

Blood-supply of sarcomas. The vascularity of sarcomas 
varies greatly ; in all, the circulation is mainly capillary. In 
the small round-celled species the vessels are often suffi- 
ciently numerous to cause a pulsation ; in the slow-growing 
spindle-celled varieties especially those undergoing chon- 
drification the vessels are not numerous, and the tumours on 
section are yellowish white. It was pointed out, in describing 
the minute structure of sarcomas, that the walls of the vessels 
are very thin, and are often so attenuated as to resemble 
channels between the cells. This explains the frequency of 
haemorrhage within the soft and rapidly growing varieties. 
Repeated extravasations of blood will sometimes convert these 
tumours into cysts containing blood intermixed with sarcoma- 
tous cells. Tumours transformed in this way were formerly 
described as malignant blood- cysts. 

Although the vessels in a sarcoma are, in the main, capil- 
laries, nevertheless the arteries supplying the tumour may be 
large and numerous. When a sarcoma grows from the distal 
end of the femur and attains a large size, arteries supply- 
ing it from neighbouring muscular, periosteal, and articular 
twigs become important branches, and in such circumstances 
an incision into the tumour will be attended with alarming 
hsemorrhage. When attempts are made to dissect out such 

39 



40 SARCOMAS 

a tumour from the limb, instead of adopting more radical 
measures such as amputation, these enlarged vessels must 
not be forgotten, or they will intrude themselves upon the 
surgeon in a very unmistakable manner. Arteries which 
under ordinary conditions are almost inappreciable will, when 
nourishing a sarcoma, attain the dimensions of the radial or 
even larger trunks. 

Dissemination. Sarcomas are liable to reproduce them- 
selves in distant organs, a phenomenon frequently referred to 
as metastasis. It is due to minute particles of the tumour 
growing into veins ; these, becoming detached, are transported 
by the blood-current to distant organs, where they are arrested 
by the capillaries, engraft themselves, and grow into indepen- 
dent tumours. This dissemination takes place mainly through 
the veins, because, as already mentioned, sarcomas are devoid 
of lymphatics. The most common organ in which to find 
secondary sarcomas is the lung (Fig. 17); when the primary 
growth is situated in the territory of the portal circulation, 
they will be found in the liver. In very malignant examples, 
especially the small round-celled species, secondary deposits 
may form in any organ of the body; they always agree in 
structure with the primary tumour. Secondary deposits of 
sarcoma in the lungs may destroy life by mechanically ob- 
structing the trachea and bronchi. I have known a nodule 
to slough and find its way into the trachea, and, when 
expelled by coughing, become impacted between the vocal 
cords, suffocating the patient, a girl aged 19. In this 
instance the primary tumour was a periosteal sarcoma of 
the femur, for which amputation had been performed several 
months before. 

Infiltrating 1 properties of sarcomas. The tendency to 
extensive infiltration of the planes of connective tissue adja- 
cent to the tumour is not peculiar to sarcomas, for it is an 
obvious character of carcinomas. This property of sarcomas 
may be studied in a marked manner in the case of rnediastinal 
lymphosarcomas. These tumours grow rapidly, enveloping 
the trachea and bronchi, the aorta and other large vessels, 
the oesophagus, and large nerve-trunks. The tumour extends 
along the branches of the bronchi, and invades the interlobu- 
lar connective tissue at the roots of the lungs. When the 



SARCOMAS 41 

tumour starts in the superior mediastinum it descends along 
the big vessels and invests the pericardium. It may even 
creep in the vessels to the heart and infiltrate its substance, 
and nodules of the tumour project into the cavity of the 
auricles. Processes of the tumour find their way along the 




Fig. 17. Section of lung, with nodules of sarcoma secondary to a chondrifying 
tumour of the testicle. (Museum of the Royal College of Surgeons.} 

sheaths of the big vessels and appear in the posterior 
triangles of the neck. 

The relation of a mediastinal lymphosarcoma to the 
adjacent structures is interesting. For instance, the large 
arterial trunks, though embedded in the tumour, are not as a 
rule damaged by it. The aorta may be so compressed by the 
tumour as to produce a murmur ; the thin- walled veins are 



42 LYMPHOSARCOMAS 

early compressed, and interference with the venous circula- 
tion is a marked feature. In some cases infiltration of the 
walls of the veins takes place, and processes of the tumour 
project into their channels. 

The bronchi are very liable to be damaged by a lympho- 
sarcoma, for the tumour moulds itself round these tubes, and 
by pressure causes them to be narrowed; apart from this 
effect, the tissues of the bronchial tubes become eroded and 
destroyed. These changes not only induce difficulty in res- 
piration by restricting the admission of air, but the com- 
pression of the vessels accompanying the bronchi leads to 
changes in the nutrition of the pulmonary tissue, rendering 
it vulnerable to pathogenic micro-organisms and septic 
changes ending in pneumonia, gangrene, and death. 

The important nerves traversing the mediastinum, the 
vagus and phrenic nerves especially, are often involved in 
the tumour, but their sheaths are rarely invaded by its 
cells ; in some instances the left recurrent laryngeal nerve is 
compressed sufficiently to produce severe laryngeal spasm, 
and even paralysis of the muscles supplied by it. 

The oesophagus becomes squeezed by an intrathoracic 
lymphosarcorna, but dysphagia is not so prominent a symptom 
as in many cases of intrathoracic aneurysm. The oesophagus 
may be invaded and even perforated ; when this happens, 
ulceration and sloughing produce a cavity in the tumour, 
and may broach the aorta. 

It is a somewhat remarkable feature of lymphosarcomas 
that they extend to and enclose neighbouring lymph-nodes 
without affecting them : it is by no means unusual in a section 
of a large mediastinal sarcoma to find bronchial lymph-nodes 
fully charged with pigment embedded in the tumour (Fig. 18). 
Some writers are of opinion that lymphosarcomas of the 
superior mediastinum arise in the thymus. This, of course, 
is possible, but it is very difficult of proof. 

The infiltrating power of sarcomas may be studied 
when they invade the sheath of a muscle. For instance, 
when a retinal sarcoma protrudes through the sclerotic 
and invades the orbit it sometimes makes its way into the 
sheaths of the recti, and converts them into masses 
resembling yellow wax. On microscopic examination the 



BURROWING OF SARCOMAS 43 

various fasciculi will be found isolated by the cells of the 
sarcoma. Periosteal sarcomas often invade "muscles, and 
this is easily comprehended when the intimate relations of 
muscles with periosteum are remembered. 

Burrowing tendencies of sarcomas. All tumours 
in their growth tend to follow the lines of least resist- 




Fig. 18. Portion of a inediastinal lymphosarcoma, to show the manner in which 
the tumour extends along the bronchi and pulmonary vessels. 

ance, and thus they enter nooks and crannies in the most 
unexpected manner. Every surgeon knows how a sarcoma 
of the maxilla will send processes into the spheno- 
rnaxillary fossa that creep through the adjacent foramina 
and appear in the cranial cavity. Sarcomas springing from 
the heads of the ribs or processes of the vertebrae have been 
known to extend through intervertebral foramina and com- 
press the cord, giving rise to fatal paraplegia (Fig. 55, p. 102). 



44 SARCOMAS AND VEINS 

It is also remarkable what slender barriers will serve as 
checks to sarcomas. It is no uncommon condition for one 
of these tumours springing from the periosteum near a joint 
to extend in all directions and envelop the synovial mem- 
brane, yet be hindered by it from invading the joint. 

Relation of sarcomas to veins. When sarcomas 
become disseminated the secondary tumours occur in 
situations which indicate that the distribution has been 
effected by means of the veins. Attention has been drawn 
already to the tendency which seems inherent in most 
species of sarcomas to burrow; this tendency comes out 
in a striking way when studied in connexion with veins. 

Perhaps the simplest form occurs in the eyeball. When 
a melanoma arises in the eye, especially if the tumour is 
in close relation with the choroid, it will remain for a 
period restricted to the interior of the globe, until it pro- 
duces such changes in the intra-ocular tension that the 
cornea sloughs and the growth protrudes externally. In 
many of these specimens, if the sclerotic be carefully 
examined in the situations where the vense vorticosse pierce 
it, small nodules of the tumour will be detected projecting 
through these openings, having made their way out by 
burrowing in the sheaths, and in some cases actually 
travelling along the lumina of the veins. 

The relations of sarcomas to veins come out strongly 
when these tumours affect bones. In some examples of 
periosteal sarcomas the medulla is invaded by processes 
of the tumour making their way along the veins traversing 
the Haversian canals. The converse of this is also true, 
for a central sarcoma will sometimes implicate the perios- 
teum by way of the Haversian canals. 

Most examples of central sarcomas occur near the 
joint-ends of bones, and yet it is exceptional to find the 
joints invaded. This comparative immunity of joints is 
usually attributed to the articular cartilage acting as 
neutral tissue; but it appears rather to be due to the 
fact that cartilage, unlike the compact tissue of bone, is 
not traversed by a multitude of vascular channels. Extra- 
ordinary examples of the invasion of veins by sarcomas 
occur in the abdomen. In cases of renal sarcomas, pro- 



SARCOMAS AND VEINS 



45 



cesses of tumour find their way into the renal vein, and 
thus enter the inferior vena cava. Periosteal sarcomas of 
the pelvic surface of the ilium are very liable to in- 
filtrate the iliac veins and extend into the vena cava (Fig. 
19). When processes from a sarcoma project into a vein, 




Inferior vena cava. 



Intravenous process 
of the sarcoma. 



Lymph - nodes in- 
fected by sarcoma. 



A .sarcoma springing 
from the ilium. 



Fig. 19. Periosteal sarcoma of the ilium invading the inferior vena cava, 
(Museum of St. Bartholomew 's Hospital.') 

the circulating blood is apt to detach large fragments, 
and these become dangerous emboli. A man with sarcoma 
of the thyroid gland died suddenly. At the post-mortem 
examination the cavities on the right side of the heart 
contained fragments of growth embedded in clot; on dis- 
section it was ascertained that the sarcoma had ulcerated 
into the internal jugular vein. (Pitt.) 

When a vein is invaded by a sarcoma, and discharges 



46 SARCOMAS 

of emboli frequently occur, they easily traverse, when 
small, the right auricle and ventricle, but are too large to 
pass through the pulmonary capillaries; hence the small 
vessels in the lungs act as filters, and the arrested particles 
grow into secondary nodules. 

Secondary changes. Sarcomas are very prone to de- 
generative changes ; for instance, haemorrhage is very apt to 
take place in those which grow quickly, producing spurious 
cysts. The tissues of the tumour are prone to liquefy, and 
myxomatous changes are very common. Calcification occurs 
in those which grow slowly, especially if connected with 
bone. When sarcomas grow rapidly and involve the skin, 
ulceration may occur and lead to profuse and oft-repeated 
haemorrhages, which not only exhaust the patient but in 
many cases induce death. The bleeding in such condition 
is due to the exposed portions of the tumour becoming 
septic. 

Occasionally considerable portions of a sarcoma will 
necrose, especially in very large tumours. In such cases a 
cavity forms in the sarcoma, and on cutting into it the fluid 
escapes, with large irregular pieces of the tumour, which 
are generally greyish-white. When necrosis occurs exten- 
sively in a large sarcoma it will sometimes check the course 
of the tumour in a very marked manner. 

Distribution. As connective tissue exists in every 
organ of the body, sarcomas are ubiquitous, but they 
occur in some situations more commonly than in others. 
They frequently grow from subcutaneous tissue and fascia, 
periosteum, the testicle and ovary. They are so rare as 
primary tumours of the liver, spleen, and bowel that it is 
not possible to write a general account of them, from 
lack of material. As primary tumours of muscles, sarcomas 
are rare. They may be of the round-celled or the spindle- 
celled species. For a time, at least, the tumour is limited 
by the sheath of the affected muscle. At first the tumour 
appears localized to a particular spot in the muscle, but 
it gradually extends until the whole belly of the muscle 
is involved and becomes transformed into an indurated 
mass. On section the muscle appears to be replaced by 
hard, tough, waxy material. When sections are examined 



SARCOMAS OF NERVES 47 

under the microscope the appearance is very striking, for 
each fasciculus is isolated from its neighbour by collections 
of cells characteristic of the sarcoma. 

As in sarcoma of other organs, haemorrhage is very 
liable to occur in the substance of the tumour, leading to 
the formation of cavities with ragged walls. 

Primary sarcomas have been recorded in the follow- 
ing muscles : rectus abdominis, peroneus longus, gracilis, 
tensor vaginse femoris, adductor brevis, sartorius, tibialis 
anticus, and the triceps. Four cases under my own notice 
occurred in the pectoralis major, the extensor carpi radialis, 
the adductor longus, and the vastus externus. 

The age-distribution of sarcoma of muscle is a wide one ; 
in the instances enumerated above, the youngest patient 
was 18, and the oldest 60 years. The disease shows 
a marked preference for the muscles of the lower limb. A 
syphilitic gumma in a muscle is often mistaken for a sar- 
coma, sometimes with unfortunate consequences. 

Sarcomas of nerves show the same preference for the 
lower limbs as in the case of muscles. In the majority 
of instances it is the great sciatic, or its branches, the 
popliteal, posterior tibial, peroneal, or the plantar nerves. 
In more than half the cases it is the trunk of the great 
sciatic that is attacked. 

Sarcoma of synovial membrane. A primary sarcoma of 
a synovial membrane is a rare disease ; and it shows the 
same marked preference for this membrane in the lower 
limb as is the case with muscles and nerves. The tumours 
may be of the round- or spindle-celled species, but some 
contain giant cells and cartilage. Sarcomas .of synovial 
membrane may be diffuse or localized ; occasionally they 
take the form of pedunculated bodies. Such tumours grow 
slowly and do not interfere with the movements of the 
joint. The diagnosis is difficult, as the disease resembles very 
closely tuberculous disease of synovial membrane. The age 
of patients varies from 20 to 35. This disease lends itself to 
three forms of operative treatment: enucleation when the 
tumour is limited to a portion of the synovial membrane, and 
resection of the joint when diffuse ; amputation seems to be 
the best safeguard against recurrence. The disease is rare. 



4 8 



SARCOMAS 



Unusual sites of origin for sarcomas are the soft tissues in 
the axilla or the popliteal space. In the axilla a sarcoma is 
often ovoid and encapsuled. 




Fig. 20. Popliteal space in section, showing an aneurysm of the popliteal 
artery embedded in a sarcoma. From a man aged 71 ; he survived 
operation about a year. (Museum of the Royal College of Surgeons.} 

A rare example of a sarcoma arising in the popliteal space 
and surrounding an aneurysm of the popliteal artery has 
been recorded by Croft (Fig. 20). Clinically, the condition 



SARCOMAS OF BURS^E 49 

was recognized as an aneurysm. As ligature of the femoral 
artery failed to cure the aneurysm, the limb was amputated, 
and a postoperative examination by Shattock revealed a 
round-celled sarcoma encompassing the aneurysm. The 
man survived the operation about a year, and died from 
recurrence of the sarcoma. 

Primary sarcomas of tendon-sheaths. Swellings resembling 
sarcomas arise occasionally in connexion with the sheaths 
of tendons belonging to the fingers, less frequently of the 
toes. In most of the cases there was distinct history of 
injury. The swellings may be round, ovoid, lobulated, or 
flat, and display on section a yellow tint, probably due to 
blood effused into the tendon-sheath ; they consist of granu- 
lation tissue containing foreign-body giant cells. These swell- 
ings have been observed between the fifteenth and fortieth 
years, and have received a variety of names. Local excision 
is the proper mode of treatment. Useful reports have been 
collected by Tourneux, Grant, Flint, and Broders. 

Primary sarcomas of fcursae. It is well known that 
bursse are prone to undergo inflammatory changes espe- 
cially when situated in exposed situations, such as those 
arising in relation with the patella, and it is a matter of 
common observation that a prepatellar bursa when chroni- 
cally irritated, as in housemaids and carpet-layers, will 
become almost solid: specimens illustrating this are common 
in pathological museums. There are a number of care- 
fully observed cases which show that a bursa may become 
the seat of sarcoma, and in which local recurrence followed 
extirpation of the tumour. Sarcomatous bursoe have been 
observed in connexion with the patella, the semimem- 
branosus sac at the knee-joint, and the subdeltoid bursa. 

The chief clinical signs on which a diagnosis may be 
founded would appear to be these : a chronically enlarged 
bursa takes on active growth, and becomes firmer in con- 
sistence, and this is accompanied by great enlargement of 
the veins in the skin overlying the bursa. Prepatellar 
bursse in syphilitics sometimes rapidly solidify. The litera- 
ture of sarcomas arising in bursal sacs has been collected 
by Adrian; it is characterized - by great poverty. 

Sarcomas of the alimentary canal. Although carcinoma 

E 



50 SARCOMAS OF ALIMENTARY CANAL 

i f 

is seen to be the prevailing type of malignant disease which 
attacks the alimentary canal from the oesophagus to the 
anus, cases of sarcoma have been observed and reported in 
sufficient numbers to enable their leading clinical features 
to be summarized. The disease arises in the submucous 
tissue, and may assume the form of a polypus, or infiltrate 
the wall of the canal, or project on the surface of the in- 
testine in the form of plaques. All species of sarcomas 
have been observed. It is also noteworthy that sarcomas 
attack those regions of the stomach and intestines which 
are in a measure respected by carcinoma. Thus, in the 
stomach, sarcomas prefer the body of the organ; and 
they occur with greater frequency in the small than in 
the large intestine. In the small intestine the liability to 
the disease increases from duodenum to ileum. Secondary 
deposits appear to be most common in the liver. An 
important clinical feature that distinguishes sarcoma of the 
intestine, large or small, from carcinoma is its occurrence 
in the early years of life ; many examples have been ob- 
served in children. The disease runs a more rapid course, 
causes more pain, and forms a much larger tumour than 
is the rule with carcinoma. As a sarcoma often becomes 
polypoid in consequence of the propulsive action of the 
bowel, the occurrence of intussusception is a frequent com- 
plication. The results of operative treatment are unfavour- 
able; rapid recurrence is the rule. (Corner and Fairbank.) 
A boy aged 5 had a chronic ileo-colic intussusception. At 
the operation the ileal portion was easily reduced from 
the caecum, but the ileo-ileac segment resisted reduction and 
made resection a necessity. Three weeks later a lump as 
big as a walnut was noticed on the boy's chest, near the 
right nipple; it proved to be a round-celled sarcoma. This 
led to a re-examination of the excised piece of ileum ; in it, 
about an inch above the valve, a small mushroom-shaped 
tumour appeared. This tumour had caused the intussus- 
ception ; it was a round-celled sarcoma. (D'Arcy Power.) 

Sarcomas of the rectum and anus are rare tumours ; 
Whiteford has collected a number of reported cases. A 
woman aged 50, under my care, had a sarcoma growing 
from the wall of the anal canal; it bulged into the left 



SARCOMAS; TREATMENT 51 

ischio-rectal fossa. The medical attendant had incised it, 
mistaking the swelling for an abscess. I removed the 
tumour ; it was encapsuled, and shelled out easily. A micro- 
scopic examination established its sarcomatous character. 
The tumour recurred quickly, grew with great rapidity, and 
destroyed the patient in ten months from the date of the 
operation. 

A Frenchwoman aged 35, from whom I removed the 
uterus for a large subrnucous fibroid, complained of a swell- 
ing that bulged into the left side of the vagina ; it was soft, 
fluctuating, of the same shape and as big as a lemon. I 
considered it to be an unusually large Bartholinian cyst. 
My surprise was great, on enucleating the mass, to find it a 
myxosarcoma of the left ischio-rectal fossa. 

Soft, rapidly growing sarcomas in uncommon situations 
often mimic, in physical signs, inflammatory swellings. 

The vagina is an uncommon situation for sarcomas ; 
in children they have a great tendency to become polypoid, 
or they form flattened masses in the submucous layer. Occa- 
sionally the tumours may be multiple. Often the sarcoma 
interferes with the functions of the rectum and bladder. 
The literature of sarcoma of the vagina in infants has been 
collected by Power; in adults, by Williams and by Gow. 

Treatment of sarcomas. - - This consists in the wide 
removal of the affected part, whenever possible, by means 
of the knife. The method of effecting this varies accord- 
ing to the seat of the disease and the organ affected. In 
the ensuing chapters, dealing with the distribution of these 
tumours, references will be made to the principles governing 
the surgical treatment applicable to each situation. There 
are many conditions, apart from the size of the tumour, 
which prevent complete extirpation, such as its position in 
relation to vital organs, and generalization (metastasis) : 
when sarcomas do not permit of radical surgical treatment 
they are said to be inoperable. Much earnest investigation 
has been made with the hope of finding some means by 
which patients wich inoperable sarcoma may be relieved, 
especially in the domain of serumtherapy. 

Adrian, C., " Ueber die von Schleimbeuteln ausgehenden Neubildungens." 
Beit. z. Uin. Chir., 1903, xxxviii. 459. 



52 REFERENCES 

Broders, A. C., " The Xanthic Extraperitoneal Tumour." Collected Papers 

of the Mayo Clinic, 1919, xi. 1032. 
Corner and Fairbank, 'Sarcoma of the Alimentary Canal." Trans. Path. 

Soc., 1905, Ivi. 20. 
Croft, J., " Aneurysm of the Popliteal Artery complicated with Sarcoma." 

Ibid., 1890, xli. 65. 

Gow, W. J. St. Bartholomew's Hosp. Repts., 1891, xxvii. 97. 
Julliard et Descoeudres, " Sarcome primitif de la Synoviale du Genon." 

Arch. Internat. de Chir., Gand, 1904, p. 539. 

Lockwood. C. B., "A Case of Sarcoma of the Synovial Membrane of the 

Knee." Trans. Clin. Soc. Lond., 1902, xxxv. 139. 
Marsh, Howard, "Primary Sarcoma of the Knee-Joint." Lancet, 1838, 

ii. 1330. 
Pitt, G. Newton, "Sarcoma of Left Lobe of Thyroid, growing round 

oesophagus, and invading left internal jugular vein and left vagus ; 

ante-mortem clot on right side of heart, containing growth." Trans. 

Path. Soc., 1887, xxxviii. 398. 
Power, D'Arcy, " A Case of Sarcoma causing Chronic Intussusception." 

Clin. Journ., 1912, xl. 193. 
Stewart, M. J., and Flint, " On the Myeloid Tumour of Tendon Sheaths." 

Brit. Journ. of Surg., 1915, iii. 90. 
Tourneux, " Les Sarcomes des Gaines tendineuses." Rev. de Chir., 1913, 

xlvii. 817. 
Turner, G. R., "Primary Sarcoma of the Synovial Membrane of the Ankle 

Joint." Trans. Clin. Soc. Lond., 1902, xxxv 137 
Whiteford, C. H., " A Case of Sarcoma of the Rectum, with details of nine 

other cases." Journ. of Path, and Bact., 1911, xv. 293. 
Williams, W. R., "Vaginal Tumours." 1904. 



CHAPTER IV 
TUMOURS OF BONE 

THE natural history of a tumour is often that of the organ 
in which it arises, and this is well shown by a study oi 
tumours arising in bone. Bones are liable to three varieties 
of tumours belonging to the benign group : they are Osteo- 
mas, Chondromas, and Myelomas. In simple language, 
bony, cartilaginous, and red - marrow tumours. They are 
also liable to sarcomas primarily, and cancer occurs in 
them in the form of secondary deposits, and especially 
from cancer of the breast. Bone is apt to be regarded as an 
unchangeable tissue, whereas it is as liable to tissue-change 
as any other organ in the body, and some of its meta- 
morphoses are remarkable. During early embryonic life 
the bones of the trunk, limbs, and the base of the skull 
are represented entirely by hyalin cartilage ; gradually the 
cartilage is replaced by bone. At birth the long bones of 
the body are not the compact elements of the skeleton 
that we are familiar with in adults. The joint-ends of 
the principal bones of the limbs in the new-born child are 
still cartilaginous ; their ossification is, in the main, a 
postnatal process. In children the ossifying ends of long 
bones remain separated from the shaft for many years by 
the epiphyseal cartilages. During infancy the interstices 
of the cancellous tissue are filled with red marrow, a 
tissue intimately concerned with the production of the red 
corpuscles of the blood. As life advances the red marrow 
in the central parts of the shafts of a long bone is re- 
placed by fat. After middle life the osseous tissue is more 
and more replaced by fat; and, in old bones, the compact 
tissue of their shafts becomes thin and brittle. In young 
bones the shafts are enveloped in a thick covering of 
tough tissue, the periosteum ; this is thin in old age. 

53 



54 COMPACT OSTEOMAS 

Bones are very vascular structures, as every surgeon knows, 
and the seat of constant tissue- change. The general features 
of the development of bones are reflected in the tumours 
that arise in them, and will be indicated in appropriate 
places in the ensuing chapters. Many of the tissue-changes 
occurring in tumours of bone are caricatures of the normal 
features of osteogenesis. 

OSTEOMAS 

An osteoma is a tumour composed of bone, arising from 
a bone. This genus contains two species (1) compact 
osteomas, (2) cancellous osteomas. It was formerly the 




Fig. 21. Osteoma of the mandible. (Museum of St. George's Hospital.) 

custom to call all tumours and irregular osseous pro- 
cesses on bones exostoses, but in this chapter an attempt 
is made to sort out from this confused group the bony 
masses to which the term tumour strictly applies. 

1. Compact osteomas. These occur as sessile tumours 
on the parietal and frontal bones ; in the frontal sinus, roof 
of the orbit, walls of the external auditory meatus, mastoid 
process, and angle of the mandible (Fig. 21). They are com- 
posed of tissue as dense and as hard as ivory, and are fre- 
quently called "ivory exostoses." Those which arise in the 
frontal sinus and orbit are very remarkable tumours, and may 
attain large proportions (Figs. 22-25). Many large tumours 
removed from the maxilla and formerly described as ex- 
ostoses were large odontomes (see Chap. xxn). 



COMPACT OSTEOMAS 55 

Large osteomas of the facial bones sometimes produce 
hideous deformity, and, when they grow from the bones 
forming the rim of the orbit, occasionally destroy the eye- 
ball. The clinical histories of some of these cases are very 
remarkable ; for example, a man came under Lediard's 
observation .with a large osteoma protruding from the orbit 
(Fig. 22). The patient, a sailor, stated that the tumour 
was noticed at birth, when it seemed scarcely larger than 




Fig. 22. Sailor with a large osteoma growing from the orbit. (From a 
water-colour sketch in the Museum of the Royal College of Surgeons.} 

a pea. It slowly increased in size, and destroyed the eye- 
ball in his ninth year. When he was 25 the skin of the 
eyelid sloughed. Eight years later the tumour fell out of 
the orbit. Osteomas of the orbit which have resisted the 
efforts of surgeons to remove them have, years after such 
operations, fallen of their own accord. 

The large and exceedingly hard ivory-like tumours which 
grow in the frontal sinuses are uncommon. An admirable 
example figured by Baillie, and preserved in the museum 
of the Royal College of Surgeons, is unfortunately without 
history (Fig. 23). 



56 COMPACT OSTEOMAS 

A good example of this variety of osteorna arising in 
the left frontal sinus is shown in Figs. 24 and 25. The 
skull was obtained, with others, by W. W. Claridge in 
Cameroon. A rounded boss of hard bone has expanded 
the horizontal plate of the frontal bone, eroded it, and 




Fig. 23. Osteoma in the left frontal sinus. (Museum of the Royal College 
of Surgeons.) 

appears on the floor of the anterior fossa of the skull by 
the side of the crista galli. Probably it did not pierce the 
dura mater. The anterior part of the skull was bisected, 
including the tumour. The section (Fig. 25) shows well 
the tumour tissue incorporated with that of the frontal 
bone. A careful study of the specimen leads me to believe 



COMPACT OSTEOMAS 57 

that this tumour is the result of chronic inflammation of 
the bone, and that it is allied to the curious disease of 
bone, well known on the West Coast of Africa, called 
goundou (see p. 64). The vomer is absent, and the bone 
on the inner surface of the maxilla being deficient also 
indicates the possible existence of some chronic infective 
disease of the nasal and associated sinuses. The specimen 
lacks a clinical history. 




Fig. 24. Anterior fossae of the skull. An osteoma arising in the left 
frontal sinus invaded the fossa by eroding the horizontal plate of 
the frontal bone. The skull was obtained near Duala, at the mouth 
.of the Wuri River, south of the Cameroon Mountain. (Museum of 
the Middlesex Hospital.} 

Osteomas of this kind arise occasionally in the frontal 
sinuses of oxen and form irregular lobulated masses some- 
times weighing as much as 16 Ib. Similar tumours grow 
from the petrosal and encroach upon the cranial cavity ; 
some of these have been reported in veterinary literature 
as ossified brains ! 

Osteomas at the margins of the external auditory meatus 
have been especially studied because they are apt to obstruct 
the meatus and cause deafness ; when both meatuses are 
affected and this is not rare absolute deafness may result. 



58 CANCELLOUS OSTEOMAS 

Osteomas of this kind have been observed in many races of 
men. Professor Sir William Turner has drawn attention to 
observations of Seligmann, Welcker, and Barnard Davis, and 
added some of his own, concerning the presence of such 
exostoses in certain deformed skulls described as Titicaca's, 
Huanaka's, and Aymara's. Also in skulls from the Marquesas 




Fig. 25. Osteoma of the frontal sinus (Fig. 24), shown in section. The 
tumour is intimately incorporated with the frontal bone. The vomer 
is absent. 

Islands. Sandwich Islands, Chatham Island, and New Zealand. 
It ' is not surprising that osteomas should arise from the 
walls of the external auditory meatus when we remember 
the number of centres by which the periotic cartilage is 
transformed into bone, and the various ossific elements that 
come into relation with each other at this meatus. 

2. Cancellous osteomas, These tumours in structure 
resemble the cancellous tissue of bone, and are soft in com- 
parison with the preceding species. They usually possess a 



EXOSTOSES 



59 



thick covering of hyalin cartilage, and when growing at the 
distal end of the radius, or tibia, present a series of deep 
channels for the passage of tendons. Occasionally an osteoma 
is pedunculated; more frequently it has a broad base (Fig. 26). 
Osteomas, whether sessile or stalked, usually grow slowly, 
but in the course of years they sometimes attain large 
proportions. They are innocent tumours, but occasionally 
imperil life by mechani- 
cally interfering with the 
function of vital organs. 
Reid described a case in 
which an osteoma grew 
from the posterior sur- 
face of the odontoid pro- 
cess and projected into 
the neural canal to the 
extent of 8 mm., com- 
pressing the spinal cord 
with fatal effect. 
Although in themselves 
painless, osteomas some- 
times induce pain by 
pressing on nerve-trunks 
in their vicinity. Often 
an osteoma is quite 
harmless. 

It has been custo- 
mary to describe all 
kinds of tumours com- 
posed of bone as exostoses. This name should be limited 
to irregular outgrowths of bone to which the term tumour 
is not in any sense applicable, such as the ossification of 
tendons, and the multiple bony outgrowths present in 
diaphysial aclasis. 

The remarkable offensive and defensive weapons of deer, 
known as antlers, are exostoses. They consist of bone with 
a central core of vascular cancellous tissue extending through- 
out its length, with ramifications into the tines. The tissue 
of the antler is dense, and as hard as ivory. It .has the 
same structure as compact bone : well-developed Haversian 




Fig. 26. Cancellous osteoma of the scapula. 
(Museum of the Royal College of Surgeons.') 



60 ANTLERS 

systems with central canal, canaliculi, and lacunae. In the 
growing stage it is very vascular. 

It is an amazing feature of antlers that such a mass 




Fig. 27. Skeleton showing multiple exostoses. 
(A. Broca and Delanglade.} 

of hard tissue, with the perfect structure of bone, is de- 
veloped in three or four months, and they are shed and 
reproduced annually. In a growing antler a cap of cartilage 



MULTIPLE EXOSTOSES 61 

appears on the summit and represents the distal epiphysis 
of a long bone (Macewen). Hence an antler is a compound 
bone like the shaft of the tibia or the radius. 

Multiple exostoses (diaphysial aclasis). Exostoses occur 
on bones, especially of the limbs and ribs, in multiples, 
and often they are fairly symmetrical in shape and position. 
Multiple exostoses of this kind occur in childhood, and are 
hereditary. Many examples have been carefully observed 
and reported in detail. The number of exostoses in some 
patients exceeds 200. A boy aged 4 had 217 exostoses 
affecting the bones of the hands and feet, most of the long 
bones, several ribs, the clavicle, and the occipital. His father 
had several exostoses (Choyce). A skeleton showing the 
distribution and bilateral symmetry of multiple exostoses is 
depicted in Fig. 27. The thickened, stunted and mis- 
shapen condition of the limb-bones is a striking feature, 
as well as the important fact that the exostoses are ex- 
clusively confined to the shafts of the bones. The exostoses 
in such cases repeat all phases in the development of normal 
bone, and during .growth are capped with cartilage and 
often surmounted with a bursa (exostosis bursata), and their 
growth ceases with that of the skeleton. 

Keith regards multiple exostoses as an expression of a 
disorder, or disturbance, of bone growth confined to bones 
preformed in cartilage and completed in membrane. There 
is reason for suspecting that the condition is due to dis- 
turbance in the functions of the glands of internal secretion 
probably the thyroid. Keith suggests that this disease 
should be designated diaphysial aclasis (a name invented 
by Morley Roberts) because the main incidence of disturbance 
falls upon the modelling, or pruning, of the diaphyses of 
the bones. The disease is allied to acromegaly, giantism, 
and cretinism (achondroplasia). 

The subjects of this disease are dwarfed in stature (Fig. 
28) but have abnormally thick bones, and the outgrowths^ 
or exostoses, which attract attention are merely secondary 
results which mask the remarkable disorder underlying 
the formation and growth of the bones of the limbs. 

The most significant feature connected with diaphysial 
aclasia is the occurrence of a sarcoma in one of the bones 



62 DIAPHYSIAL ACL ASIA 

0. Weber described an example in 1886. A man aged 25, 
the subject of multiple exostoses, had a very large chondro- 




Fig. 28 Boy aged 10, with multiple exostoses. Several 

were removed ; they were covered with translucent cartilage. 

(Pepper.') 

sarcoma of the right hip-bone. The tumour perforated the 
wall of the external iliac vein, and pieces of the tumour, 
detached as emboli, were arrested in the pulmonary arteries. 



EXOSTOSES 



Other similar cases are known. Occasionally a sarcoma 
arises in an exostosis. 

Exostoses formed by ossification of tendons at their attach- 
ments. The long bones of a child at birth are smooth 
in outline and almost cylindrical in shape ; the peri- 
osteum is relatively thick, and gives attachment to the 
muscles. On examination of the long bones of a muscular 
man their shafts are found to be irregular and to present 
many asperities, such as the linea 
aspera, gluteal ridge (sometimes 
called the third trochanter), oblique 
lines, and the like. These ridges 
and lines, in the majority of in- 
stances, are the ossified insertions 
of muscles ; occasionally they are 
so pronounced as to be appreci- 
able through the soft structures, 
and are then described clinically 
as exostoses. The two most fre- 
quent examples of this form of 
exostosis are the adductor tubercle 
of the femur and the tubercle on 
the first rib at the insertion of 
the scalenus anticus. Probably the 
most common exostosis is that 
which occurs in the tendon of 
insertion of the adductor magnus Fig . 29,-Exostosis in the ten- 
(Fig. 29) : it usually assumes the 
form of a broad ledge of bone ; 
exceptionally it is stalked, and 
occasionally surmounted by a bursa ; the walls of such bursa3 
are now and then furnished with villi, and loose bodies have 
been found in them (Orlow and Riethus). Care must be taken 
not to confound a supracondyloid process of the humerus, or 
the third trochanter of the fernur, with an exostosis. 

Localized enlargements of the facial bones are called 
exostoses. They are often bilateral and symmetrical (Fig. 30). 

Exostoses of the maxillae have been observed in natives 
of the West Coast of Africa, and are probably the source 
of the myth that horned men exist in that country (Fig. 31). 




don of the adductor magnus. 
(Museum of the Royal Col- 
lege of Surgeons?) 



6 4 



HORNED MEN 



Interesting particulars relating to this question are furnished 
by Macalister and by Lamprey. Strachan observed them 
in the West Indian negro, and Dr. Maclaud, of the French 




Kg. 30. Symmetrical exostoses of the nasal processes of the maxillas. 
(Hutchinson.} 

Navy, met with them frequently in the natives of certain 
villages on the Ivory Coast, where the disease is known as 




Fig. 31. So-called horned men of the Ivory Coast. (Maclaud.} 

goundou. These bony swellings may become so large as to 
obscure the patient's vision, and in order to see over the top 
of them he is obliged to bend his head down. 






CH^TODON 65 

The subungual exostosis is a troublesome outgrowth 
from the lingual phalanx of the big toe; it makes its way 
through the bed of the nail, and peers out between the* 
nail and the skin at the tip of the toe, near the inner side 
(Fig. 32) ; its appearance is so characteristic that it only 
requires to be once seen to be appre- 
ciated readily. It is rarely bigger than 
a cherry-stone. 

When the soft investing tissues are 
removed, the tumour appears as a low 
prominence of cancellous bone jutting 
from the dorsal surface of the terminal 
phalanx. These outgrowths are probably 
due to the irritation of ill-fitting boots. 

Bony tumours are of fairly frequent 
occurrence in all vertebrates, and especi- 
ally fishes. Perhaps the most striking example is furnished 
by the skeleton of the fish chaetodon, in which some of 
the bones are furnished with rounded bony tumours. The 




Fig. 32. Subungual 
exostosis of big toe. 




Fig. 33. Bell's specimen of chaetodon with its tumours and large occipital crest. 



museum of the Royal College of Surgeons contains many 
loose bones with tumours, as well as the skeleton of the 
original fish sent by William Eell to John Hunter (Fig. 
33). Single bones of chaetodon are common in osteological 
collections. Cuvier explained this by stating that they were 



66 OSTEOMAS: TREATMENT 

brought home by travellers who had eaten the fish. On 
section the outline of the ray can be seen running through 
the tumour. The occipital bone of this fish is very thick 
(Fig. 34). 

Clinical characters of osteomas. Osteomas are easily 
recognized on account of their extreme hardness, and by 

being localized to bones : they 
rarely cause pain, except when 
growing in the vicinity of and 
pressing upon the trunks of 
nerves. Osteomas growing from 
the walls of the auditory mea- 
tus will occasionally interfere 
with hearing, and, if they are 
bilateral and completely block 
both meatuses, produce total 
deafness. Large osteomas of the 
orbit and frontal bone distort 
the eyeball, and produce hideous 
deformity. In determining the 
characters and mode of attach- 
ment of an osteoma, especially 
in the limbs, X-rays render 
valuable assistance. 

Treatment. Osteomas, un- 
less they interfere with nerves 
or with the movement of joints, 
or, as in the case of the facial 
bones, produce deformity or 
deafness, are rarely interfered 

with. In a patient under the writer's care, with a large 
intrapelvic osteoma, a process of the tumour pressed upon 
the great sciatic nerve as it issued from the pelvis ; 
this offending process was exposed through an incision 
in the buttock, and removed by means of a chisel and 
'mallet. Pedunculated osteomas may be easily removed 
with the help of stout forceps. The removal of an ivory 
osteoma sometimes requires the most persevering efforts of 
the surgeon, aided by the best surgical cutlery. Exostoses 




Fig. 34. Thickened occipital 
"bone of a fish, with a man's 
face artificially carved upon it. 



OSTEOMAS 67 

near joints should not be interfered with, unless they 
produce great inconvenience. 

Osseous tumours of the cranial bones are often formid- 
able objects for the surgeon ; when they grow from the 
roof of the orbit or the frontal bone they not infrequently 
extend as deeply into the cranial cavity as they project 
beyond it. The museum of St. George's Hospital contains 
a small ivory tumour which grew on the frontal bone 
of a man. Keate vainly endeavoured to remove it with 
trephine, saw, chisel and mallet for nearly two hours. 
Potassa fusa and nitric acid were applied to the base, and 
in the course of years the tumour dropped off. Subungual 
exostoses are often so painful that patients are glad to 
have them removed. 

Bell, William, " Description of a Species of Chastodon, called by the Malays 

Ecan Bonna." Phil. Trans., 1793, Part i., p. 1. 
Bland-Sutton, J., " On an Exostosis from a Fish." Trans. Path. Soc., 1888, 

xxxix. 472. 

Choyce, C. C., " System of Surgery." 1914, iii. 597. 
Hutchinson, Sir J., "Illustrations of Clinical Surgery," 1878, 11. 
Keith, A., "Studies on the Anatomical Changes which accompany certain 

Growth-Disorders of the Human Body." Journ. of Anat., 1920, liv. 101. 
Lamprey, J. J., " Horned Men in Africa : Further Particulars of their 

Existence." Brit. Med. Journ., 1887, ii. 1273. 
Lediard, Trans. Ophthal. Soc., 1883, iii. 23. 
Macalister, A., " Further Evidence as to the Existence of Horned Men in 

Africa." Proo. Roy. Irish Acad., 1883, 2nd Series, iii. 771. 
Macewen, "The Growth and Shedding of the Antlers of Deer." Glasgow, 1920. 
Maclaud, " Goundou or Anakhre (Gros Nez)." Brit. Med. Journ., 1895, 

i. 1217. 
Orlow, L. W., " Die Exostosis Bursata und ihre Entstehung." Deut. 

Zeitschr. /. Chir., 1891, xxxi. 293. 
Reid, J., " Case of Disease of the Spinal Cord, from an Exostosis of the Second 

Cervical Vertebra." Lond. and Edin. Monthly Journ. of Med. SoL, 1843, 

iii. 194. 
Riethus, 0., " Exostosis Bursata mit freien Knorpelkorpern." Beit. z. him. 

Chir., 1903, xxxvii. 639. 
Strachan, H., "Bony Overgrowths or Exostoses in the West Indian Negro." 

Brit. Med. Journ., 1894, i. 189. 

Turner, Sir William, " On Exostoses within the External Auditory Meatus." 
Journ. of Anat. and Phys., 1879, xiii. 200. 

Weber, Otto, " Zur Geschichte des Enchondroms namentlich in Bezug auf 
dessen hereditares Vorkommen und secundare Verbreitung in inneren 
Organen durch Embolie. " Virchow's Arch. f. path. Anat., 1866, xxxv. 501. 



CHAPTER V 
TUMOURS OF BONE (continued) 

CHONDROMAS (CARTILAGE TUMOURS) 

A CHONDROMA (or enchondroma) is a tumour composed of 
hyalin cartilage. Its tissue resembles histologically the 
bluish translucent cartilage of an epiphysis. This genus 
contains three species (1) chondroma, (2) ecchondrosis, 
(3) synovial chondroma. 

1. Chondromas. This species in its most typical con- 
ditions occurs in long bones, and, as a rule, in relation 
with the epiphyseal cartilages ; hence this tumour is most 
frequently observed in children and young adults. A single 
tumour may be present, but frequently many grow con- 
currently, especially on the long bones of the hand and 
feet (Fig. 35). This condition is closely allied to diaphysial 
aclasis (see p. 61). 

Chondromas are always encapsuled, and often form deep 
hollows in the bones. They are painless, and grow slowly. 
Frequently they undergo mucoid degeneration, then the 
softened area fluctuates on pressure. This serves to distin- 
guish them from osteomas, with which they are apt to be 
confounded clinically. Chondromas often calcify. 

The frequency of chondromas in those who suffered 
from rickets in early life may be due, as Virchow thought, 
to the existence of untransformed pieces of cartilage 
acting the part of tumour-germs. Such remnants of un- 
ossified cartilage are not difficult of demonstration in 
rickety bones (Fig. 36). 

A chondroma is a benign tumour and, even when it 
grows into the skull, may require a long time to destroy 
life, as a very remarkable specimen in the museum of 
St. George's Hospital proves. It is a cartilage-tumour 



CHONDROMAS 



69 






which arose in the mesethmoid of a young woman, and 
then filled the nasal fossae and occupied both orbits, and 
dislocated the globes outwards ; it filled the antra, 
expanded the nasal bones, invaded the spheno-maxillary 
fossse and formed a large mound in the anterior fossa of 
the skull, and almost reached the roof of the cranium. 




Fig. 35. Multiple chondromas. (The lad was stunted from rickets.) 

Its disruptive effects upon the facial bones were very extra- 
ordinary. In spite of this, the patient's health was but 
little disturbed ; she had no loss of intellect, and, it is 
believed, no paralysis. The course of the disease from its 
origin till the patient died was about six years. 

Although a chondroma invading the skull may require 
(as in the example just described) years to kill a patient, 
there is a situation in which in certain circumstances it 



70 EGGHONDROSES 

will cause great distress and death namely, in the pelvis. 
The effects which such tumours produce on the pelvic 
viscera are in some cases very remarkable. For example, 
a woman aged 21, with a large chondroma in her pelvis, 
became pregnant, and, delivery by natural means being 
impossible, hysterectomy was performed; but the patient 
died (Fig. 37). Apart from obstructing labour, the tumour 
had pressed on the ureters and produced dilatation of both 
of them and sacculation of the kidneys. This unfortunate 

woman was known to have a 
tumour in her pelvis seven 
years previous to her tragic 
death. 

Pathological cartilage occurs 
in spindle-celled sarcomas (p. 
33); also in tumours of the 
salivary glands, especially the 
parotid. Cartilage - containing 
tumours grow in the lachrymal 
gland, in the testicle, and in 
the breast. 

Fig. 36. Condyles and epiphyseal line 2. EcchondrOSCS. These 

of a rickety femur, with a carti- may be defined as Small local 
lage island. (Museum of the Middle- ,* /. ,.-, m1 

sex Hospital.) overgrowths of cartilage. They 

are best studied along the edges 

of articular cartilages, the laryngeal cartilages, and the 
triangular cartilage of the nose. 

Ecchondroses are especially common in the knee-joint, 
and often in association with the condition termed rheu- 
matoid arthritis. They are frequent in the joints of indi- 
viduals who have passed the meridian of life, and they occur 
as small projecting prominences along the margins of the 
articular cartilage. Often the edge of the cartilage is pro- 
duced into a raised prominent lip, the regularity of which is 
broken here and there by a sessile or a 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 




SYNOVIAL GHONDROMAS 



71 



parts are at rest. Occasionally erosion of an 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 joint-cavity, or it 
may be retained in position by its attachments to the 
fibrous structures of the joint. 

Laryngeal ecchondroses are by no means common; 




Fig. 37. Pelvis occupied by a large, partially ossified chondroma, shown in 
sagittal section. From a woman aged 21, who died after hysterectomy 
performed for obstructed labour at term. {Museum of University 
College, London.) 

they grow from the thyroid, cricoid, and occasionally the 
arytenoid cartilages, but very rarely from the semi-rings 
of the trachea. 

Small outgrowths from the triangular cartilage of the 
nose are by no means uncommon ; they never attain a large 
size, and are always sessile ; surgeons who study diseases of 
the nasal passages view them with disfavour. 

3. Synovial chondromas. It is customary to describe 
as loose bodies in joints fragments of cartilage, or pieces of 



72 SYNOVIAL GHONDROMAS 

bone covered with cartilage, which have been detached 
from the articular surfaces of the bones forming the joint. 
The bodies described as synovial chondromas have a dif- 
ferent origin. 

In large joints, such as those of the hip, knee, or shoulder, 
it is easy to demonstrate, in the recesses of the joint, near 
the spot where the synovial membrane becomes continuous 
with the margin of the articular cartilage, villous-like pro- 
cesses of the synovial membrane projecting into the joint. 
Under certain conditions, especially that known as rheu- 
matoid arthritis, these villi become greatly enlarged and 
increase in number until the whole synovial membrane 
may be so covered with them as to present a soft velvety 
appearance. Structurally, these synovial villi consist of 
a reduplication of the serous membrane, and contain tufts 
of capillaries. As they enlarge, some of them undergo 
chondrification, and this change may take place so ex- 
tensively that a villous process is entirely converted into 
hyalin cartilage, and becomes the matrix for a deposit of lime 
salts. As these nodules of cartilage are merely sustained 
by narrow pedicles, the nodules may be detached either 
by their mere weight, by 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 
chondrifying, are converted into oval bodies which, on micro- 
scopical examination, present a central cavity surrounded by a 
laminated structureless substance. To the naked eye many 
of these oval bodies resemble cartilage, and it is only on 
microscopical 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. 
I counted 1,532 from a shoulder-joint, arid Berry found 
1,047 in the knee-joint of a man aged 18. Bodies of this 
description occur not only in joints, but in compound ganglia 
and bursse. 



GHONDROMAS : TREATMENT 73 

A good physiological type for the loose cartilaginous bodies 
which infest joints is furnished by the ternporo-mandibular 
joint of the skate. A recess communicating with this articular 
cavity usually contains a collection of smooth cartilaginous 
bodies, in contour and size like melon- seeds. 

A remarkable variety of loose body occurs in large joints 
in the form of a discoidal piece of cartilage; it may be 
smooth, or resemble a piece of coral. (Fig. 38.) Such a body 
consists chiefly of hyalin cartilage impregnated with calcine 
matter, or contains a nodule of bone ; it must be distinguished 
from a piece of articular cartilage detached by accident. 





Fig. 38. Loose body from the knee-joint of a labourer aged 55 ; 
in section and entire. (Museum of tlie Royal College of 
Surgeons.) 

It has happened that a loose body of this description 
has been removed from one joint, and a body, identical in 
size and shape, has been found in the corresponding joint of 
the opposite limb of the same person (Bowlby, Weichselbaum). 

Treatment. The operative treatment of chondromas has 
been greatly simplified since surgeons have appreciated the fact 
that these tumours, when growing in relation with bones, are 
distinctly encapsuled. Now, when it is necessary to interfere 
with a chondrorna, 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 



74 JOINT-MICE 

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. Fortunately, such severe 
treatment is 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 joint, to open the synovial cavity 
and remove them. If 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 larger pieces of cartilage, which can be pushed in and 
out of the great cul-de-sac above the patella almost as readily 
as a marble may be manipulated under a tablecloth. 

Bowlby, A. A., ' ; Rare Forms of Loose Bodies from the Knee - Joints." 

Trans. Path. Soc., 1888, xxxix. 281. 
Brims, Paul, " Enchondrom des Kehlkopfs." Beit. z. klin. Chir. (Bruns), 

1888, iii. 347. 
Fisher, A. G. T., "A Study of Loose Bodies in Joints." Brit. Journ. of Surg., 

1921, viii. 493. 
Weichselbaum, A., " Zur Genesis der Gelenkkorper." Virchow's Arch. /. 

path. Anat., 1873, Ivii. 127. 

Kast and von Recklinghausen, "Bin fall von Enchondrom. "IUd., 1889, i. 
Steudel, "Multiple Enchondrome." Bruns' Beit., 1892, viii. 503. 



CHAPTER VI 
TUMOURS OF BONE (continued) 

MYELOMAS; CYSTS IN BONES 

Myelomas. A myeloma is a tumour composed of tissue 
identical in structure with the red marrow of young bones. 
These tumours were described by Lebert (1853) as fibro- 
plastic tumours, but Paget recognized their relationship to 
red marrow, appreciated the importance of the multinuclear 
cell, and called them myeloid sarcomas ; they were included 
among sarcomas until 1893. In the first edition of this 
book they were removed from the genus Sarcoma ; sub- 
sequent clinical and pathological observations have justified 
the separation, and many useful limbs have been saved in 
consequence. 

Myelomas arise only in the cancellous tissue of bone. 
When fresh, the cut surface of the tumour is dark red, 
looks like a piece of liver, and is very vascular. This tissue 
abounds in large multinuclear cells embedded among round 
and spindle cells. The giant cells are so numerous as to 
constitute the greater portion of the tumour. Myelomas are 
benign : they do not infect the lymph-nodes nor disseminate. 

Myelomas grow chiefly in the shafts of long bones 
immediately adjacent to an epiphysis, and the epiphyseal 
cartilage appears to play the same neutral part as in a 
sarcoma. When a myeloma arises in a long bone after the 
epiphysis has fused with the shaft, the tumour-tissue will 
destroy the bone quite up to the articular cartilage. These 
tumours usually arise during childhood and adolescence ; 
they are more frequent in the long bones of the lower than 
in those of the upper limb. They show a decided preference 
for the head of the tibia and the lower end of the femur. 
(Fig. 39.) In the radius they prefer the lower end, but 

75 



76 MYELOMAS 

t 

occasionally grow in its neck. Myelomas prefer the head 
of the fibula, but the lower end of the ulna. These facts 
indicate that they arise most frequently in that part of a 
bone where red marrow is most abundant. In the clavicle 
many examples have been observed in the sternal portion, 
and I removed one from its acromial end, an excessively 
rare situation for a tumour of any kind. In the humerus, 




Fig. 39. Myeloma in the lower end of the femur. Kemoved by 
amputation from a girl aged 16. 

myelomas prefer the upper end of the shaft; they have 
been reported, though rarely, at the lower end of this bone. 
In the femur they frequent the condyloid end, and 
occasionally attack the great trochanter and invade its 
neck. In a series of myelomas of long bones collected by 
Stewart and by Gask, the lower end of the femur was the 
commonest site among all the long bones. The uncommon 
bones selected by myelomas are the innominate bone, of a 
man aged 51 (Gordon Watson), the patella (Fig. 40), and 



MYELOMAS 77 

the coccyx, in a woman of 27 (Stewart). Vertebrae are 
rarely attacked by them. A myeloma is common along 
the alveolar borders of the jaws, often appearing as a plum- 
coloured nodule ; when one of these tumours arises in the 
premaxilla it sometimes invades the alveolar margins on 
each side of the premaxillary suture. 

Myelomas of long bones are not common tumours, and 




Fig. 40. Myeloma of the patella. From a girl of 20. 
(Museum of the Royal College of Surgeons.} 

a careful perusal of periodical surgical literature and 
Hospital Reports shows that in each of the large general 
hospitals of London one myeloma of a long bone annually 
is above the average. These tumours grow slowly and 
expand the surrounding bone until the osseous tissue 
becomes so thin that it crepitates on pressure (egg-shell 
crackling) a valuable diagnostic sign when present. The 
soft tissue of the tumour sometimes perforates the bony 
capsule and pulsates. When a bone that has been expanded 
by a myeloma is macerated, the bony calyx is called a spina 



7 8 



SPINA VENTOSA 



ventosa, and an example is usually found in pathological 
museums. (Figs. 41 and 42.) 

The naked-eye characters of myelomas are so striking 




Fig. 41. Fibula showing the 
change produced by a 
myeloma. 




c. a . 



Fig. 42. Kadius and ulna. The 
neck of the radius is ex- 
panded by a myeloma that 
had become cystic. The 
tissue around the expanded 
bone is the supinator brevis 
muscle. The epiphysis is 
unaffected. From a girl. 
(Museum of the Middlesex 
Hospital.} 



that surgeons sometimes fail to make a microscopic exami- 
nation of red central tumours of bone. There are endosteal 
tumours that resemble myelomas in colour, consistence, 



BENIGN CYSTS OF BONES 79 

and clinical conduct, but differ from them in structure. 
Diagnosis does not rest on colour alone. 

Myelomas are so essentially tumours of childhood and 
adolescence that a red endosteal tumour occurring in an 
unusual situation at an unusual age should be critically 
investigated. Stewart, in an analysis of eleven myelomas 
(at the Leeds Infirmary), found them most frequent between 
the twentieth and fortieth years. Myelomas being very 
vascular, their centarl parts are often destroyed by hemor- 
rhage, so that the tumours become transformed into what 
were formerly called blood-cysts, the rnyeloid elements being 
represented by a thin stratum of tissue lining the walls of 
an osseous capsule. Such a change is represented in the 
upper end of the radius (Fig. 42). It resembles a jar, and 
the discoid epiphysis rests on the crown of the tumour like 
a lid. 

Benign cysts of bones. The tendency for myelomas to 
become cystic throws some light on a puzzling endosteal con- 
dition known as benign cysts of bones. Cysts or cavities in 
the shafts of long bones may be caused by abscesses, hyda- 
tids (echinococcus-disease), and by the softening of cartilage 
tumours. A variety of cyst occurs in long bones apart from 
these causes. For example: A lad aged 19 hurt his shoulder 
whilst leaving a motor-bus in motion. A skiagraph furnished 
evidence that the humerus was broken at the surgical neck, 
but the bone at the seat of injury exhibited a shadow which 
suggested the presence of a myeloma. When the upper third 
of the humerus was excised and the exsected piece of bone 
split longitudinally, the cancellous tissue immediately below 
the epiphysis was found to be hollowed out and the irregular 
cavity filled with pink fluid (Fig. 43). The recesses in the 
osseous boundaries of the cavity contained fibrous tissue 
and large multinuclear cells. A study of this and similar 
specimens leads me to believe that some benign cysts of 
bone are closely related to myelomas. Such cysts commonly 
occur in those long bones of children and adolescents most 
frequented by myelomas, such as the lower end of the 
radius, the upper end of the fibula, and especially the upper 
end of the shaft of the humerus. The epiphyseal cartilages, 
as with myelomas, act like neutral lines. This is illustrated 



8o 



CYSTS OF BONES 



by Fig. 44, which represents the upper two-thirds of a 
humerus completely hollowed out below the upper epiphyseal 
line. The cavity contained clear straw-coloured fluid. Here 
and there are seen membranous septa consisting of spindle- 
celled tissue containing 
numbers of giant cells. 
The hurnerus was removed 
from a boy aged 7, by 
amputation through the 
neck of the scapula, on 
an erroneous diagnosis. 




Fig. 43. Upper end of the 
humerus in longitudinal 
section: it contains a be- 
nign cyst. From a lad aged 
19. (Museum of the 'Royal 
College of Surgeons. ) 




Fig. 44. Upper two - thirds of the 
humerus hollowed out into a benign 
cyst. From a boy aged 7. (Museum 
of the Royal College of Surgeons.) 



The natural history of red marrow is instructive in rela- 
tion to this view. In the foetus the shaft of a long bone is 
filled with red marrow ; gradually, in the middle section of 
the shaft, this, as we have seen, is replaced by fat ; and as age 
advances, the marrow at the ends of the bone is also partially 



MYELOMAS : TREATMENT 81 

replaced by fat. Benign cysts in bones may arise in conse- 
quence of the destruction of the red marrow by haemorrhage 
into it, or from the spontaneous atrophy of the tissue of a 
myeloma. The resulting cavity is the only evidence of the 
unwonted activity of the red marrow, and, like a circular lake 
in the crown of a mountain that was once an active volcano, is 
a silent witness of its former activity. The age-incidence, the 
distribution of benign cysts among bones, and their frequent 
juxta-epiphyseal position favour this opinion. All benign 
cysts of bone do not arise from the retrogression of myelomas. 
Little is known of the change called fibrocystic disease of 

ULNA RADIUS 




Fig. 45. Myeloma of the lower end of the radius. (Museum of 
St. Thomas's Hospital.) 

bone ; it affects mainly the cancellous tissue and red marrow 
of long bones. Pulsating tumours of bone, called by our 
predecessors osteo-aneurysms, were probably myelomas. 

Treatment. When the patient comes under observa- 
tion before the myeloma has perforated its capsule, it may 
be thoroughly extirpated without fear of recurrence. The 
manner of thorough extirpation varies with the situation of 
the tumour. 

In the upper limb, the lower extremities of the radius 
(Fig. 45) and ulna have been excised for myeloma, leaving 
an extremely useful hand. It is an important fact to 
remember that the lower third of the ulna may be excised 
alone, but when the radius is the affected bone it is an 
advantage to remove the corresponding section of the ulna. 
The upper third of the humerus, the inner half and the outer 
G 



82 MYELOMAS: TREATMENT 

half of the clavicle (Fig. 46), have been resected for myeloma 
with excellent results. In the case of the jaws, partial excision 
has been performed for myeloma with good consequences ; but 
when the patient allows one of these tumours in the maxilla 
to fungate before seeking surgical aid, the marrow tissue will 
so invade the surrounding soft parts that complete extirpa- 
tion is a chance event and recurrence probable. 

In the lower limb the best method of dealing with 
myelomas is not so certain. For those in the lower end 
of the femur, amputation has often been performed. This 
method has also been employed for the patella (K. Jones). 
Excision has been carried out by many surgeons since Morris 




Fig. 46. Myeloma of the acromial end of the clavicle. From a woman 
aged 26. She was in good health twenty-nine years afterwards. 
(Museum of the Royal College of Surgeons.} 

initiated it in 1877. In many bones a milder method, 
enucleation or scraping, suggested and practised by Sir James 
Paget, has given excellent results, and is now widely advo- 
cated and practised. 

It is fair to assume that in the remarkable case in which 
Mott (1828) excised the sternal two-thirds of the clavicle 
for what he called, in the terms of his day, "an osteo- 
sarcoma/' in a lad aged 18, the tumour was, in all probability, 
a myeloma. The boy survived the operation fifty-four years 
(Porcher). 

Previous editions of this book were furnished with a 
table of cases representing the good consequences, immediate 
and remote, which followed conservative methods of treat- 
ment. This is no longer necessary. One of the difficulties 



CYSTS OF BONE: TREATMENT 83 

connected with the treatment of a myeloma is the doubtful 
character of the diagnosis in many instances. A myeloma 
at the lower end of the radius is rarely missed, but in other 
long bones a tumour of this kind is simulated by tuber- 
culous disease, the common species of sarcoma, gumma, and 
echinococcus-disease. In well-marked examples the thinned 
and expanded bone furnishes the egg-shell, or parchment- 
like, crackling a clinical sign of great value. Radiography 
is of great service in the diagnosis of myelomas and benign 
cysts, especially in combination with the clinical appearances, 
but there are cases where the diagnosis between the two 
conditions is extremely difficult, and only possible with the 
assistance of an exploratory incision. It is worth bearing 
in mind that a fracture, often caused by a slight injury, 
attracts attention to a benign cyst of bone. In the majority 
of the reported cases where amputation has been performed 
for a benign cyst, or where the end of a bone has been resected 
for this disease, these radical methods have been carried out 
under an erroneous diagnosis, the cysts being mistaken for a 
malignant tumour. 

Cysts of bone are treated by scraping, followed by stuffing 
with gauze, and the cavity allowed to fill up by granulation. 
Excision, like amputation, is now being abandoned for the 
simpler and more conservative measures, the outcome of a 
careful study of the pathology of these curious cavities in 
bones. 

Elmslie, R. C., "Fibrocystic Disease of the Bones." Brit. Journ. of Surg., 
1914, ii. 17. 

Gask, G. E., Proc. Roy. Soc. of Med., 1912, vi., Surgical Sect., p. 61. 

Hinds, " Case of Myeloid Sarcoma of the Femur treated by Scraping." Brit. 
Med. Journ., 1898, i. 555. 

Morris, H., Trans. Clin. Soc., 1877, x. 138. 

Porcher, F. P., "Post-mortem Dissection of the Region of the Clavicle, this 
bone having been removed for Osteo-Sarcoma by Dr. Valentine Mott of 
New York, in 1828, when the subject was in his nineteenth year, and fifty- 
four years before his death." Amcr. Journ. Med. Sci., 1883, Ixxxv. 146. 

Stewart, M. J., "Observations on Myeloid Sarcoma, with an Analysis of 
Fifty Cases." Lancet, 1914, ii. 1236. 



CHAPTER VII 
TUMOURS OF BONE (continued) 

SARCOMAS 

THE phrase "sarcoma of bone" is conventionally applied to 
all varieties of primary malignant tumours of bone. It 
includes sarcomas arising spontaneously, as well as the 
excessively malignant tumour that sometimes follows a single 
intensive injury. 

It has been the custom to arrange sarcomas of bone in two 
groups : (a) those arising in the interior of a bone were 
described as central or endosteal sarcomas, and (b) those 
growing from the periosteum were known as peripheral or 
periosteal sarcomas ; but the isolation of the myelomas into a 
special genus and the appreciation of their benignity have had 
an unexpected effect on this classification, for we find that 
a central sarcoma of a long bone is a rare tumour. There are 
central tumours of bone, but the term has entirely lost its 
former import in relation to sarcomas; and some central 
tumours of bone, which in naked-eye characters are indistin- 
guishable from myelomas, prove on microscopic examination 
to be secondary hypernephromas (see Chap, xxxvn). 

The pathological and clinical features of sarcomas arising 
in connexion with bone can be studied in their simplest con- 
dition in the limbs ; the more complex arise in relation with 
those bones of the face and skull which are partially invested 
with muco-periosteum, like the jaws, the ethmoid, and the 
palate bones. The most complex conditions arise in connexion 
with the bones sheltering the central nervous system. Sar- 
comas of bone may be round-celled or spindle- celled : 
occasionally a sarcoma arising from periosteum may possess 
spindles transversely striated (myosarcornas). Periosteal sar- 
comas are very liable to chondrify, to calcify, and to ossify. 

8 4 



SARCOMAS OF BONE 85 

When growing from the periosteum near the middle of the 
shaft a sarcoma may be restricted to a portion of the cir- 
cumference of the bone, or entirely surround it, producing 
a fusiform swelling. In such a specimen the shaft of the 




Fig. 47. Skeleton of an ossifying periosteal sarcoma of the femur. 

bone traverses the tumour, and, beyond a slight amount of 
erosion, may be unaffected by it. The medulla is sometimes 
infected by the sarcomatous cells invading the Haversian 
canals. Bones permeated in this way occasionally break from 
very slight violence so-called spontaneous fracture. (Fig. 47 .) 



86 SARCOMAS OF BONE 

Sarcomas have a greater predilection for the joint-ends of a 
bone than for the central portions of its shaft, but they 
rarely invade joints. 

The relation of a sarcoma to the periosteum is very 
intimate, and the fusiform shape of sarcomas of long bones 
like the humerus and femur, in young subjects, is due to the 
ease with which this membrane is stripped from the bone by 
the growing tumour, and its limitation by the firmer union of 
the periosteum at the epiphyseal lines. The mode in which 
sarcomas spread along periosteum is shown in Fig. 50, where 
a detached nodule of sarcomatous tissue lies above the upper 
pole of the primary tumour. It is often difficult, when 
examining limbs amputated on account of periosteal sar- 
comas, to decide whether the tumour really arose in the 
periosteum, or in the muscles at their attachment to the 
periosteum. 

In size periosteal sarcomas vary greatly : in exceptional 
cases they have been known to exceed a metre (40 inches) in 
circumference. Many become more or less ossified, the 
osseous matter taking the form of delicate spicules arranged 
at right angles to the shaft of the bone ; sometimes it forms 
an irregular bony inesh, the spaces being filled with sarco- 
matous tissue. The extensive ossification of the tissue of 
periosteal sarcoma is usually attributed to the periosteum ; 
Knaggs points out that it also occurs in endosteal sarcomas, 
and he believes that the active element in the ossification of 
these tumours is the sarcoma cell. He thinks also that 
environment plays a part in the process, and that ossification 
in a sarcoma is not necessarily a sign of a low degree of 
malignancy. I concur in this opinion. 

There are tumours of bones concerning which, after a 
microscopic examination, an opinion can be definitely ex- 
pressed for or against malignancy ; there are others which 
the most expert histologist hesitates to call either innocent or 
malignant. One of the most remarkable features connected 
with the histology of periosteal sarcomas is the great varia- 
tion in their malignancy according to the bone attacked. 
Sarcomas of the femur, humerus, ilium, and clavicle are 
often excessively malignant, but tumours with the same 
microscopic characters growing from the tibia, fibula, radius, 



SARCOMA OF FEMUR 87 

or ulna run a slower and milder course. The rapidity with 
which a sarcoma of the femur will destroy life is illustrated 
by the following case : 

An actor aged 24 felt pain in his knee ; a month later it 
was found that a tumour occupied the lower end of his femur. 
Two months afterwards he came under my care, and the leg 




Fig. 48. An ossifying spindle- celled sarcoma of the femur : in transverse section. 

was promptly amputated. The tumour, a periosteal sarcoma, 
had circumscribed the lower part of the femur (Fig. 48). A 
few days after the operation, difficulty of breathing declared 
itself, and a few months after the operation the man died, 
slowly suffocated. At the post-mortem examination secondary 
deposits were found in the liver, pancreas, and ileum ; the 
lungs were thickly occupied with secondary deposits ; a large 
conglomerate mass as big as the fist compressed the trachea 



88 SARCOMA OF FIBULA 

and the adjacent bronchi. The secondary deposits were hard 
and grated under the knife, and some of them seemed to be 
contained in an imperfect osseous capsule. In its general 
characters and in the mode by which the tumour destroyed 
this man it displayed thoroughly the usual features of an 
ossifying periosteal sarcoma of the femur. The patient had 
no notion that anything was wrong with his thigh until 
October, and by the middle of the following February he was 
suffocated by large secondary nodules of sarcoma compressing 
the bronchi. For comparison the following case is instructive : 
A girl had a sarcoma growing from and surrounding the 
lower half of the shaft of the tibia. The leg was amputated 
through the knee-joint and bisected (Fig. 49). Microscopic- 
ally it was an ossifying spindle-celled sarcoma. Seven years 
afterwards this girl was alive and in good health. 

The femur. This bone is very liable to sarcomas ; they 
grow most often from its lower part, and almost invariably 
run a rapidly fatal course. The duration of life rarely exceeds 
eighteen months ; often it is much less. They usually occur 
between the fifteenth and fortieth years. A sarcoma growing 
from the lower end of the femur often simulates chronic 
disease of the knee-joint and sometimes causes great difficulty 
in diagnosis. A sarcoma of the femur invading the knee-joint 
resembles a primary sarcoma of the synovial membrane. 

I followed up ten patients with sarcoma of the femur. 
Nine of them died within a year of the operation, from 
dissemination of the tumour or from recurrence in the stump. 
The more fortunate patient was a boy aged 15, with a large 
spindle-celled sarcoma at the upper end of the femur. He 
was alive, and in good health, three years after removal of 
the limb at the hip-joint. 

The tibia. Sarcomas are common in this bone, preferring 
the upper to the lower end, and they do not behave with such 
malignity as in the femur. Many central tumours of the tibia 
formerly classed as sarcomas were myelomas. 

The fibula. Sarcomas of this bone (Fig. 50) are interesting 
because its upper half is vestigial, and its persistence is 
probably mainly due to the fact that it affords attachment 
to the muscles of the leg. The lower end has undergone 
excessive development to meet the demands of the ankle- 



SARCOMA OF FIBULA 



89 



joint for greater security necessitated by the upright 
position in man. These facts induced me some years ago 
to depart from the usual rule in treating periosteal sar- 




Epiphysis. 
Epiphyseal line. 



Oancellous tissue, with 
red marrow. 



Medullary canal. 



Periosteum. 



Sarcoma. 



Fig. 49. Coronal section of the tibia of a girl with a periosteal sarcoma. 
She was alive, and well, seven years after the amputation. 

coma of the fibula. We know that when these tumours 
attack the bones of the leg they do not run a very rapid 
course, so in a favourable case which came under my care 



90 SARCOMA OF FIBULA 

in 1895 I resected the upper half of the fibula. The 
patient recovered with a very useful limb, and was able 
to walk about. Recurrence took place in the scar eighteen 
months later ; this was removed. Six months afterwards a 




Accessory nodule of 
sarcoma. 



Interosseous membrane. 



Sarcoma. 



Flexor longus hallucis. 



Peroneus longus. 

Detached portion of the 
flexor lougus lialhmis 



Fig. 50. Spmdle- celled sarcoma of the fibula. (Museum of the Middlesex 

Hospital.} 

more extensive recurrence rendered amputation a neces- 
sity. The patient died, two years and six months after the 
original operation, with signs indicating dissemination in 
the lungs. 

A careful examination of the literature relating to sarcoma 
of bone makes me think that these tumours are rare in the 



SARCOMA OF SCAPULA 9* 

fibula, and certainly they do not run a very rapid course. A 
sarcoma may arise in any part of the shaft of this bone, but 
the upper end is the favourite situation. 

The humerus. Periosteal sarcomas of this bone are 
very dangerous to life ; they occur at all ages, generally 
involve the whole shaft of the bone, and form large, soft, 
rapidly growing, spindle-shaped masses. 

Sarcomas situated at the upper end of the humerus 
have been very freely operated upon since 1887 by the 
interscapulo-thoracic method of amputation. The immediate 
results are good, but the remote consequences are dis- 
couraging. 

The radius and ulna. Sarcomas of these bones, 
whether central or periosteal, are so rare that it is 
impossible to collect a sufficient number of cases to make 
deductions of any value. The few available records are 
sufficient to show that amputation has been followed by 
good consequences, immediate and remote. Some of these 
tumours, however, may have been myelomas. 

Clavicle. Periosteal sarcomas of this bone are rare, 
and in nearly all the recorded cases have originated near 
the middle of the bone. A fair number of cases have been 
reported in which the bone and tumour have been suc- 
cessfully excised. Examples reported to be central sarcomas 
arose mainly in the sternal end, but these were in all prob- 
ability myelomas (see p. 82). Partial or complete extirpation 
of the clavicle does not impair the utility of the limb. 

Scapula, It is easy to collect a score or more of records 
relating to sarcomas of the scapula. They arise mainly 
from the periosteum of the dorsal and ventral surface of 
this bone, and often assume formidable proportions. It is 
rare for sarcomas to arise in connexion with the pro- 
cesses of the scapula, but a central sarcoma of the coracoid 
process has been observed. 

Scapular sarcomas are usually of the spindle-celled 
species, and many of them chondrify and ossify, often very 
extensively (Fig. 51). 

Since 1887, when Berger introduced the operation 
known as interscapulo-thoracic amputation, many surgeons 
have removed the scapula arid upper limb in cases of 



9 2 



SARCOMA OF INNOMINATE BONE 



scapular sarcoma. The immediate results of this formid- 
able operation are very gratifying, and though in a large 
proportion of the patients there is a quick recurrence, 
nevertheless life is often prolonged. Occasionally, when 
a sarcoma is confined to a limited area of the scapula, 



CORACOID 



ACROMION 




Fig. 51. Skeleton of a periosteal sarcoma of the scapula. 
(Museum of St. Thomas's Hospital.} 

it is possible to excise the body of the bone, leaving the 
head in its normal relation to the shoulder-joint : some 
patients have recovered from this operation with a useful 
upper limb. 

Innominate bone. Sarcomas occasionally arise in this 
bone; they may be periosteal or central and may occur in 



TRAUMA AND SARCOMA OF BONE 93 

any part of it. On the whole, the ilium is the segment 
most commonly affected, and the tumours attain a great 
size. Stimulated by the success of the interscapulo-thoracic 
amputation for sarcoma of the scapula, attempts have 
been made to remove the innominate bone, or the greater 
part of it, with the lower limb, as a radical means of 
dealing with sarcoma of the ilium. This operation has 
been termed the interilio-abdominal amputation (Jaboulay. 
1894). Keen and Da Costa have collected fifteen cases 
and added one under their own care. The results are not 
encouraging. 

Bones of the hand and foot. Sarcomas of the meta- 
carpal and metatarsal bones, or the phalanges, are very ex- 
ceptional. Large, rapidly growing sarcomas arise from the 
tarsus, but it is unusual to find a central tumour in. these 
cubical bones, though they have been reported in the cal- 
caneum (Barthauer). 

Sufficient facts are not available to enable anything 
like a satisfactory account to be furnished of the clinical 
course of sarcomas of the hands and feet; this is due to 
their rarity. 

Patella. A sarcoma of this bone is a great rarity, 
but a careful report of a case has been published by 
Parker. 

Trauma in relation to sarcoma of bone. The relation 
of injury to sarcoma of bone is a matter of some importance. 
For example, a man aged 21 received a blow on the shin 
from a barrow filled with bricks. One month later a swell- 
ing was noticed ; it grew quickly, and the leg was amputated. 
The tumour was a round-celled sarcoma of the tibia as big 
as a coco-nut. A man aged 20, "whilst pitching hay in 
a loft, bumped his malar bone against a protruding portion 
of the roof." Three days later a swelling, about the size of 
an olive, appeared where the bone had been struck. Six 
months later this swelling had become a large tumour. It 
was freely removed. The tumour had the microscopic fea- 
tures of an ossifying sarcoma. (Murphy.) Many similar 
examples have been recorded. 

Every pathological museum of any pretensions contains 
specimens of sarcomas growing in bones of the head and 



94 SARCOMAS OF BONE: TREATMENT 

the limbs as the sequel to a severe single physical injury. 
The majority of surgeons believe that a single intensive 
injury may occasionally induce the growth of a sarcomatous 
tumour, but there is a wide diversity of opinion as to the 
exact condition under which any given case of tumour is 
to be regarded as of traumatic origin. All agree that the 
situation of the tumour must correspond to the site of 
the injury, but there is no definite agreement among sur- 
geons as to how long an interval may elapse between the 
injury and the appearance of the tumour in order that they 
may be regarded as cause and effect. This can only be 
decided by a careful study of individual cases. (See also 
Chap, xxiv.) 

The most puzzling cases for the pathological histologist 
are those in which there is an exuberant formation of 
reparative tissue around a fracture. Often, this forms a 
sarcoma-like mass which, microscopically, is indistinguish- 
able from sarcomatous tissue. This condition has been dis- 
cussed by Shattock with great skill and acumen. Pollard 
also has described a remarkable case. One of the most 
extraordinary examples is preserved in the museum of the 
Royal College of Surgeons, England. A tumour slowly 
formed within the shaft of the tibia after a fracture 
(Fig. 52), and grew for ten years. The leg was amputated 
by Eve, who described the tumour in detail. The minute 
structure agreed with that of a slowly growing spindle- 
celled sarcoma. 

Treatment. The method of surgical treatment adopted 
for sarcoma of a limb bone is based on the natural history 
of the tumour. Periosteal sarcomas spread along the peri- 
osteum, infiltrate the muscles, and invade the veins ; when 
the overlying skin is involved the lymph-nodes are infected 
with the disease. It is for these reasons that surgeons 
amputate the limb in such a manner that whenever possible 
they remove the whole of the affected bone. The way of 
effecting this has been incidentally mentioned in discussing 
sarcoma of individual limb bones. A careful survey of the 
results of amputation for sarcoma is very depressing; long 
survivals after such operations are very few. The contra- 
dictory results of opposite methods .of treatment can only 



SARCOMAS OF BONE 



95 



be explained on the ground that sarcomas of apparently 
identical microscopic structure vary in malignancy. 




Fig. 52. Tibia and fibula : the tibia expanded by a slow-growing central tumour. 
From a man aged 24. (Museum of the Royal College of Surgeons.} 



9& REFERENCES 

Barthauer, S., " Ueber die Exstirpation des Calcaneus, nebst Beschreibung 
eines Falles von centralem Sarkom des Calcaneus." Deut. Zeitschr. f. 
Cfiir., 1894, xxxviii. 462. 

Battle, W. H., and Shattock, G. S., " A Remarkable Case of Diffuse Cancellous 
Osteoma of the Femur following a Fracture, in which similar growths 
afterwards developed in connection with other bones." Proo. Roy. Soc. 
of Med., 1908, i., Pathological Sect., p. 84. 

Berger, "De 1' Amputation Interscapulo-thoracique dans le Traitement des 
Tumeurs malignes de 1'Extremite superieure de 1'Humerus." Rev. de 
Ckir., 1898, xviii. 861. 

Bland-Sutton, J., " On a Case in which the Upper Half of the Fibula was 
excised for a Sarcoma." Brit. Med. Journ., 1896, i. 1086. 

Eve, F. S., " Specimen of Central Fibro-Sarcoma expanding Tibia, accom- 
panied by extreme Cystic Degeneration ; with remarks on the Relation 
of Injury and Inflammation to the production of Sarcoma of the 
Bones." Trans. Path. Soc., 1888, xxxix. 273. 

Keen, W. W., "Resection of the Sternum for Tumours; with report of 
two cases and a table of seventeen previously reported cases." Med. 
and Surg. Reporter, 1897, Ixxvi. 385. 

Keen, W. W., and Da Costa, J. C., "A Case of Interilio- Abdominal Amputation 
for Sarcoma of the Ilium, and a synopsis of previously recorded 
cases." Internat. Clinics, 1904, iv. 127. 

Knaggs, R. L., "A Contribution to the Study of Ossification in Sarcomata of 
Bone." Brit. Journ. of Surg., 1915, ii. 366. 

Murphy, J. B., Clinics, 1915, iv. 549. 

Pringle, J. H., " Some Notes on the Interpelvio-Abdominal Amputation, with 
report of three cases." Lancet, 1909, i. 530. 






CHAPTER VIII 
TUMOURS OF BONE (concluded) 

SARCOMAS OF THE CRANIAL AND FACIAL BONES, 
THE VERTEBRA, AND THE RIBS 

SARCOMAS of the bones of the head and face do not differ 
structurally from those attacking the bones of the limbs, 
but they differ in their clinical manifestations. Those which 
arise from flat bones, such as the parietal, frontal, temporal, 
and occipital bones, often come into relation with the brain. 
Some of the bones, such as the maxilla, vomer, and ethmoid, 
are more or less invested with the muco-periosteum in relation 
with the respiratory passages. Sarcomas arising in connexion 
with them are more easily and quickly infected than those of 
the limbs. When sarcomas arise from the vertebrse, symptoms 
due to interference with the spinal cord are common. The 
large bones of the cranial vault are liable to periosteal sar- 
comas; they grow rapidly and are not often submitted to 
surgery. Crania exhibiting the peculiar formation of spicu- 
lated new bone characteristic of periosteal sarcomas are 
common in pathological museums. 

Sarcomas arising from the facial bones produce horrible 
distortion. The ethmoid is a rare situation for a sarcoma. 
Moore described an extraordinary example which arose in the 
mesethmoid of a man aged 22 (Fig. 53). As the tumour 
increased in size it compressed the walls of the antrum and 
flattened out the body of each maxilla until these bones formed 
a thin expanded shell to the tumour, without being eroded 
or invaded by it. The sarcoma also greatly widened the space 
between the orbits and flattened out the nasal bones, causing 
the deformity known as " frog-face," but did not invade the 
skull. There was no pain. Moore (1864) attempted the 
formidable task of removing this tumour, but the patient died 
H 97 



98 NASO-PHARYNGEAL SARCOMAS 

during its progress. The skull and tumour are preserved 
in the museum of the Middlesex Hospital. 

Sarcomas arising in the muco-periosteurn of the roof of the 
pharynx constitute an important clinical group under the 
name of naso-pharyngeal tumours. These are most common 
in patients between the ages of 15 and 20 ; in many instances 
they grow from the muco-periosteum of the under-surface of 
the body of the sphenoid, or the lining of the sphenoidal 
sinuses. Such tumours sometimes extend into and plug one 
or both nasal fossse. A process of the tumour may appear at 




Fig. 53. " Frog-face deformity " produced by a sarcoma of the mesethmoid. 
(Moorels case.) 

the nostril, or creep through the spheno-maxillary fissure and 
invade the orbit and cause proptosis. Outrunners force their 
way through the nerve-foramina in the base of the cranium, 
especially those which transmit divisions of the fifth cranial 
(trigeminal) nerve, and set up neuralgia. Sometimes the 
bones at the base of the skull are perforated, and if the 
tumour become septic the infection spreads to the dura 
and sets up meningitis. When a naso-pharyngeal tumour 
implicates the dura it causes agonizing pain and intense 
frontal headache. When the tumour is extensive it invades 
the pharynx and may impede deglutition. Portions of a 
tumour have been known to slough and, becoming impacted 



NASO-PHARYNGEAL SARCOMAS 99 

in the larynx, suffocate the patient. Such tumours send 
prolongations that creep along the Eustachian tube to the 
tympanum and emerge at the external auditory meatus. 

Trotter, after a careful study of malignant naso-pharyngeal 
tumours, formulated a group of symptoms based on their 
invasiveness. There are three important symptoms deafness, 
neuralgia, and bulging of the soft palate. The deafness, 
usually unilateral, is due to the growth implicating the 
Eustachian tube ; facial neuralgia to involvement of the fifth 
nerve in the spheno-maxillary fissure ; and a bulging of the 
palate, on the side occupied by the tumour, to infiltration of 
the levator palati, for the muscle becomes in consequence 
inextensible ; this leads to defective mobility of the soft 
palate. In advanced stages of the disease, when the tumour 
is infected, bleeding from the nostril (epistaxis) is common. 

Naso-pharyngeal sarcomas may be round-celled, spindle- 
celled, or lymphosarcomas. Some of them are complex in 
structure. As a rule, when the diagnosis is established, 
the pharynx is found filled with growth ; in the late stages 
the pterygoid and temporal muscles are infiltrated with 
sarcomatous growth and the jaw is fixed. In the latest 
stages of the disease the deep cervical lymph-nodes are 
infected. -In the early stages the symptoms are often such 
as to lead the surgeon to believe that he has to deal with 
a tumour situated in the middle cranial fossa, or in the 
vicinity of the pituitary fossa. In such cases an X-ray 
examination is of great assistance. 

Sarcomatous tumours of the naso-pharynx are more com- 
mon in men than in women ; many of the patients are young 
adults and, exceptionally, children. Some cases run a chronic 
course. A young woman under my care had a fibrosarcorna 
which arose in the mucous membrane on the roof of the 
naso-pharynx; after filling this cavity, the tumour invaded 
each orbit and slowly pushed the eyeballs out of the orbits. 
Each globe suppurated and sloughed. The orbits were then 
gradually filled with outgrowths from the tumour, which in 
their turn emerged from between the eyelids. Eventually 
this sarcoma penetrated into the cranial cavity. The tumour 
grew so slowly that the woman lived ten years after the be- 
ginning of the symptoms, and was totally- blind for five years. 



ioo SARCOMAS OF THE JAWS 

In the latter part of her life there was occasionally severe 
bleeding from the nose. She died from septic meningitis. 

Sarcomas of the jaws. Although it is customary to 
regard sarcomas of the maxilla and mandible clinically as 
tumours of the jaws, it would be erroneous to describe 
them indiscriminately as tumours of bone. In each jaw 
there are, in addition to the bone and periosteum, two 
structures to consider mucous membrane and teeth. In the 




Fig. 54. Large recurrent sarcoma of the mandible. 

case of the maxilla the antrum requires to be considered, 
with its gland-containing muco-periosteum. 

Periosteal sarcomas of the jaws are rare before the 
fifteenth year, but they may occur at any age, even in 
infants a few months old. They belong to the round- and 
spindle-celled species, and grow very rapidly (Fig. 54). 
These tumours are less frequent on the mandible than on 
the maxilla ; they grow from any part of it. Those which 
spring from the outer surface of the ramus are apt to be 
mistaken for parotid tumours. 

Periosteal sarcomas originate in any part of the 
maxilla, but they rarely arise from its facial surface, and, 






SARCOMAS OF THE PALATE 101 

though fairly frequent on the gums, are very rare in con- 
nexion with the mucous membrane of the palatine process. 
The muco-periosteum of the antrum is a common situa- 
tion for these tumours, and as they grow they cause thin- 
ning and expansion of the walls of this chamber. This 
enlargement of the body of the maxilla causes it to 
encroach on the nasal fossa and obstruct respiration ; often 
the tumour pushes up the orbital plate and displaces the 
eyeball (proptosis), and in a certain proportion of cases 
the alveolar border is depressed. The nasal duct is fre- 
quently implicated, and when completely obstructed epiphora 
is the consequence. Clinically, a sarcoma originating within 
the antrum expands its walls, and by degrees processes of 
the tumour make their way through and implicate the 
skin of the cheek, or, projecting into the nasal fossa, ulcerate 
and, becoming infected, give rise to frequently recurring 
haemorrhage. When the tumour perforates the posterior 
wall of the antrum it will enter the zygomatic and spheno- 
maxillary fossae, and creep thence into the temporal fossa, 
or make its way through the spheno-maxillary fissure and 
ramify in the orbit, or steal through the sphenoidal fissure or 
the foramen rotundum into the middle fossa of the cranium. 

Sarcomas of the palate. The mucous membrane of the 
hard and soft palate is liable to sarcomas and squamous- 
celled carcinoma. It is also liable to a peculiar tumour 
which is somewhat rare, named " adenoma of the palate." 
These tumours are usually ovoid in shape, and vary in 
size from an olive to a hen's egg ; they occur more fre- 
quently in the soft than in the hard palate, and are 
invariably encapsuled. These " palatine adenomas " are 
complex in structure. Some possess glandular tissue with 
ill-formed ducts and acini which in their structure mimic 
cancer, while the strorna in which they are embedded imi- 
tates sarcomatous tissue. They occur commonly between 
the thirtieth and fiftieth years, but they have been met 
with at puberty. They are innocent tumours, and have 
been carefully studied by Stephen Paget and Hutchinson. 
Similar tumours occur on the parotid and submaxillary 
glands (see Chap, xxxvi). 

Sarcomas of the vertebrae, Primary sarcomas of the 



102 



SARCOMAS OF THE SPINE 



vertebral column are rare tumours. They tend to invade 
the spinal canal and compress the cord (Fig. 55). It is very 
unusual for them to be amenable to surgical treatment, but 
Davies-Colley succeeded in removing one, and the patient, 
who was paraplegic, recovered motion and sensation. I re- 
moved a chondrifying sarcoma growing from the arches of 
the second lumbar vertebra of a man aged 40. The tumour 
was as big as a tennis-ball. The patient was in good health 
and free from recurrence five years afterwards. 




Fig. 55. Chondrifying sarcoma of the vertebrae and ribs. A portion of 
the tumour crept into the spinal canal and produced fatal paraplegia. 
(Museum of St. Bartholomew's Hospital.) 

A rare situation for a sarcoma is the posterior arch 
of the atlas. Even in this dangerous situation Jourdan 
succeeded in extirpating one ; the patient, a man aged 35, 
recovered. He nearly died from haemorrhage and failure 
of respiration in the course of the operation. After the 
arch of the atlas was removed the bulb lay bare at the 
bottom of the wound. 

Secondary deposits of sarcoma and cancer occur with 
tolerable frequency in the spine ; and it is not an un- 
common event for a patient to come under observation 



SARCOMAS OF BONES 



103 



complaining of severe pain in the vertebral column, which 
may or may not be accompanied by a local swelling, proved 
by careful investigation to be due to a secondary deposit 
of malignant disease. In some of these cases the primary 
source of the disease was not known to exist until the 
" pain in the back " led to the examination. There is 
one aspect of secondary malignant disease of the spine 
which needs consideration. 
When a deposit of sarcoma 
occupies bone, it softens the 
texture of the bone ; when 
this happens in the body of 
a vertebra, especially of the 
lumbar set, the superincum- 
bent weight will gradually 
compress and slowly efface the 
affected centrum. In some 
cases this is so complete 
that the intervertebral discs 
formerly separated by the 
diseased vertebra will come 
into apposition (Fig. 56). 

The pain which is set up 
by this slow " settling " of 
the column is very great, and 
may often be described as 
agonizing. This occurs in the 

Cervical as Well as in the Fig> 5 6. -Portion of the lumbar spine 
lumbar Segments of the VCr- infiltrated with malignant disease 

tphrfll polmrm and slowly absorbed tin the inter ' 

m ' vertebral discs came into apposition. 

Sternum. This bone is 

sometimes the seat of primary sarcoma, and a few surgeons 
have excised portions of the bone with the hope of eradi- 
cating the disease. The results, immediate and remote, are 
not calculated to bring the operation into favour. Keen 
has reported a very successful example and collected the 
best-known cases. 

Ribs. Sarcomas attack the ribs and, when they 
grow from the heads or the necks of these bones, are 
apt to send processes through the intervertebral foramina, 




J04 SARCOMAS OF BONES 

which, extending into 'the spinal canal, compress the cord 
(Fig- 55). 

A number of instances have been described in which 
surgeons have removed costal sarcomas, in some cases with- 
out opening the pleura ; but the results are not encouraging, 
and in the cases where the pleura was opened in the course 
of the operation the effects upon respiration and circulation 
were very grave. Webber, in removing a spindle-celled sar- 
coma of the sixth rib from a man 46 years of age, opened 
the left pleura and the pericardium. The patient recovered. 

Davies-Colley, N., " A Case of Fusiform Sarcoma of Lammas of Dorsal 
Vertebrae: Pressure upon Spinal Cord; Rachiotomy ; Cure." Trans. 
Clin. Soc., 1892, xxv. 163, 

Hutchinson, J., jun., " Two Cases of Adenoma of the Palate, with ex- 
ceptional clinical features." Trans. Path. Soc., 1886, xxxvii. 490. 

Jourdan et Oeconomos, " Sarcome de 1'Arc posterieur de 1'Atlas ; Extirpa- 
tion ; G\ieriaon"Montpellier Med., 1912, xxxv.' 356. 

Moore, Chas. H., " Cranio-Facial Enchondroma." Trans. Path. Soc., 1868, 
xix. 332. 

Paget, S., "Tumours of the Palate. "Ibid., 1887, xxxviii. 348. 

Que"nu et Longuet, "Tumours du Squelette thoracique." Rev. de Chir., 
1898, xviii. 365. 

Trotter, W., "Malignant Tumours of the Naso-Pharyngeal Wall." 2?r#. Med. 

Journ., 1911, ii. 1057. 
Webber, H. W., " A Case of Sarcoma of the Sixth Rib in the removal 

of which the Pericardial and Left Pleural Cavities were opened ; 

Recovery." Lancet, 1900, ii. 1347. 



CHAPTER IX 
SARCOMAS OF GLANDULAR ORGANS 

COMPOUND glandular organs like the kidney and prostate 
are liable to sarcomas at all ages, but they are more frequent 
in the early years of life. This is well shown by sarcomas 
of the prostate : nearly half the recorded cases occurred 
in the first ten years of life, many of them during infancy. 
Proust and Vian collected the records of thirty-four ex- 
amples of this disease ; the youngest was an infant of 5 
months, the oldest a man aged 73. Of these thirty-four 
patients, fifteen were under 8 years. 

As is the case with sarcoma generally, the onset and 
early course of the disease are very insidious, and painless, 
until the tumour interferes with some important function, 
or becomes septic. In the case of the prostate, it is the 
interference with micturition that draws attention to the 
existence of a tumour. In a boy under my own care 
the prostate was converted into a large mass which pushed 
the bladder high in the belly. The retention was caused 
by a bud-like process of the tumour which acted as a valve 
at the vesical orifice of the urethra (Fig. 57). 

The kidney is more frequently the seat of sarcoma 
than the prostate, but the disease shows the same relative 
frequency in early life. The type of sarcoma which grows in 
the kidneys of infants and children differs from that of adults. 

Renal sarcomas of infants. These originate in the con- 
nective tissue of the renal sinus, and gradually distend 
the cortex until the tumour is enclosed in a thin cap- 
sule formed of expanded secreting tissue of the kidney. 
On this account these tumours are described as being 
encapsuled, but it is a spurious encapsulation formed 
partly by renal tissue and in part by the true capsule 

105 



io6 



SARCOMAS OF THE KIDNEY 



of the kidney (Fig. 58). On section, such sarcomas are 
yellowish-white, and the cut surface is often dotted with 
groups of small cavities due to secondary changes. 

The base of such sarcomas is connective tissue containing 
cells of various shape and size, some of which are round or 
oat-shaped, and others are spindles. In a fair proportion 




Fig. 57. Bladder and urethra in section : the prostate is occupied 
by a sarcoma. From a boy aged 7. 

of specimens many of the spindle cells present the cross 
striation so characteristic of the fibres of voluntary muscle, 
and they lack a sarcolemma. When these cells are present 
the tumour is sometimes termed a myosarcoma. 

A careful microscopic study of these tumours and a 
critical analysis of the published descriptions indicate that 
when the striped cells are very abundant the tubules are, as a 
rule, absent. In examples containing many tubules as well 
as those in which striped spindles are numerous, the round, 



SARCOMAS OF THE KIDNEY 



107 



oat-shaped, and spindle sarcoma cells are equally abundant. 
It has been suggested by Paul that, as the most typical 
myosarcomas are more sharply delimited from the other 
varieties, the tubular elements may be derived from the 
kidney. I did not at first acquiesce in this view, but a 
more extended inquiry leads me to accept it. This is a 
matter worth consideration, because a study of the foetal 
kidney demonstrates very clearly that the renal sarcomas 
of infancy arise in the connective tissue of the renal sinus. 




Fig. 58. Renal sarcoma in section ; removed from a child aged 20 months. 

The epithelial cylinders are due to the entanglement of 
uriniferous tubules, in consequence of the sarcoma invading 
the cortex, while the striated spindles are derived from 
the muscle- tissue of the renal pelvis, which is an expansion 
of the hollow muscle known as the ureter. 

These studies demonstrate in no uncertain way that 
renal sarcomas of infants are extrinsic in origin, and 
strictly non-renal. This view is now held by all who 
have carefully looked into the matter; and it is worth 
mention that in 1857 van der Byl exhibited at the Patho- 
logical Society, London, a large renal tumour, from a 
boy aged 8 years, which was 82*5 cm. in circumference and 
weighed 31 Ib. ; and in the description of the specimen 



io8 



SARCOMAS OF THE KIDNEY 



in the catalogue of the Middlesex Hospital museum it is 
definitely stated that the growth appears to have sprung 
from the concavity of the kidney, and a narrow band of 
renal tissue can be traced round a great part of the circum- 




Fig. 59. Boy aged 8 with a renal sarcoma that weighed 31 Ib. 



ference of the kidney. The general appearance of this boy 
in such dreadful circumstances is shown in Fig. 59. It is 
characteristic of these sarcomas that the ureter is rarely 
obstructed. This extraordinary freedom of the ureter from 
invasion explains the rarity of hsernaturia in such cases, 
and, perhaps, what is otherwise remarkable, the painless- 
ness of these tumours in children, for there is no pressure 



SARCOMAS OF THE KIDNEY 109 

from accumulated urine. A child with a very large 
renal sarcoma has been absolutely free from pain, and 
amusing himself with his playmates in the garden three 
days before he died. Indeed, many mothers, when the 
gravity of a renal tumour of this kind is explained to 
them, will express their astonishment that a child, apparently 
in excellent health and spirits, could be in such serious 
straits as the surgeon would have them believe. 

Though the ureter so constantly escapes invasion, yet 
the veins are always implicated; and this constitutes a 
most peculiar as well as most dangerous feature of renal 
sarcomas in children. The tumour tissue extends into 
the renal vein, and often projects and even runs for a 
long distance into the inferior vena cava ; portions are 
detached and carried to the pulmonary circulation, and 
are arrested in the capillaries of the lung and form 
secondary deposits. The intravenous apex of such an out- 
runner is usually cone-shaped and smooth. Occasionally a 
large fragment is detached, and this has been known to 
block the right auriculo-ventricular orifice (Osier). Such a 
gross embolus is uncommon. Plugging of the vena cava by 
an outrunner is by no means rare, and causes O3dema 
of the lower limbs. In a case under my own care the 
inferior vena cava was completely obstructed from its 
origin to its termination by a sarcomatous extension of 
this kind. 

It is a singular and well-established fact that when 
certain of the paired viscera, such as the kidneys, ovaries, 
eyeballs, and crura cerebri, are in early life attacked 
by sarcomas, in a very large proportion of the cases, 
perhaps half the number, the disease is bilateral. In 
relation to .this matter, Abbe made the following obser- 
vation. He successfully extirpated a kidney for sarcoma 
in a child aged 14 months. Four and a half years 
later the little patient again came under his care with a 
sarcoma in the remaining kidney. In 1893 I collected 
and tabulated in the first edition of this book 21 com- 
plete records of renal sarcoma in infancy which had 
been submitted to nephrectomy. In the list of 21 cases 
12 patients died as a result of the operation ; of those 



no SARCOMAS OF THE KIDNEY 

who recovered, all died of recurrence within a year. 
Since the publication of that table a large amount of 
interest has been aroused in the question of the results 
of nephrectomy for sarcoma, and it is now an easy 
matter to collect a hundred records. The analysis of a 
large number of these reports shows that nephrectomy for 
renal sarcomas in children under 6 years has a mortality 
of over 50 per cent. Of those who recover, 45 die from 
recurrence at periods varying from two months to a year. 
In the remaining 5 life may be prolonged. Malcolm removed 
a sarcomatous kidney from a child aged 18 months. The 
patient was alive and well twenty-eight years afterwards. 
The tumour has been re-examined by Shattock, who con- 
sidered it to be an adenoma. Abbe removed the kidney 
of an infant aged ] year and weighing 15 lb., the tumour 
being a myosarcoma weighing 7J lb. The patient was alive 
and well twenty years later. 

It is very certain that a child with a renal sarcoma runs 
an enormous risk of losing its life when submitted to 
nephrectomy, and at the ^same time the chances of pro- 
longing life are more slenaer than in any other surgical 
operation. It must, however, be borne in mind that the 
disease is surely fatal within a very limited period when 
allowed to run its own course. 

Renal sarcomas of adults. These differ in many impor- 
tant particulars from the sarcomas of infancy. In the first 
place, a sarcoma in the adult arises in the cortex, usually 
in connexion with the capsule, and then gradually invades 
the true tissue of the kidney. The relation of renal sar- 
comas to the capsule is of some importance, because 
similar tumours arise in the connective tissue in which the 
kidney is embedded ; these are perirenal sarcomas, and, as 
far as my observations go, this is a more frequent position 
for them than for those which we term renal sarcomas. A 
careful comparison of these tumours leads me to believe 
that, in the adult, sarcomas of the type represented in 
Fig. 60 have their origin in the renal capsule, whereas the 
sarcoma of childhood arises, as already pointed out, in the 
connective tissue of the renal sinus. This is a subject of 
some interest, because a critical comparison of the mode 



SARCOMAS OF THE BREAST in 

of origin of sarcomas in viscera similar to the kidney, e.g. 
the spleen, thyroid gland, and prostate, shows that such 
tumours are not only uncommon, but are often closely 
connected with the connective-tissue investments of those 
organs. 

Treatment. The only available treatment for renal sar- 
coma is early excision of the affected organ. This is 
rarely of much service. The mortality of the operation is 




Fig. CO. A kidney in section with a sarcoma invading its cortex. From 
a man aged 51. (Museum of the Middlesex Hospital.} 

now very small, but recurrence usually takes place within 
a year. 

The tumours of the kidney called hypernepkromas, which 
are supposed to arise in accessory adrenals, are considered 
with renal carcinomas in Chap, xxxvu. 

Sarcoma of the breast. The mammary gland is embedded 
in connective tissue with a variable quantity of fat ; sarcomas 
arise in this tissue unconnected with the glandular elements. 
Sarcomas of the breast are rare tumours, and grow slowly, and 
like these tumours in other situations, may contain tracts of 
hyalin cartilage and even bone. They occur at any time of 
life and in any condition of the breast, whether it be large and 



112 



SARCOMAS OF THE BREAST 



plump, or withered with age. A spinster aged 50, with 
plump breasts, employed as a cook, let a round of beef fall on 
her breast. It gave her a severe blow. Four weeks later 
she noticed a hard lump in the injured breast, which grew 
quickly into a large tumour. The breast was removed. 
The lump proved to be a sarcoma and it quickly re- 




B 



Fig. 61. A, Breast in section, showing an ossifying sarcoma (* the nipple). 
B, The osseous element of the tumour. From a woman aged 73. 

curred. She died within 15 months of receiving the blow. 
(Beatson.) 

A multipara aged 73 under my care had a hard tumour 
of the breast. After removal the tumour was so hard that 
a saw was needed to divide it (Fig. 61). Microscopically 
the tumour had the features of an ossifying sarcoma. She 
died a j^ear later, but no evidence of a primary tumour in 
bone was found. The hard tissue of the tumour had the 
microscopic features of bone. Sometimes hyalin cartilage 



SARCOMAS OF THE BREAST 

is associated with bone (Battle) ; and a greater rarity is a 
chondrosarcoma of the breast (Bowlby). 

A multipara with flat and inconspicuous breasts noticed a 
painful tumour in the right one. It grew rapidly and doubled 
its size in six weeks. I removed the breast, and found it to be 




Fig. 62. Breast in section. It contains a round-celled sarcoma 
The nipple is not retracted. From a multipara aged 85. 

a round-celled sarcoma (Fig. 62). She died six months later 
with an extensive, but painless, recurrence. 

Secondary deposits of sarcoma are very rare in the mam- 
mary glands. 

A perusal of recorded cases indicates that chondrify- 
ing and calcifying tumours of the breast exhibit the worst 
features of sarcomas, namely, quick recurrence and wide 
dissemination. 
I 



ii4 REFERENCES 

Abbe, H.-Ann. of Surg., 1912, Ivi. 469. 

Battle, W. H., " Osteochondrosarcoma of the Breast." Trans. Path. Soc., 

1886,xxxvii. 473. 
Bland-Sutton, J., "An Ossifying Sarcoma of the Female Breast." Arch. 

Middx. Hosp., 1910, xix. 98. 
Bowlby, A. A., " Chondro-Sarcoma of the Female Breast." Trans. Path. Soc., 

1881, xxxiii. 30G. 
Malcolm, J. D,, Presidential Address. Proc. Roy. Soc. of Med., 1920, xiii., 

Obst. and Gyn. Sect., p. 214. 



CHAPTER X 
PIGMENTED TUMOURS 

Melanesia. In the majority of mammals there are certain 
epithelial and connective tissues which normally contain 
pigment. Among pigmented tissues the skin, the choroid, 
and the epithelial layer of the retina hold the first place. 
In skin the pigment is chiefly contained in the deeper 
layers of the rete mucosum ; and hair, being derived from 
the cells of this layer, is pigmented also. In many mam- 
mals other tissues contain pigment, such as the mucous 
membrane of the roof of the mouth of the dog, and the 
blue coloration of the vaginal mucous membrane of the 
vervet monkey. 

In man the amount of pigment varies greatly, so that 
we may pass gradually from individuals whose skins are 
intensely black to others who have no trace of cutaneous 
pigment. 

It is noteworthy that animals with no pigment in the 
skin also lack pigment in the uveal tract of the eyeball. 
A familiar example of this is the white rabbit with pink eyes. 
Such a condition is termed albinism, and colourless animals, 
or albinos, occur among all classes of animals, vertebrate 
and invertebrate. Excessive development of black pigment 
in the skin is known as melanism ; this is much rarer than 
albinism. 

Abnormal distribution of pigment in the skin of man 
occurs in two forms, leucoderrna and piebaldism. Leuco- 
derma is a fairly common change in the skin, characterized 
by white patches irregularly distributed, but with some 
tendency to bilateral symmetry, in persons whose skins 
were previously coloured uniformly. 

Piebaldism is also a condition depending on irregular 
distribution of pigment in the skin, but it is congenital 



n6 



HUMAN PIEBALDS 



in origin and rare. The contrast of colour is greater in 
piebalds than in leucodermics. Maria Sabina, one of the 
classical human piebalds (Fig. 63), was described by a 
priest named Gummilla ; her portrait (in oils) is preserved 




Fig. 63. Maria Sabina, aged 5, a human piebald. (From an oil painting 
in the Museum of the Royal College of Surgeons, England.} 

in the museum of the Royal College of Surgeons, England, 
and the adventurous history of the picture is duly inscribed 
on the label. The girl was born at Cartagena of the Indies 
(Colombia) in 1743. Her mother, a married negress, attri- 
buted the parti- coloured condition of her child to maternal 






MELANOSIS 117 

impression, for the negress possessed a black-and-white 
bitch. 

Simpson (1913) described "a family of spotted negroes." 
The mother, born in 1863, was piebald; she married a negro 
and had fifteen children. They were all alive in 1913, 
eight of them being piebald. Simpson's paper is illus- 
trated by excellent photographs. 

Variations in pigmentation, coming under the head of 
albinism, leucoderma, piebaldism, the winter-whitening of 
the hair of mammals and the feathers of birds, are ex- 
haustively treated by Karl Pearson, Nettleship, and Ussher 
in their monograph on albinism in man. 

In white races of men the pigment granules are almost 
entirely confined to the cells of the rete mucosum, but 
when the pigmentation is very marked it will be found 
distributed in the other tissues of the skin. The pigment 
(melanin) lies within the cells in the form either of black 
or of brown granules, or they may be uniformly stained by 
it. It is stated that white skin transplanted on to a negro 
soon becomes pigmented, and that when the skin of a 
negro is grafted on to a white man it undergoes depig- 
mentation. It has long been known that leucocytes carry 
pigment. 

In amphibians and fishes pigment occurs in the branch- 
ing cells (Deiters' cells) situated beneath the epidermis. 
These cells are filled with black melanin granules, obscuring 
the nucleus. On exposure to light these protoplasmic 
processes retract, and the pigment is concentrated in the 
cell -body, but when kept in the dark the processes are 
protruded and the pigment is diffused in the surrounding 
structures. The pigment cells, known as chromatophores, 
are in some way controlled by the nervous system. Cunning- 
ham studied the feeding habits of cuttle-fishes at Plymouth, 
and in the aquarium he observed Sepia pursue and capture 
prawns ; it stalks them with great caution and determina- 
tion ; " the rapid play of the chromatophores gives evidence 
of its excitement." The most remarkable example of pig- 
ment formation is found in Octopus ; this animal possesses an 
ink-bag from which, when irritated, it ejects a black pigment 
(sepia) in such abundance as to colour the surrounding 



i iS MELANOMAS 

water to the extent of a cubic yard or more, and under 
cover of this dark cloud escapes from its enemies. The 
ink of cuttle-fishes was used as a writing material by the 
Kornans. 

Melanosis is sometimes produced by parasites. This 
variety of melanism is rarely seen in man, but is fairly 
frequent in other animals (Fig. 64). 

Melanomas. Pigmentation in its most serious form 
occurs in connexion with tumours known as melanomas, 
which arise in regions of the body where pigment is found 
normally the skin and the eyes, tissues exposed to the 




Fig. 64. Anterior portion of a dace; each black spot contains a central 
white dot representing an encysted parasite. 

influence of light. Melanomas of the skin grow in abnormal 
pigmented areas such as moles and warts, and in patches 
of pigment sometimes found near the matrix of a nail either 
of a finger or a toe. Occasionally they follow punctured 
wounds of the skin. 

The liability of moles and pigment patches to become 
malignant has led to careful investigations of their minute 
structure. The tissue immediately beneath a hairy mole 
has an alveolar arrangement that is repeated in some 
pigmented forms of malignant melanomas. The common 
nsevus is sometimes the starting-point of a malignant 
tumour. 

All cutaneous melanomas arise in pre-existing patches 
of pigment, and this is probably true of those arising in 



MELANOMAS 119 

the choroid and iris (see p. 123). Hairy moles, distinguished 
as much by pigment as by hair, are by no means confined 
to the glabrous parts of the body; they are often present 
on the hairy scalp, and occasionally on the mons veneris. 

Recklinghausen regarded nsevus cells as proliferations of 
lymphatic endothelium. Unna believed them to be derived 
by a snaring-off of parts of the deep epidermis so as to 
form masses of epithelial cells embedded in the corium. 
(For a careful summary of these theories, see Whitfield.) 
The origin of moles and nsevi is still nebulous and sur- 
rounded by superstition. 

Malignant melanomas are classified as round- or as 
spindle-celled sarcomas according to the prevailing type of 
cell. A rare variety, detected by Collins, arises in the 
glandular epithelial cells of the ciliary body (see p. 128). 

Ribbert (1897) found that if choroidal melanomas are 
examined by teasing out the cells, some contain stellate pig- 
mented chromatophores. Ribbert regards the pigment cells 
in the choroid as chromatophores, and suggests that the 
melanomas might be appropriately termed chromatophoro- 
mas. In regard to this, it is necessary to point out that 
the black pigment (melanin) in the pigment cells of verte- 
brates only agrees (according to MacMunn) with that of 
invertebrates in the common attribute, blackness. The 
interest of Ribbert's observations lies in the fact that in 
secondary nodules of choroidal tumours found in the liver 
and brain (Fig. 65) the cells were identical with the chroma- 
tophores so characteristic of the lamina fusca element of the 
choroid. 

The origin of segregated pigment in vertebrates is a 
vexed question. Ehrmann describes some specialized con- 
nective-tissue cells in the upper layers of the corium around 
blood-vessels. These cells melanoblasts obtain material 
from the blood and transform it into melanin, which is 
absorbed by the epidermal cells. 

The amount of melanin present in pigmented tumours 
varies greatly ; in some it is so small that the tissue takes 
on merely a brown coloration, in others the tissues are 
as black as ink. The pigment particles are lodged in and 
among the cells of the tumours, even in the walls of 



120 



MELANIN 



the blood-vessels. Occasionally the secondary nodules are 
blacker than the primary tumour. 

Melanin. This occurs as fine, irregular, amorphous 
granules varying from light brown to intense black. It is 
soluble in ether, alkalis, and strong acids, and is bleached by 




B 



Fig. 65. Pigmented stellate cells from a melanosarcoma. The cells in 
the lower part of the figure (B) are from a secondary nodule in the 
liver ; the upper (A) from a metastatic nodule in the brain. The 
primary tumour in each instance arose in the choroid. (Teased speci- 
mens.) (Eibbert.} 

chlorine a fact which is useful in examining the microscopic 
features of melanomas. 

The urine of patients with melanomas often contains 
black pigment (melanogen), usually in solution, but occa- 
sionally suspended in the form of granules. The urine is, 
as a rule, clear when first voided, but blackens on exposure 
to the air, and becomes intensely black when submitted to 



MELANOMAS OF THE SKIN 121 

oxidizing reagents, e.g. a mixture of sulphuric and hydro- 
chloric acids to which a few drops of ferric chloride have 
been added. 

A more sensitive test is the addition of bromine water 
to the urine, which yields a yellow precipitate turning 
black on exposure to light. I made several observations on 
the urine of patients suffering from melanomas, in the hope 
that some opinion might be formed as to the gravity of 
the patient's condition according to the amount of melanin 
present. An abundance of melanin is of the gravest import. 
Melanuria usually occurs when there are extensive second- 
ary deposits of melanoma in the viscera, and especially in the 
liver. (See also Ochronosis and Alkaptonuria, p. 130.) 

Primary melanomas of the skin. These arise in moles, 
especially the black blemish known as nsevus spilus, and in 
pigmented warts. A mole may remain quiescent through- 
out a long life and never cause the least inconvenience ; 
in other instances, fortunately rare, as life advances the 
mole ulcerates, perhaps bleeds freely, and may even partially 
heal ; but with the onset of ulceration the adjacent lymph- 
nodes enlarge, become charged with pigment and sarcomat- 
ous tissue, spaces filled with inky fluid form in them, and 
finally the overlying skin ulcerates. The infection may not 
proceed farther chan this ; recurrent haemorrhage from the 
fungating lymph-nodes, or furious bleeding should a large 
vein or artery become broached by ulceration, carries off' the 
patient. In many cases the morbid material is transported 
into distant parts, secondary knots form in the liver, lung, 
kidney, or brain, and death arises from interference with 
the functions of these organs. 

In other cases the mole, instead of ulcerating, is observed 
to become more prominent, and finally forms a tumour of 
some size standing out prominently from the skin. In due 
course the lymph-nodes in anatomical relation with the part 
from which the tumour arose enlarge, and secondary deposits 
occur in the viscera, bones, or skin. 

It does not necessarily follow that in all cases of melano- 
mas arising in moles secondary deposits are formed in the 
viscera. In some cases which, however, are very rare the 
tumour seems to become mainly a source of pigment, large 



122 MELANOMAS 

quantities of which enter the circulation, to be discharged 
with the urine. Exceptionally the skin assumes a dusky 
tint. 

Many melanomas arise in pigmented warts, especially the 
solitary congenital kind. After middle life such a wart may 
grow, ulcerate, stink, cause the adjacent lymph-nodes to 
enlarge, and then infect the system with secondary nodules. 

Melanosis in connexion with the fingers and toes assumes 
two forms : it may occur as a deep pigmentation of the skin, 
usually in the immediate neighbourhood of the nail, often 
involving the matrix, and even the nail itself; or a small 
pigmented nodule will arise in the nail matrix or in the 
adjacent skin, and ulcerate, dissemination following. 

The hallux is the digit most prone to be attacked by 
a melanoma, and several examples have been carefully 
recorded, most of the patients being women. 

The skin of the external genital organs in both sexes 
and around the anus is rich in pigment, and is liable to 
melanoma. Malignant melanoma of the vulva is rare, and 
of the clitoris rarer ; Holland collected the records of vulvar 
melanoma, and Lockhart those of the clitoris. Melanoma 
of the penis is uncommon; examples have been described 
by Fischer and Payr. 

In relation to melanoma of the penis, it is worth mention 
that in uncircumcised negroes the skin of the glans is un- 
pigmented, as in the white races of men, but after circum- 
cision it becomes black like the rest of the skin (Shattock). 
The scar usually remains white. The non-pigmentation of 
the scar does not admit of an easy explanation. In many 
women the linea alba, from the pubes to the navel, blackens 
during pregnancy, especially in primigravidse. In gravid 
women, when it has been necessary to open the abdomen 
by the usual median subumbilical incision, the scar blackens, 
then gradually bleaches after delivery. 

A change similar to the pigmentation of the skin cover- 
ing the glans occurs in the neck of the uterus. The vaginal 
portion of the cervix uteri is covered with stratified epi- 
thelium, and is pink in dark as well as in white races of 
mankind. In complete prolapse of the uterus in black 
women the surface of the neck of the uterus becomes 



MELANOSIS OF THE COLON 123 

pigmented like the skin. Barnes described an example 
in 1883 ; I have seen several. Pigment is occasionally 
present in the skin which is so common in ovarian der- 
moids (see Chap. LV). 

The theories relating to the connexion between abnormal 
patches of pigment, moles, and melanoma have been sum- 
marized by Fox. When squarnous-celled cancer arises in 
the skin of a negro, the cells do not contain more pigment 
than in the white races of mankind. 

Melanosis of mucous membrane. Primary melanoma of 
mucous membrane is very rare, and it is odd that the 
recorded cases have been observed on the muco-periosteum 
of the hard palate. 

Melanosis of the colon. Occasionally the mucous mem- 
brane of the large intestine from the ileo-csecal orifice to 
the anus (including, the vermiform appendix) is intensely 
black (Fig. 66). Virchow (1847) drew attention to this pecu- 
liar form of melanosis, and some cases were described in 
England by C. J. Williams (1867), G. Newton Pitt (1891), 
and H. D. Rolleston (1892). W. H. Battle (1912) described 
some specimens of this form of pigmentation of the mucous 
membrane of the vermiform appendix. Pick discusses in 
an exhaustive manner the anatomical, histological, arid 
chemical features of colic pigmentation, and gives a useful 
summary of nearly a score of similar cases. The coloration 
is not due to metallic deposit, as some writers think, but is 
essentially a pigmentation of the connective tissue of the 
mucous membrane, and is hoematogenous. (Fig. 67.) 

Although the pigmentation, as a rule, begins at the 
ileo-csecal valve and extends to the anus, there are cases 
where it does not extend throughout the colon. When the 
whole of the large gut is involved the pigmentation is 
revealed by the use of the rectal speculum. The coloration 
is a curiosity without any sinister clinical significance. 

I had an opportunity of studying the microscopic features 
of a cancer that arose in the pigmented colic mucous inern- 
brane of a septuagenarian spinster. There was nothing to 
distinguish it from cancer arising in non-pigmented mucous 
membrane, and the cells were devoid of pigment. 

Intra-ocular melanomas. The common situation for these 



124 



INTRA-OCULAR MELANOMAS 



tumours is the choroid coat of the eye. Innocent pigmented 
tumours, resembling black moles on the skin, occur on the 
iris, and oval dark patches, with sharply denned margins, 
may sometimes be seen in the choroid when eyes are 




Fig. 66. Caecum and appendix turned inside out. The mucous 
membrane is charged with black pigment. From a 
woman aged 63. (Museum of the Middlesex Hospital.} 

examined with the ophthalmoscope. Some of the patches, 
found by accident when examining eyes removed for disease, 
were densely packed with chromatophores. Such choroidal 
moles may be the starting-points of malignant melanomas. 

The distribution of intra-ocular melanomas is peculiar: 
they are rare in the iris, rarer in the ciliary body, but more 



INTRA-OGULAR MELANOMAS 



125 



common in the posterior than in the anterior portion of the 
choroid. Some of the pigrnented tumours of the ciliary body 
are carcinomas (see p. 128). 

Melanomas of the uveal tract are most frequent between 
the fortieth and sixtieth years, but they have been observed 
as early as the second and as late as the eighty- fourth year. 

In structure they may be round-celled, spindle-celled, or 
mixed-celled, the size of the cells varying greatly in different 
tumours. The amount of pigment in intra-ocular melanomas 
also varies greatly ; in some specimens it is so abundant that 
the tumours are black ; in others it is only sufficient to impart 




Fig. 67. Melanosis of the colic mucous membrane, showing the deposits 
of pigment in the stroma between the crypts. (Pick.} 

a grey tint. Occasionally the pigment is so irregularly dis- 
tributed that some parts of the tumour are almost colourless. 

A melanoma remains for a time restricted to the interior 
of the globe, but it tends to escape in three directions : 
(a) along the venae vorticosoe, appearing outside the sclerotic 
in the situations where these veins emerge ; (b) the presence 
of the tumour leads to an increase in the intra-ocular ten- 
sion, and finally to sloughing of the cornea ; (c) it may 
invade the optic nerve. 

Melanosarcomas are very apt to recur after removal, and to 
become disseminated. The most frequent situation in which 
to find secondary deposits is the liver ; but any organ 
may contain them, even the bones, and the nerves within 



126 INTRA-OGULAR MELANOMAS 

the cranium (Fig. 68). The amount of dissemination varies 
greatly : in some cases secondary knots occur in . almost 
every organ ; in others they will be limited to the liver. 
The lymph- nodes adjacent to the orbit are seldom infected. 
The duration of life in patients with intra-ocular melano- 
mas rarely extends beyond three years. A careful analysis 




Fig. 68. Base of a skull anterior to the foramen magnum. The intra- 
crauial portions of the second, third, fifth, and seventh nerves are 
nodular from deposits of melanoma. From a man aged 25, whose 
eye had been removed for a melanoma. He died subsequently with 
cerebral symptoms. (Museum of the Royal College of Surgeons.} 

of a large number of cases shows, however, that in many 
instances life may be indefinitely prolonged by early removal 
of the globe, and cases are known in which patients have 
been reported alive and well five, six, eight, nine, sixteen and 
eighteen years after the operation. In the majority of cases 
that recur the recurrence takes place within three years of 
the operation. Collins and Lawford, calculating cases in 
which recurrence does not take place within three years 



MELANOGARGINOMAS 127 

of operation as recoveries, have come to the conclusion, 
from an analysis of 79 cases of which they were able to 
obtain complete records, that the rate of recovery is 25 
per cent., but they point out that patients have died 
from recurrence or secondary deposits after a much longer 
interval than three years. Dissemination has been deferred 
for so long a period as eleven years after excision of the 
eyeball (Hutchinson). 

Melanoma of the conjunctiva. This is a rare tumour. A 
brunette aged 25 noticed a pigment spot no bigger than a 
pin's head on the eye near the corneo- sclerotic junction at the 
outer side of the left eye. She had many moles on her skin. 
The tumour on the eye grew slowly for ten years ; it was re- 
moved and proved to be melanosarcoma. It recurred in the 
scar, and though there was no impairment of vision the eye 
was excised. The sclera was infiltrated with tumour tissue. 
A year after the excision of the globe a secondary tumour 
appeared in the temple. This was removed and had the same 
structure as the primary tumour. Wolff and Deelman, in 
reporting this case, give the literature and state that, as a 
rule, metastasis is slow. 

Flat sarcomas of the choroid. Fuchs, in 1882, recog- 
nized two varieties among choroidal sarcomas. The common 
variety is a discrete tumour ; but the rarer kind, often called 
a flat sarcoma, is diffuse, for it infiltrates the choroidal tissues 
without the formation of a definite tumour. Flat sarcomas 
cause few symptoms so far as the eye is concerned, although 
they give rise to secondary deposits. In their microscopic 
features they are spindle- celled sarcomas, and some ophthal- 
mologists regard them as endotheliomas (Parsons). The 
quiet growth of diffuse sarcomas of the choroid makes them 
difficult to detect, and some of them remain undetected 
until the growth penetrates the scleral tunic. This makes it 
justifiable to "assume that in some cases, in which melanosis 
of the central nervous system, or of its membranes, has 
been regarded as primary, it was really secondary to an 
intra-ocular tumour, for, in many of the cases, the eyes were 
not fully examined" (Greeves). 

Melanocarcinomas. Several writers who have devoted 
attention to intra-ocular tumours describe some of the 



128 NEURAL EPIBLASTIG TUMOURS 

pigmented tumours as carcinomas, using the term in the 
definite sense in which it is employed in this work. Treacher 
Collins demonstrated the existence in the ciliary body, in the 
space extending from the root of the iris to the ora serrata, 
of a number of small tubular processes composed of epi- 
thelial cells with the free ends projecting towards the 
ciliary muscle (Fig. 69): he succeeded in demonstrating the 
existence of these processes by bleaching the cells. The 
ciliary glands are interesting in connexion with melano- 
carcinoma, for Collins discovered among the intra-ocular 
tumours preserved in the museum of the Moorfields Hos- 



'-/ -rt 5t^ %-V; -. i 




Fig. 69. Bleached section of the glands of the ciliary body. (Collins.) 

pital two examples from the ciliary body which were 
epithelial in character. 

Neural epiblastic tumours. The pathological behaviour 
of the ciliary glands makes it desirable to mention the small 
cysts found on the inner surface of the iris, ciliary body, and 
choroid. The cysts are lined with epithelium, sometimes 
pigmented, sometimes not ; a few have walls formed of tissue 
derived from neural epiblast, and are probably connected with 
defective involution of the secondary optic vesicle. Cysts 
such as these are sometimes associated with microphthalmia 
and coloboma of the retina and optic nerve. Greeves de- 
scribed some cysts growing from the iris and projecting 
into the anterior chamber: the walls of one had the 



MELANOMAS OF HORSES 129 

microscopic structure of embryonic retina. The contents 
of some of the cysts resembled in structure normal vitre- 
ous, and the walls of others displayed rosettes such as can 
often be demonstrated in retinal gliomas (see p. 163). 

Pigmented tumours in horses, Melanomas occur in 
horses : the regions most affected are the tail and the 
parts about the anus, where they form large mushroom- 
like excrescences, with little disposition to ulcerate. The 
tumours in some cases attain large proportions, and have 
been known to weigh 40, 50, and even 60 Ib. When a large 
tumour grows from a horse's tail it becomes a great encum- 
brance, which the veterinarian removes by amputation. It 
occasionally happens that in the operation a portion of the 
tumour is left behind, and its cut surface heals like other 
tissues. These pigmented tumours are very prone to dis- 
seminate, and secondary nodules occur in almost all the 
viscera : in spite of this, melanosarcoma does not appear to 
be such a malignant affection in horses as in men. 

Although most common in grey, it also occurs in 
white, and occasionally in black, horses ; and in cows. 
Next to the anus and tail, the udder is the most frequent 
seat of the primary tumour, and it may spring up in the 
subcutaneous connective tissue in any part of the body. 
Horses may be attacked at any age from 4 years upwards. 
In structure melanosarcoma of the horse resembles a hard 
uterine fibroid rather than a sarcoma. In these animals 
melanosarcoma of the uveal tract is very rare. 

De Morgan spots (canceroderms). It is not uncommon 
to find on the skin, especially of the abdomen and chest, 
of patients debilitated by cancer, numbers of small raised red 
spots looking like neevi. These are often called " De Morgan 
spots," after Campbell De Morgan (1872), who regarded 
them as almost pathognomonic of cancer: they are patches 
of pigment ; not nsevi. 

De Morgan spots have been carefully studied by Brand 
and Leser. They point out that the spots do not appear in 
healthy subjects, nor in persons suffering from other dis- 
eases in early or middle life, and never even in old age in 
large numbers. When these spots are plentiful there is 
every reason to suspect cancer. I have made careful 
j 



130 OGHRONOSIS 

observations of them for twenty-five years in regard to 
their association with cancer, and find that they are as 
common in the non- cancerous as in the cancerous. 

Red pigment is rare as a pathological production. The 
best example of erythrism occurs in the flamingo (PAomi- 
copterus) : the bright-red pigment so conspicuous in some 
of the feathers permeates the bones. 

Ochronosis and alkaptonuria. For many years after 
Virchow, in 1866, drew attention to the peculiar discolora- 
tion of the cartilaginous tissues of the body under the 
designation ochronosis, it may be said to have remained a 
pathological curiosity, until Albrecht (1902) drew attention to 
the occasional relationship which exists between this disease 
and the curious and rare condition of the urine known as 
alkaptonuria. 

The condition termed ochronosis scarcely amounts to a 
disease, as it in no way shortens life, and in the early cases the 
changes, which consist of blackening of the costal cartilages, 
the gristly parts of the pinna, and the sclerotic, were only 
discovered at a post-mortem examination. In cases sub- 
sequently reported, such fibrous structures as the inter- 
vertebral discs and the chordae tendinese have been found 
discoloured, and in a remarkable case, recorded by Pope, the 
rib cartilages were blue-black, the ears were blue, there 
were black patches on the inside of the lips, and the skin 
of the face had brown patches not unlike the pigmentation of 
Addison's disease. On microscopic examination of a patch of 
pigmented skin from a patient with ochronosis, the pigment 
particles were found in the elastic tissue of the skin, but not 
in the rete Malpighii. Osier has reported a case in which 
there was skin pigmentation. 

Alkaptonuria has been particularly investigated by 
Garrod. Its essential features are as follows : The urine, 
though of normal appearance when passed, becomes deep 
brown, and ultimately black, on exposure to the air. The 
colour is intensified by alkalis. The urine reduces Fehling's 
solution with the aid of heat, and actively reduces amino- 
niacal silver-nitrate solution in the cold. Fabrics moistened 
with alkaptonuric urine become deeply stained on exposure 
to the air. 



ALKAPTONURIA 131 

This anomaly often dates from infancy, and, in one case 
at least, staining of the napkins by the urine was noticed 
the day after birth. 

Garrod, in his classical analysis of this disorder, states 
that " hornogentisic acid is a constant constituent of 
alkapton urines, and plays the chief part in the production 
of alkaptonuria." 

In regard to the relationship between ochronosis and 
alkaptonuria, Garrod writes : " There are very strong grounds 
for believing that in later life alkaptonuric subjects tend to 
develop the characteristic pigmentation of cartilages ; in other 
words, that alkaptonuria is a cause, but not the only cause 
of ochronosis." 

Chloroma (green tumours). This is an exceedingly rare 
disease in which sarcoma-like masses form on the bones of 
the skull and face, especially in the neighbourhood of the 
orbits, and infect other organs secondarily. After death 
the colour of the tumour-like masses is grass-green. The 
nature of the disease is obscure : some writers regard it as 
a form of leukaemia. It has been carefully studied by 
Melville Dunlop. 

Xanthoma. This, with its many synonyms, is a curious, 
harmless pigment disease, especially liable to appear in 
the skin of the eyelids near the inner canthus. Histologic- 
ally it consists of a fibrous and fatty tissue containing yellow 
pigment connected with the corium. In the eyelids the 
disease is usually symmetrical. 

The pigment material in a xanthoma patch is the product 
of a peculiar fatty degeneration affecting the muscular fibres 
of the eyelid (Pollitzer). 

The only normally pigmented tissue found in the human 
body resembling the yellow and orange of xanthoma patches 
is the lutein tissue in the corpus luteurn and the walls of 
lutein cysts arising therefrom. 

The orange-coloured pigment is interesting from a phy- 
siological point of view in connexion with the oil-gland 
of the rhinoceros hornbill (Bucorvus abyssinicus) : this 
secretes an orange-coloured material with which the bird 
preens its feathers. 



132 REFERENCES 

Barnes, R., "Pigmentation of the Cervix Uteri." Trans. Path. Soc. t 1883, 
xxxiv. 176. 

Battle, W. H., "The Black (Pigmented) Appendix." Lancet, 1913, ii. 135. 
Brand, A. T., " Canceroderms." #/#. Med. Journ., 1902, ii. 494, 730. 

Collins, E. Treacher, " Cysts of the Glands of the Ciliary Body : Researches on 
the Anatomy and Physiology of the Eye." London, 1900. 

Collins and Lawford, " Notes on Three Hundred Cases of Sarcoma of the Uveal 
Tract." Roy. Lond. Ophthal. Hosp. Repts., 1891, xiii. 104. 

Dunlop, G. H. M., " Chloroma." Brit. Med. Jo urn., 1902, i. 453. 
Fischer, G., Deut. Zeitschr. f. Chir., 1887, xxv. 313. 

Fox, Wilfrid S., " Researches into the Origin and Structure of Moles, and their 
Relation to Malignancy." Brit. Journ. of Derm., 1906, xviii. i. 

Garrod, A. E., "A Contribution to the Study of Alkaptonuria." Med. -Chir. 
Trans., 1899, Ixxxii. 367. 

Greeves, R. A., and Holmes, G., "Flat Sarcoma of the Choroid with Multiple 
Metastases." Tram*. Ophth. Soc., 1914, xxxiv. 113. 

Greeves, R. A., and Spicer, H., " Multiple Cysts in the Anterior Chamber derived 
from a Congenital Cystic Growth of the Ciliary Epithelium." Proc. 
Roy. Soc. of Med., 1914, viii., Sect, of Ophth., p. 9. 

Holland, E., " Malignant Melanoma of the Vulva." Journ. of Obstet. and 

Gyn., 1908, xiv. 309. 

Lockharfc, F. A. L., "Melanotic Sarcoma Clitoridis." Ibid., 1912, xxii. 85. 
Parsons, J. H., Arch, of Ophth., 1904, xxxiii. 101. 
Payr, E., Deut. Zeitschr. f. Chir., 1899, liii. 221. 

Pollitzer, S., "The Nature of Eyelid Xanthoma." Journ. Cutaneous Diseases, 

1910, xxviii. 633. 

Pick, L., " Ueber die Melanose der Dickdarmschleimhaut." Berl. klin. Woch., 

1911, xlviii. 840. 

Pope and Garrod, " A Case of Ochronosis, with table of eleven cases previously 
reported." Laneet, 1900, i. 24. 

Shattock, S. G., " Pigmentation of the Glans Penis in the Negro after Cir- 
cumcision." Trans. Path. Soc., 1892, xliii. 99. 

Simpson, Q. L, and Castle, W. E., " A Family of Spotted Negroes. 'Awcr. 
Naturalist, 1913, xlvii. 50. 

Whitfield, A.. Brit. Journ. of Derm., 1900, xii. 267. 

Wolff, L. K., and Deelman, H. T., " Melanoma of the Conjunctiva." Brit. Journ. 
of Ophth., 1921, v. 4. 






CHAPTER XI 
MOLES 

MOLES are pigmented and, usually, hairy patches of skin. 
These patches are congenital, and vary greatly in size ; many 
are no bigger than split peas, others cover extensive tracts 
on the face, trunk, or limbs (Figs. 70 and 71). 

The common variety consists of a slightly raised brown 
patch ; it is sometimes quite black, and is, as a rule, covered 
abundantly with hair, which is commonly short (ncevus 
pilosus) ; occasionally it is as long as that naturally found 
upon the scalp. The hairs are furnished with sebaceous 
glands, and sweat-glands are often present. The amount of 
pigment varies ; occasionally it is so abundant as to produce 
an inky blackness. Some black blemishes are glabrous 
(ncevus spilus). Moles are very vascular, and the tissue 
immediately underlying them is arranged in alveoli. The 
most important change to which they are liable is to become 
later in life the starting-point of melanomas, or squamous- 
celled cancers. (The relation between moles and neuromas 
is discussed on p. 152.) 

When very large moles occur on the trunk the hairy 
part is sometimes very sensitive, almost hypersesthetic. In 
large moles, pendulous skin-folds are sometimes present ; 
these folds are large in the young, but, as a rule, they shrink 
and become quite small in the adult. As many as fifty moles 
may be present on one individual. A mole on an exposed 
part is a serious disfigurement: in an unexposed situation it 
is sometimes a source of embarrassment. A young woman 
had a mole so extensive as to resemble a black waistcoat and 
drawers : her husband adored her, but was horrified when 
he saw the mole (Alibert). 

Small hairy moles do not, as a rule, cause much 

133 



134 HAIRY MOLES 

t 

inconvenience even when they occur on the face, in which 
situation they are known as " beauty spots." A small hairy 
mole on a fair cheek is regarded often as an additional charm 
rather than a disfigurement, if we can trust the taste of 
story-tellers, poets, and playwrights. 

Cervantes, describing the comic achievements of Don 
Quixote, makes the beautiful Dorothea describe her cham- 
pion as having on his right side, under the left shoulder, 
or somewhere thereabouts, a tawny mole overgrown with a 
tuft of hair not unlike that of a horse's mane. 

In the Arabian Nights the allusions are many ; thus the 
youth in the Eldest Lady's Tale says : " Persian poets have a 
thousand conceits in praise of the mole." Some of these 
allusions are certainly exquisite : 

"A nut-brown mole sits throned upon a cheek 
Of rosiest red beneath an eye of jet." 

English writers often refer to moles. Marlowe, in his 
powerful tragedy Dr. Faustus, when he causes Alexander and 
his paramour (Act iv, sc. 1) to appear before Charles, Emperor 
of Germany, makes the Emperor say : 

' I have heard it said 

That this fair lady, when she lived on earth, 
Had on her neck a little wart or mole." 

There are numerous references to moles scattered in 
Shakespeare's plays. All who have read Cyinbeline will 
remember the cunning use lachimo makes of the fact that 

Imogen had 

" On her left breast 

A mole cinque-spotted, like the crimson drops 
I' the bottom of a cowslip." 

Cymbelirie, when his lost sons, Guiderius and Arviragus, are 
presented to him in his tent, says : 

" Guiderius had 

Upon his neck a mole, a sanguine star ; 
It was a mark of wonder." 

To which Belarius replies: 

" This is he, 

Who hath upon him still that natural stamp 
it was wise Nature's end in the donation, 
To be his evidence now." 



MOLES 135 

In the Comedy of Errors, Dromio of Syracuse, in his 
comic account of the kitchen wench, tells his master that 
she knew what private marks he had about him, such as 
" the mole in my neck, the great wart on my left arm," 
etc. (Act iii, sc. 2). 

Moles and "eye-offending marks" have always been 




Fig. 70. An extensive hairy mole on a gardener aged 47. The nodule on 
the right shoulder is squamous- celled cancer. It was excised ; the 
man died with signs of recurrence in the abdomen five months later. 
(From a picture in the Museum of the Middlesex Hospital.} 

subjects of speculation among matrons and the supersti- 
tious of all countries and all times. Peculiarly marked bull- 
calves (apis bulls) were specially venerated by the priests 
at Memphis, and when these bulls died they were accorded 
remarkable sepulchral rites. 

Moles are more particularly related to the " longings " of 



136 



HAIRY MOLES 



pregnant women. Though these matters receive no support 
from the scientific investigator, there is no belief more 
deeply rooted in the minds of matrons, young or old. The 
tradition comes to us from remote antiquity, and the way in 
which Jacob turned it to advantage is well set forth in his 
crafty management of Laban's flock. 




Fig. 71. Extensive hairy mole upon the face of a boy a year old. 

The case of Esau, who " came out red all over like an hairy 
garment" (Genesis xxv, 25), which curiously fascinates biblical 
commentators and students, had a parallel in a girl born at 
Pisa, hairy all over. In this instance the mother attributed 
it to the fact that during her pregnancy she had gazed at a 
picture of John the Baptist. Montaigne, in an essay " On the 
Force of the Imagination," states that this picture hung 
within the curtains of her bed. This is a good example of 
the circumstantial and plausible way women endeavour to 



MOTHER-MARKS 137 

account for these things. The belief even survives the ridicule 
of Charles Dickens, for he represents Mrs. Gamp telling about 
a man six-foot-three, " marked with a mad bull in Wellington 
boots upon the left arm," because his mother took refuge in 
a shoemaker's shop when frightened by a mad bull during her 
pregnancy (" Martin Chuzzlewit," chap. xlvi). 

Moles and mother-marks in general always excite vulgar 
curiosity. Among Christians, these, with deformations in 
general, were regarded as the handiwork of Satan. Astro- 
logers ascribed them to the influence of the moon, the 
conjunction of planets, and similar occult influences. In 
1664, Richard Saunders, an astrologer, published a book on 
the Science of Moles, in which he professed ability to read a 
person's character by moles on the face. After a long study 
of the distribution of birth-marks, he stated that every mole 
on the /ace had upon some other part of the body a corre- 
sponding mole or mark, and the position of the sister-mark 
could be localized with tolerable accuracy. For example : 
a mole near the right ear of a man should have as a sister- 
mark a mole on the right calf, a combination signifying that 
he was foolhardy, but valiant and strong. In a woman it 
denoted infelicity. Birth-marks are often multiple; and the 
combinations mentioned by Saunders are common, and as 
amusing as many of the inferences drawn from the " astra- 
dominations " such combinations are supposed to indicate. 

Hairy patches on the conjunctiva (conjunctival moles). 
The mucous membrane (conjunctiva) on the ocular surface 
of the eyelids and adjacent portions of the eyeball occasionally 
presents a patch of skin which in appearance and structure 
resembles a hairy mole. Such a patch is called a dermoid 
pterygium. 

These dermoid patches occur most frequently at the 
margins of the cornea, and usually in the line of the palpe- 
bral fissure that is, directly in the equator of the cornea but 
they are by no means confined to these situations. Usually 
they are limited to the conjunctiva covering the sclerotic, or 
trespass but little on the cornea. Sometimes, however, they 
involve a considerable extent of the corneal surface (Fig. 72). 
Wardrop described one in a man aged 50 ; it was congenital. 
Twelve long hairs grew from its middle, passed between the 



*3$ CONJUNGTIVAL MOLES 

eyelids, and hung over the cheek. These hairs did not appear 
until the sixteenth year, at which time the beard began to 
grow. 

Occasionally a mole will be found on each side of the 




Fig. 72. Dermoid pterygium common variety. 

cornea in the line of the palpebral fissure. A rare variety 
is limited to the caruncle (Fig. 73). 

These moles are occasionally associated with malforma- 
tions of the eyelids, especially the one known as coloboma 
of the upper eyelid. When this association occurs, the 
defect in the lid corresponds to the cutaneous patch on the 
conjunctiva. This combination is of some importance, as it 







Fig. 73. Excessive growth of hair on the caruncle, associated with au 
eccentric pupil. (Demours.) 

is used as evidence in support of an explanation that has 
been put forward in regard to such hairy patches, based 
upon the development of the eyelids. 

In the embryo the tissue covering the outer surface of 
the eyeball, which ultimately becomes the conjunctiva, is 
directly continuous and in structure identical with the 
skin at the margin of the orbit. Very early, cutaneous 



GONJUNGTIVAL MOLES 



139 



folds arise and gradually grow over the surface of the eyeball, 
and come into apposition at a spot corresponding to the 
future palpebral fissure. These folds ultimately become the 
eyelids. The surface of each fold, which is continuous with 
the covering of the eyeball, becomes converted into mucous 
membrane termed conjunctiva. In every normal eye the 
conjunctiva bears evidence of its transformation from 
skin, inasmuch as the caruncle at its inner angle is fur- 
nished with delicate hairs. It is reasonable to suppose that, 




Fig. 74. Dermoid pterygium in a sheep. 

as the occlusion of the proper covering of the eyeball 
by the eyelids is the cause of the conversion of the con- 
junctiva into mucous membrane, if from any cause a part, 
or even the whole of it, were left uncovered, the exposed 
part would persist as skin. This is precisely what occurs. 
When the eyelid is in the condition of coloboma a defect 
due, in all probability, to the imperfect union of the em- 
bryonic eyelid to the skin covering the fronto-nasal plate 
a piece of conjunctiva persists as skin and forms a mole 
occupying the gap in the lid. Moles occur on the con- 
junctiva unassociated with coloboma, but in nearly every 
instance they are situated on the cornea in the line of the 



140 NATURE'S BLOTS 

palpebral fissure. This circumstance would indicate that 
during development the conjunctiva was imperfectly covered 
by the developing lids. In some very exceptional cases 
the eyes have been found completely covered with skin 
without any traces of eyelids. Such a condition is known 
as cryptophtkalmos. In these cases the eyelids have failed 
to appear, and the conjunctiva persisted as skin. 

Conjunctival moles have been observed in horses, sheep, 
oxen, and dogs, and are furnished with hair or wool, 
according to the nature of the tegumentary covering of 
the mammal in which they occur. 

In 1779 Sir William Hamilton wrote to Sir Joseph Banks : 
" The King of Naples sent me a spaniel puppy of about four 
months old to show me as a curiosity. Out of the pupil, or 
centre, of his left eye grows a tuft - of soft hair like that of 
his body, about an inch long " (Smith's " Life of Sir Joseph 

Banks"). 

Shakespeare calls congenital blemishes Nature's blots- 
In the last scene of A Midsummer Night's Dream, Oberon 
bids each fairy stray and bless the best bride -bed, so 

that 

" The blots of Nature's hand 
Shall not in their issue stand; 
Never mole, hare-lip, nor scar, 
Nor mark prodigious, such as are 
Despised in nativity, 
Shall upon their children be." 



CHAPTER Xll 

NEUROMAS AND ALLIED CONDITIONS OF THE 
NERVOUS SYSTEM 

NEUROMA 

THIS may be defined as a tumour growing from, and in 
structure resembling, the sheath of a nerve. 

The term neuromas is frequently used, especially in 
clinical work, as signifying tumours on nerves, but, as such 
tumours are sometimes composed of fibrous, fatty, or even 
sarcomatous tissue, it would be better to speak of them 
as lipomas of nerves, sarcomas of nerves, and so on. 

The tumours which most strictly correspond to my 
definition are those called Yieurofibromas, and it will be 
convenient to include the curious nodule known as the 
" painful subcutaneous tubercle." 

A neurofibroma is usually fusiform, and grows from 
the side of a nerve; when large, it may spread out the 
fasciculi of the nerve ; exceptionally the nerve-fibres will 
traverse the tumour. The long axis of the neuroma 
coincides with that of the nerve from which it grows. 

In size neurofibrornas vary greatly: some are no 
larger than lentils, others may be as big as eggs ; larger 
specimens are exceptional. They occur on the cranial 
as well as on the spinal nerves, and grow from their roots, 
trunks, branches, and terminal twigs. Neurofibrornas form 
smooth swellings, which are mobile and, when situated in 
the subcutaneous tissue, glide easily under the skin; they 
are encapsuled, and easily enucleated ; they are extremely 
liable to become myxomatous, and in large specimens 
this change leads to the formation of cavities in the 
tumours. These changes account for the various names 
applied to them, such as myxoma, niyxofibroma, inyxo- 
sarcoma, and the like, 

141 



142 GANGLION-NEUROMAS 

Painful subcutaneous tubercle. This term was applied 
by Wood in 1812 to a small discrete nodule which forms 
in the subcutaneous tissue. It is usually of the "size and 
form of a flattened garden pea," but it very rarely exceeds 
the size of a coffee-bean. When examined by the finger 
it feels like a shot slipping about immediately beneath 
the skin. Structurally the " tubercle " consists of fibrous 
tissue very like that which constitutes the bulk of the 
nodules in molluscum fibrosum ; it is rare that a nerve- 
fibril can be traced to it. 

The interest of these bodies is due to the " very 
severe and excruciating pain" associated with them. The 
pain is paroxysmal, and usually increases in severity and 
in frequency according to the length of time the disease 
has existed. If the " tubercle " for it is usually solitary- 
is struck, or even touched, acute pain is produced. 

The nodules occur much more frequently in women than 
in men, and are commonly met with in early adult life ; and 
though a " tubercle " may form on any part of the body, 
it shows marked preference for the lower lirnb. Excision of 
the little body at once, and permanently, arrests the pain. 

Small, multiple, painful, subcutaneous tumours, often 
regarded clinically as lipomas, are neuromas containing fat. 
The nerve elements may be detected by teasing out the tissue, 

Ganglion-neuromas. These are tumours composed of 
nerve-cells, nerve-fibres, and neuroglia. It might be supposed 
that tumours of this kind would arise in the brain and spinal 
cord, and that some of the tumours classed as gliomas may 
have been ganglion-neuromas ; on the other hand, however 
carefully the histologic features of such tumours may have 
been described, there would be a doubt that normal brain 
tissue may have been accidentally included in the tumour. 

It is now established that tumours containing ganglion 
tissues occur in connexion with the great cords and ganglia 
of the sympathetic system, as well as in the subcutaneous 
tissue. Knauss recorded an example with great care. A girl 
aged 8 had 63 tumours in the subcutaneous tissue of the 
trunk and thighs, varying in size from a pea to an orange ; 
firm, elastic, and not painful. Microscopically these tumours 
were composed of ganglionic nerve-cells, medullated and non- 



GANGLION-NEUROMAS 



143 



medullated nerve-fibres. Knauss believed that the tumours, 
which clinically resembled lipomas, were derived from ganglia 
on fine terminal fibres of the sympathetic nerves. Ganglion- 
neuromas have been reported in connexion with sympathetic 
nerves in the neck, thorax, and abdomen. The most remark- 
able arise in the mesentery. To the naked eye they resemble 
the large fibrosarcomas described on p. 36, but when ex- 
amined microscopically they present nerve-fibres and ganglion- 




Fig. 75. Ganglion-cells of a ganglion -neuroma of the mesentery. 
Nissl's staining. X 350. 

cells such as belong to the sympathetic nervous system. 
Turnbull furnished the description of a tumour of this 
character ; it had an average diameter of 18 cm., and was 
removed by Macnaughton Jones from the mesentery of a girl 
aged 18. Paterson described a similar tumour from a boy 
aged 9. In 1917 I removed from a boy aged 10 a tumour of 
the size and shape of a coco-nut. It occupied the mesentery, 
and had been noticed since birth. Suspecting it to be a 
ganglion-neuroma, I submitted it to Prof. Browning for 
examination. Nerve-cells and nerve-fibres were abundant 
(Fig. 75). When fresh the soft central part of the tumour 



144 GANGLION-NEUROMAS 

resembled grey matter of the spinal cord. Before the 
operation this boy had bilateral spastic talipes equinus. Two 




Fig. 76. Multiple inolluscum fibrosum. 

years after the operation the talipes had disappeared. One 
half of the tumour is in the museum of the Middle- 



NEUROFIBROMATOSIS 145 

sex Hospital, the other in that of the Royal College of 
Surgeons. 

In 1915 Prof. J. Shaw Dunn collected and tabulated the 
reported cases of ganglion-neuromas. Such tumours of large 
size are more common in children than in adults. They 
are rare in the mesentery, and in this situation appear 
only during childhood and adolescence. Clinically they are 
innocent. 

A remarkable example of ganglion-neuroma arises in the 
medulla of the adrenal and has been described as a round- 
celled sarcoma, but Marchand and others have shown that the 
tissue resembles that seen in the embryonic stage of the sym- 
pathetic nervous system. These adrenal tumours disseminate ; 
secondary nodules have been found in lymph-nodes, skull, 
ribs, liver, kidney, etc. Because these tumours are composed 
mainly of tissue representing undifferentiated sympathetic 
neuro blast they have been called neuroblastomas. 

Neurofibromatosis. Under this heading will be described 
several affections which were formerly regarded as being 
quite distinct. These are multiple neuromas, molluscum 
iibrosum, plexiform neuromas, sarcomas of nerves, and 
gliomas. It will be useful to state a few facts concerning 
each of these conditions before describing their intimate 
relationship. 

It has long been known that neuromas sometimes 
occur on nerves in extraordinary numbers. The remark- 
able case of Michael Lawlor, described in Smith's classical 
monograph, was in all probability an example of this com- 
bination. The man had at least 2,000 tumours. There 
were 450 tumours on the nerves of the right lower limb, 
300 on the left; 200 on the right and 100 on the left 
upper limb. The pneumogastric nerves and their branches 
possessed 60 tumours, some of large size. The remainder 
were on the trunk. 

Several cases of this kind have been carefully described, 
but probably in no individual has a greater number of 
nodules been detected. 

In 1882 Recklinghausen published a monograph in 
which he demonstrated not only that multiple neuromas 
were sometimes associated with molluscum iibrosum, but 
K 



146 



NEUROFIBROMATOSIS 



that the two conditions were closely related, and he stated 
that the molluscum bodies of the skin are formed on the 
cutaneous nerves, and are as truly neuromas as the tumours 
on the epineurium of the larger nerves. 




Fig. 77. Native of Sierra Leone aged 50 with molluscum fibrosum. The 
tumours, which were congenital, varied in size from a peppercorn 
to a billiard-ball. (Lamprey.} 

In 1871 Fergusson amputated the upper limb of a man 
aged 34. The dissected limb is preserved in the museum of 
the Royal College of Surgeons to show the concurrence of 
molluscum fibrosum and neurofibromatosis. All the main 



RECKLINGHAUSEN'S DISEASE 147 

nerves of the limb are affected, and the median nerve is as 
thick as a man's finger. 

In typical cases of Recklinghausen's disease the skin of 
the trunk and limbs presents hundreds of small tumours, 
consisting mainly of fibrous tissue springing from the 
subcutaneous connective tissue. These tumours are of 
various sizes, some being no larger than a pin's head, whilst 
many are as big as a filbert, and a few even larger ; many are 




Fig. 78. Native of Bengal with molluscum fibrosum of the arm : there 
were also discrete nodules on other parts of the body. The mail 
belonged to the cowkeeper caste. (From a photograph sent ly Dr. 
Maddox, Bengal.} 

about the size of a small pea. Some are sessile, and others 
are distinctly pedunculated, but all are covered with skin. 
The nodules spare the palms and soles. These tumours are 
mobile, soft to the touch, and of the consistence of firm fat. 
Sometimes the disease affects a broad area of skin on the 
head, trunk, or limbs, causing it to hang in pendulous folds 
(Figs. 77, 78). Exceptionally the pendulous and nodular 
lesions occur in the same patient. Often the skin on and 
in the vicinity of molluscum nodules and folds is pigmented. 



148 



MOLLUSGUM FIBROSUM 



In its mildest form molluscum fibrosum appears as a 
single pedunculated tumour, a frequent situation being the 
labium majus (Fig. 79). 

The structure of these solitary tumours is the same as the 




Fig. 79. Molluscum fibrosum of the vulva in a negress. The tumour was 
removed : it weighed 75 Ib. The tumour had been growing ten years : 
after its removal the patient conceived, and was delivered of twins in 
the bush. She died of puerperal fever. 

nodules in the multiple forms and the pendulous skin-folds. 
An unusual situation is the mammary areola or the nipple 
(Fig. 80). When these nodules grow from the nose they are 
apt to be confounded with the condition commonly but 
erroneously called lipoma nasi (Fig. 81). 



MOLLUSCUM FIBROSUM 149 

Concerning the cause of molluscum fibrosum nothing is 
known. The disease is not confined to any climate or race, 
for it has been observed in North America, the British Isles, 
India, Germany, and the West Coast of Africa. 

Under the term pachyderrnatocele, Mott (1854) described 
and figured several examples of the pendulous form of mol- 
luscum fibrosum which were successfully submitted to opera- 
tion, and the early volumes of the Transactions of the 
Pathological Society, London, contain descriptions and figures 
of this disease under a variety of names. The frontispiece to 




Fig. 80. Pedunculated molluscum fibrosum from the nipple of a woman. 
(Museum of the Middlesex Hospital.} 

Virchow's "Die krankhaften Geschwulste" is a representation 
of a woman with pendulous folds and a multitude of 
cutaneous nodules, under the title " fibrosum molluscum 
multiplex." The disease appears to be equally common 
in men and in women. 

An important feature connected with the typical gener- 
alized neurofibromatosis is the liability of the patients to 
sarcoma ; this may develop primarily, or arise as a malignant 
change in a molluscum nodule which has existed very 
many years. 

Neurofibromatosis in its various forms is sometimes 
associated with multiple exostoses and chondroinas. These 



150 NEUROFIBROMATOSIS 

diseases are hereditary and probably depend on some dis- 
turbance of the endocrine glands. Sarcoma as a terminal 
affection in all these diseases is significant 

In generalized neurofibromatosis, death often results from 
gradual exhaustion, due to ulceration, septic changes, or 




Fig. 81 .Multiple molluscum nodules on the scalp, uose, and fingers. The 
nodules on the fingers are in the course of the digital nerves. 

sloughing of the pendulous portions of the skin. In many 
cases some intercurrent malady supervenes, such as pneu- 
monia ; in patients with multiple nodules on the roots of the 
spinal nerves, one of them may so enlarge as to press on 
the cord and produce fatal paraplegia. Hunt has recorded 
such a case. 



SARCOMA OF NERVES t$t 

In regard to sarcoma supervening in the molluscum 
nodules, it is necessary to remember that spindle-celled 
sarcomas arise primarily in nerve-trunks, especially in the 
great sciatic and its branches, quite apart from the existence 
of neurofibromatosis, localized or general. A sarcoma of a 
nerve recurs after removal or amputation of the limb, but 
dissemination is not frequent. 

Bland-Sutton, J., "Ganglion-Neuroma of the Mesentery." Lancet, 1918, 
i. 429. 

Dunn, J. S., "Neuroblastoma and Ganglio-Neuroma of the Suprarenal Body." 
Journ. of Path, and Bact., 1915, xix. 456. 

Hunt, J. R., "A Contribution to the Symptomatology and Surgical Treatment 
of Spinal-Cord Tumours." Ann. of Surg., 1910, lii. 289. 

Knauss, K., " Zur Kenntnissder iichten Neuroma." Virchow's Arch. f. path. 
Anat., 1898, cliii. 29. 

Macnaughton-Jones, H., "A Case of Ganglion-Neuroma of the Mesentery." 
Proc. Roy. Soc. of Med., 1912, vol. v., Sect, of Obstet. and Gyn., p. 287. 

Mott, Valentine, " Remarks on a Peculiar Form of Tumour of the Skin 
denominated ' Pachydermatocele ' ; illustrated by cases." Med.-Chir. 
Trans., 1854, xxxvii. 155. 

Paterson, P., "A Neuroma-Myoma of the Mesentery." Lancet, 1913, ii. 997. 

von Recklinghausen, F., " Ueber die multiplen Fibrome der Haut, und ihre 
Beziehung zu den multiplen Neuromen." Festschrift zu Rudolf Virchow 
dargebracht, Berlin, 1882. 

Smith, R. W., " Treatise on the Pathology, Diagnosis, and Treatment of 
Neuroma." Dublin, 1849. 



CHAPTER XIII 

NEUROMAS AND ALLIED CONDITIONS OF THE 
NERVOUS SYSTEM (continued) 

PLEXIFORM NEUROMA 

THE peculiar condition to which this term has been applied 
is essentially a fibroin atosis confined to a particular nerve or 
plexus of nerves. A plexiform neuroma, instead of forming a 
distinct tumour as in the case of the solitary neurofibroma, 
appears as if the branches of a nerve distributed to a par- 
ticular area of the skin became enlarged and elongated. 
The overlying skin becomes stretched, thinned, and raised 
over the thickened nerves, and is often pigmented, the usual 
colour being brown, like that characteristic of the hairy mole, 
and occasionally the skin is coarse and hairy. 

The tumour feels like a bag containing a number of 
tortuous, irregular, vermiform bodies, soft to the touch and 
mobile. These bodies vary in thickness from a crow-quill to 
that of the thumb ; manipulation does not produce pain } 
though the lumps themselves are sensitive. When the skin 
covering the tumour is reflected these elongated bodies will 
be found to lie in the direction of the nerve distributed to 
the part.. Thus, on the back they will run in a transverse 
direction (Fig. 82), whereas on the scalp they will trend to 
the vertex, and so on. 

When these thickened nerves are divided the enlarge- 
ment will be seen to be due to the presence of a gelatinous 
tissue, and the appearance of the cut surface reminds one 
of the umbilical cord. Microscopic examination shows that 
this thickening is due to overgrowth of the nerve-sheath, 
and especially that part of it known as the endoneurium 
that is, the delicate connective tissue between the indi- 
vidual fibres of a nerve-bundle. The enlargement is by 



PLEXIFORM NEUROMA 153 

no means uniform, so that the so-called multiple neuromas 
are due to local irregularities in a diffuse overgrowth of 
the connective tissue of the nerve- sheath. 

Widely different opinions are held by equally competent 




Fig. 82. Plexiform neuroma from the back of a youth aged 19. The 
skin was the seat of a brown hairy mole. (runs.) 

observers in regard to the effects of these changes in the 
sheath upon the axis-cylinders of the nerves. Some main- 
tain that degeneration occurs, and others that they are not 
affected. This question requires careful investigation. 

The diffuse character of the enlargement in plexiform 
neuromas is well shown in a remarkable specimen preserved 



154 



PLEXIFORM NEUROMA 



Fig. 83. Fibromatosis of the cauda equina and 
the crural nerve. A nodule on a spinal 
root in the cervical region compressed the 
cord. (Museum of the Middlesex Hospital.) 



in the Middlesex Hospital museum 
(Fig. 83). A man aged 45 was 
admitted into the hospital with 
well-marked paraplegia. At the 
post-mortem examination a large 
number of small nodules were 
found on the roots of the nerves. 
Many of the roots were so beset 
with them as to resemble strings 
of beads. In the cervical region 
a tumour as large as a nut had 
compressed the cord and produced 
paraplegia. There was a neuroma 
as big as an orange on the anterior 
crural nerve; there were smaller 
examples on the branches of the 
lumbar plexus. 

When these nerve-roots are 
carefully examined they present 
the annulated appearance so char- 
acteristic of the root of the ipe- 
cacuanha plant, and it is clearly 
seen that the nerve-roots are thick- 
ened throughout, and that the 
nodosities are local exaggerations. 
The details of this case were 
recorded by Sibley in 1866. 

Any nerve, 
cranial or spinal, 
is liable to this 
disease, but 
among the cra- 
nial set it shows 
marked prefer- 
ence for the 
vagus and the 
trigeminus. It 
may affect parts 
of several nerves, 
or be limited to 




PLEXIFORM NEUROMA 155 

certain branches of a single nerve. A girl aged 17 had diffuse 
neuron bromatosis involving the cerebro-spinal trunks almost 
universally and their roots. The intracranial masses were 
so large as to deform the pons and the medulla. (Beattie 
and Hall.) 

The roots of nerves and terminal twigs may be attacked 
as well as their trunks; and the branches of nerves within 
the muscles may display nodosities. The sympathetic 
nerves do not escape, for the great lateral cords as well 
as the visceral branches may be nodular with this disease. 
(Alexis Thomson.) 

In one instance the nerves involved included the facial, 
hypoglossal, motor portion of the fifth and its lingual branch. 
The enlargement of the lingual and hypoglossal nerves 
produced macroglossia in a child aged 4, for which Abbott 
excised the protruding part of the tongue. Shattock investi- 
gated the diseased organ, and the outcome was an admirable 
paper of great value. 

As examples of the disease limited to part of a nerve, 
reference may be made to some cases in which the ophthal- 
mic division of the trigeminus has been affected, leading to 
enlargement of the upper eyelid and proptosis, which neces- 
sitated excision of the eyeball, in one patient with fatal 
consequences. (Friedenwald, Rockliffe and Parsons, Treacher 
Collins and Batten.) 

I have seen a plexiform neuroma strictly limited to the 
great occipital nerve. The scalp covering the affected nerve 
was transformed into a brown mole. 

In the limbs any nerve may be attacked, and the disease 
is usually limited to one nerve, and follows it out to its 
final ramification. The musculo-spiral nerve in De Morgan's 
patient (Figs. 84 and 85) is as thick as the thumb ; it looks 
gelatinous like an umbilical cord. An ovoid tumour as big 
as an egg is connected with a branch of the nerve. 

Clinical features. Neuromas are in the majority of 
cases innocent tumours; they very rarely recur after com- 
plete removal. In an exceptional environment a neuroma 
will cause death, and many examples have been observed in 
which even small neuromas on the roots of spinal nerves 
have produced paraplegia with a fatal ending (Fig. 83). 



156 PLEXIEORM NEUROMA 

Smith refers to a woman who complained of severe pain in 
the course of the right trigeminal nerve ; this pain was so 
much increased by mastication that she ate but little, and 
speaking aggravated it to such a degree that she remained 
silent unless interrogated, and even on these occasions she 
often preferred to reply by signs. She died after enduring 
severe and uninterrupted pain during four and a half months. 
At the autopsy a neuroma as large as a walnut occupied the 
situation of the right Gasserian ganglion. With modern 
methods of surgery no person would be allowed to suffer in 
this awful manner, for the tumour would be removed. 

Solitary neuromas are not uncommon on the intracranial 
portions of the fifth and eighth nerves. Neuromas of the 




Fig. 84. Arm in which the musculo- spiral nerve and its branches were 
transformed into a plexiform neuroma. From a girl aged 15. The 
arm was amputated by Campbell De Morgan in 1875. 

eighth nerve are known as acoustic tumours, and cause 
characteristic clinical signs. 

When a neuroma involves the roots of a spinal nerve, pain 
is a prominent symptom until the tumour is big enough to 
compress the cord and produce paraplegia : these signs are 
not peculiar to neuromas of the roots of the spinal nerves. 
Neuromas on the nerves of the limbs are usually solitary 
and ovoid, and the long axis of the tumours coincides with 
that of the limb. When a neuroma is pressed, painful 
sensations radiate throughout the distribution of the nerve 
below the point of attachment of the tumour. 

In a remarkable case recorded by Semon an ovoid 
tumour, in all probability a neuroma of the internal branch 
of the superior laryngeal nerve, projected into the ventricle 



PLEXIFORM NEUROMA: TREATMENT 157 

of the larynx of a woman aged 40. The tumour was noticed 
in 1888, and it caused very little trouble, except when 
pressed or handled (then coughing and retching occurred 




Humerus. 

Musculo-spiral nerve, 
upinator longus. 

Neuroma. 



The cutaneous branches 
of the musculo- spiral 
nerve. 



Fig. 85. The arm represented in the preceding figure, dissected: the 
musculo -spiral nerve and its branches are transformed into a plexi- 
form neuroma. (Museum of the Middlesex Hospital.) 

immediately), until 1891, when it was necessary to perform 
tracheotomy. In 1904 Semon removed the tumour. 

Treatment, A solitary neuroma in an accessible position 
is easily removed, care being taken during the enucleation 



158 PLEXIFORM NEUROMA: TREATMENT 

not to damage the fibres of the nerve. It sometimes happens 
that the neuromatous nature of a tumour is not recognized 
until after its removal with a segment of the nerve. Per- 
sistent facial palsy has followed the removal of a neuroma 
lodged in the parotid gland (Chap, xxxvi). 

From a man aged 36 I enucleated 14 neuromas ; some 
were of the size of sparrows' eggs, others as big as ducks' 
eggs. The big neuromas were cystic, and occupied the 
great sciatic and popliteal nerves. 

Neuromas within the spinal canal are often excised with 
good results. Multiple neuromas, especially when associated 
with molluscum fibrosum, are beyond the art of surgery. 

Plexiform neuromas have been several times successfully 
excised : exceptionally, when affecting a limb, amputation has 
been found necessary. This form of neuroma involving the 
hypoglossal and lingual nerves has produced enlargement of 
the tongue resembling macroglossia : the condition was 
remedied by excision of a portion of the tongue. 

A coloured boy aged 3J had a swelling in the hypo- 
gastrium resembling a urachal cyst. Cullen removed a 
portion of the mass ; it was the bladder with very thick 
walls. The boy died. A plexiform neuroma was discovered 
between the muscular wall and the mucosa, surrounding 
the cavity of the bladder " like a mantle composed entirely 
of nerves." 

Beattie, J. M., and Hall, A. J., " A Case of Diffuse Neuro-fibromatosis." Proc. 
Roy. Soo. of Ned., 1912, v., Path. Sect., p. 140. 

Cullen, T. S., " Embryology, Anatomy, and Diseases of the Umbilicus." 
Philadelphia and London, 1916. 

Friedenwald, H., "A Case of Plexiform Neuroma of the Eyelid (Ranken- 
neurom)." Johns Hopldns Hasp. Repts., 1900, ix. 355. 

Semon, F., "Soft Fibroma of the Larynx." Brit. Mcd. Journ., 1905, i. (5. 
Thomson, H. Alexis, " Neuroma and Neuro-fibromatosis." Edinburgh, 1900. 



CHAPTER XIV 

NEUROMAS AND ALLIED CONDITIONS OF 
THE NERVOUS SYSTEM (concluded) 

GLIOMA OF THE BRAIN; OF THE RETINA AND 
OPTIC NERVE ; AND OF THE SPINAL CORD 

Glioma of the brain. Ever since I became practically 
acquainted with the changes in the nerves constituting a 
plexiform neuroma, it has seemed to me that they are akin 
to the localized neuroglia overgrowth in the brain known 
as gliorna; and I was sufficiently convinced of this to draw 
attention to the likeness in the first edition of this mono- 
graph (1894). 

A glioma of the brain occurs as a translucent swelling 
imperfectly demarcated from the surrounding parts ; the 
gliomatous tissue may have the consistence of the vitreous 
or be as firm as the tissue of the pons. Microscopically 
it has the characters of an overgrowth of neuroglia. A 
glioma is the characteristic brain-substance tumour; it may 
be encapsuled, or diffuse. An incomplete encapsulation is 
common, and a glioma is often the seat of retrogressive 
change and cyst-formation. 

Gliomas are universal in the brain. Virchow pointed 
out that when a glioma is situated near the surface of 
the cerebral cortex it appears like a colossal convolution. 
Should it grow in the tissue of an optic thalamus, this 
structure will bulge into the third ventricle as though 
overgrown ; and a glioma of the occipital lobe will project 
into the descending cornu like an additional thalamus. The 
best illustrations of this indefiniteness, so characteristic of 
gliomas, come out very strikingly when the pons and the 
cerebral crura are occupied by this form of tumour. 

A glioma occasionally occurs in the pons, and forms 



i6o GLIOMA OF THE BRAIN 

JP 

a tumour of considerable size. It may be confined to 
one side, and extend into the adjacent cerebellar crura. 
In a case described by Cayley, which occurred in a child 
aged 2 years, a glioma as large as a walnut occupied 
the right half of the pons and extended along the superior 
cerebellar peduncle of that side, reaching as far forwards as 
the corpora quadrigemina. The gliomatous mass formed a 
prominence on the corresponding half of the floor of the 
fourth ventricle, and obstructed the Sylvian aqueduct. 

In some cases both sides of the pons are involved, and 
the overgrowth of neuroglia extends forwards into the cere- 
bral crura and the cerebellar peduncles, and involves the 
corpora quadrigemina. In a few it extends downwards into 
the medulla, and may even involve the cervical portion of 
the cord. Sometimes the gliomatous tissue is so abundant 
as to produce an enlargement of the pons and cerebral 
peduncles (Fig. 86). 

The appearance of such brains is very peculiar : the 
basilar artery and its branches look as though sunk in 
deep furrows, which cause the parts to resemble " a soft 
package tightly corded " (Dickinson). Such conditions are 
rare, and in nearly all instances the patients have been 
under 12 years of age. The relations of a glioma to sur- 
rounding tissues are best seen in recent specimens. On 
examination soon after death the diseased parts are found 
abnormally large, and on section pale blue ; but in thin 
sections the tissue has a delicate translucency. The tumour 
itself is very soft, and imparts to the fingers a sensation 
like fluctuation. When the parts are immersed in alcohol 
the tissue becomes firm, opaque, and white; under these 
conditions it is particularly difficult to determine the limits 
of the tumour. Gliomas constitute nearly 50 per cent, of 
all tumours of the brain and its membranes. The greatest 
number occur between the twentieth and fortieth years. 
Tooth published in 1912 a careful analytical study of the 
records of 500 cases of intracranial tumours : in regard to 
gliomas he points out that from the histological standpoint 
they present a bewildering variety of appearances, and his 
excellent series of figures supports this view. 

Gliomas are not often multiple and do not disseminate, 



GLIOMA OF THE BRAIN 



161 



but they are liable to cystic degeneration : they are clini- 
cally malignant from environment, and cause death from 
simple mechanical increase in bulk. The subjoined opinion 
expressed by Tooth in regard to the diagnosis and surgical 
treatment is instructive, for it is founded on a careful con- 
sideration of the complete history of many cerebral gliomas : 




Fig. 86. Bilateral gliomatous enlargement of the pons and crura cerebri. 
(Angel Money.} 

" One may almost assume that the earliest possible stage of 
growth, when the tumour might conceivably be removed 
completely, is undiagnosable in most parts of the brain. 
A removal as complete as possible seems to be followed 
by increased activity, and recurrence; or, worse still, a 
relatively latent growth may be awakened into malignity. 
It seems that in the present state of our knowledge we 
must be content with_relieving pressure by decompression 
lest worse befall." 
L 



1 62 OPTIG-NERVE TUMOURS 

Sarcoma of the optic nerve. Tumours of the optic 
nerve are very rare. A careful analysis of recorded cases 
does not afford much clear information on the pathologic 
aspect of these tumours, and they are described under titles 
such as glioma, rnyxoma, myxosarcoma, fibroma, and sarcoma. 

The recorded clinical facts are sufficient to prove that 
connective -tissue tumours with malignant characters do 
arise from and in the optic nerve. They are unilateral, 
and more frequent in the young than in adults. 

The optic nerve is a complex structure, and in the 
embryo it is preceded by an outgrowth from the brain 
known as the optic stalk ; this is hollow, and consists of 
epithelial cells. The stalk is ultimately replaced by a 
fibrous nerve, the nerve elements of which are in part 
derived from the retina and in part, perhaps, from the 
brain (Robinson). Thus the early tissue of the optic stalk 
is identical in structure and continuous with the susten- 
tacular tissue of the embryonic retina. 

In some cases, especially in adults, sarcomas arise from 
the sheath of the nerve, and do not primarily involve the 
nerve-fibres. Pockley has excised a tumour from the optic 
nerve, and saved the nerve and the globe. The patient was 
a boy aged 19. The tumour is described as an encapsuled 
round-celled sarcoma. Some recently recorded cases point 
to the conclusion that many of the tumours arising within 
the sheath of the nerve, especially in children, are closely 
connected with the pial sheath, and in construction allied, 
if not identical, with the retinal sarcoma (glioma) of infancy. 
The malignancy of optic-nerve sarcomas, though pronounced, 
is not excessive. 

Tumours of the optic nerve are usually ovoid in shape, 
and the long axis is coincident with that of the nerve. 
Their surfaces are usually smooth, and in size they vary 
greatly, but rarely exceed that of a pigeon's egg. They do 
not tend to invade the globe, but are apt to creep through 
the optic foramen and involve the intracranial portion of 
the nerve. As the fibres of the nerve are early implicated, 
vision is soon interfered with ; there is proptosis, but the 
movements of the eye are free, and there is no pain, even 
on manipulation. 



GLIOMA OF THE RETINA 163 

Much of the confusion relating to the nomenclature 
and structure of tumours of the optic nerve is due to 
their rarity, and those interested in this question will do 
well to study the careful work of Treacher Collins and 
Devereux Marshall. 

Glioma of the retina. Although the retina is one of 
the most delicate structures in the body (in its thickest 
part it only measures 0'5 mm.), histologists have succeeded 
in detecting in it eight peculiar layers of cells, in addition 
to the sustentacular framework and limiting membranes. 
The retina is derived from the diverticulum of the fore- 
brain, known as the optic cup, and the retinal layer of 
the cup contains all the structures found in the spinal 
medulla of the embryo. This justifies the inclusion of 
the tumours called retinal gliomas among gliomas of the 
brain and spinal cord, although the cells of the retinal 
glioma differ from those found in cerebral gliomas. 

Treacher Collins points out that the cells of a retinal 
glioma are peculiar to it; they possess large round or 
oval nuclei, and very little cytoplasm ; they resemble the 
cells of which the whole retina is composed at the third 
month of foetal life, before the differentiation of the layers. 
They are like the cells of the nuclear layer. Some of the 
cells resemble rudimentary rods and cones, and rudimentary 
ganglion cells ; sometimes these cells form circular groups 
that have been described as rosettes. 

When the tumour protrudes from the outer layer of 
the retina it is called glioma exophytum, and the retina 
is displaced towards the lens. This is the common variety. 
When the tumour protrudes from the inner surface it is 
known as glioma endophytum, and the retina remains in 
position; the glioma extends into the vitreous chamber, 
and detached flocculent pieces occupy the vitreous humour. 
In rare instances a glioma arises in the pars ciliaris 
retince and extends over the surface of the iris and the 
anterior surface of the lens. 

Retinal glioma occurs exclusively in children; exception- 
ally it has been detected at birth, but it usually makes 
its appearance during the first four years of life; it is 
very rare after the seventh and is almost unknown after 



164 GLIOMA OF THE RETINA 

the twelfth year. In a certain proportion of patients 
(20 per cent.) both retinae are affected, either simul- 
taneously or after a brief interval. This is always an 
indication that the tumour is highly malignant. In 
the early stages there is usually no pain or symptom 
denoting the presence of a tumour ; gradually the pupil 
dilates, and a peculiar reflex is noted at the fundus (this 
is often termed cat's-eye), and, when tested, the eye will be 
found quite blind. As soon as the existence of a glioma 
is discovered by the surgeon the eye is, as a rule, promptly 
excised. In cases where treatment of this kind is refused 
or deferred, the following changes occur. The tumour, 
continuing to increase, pushes forward the intra-ocular 
structures and causes great pain as the result of the in- 
creased intra-ocular pressure it produces, until the cornea 
yields and the tumour bursts forth and, growing very 
rapidly, soon makes its way between the eyelids, which 
become swollen and everted; and then, in consequence 
of exposure, it assumes a dusky red fleshy appearance, 
whilst from its surface a sanious fluid exudes which may 
form crusts on the surface of the tumour. Should the 
parts become excoriated or be handled, they bleed freely. 
A fungating tumour of this kind sometimes attains a 
very large size before it destroys the child's life. In rare 
cases an eye affected with glioma, instead of becoming 
glaucomatous and enlarged, shrinks, and the growth of the 
tumour is arrested. In the majority of such cases both 
eyes are affected but only one shrinks. The cause of this 
atrophic process has not been determined. 

After excision of an eye for retinal sarcoma the dis- 
ease is very prone to recur, and the recurrent tumour 
may attain very large proportions before it destroys life. 
When the operation has been long delayed the growth 
may have burst through the sclerotic and invaded the 
orbital tissues; in a larger proportion of cases it has infil- 
trated the optic nerve, and it is in this structure that the 
disease reappears. The frequency with which glioma re- 
turns in the stump of the optic nerve is, in all probability, 
due to the intimate lymphatic relations of this nerve with 
the intra-ocular lymph-spaces. 



GLIOMA OF THE CORD 165 

In regard to the question whether " glioma " may " run " 
in a family, there is little evidence to guide us. Fuchs 
has recorded a case in which 2 children were affected in 
one family, and two very extraordinary reports have recently 
come from Australia. Earle Newton states that in a family 
of 16 children 10 died from retinal glioma; 3 of the cases 
were unilateral and 7 bilateral ; all the affected children, with 
one exception, died about the third year. Maher tells of a 
family of 4 children, of whom 3 died of glioma, and in 2 
it was bilateral. 

Dissemination of retinal glioma is exceptional. The 
common situations for secondary deposits are the brain, the 
preauricular lymph-nodes, the periosteum of the skull-bones ; 
and occasionally secondary deposits are found in the liver. 

The treatment for retinal sarcomas is removal of the 
eye, and the importance of promptness in this matter is 
indicated in the careful inquiry conducted by Lawford 
and Collins. They prove very clearly the following points : 
The sooner an eye is removed after the discovery of the 
disease, the better the prospect of cure. In the majority of 
cases the disease returns in the orbit, and in a very small 
proportion of cases secondary deposits occur in other parts. 
When recurrence takes place it is rarely delayed beyond nine 
months ; but one undoubted case has been reported in which 
the disease returned three years after the primary operation. 
If three years elapse and there is no recurrence, the recovery 
may be regarded as permanent. Out of 54 cases in Lawford 
and Collins's list, 8 patients were alive and free from recur- 
rence three years after the removal of the eye for retinal 
glioma. It is significant to note that in 7 of these cases 
the disease affected one eye only. This shows the almost 
hopeless condition of the patient when both eyes are affected. 

Other statistical inquiries have been conducted with the 
view of obtaining the percentage of cures in this disease, and 
they work out at about the same proportion as in the paper 
mentioned above. 

Glioma of the spinal cord. A glioma of the spinal 
cord is a very rare tumour, and, judging from the scanty 
records, it would appear that a glioma in the brain is 
twenty times more frequent than in the cord. The tumour 



i66 GLIOSIS 

is imperfectly demarcated from the nervous tissue, and often 
causes a general enlargement of the cord, producing upon 
it an effect like gliomatous disease of the pons, crura, and 
medulla. It was pointed out in connexion with this disease 
of the medulla that it sometimes involves the adjacent 
segment of the spinal cord. When the cord is extensively 
involved the condition has been called gliosis. 

The disease may attack any part of the cord, but is most 
frequent in the cervical enlargement. In a few instances the 
tumour was seated in the lumbar region. It appears most 
frequently between the seventeenth and thirtieth years, but 
it has been observed as late as 50. 

Treatment. In previous editions of this book the de- 
scription of spinal gliomas ends with this opinion : " The 
peculiar relation of the gliomatous tissue to the nerve- 
tissue of the cord precludes surgical interference." Elsberg 
and Beer, of New York, have removed intramedullary 
tumours from the cervical segments of the spinal cord; 
they point out that when an intramedullary tumour is 
exposed by laminectomy and division of the dura, if the 
tumour be exposed by a short median incision in the 
posterior median column, at the spot where the growth 
seems to be nearest to the surface of the cord, the 
tumour will begin to bulge through the incision. They 
therefore recommend that in removing such tumours the 
operation should be done in two stages : (1) The laminec- 
tomy, exposure, and incision of the cord. The wound is 
then closed. (2) A week later the wound is reopened, and 
in all probability the tumour will be found extruded from 
the cord and easily removed. 

Collins, E. T., " International System of Ophthalmic Practice." Phil., 1911. 
Elsberg, C. A., and Beer, E., "The Operability of Intramedullary Tumors of 

the Spinal Cord." Amer. Journ. of Med. Sci., 1911, cxlii. 636; and 

Surg., Gyn., and Obstet., 1914, xviii. 170. 

Fuchs, E., "Textbook of Ophthalmology," 4th ed., 1911, p. 566. 
Maher, Australasian Med. Gaz., 1902. 
Newton, E., Ibid., 1902. 
Pockley, Ibid., Oct., 1901. 
Tooth, H. H., Presidential Address, " Some Observations on the Growth and 

Survival-Period of Intracranial Tumours, based on the records of 500 

cases, with special reference to the Pathology of the Gliomata." Proc. 

Roy. Soc. of Med., 1913, vi., Neurological Sect., p. 1. 



CHAPTER XV 
ANGIOMA AND LYMPHANGIOMA 

AN angioma may be defined as a tumour composed of an 
abnormal formation of blood-vessels. This genus contains 
three species, viz. : 1. Simple nsevus. 2. Cavernous nsevus. 
3. Plexiform angioma. 

1. Simple naevus. This is the common species of nsevus, 
and in its typical form affects the skin and subcutaneous 
tissue. A nsevus may appear as a superficial discoloration 
of the skin, and is either bright pink or deep blue : these 
are known as " port- wine stains." Such nsevi may involve 
an area of skin 2 cm. square, or extend over a large portion 
of the face, or half the trunk, or be restricted to a limb. 
James II of Scotland had a stain on one cheek and was 
called " Fiery-Face." 

A very common variety of nsevus is that often referred to 
as telangiectasis ; it consists of an abnormal collection of 
arterioles situated in the skin and subcutaneous tissue ; it 
may be present at birth, but much more frequently appears 
in the course of the first few weeks of life. Fitzwilliams 
believes that nsevi are nearly always present at birth ; com- 
paratively few appear during the first weeks of life, and very 
few indeed at a still later date. They often escape notice 
until the child is a few days old. He gives convincing 
figures. Sometimes a nsevus appears as a red spot no larger 
than a split pea; then suddenly it grows actively, and in 
two or three months will involve an area of skin 4 cm. 
square. When the nsevus consists mainly of arterioles it 
will be bright pink ; when composed mainly of venules it is 
of a bluish tint. Lymphatics are often present. Structur- 
ally, nsevi are composed of minute blood-vessels embedded 
in fat; usually two or more large vessels establish a com- 
munication between the nsevus and an adjacent artery or 

167 



i68 CAVERNOUS N^VUS 

vein. The vessels of the nsevus are often sacculated. When 
they are gently compressed the blood is driven from the 
mevus, which at once loses its colour ; but the colour 
returns as soon as the pressure is relieved. The spider 
nsevus (ncGvus araneus), usually seen on the face, consists of 
an enlarged vessel that brings blood to the surface, and a 
number of fine arterioles radiate from it, producing an 
appearance not unlike a spider's web. Simple nsevi are 
common in the skin of the face, scalp, neck, and back ; 
less frequent on the limbs; and rare on the labia, the lips, 
tongue, and conjunctive. Naevi of small size frequently 
disappear spontaneously ; often they gradually increase in 
size, and may become converted into cavernous naevi, or 
plexiform angiomas. 

2. Cavernous nsevus. This is the species to which the 
term erectile tumour is most applicable. In structure it 
is comparable to the spongy tissue characteristic of the 
cavernous tissue of the penis. Cavernous, like simple nsevi 
are most frequently seen in connexion with the skin, where 
they form distinct tumours, red, crimson, or blue, rising- 
above the general surface ; sometimes they display the 
peculiar tint characteristic of fluid contained in thin- walled 
cysts, for which a cavernous naevus is often mistaken, especi- 
ally when situated near the outer angle of the orbit. In most 
cases the blood can, by firm and steady pressure, be squeezed 
out of a nsevus, but the swelling quickly reappears after the 
compression is removed. The surface of a nsevus may feel 
warmer than the surrounding skin, and sometimes the tumour 
pulsates, the movement being appreciable to the finger and 
occasionally perceptible to the eye. 

Structurally, cavernous noevi are made up of variously 
shaped spaces and sinuses, the walls of which are merely 
fibrous septa lined with endothelium. Some of these nsevi 
consist in part of vessels and in part of cavernous spaces. 
When an angioma consists entirely of irregular blood-con- 
taining spaces, a dissection round its periphery will reveal the 
existence of vessels, sometimes of considerable size, conveying 
blood to it from adjacent arteries. Cavernous, like simple 
nsevi are, as a rule, congenital, but a nsevus which during 
infancy is small and inconspicuous may later in life become 



ANGIOMA OF MUSCLES 169 

converted into a cavernous nsevus of large size, and one that 
will, under certain conditions, jeopardize life. Image described 
a remarkable example in the breast of a woman (1847), 
and I removed a large one that arose in the breast of a 
lad (1889). 

Cavernous nsevi occasionally occur in the tongue ; as a 
rule, they are situated near the surface, and form slightly 
elevated patches, deep-blue or purple in colour. Such nsevi 
rarely give rise to any difficulty in diagnosis: their colour, 
general appearance, and the fact that firm pressure suffices 
to drive the blood out of the tumour are sufficient to 
indicate their nsevous character. 

A cavernous angioma of the palm, associated with ab- 
normal arteries and veins, is shown in Fig. 87. The man 
had noticed the condition from childhood. The palm con- 
tained a large compressible swelling, portions of which 
bulged between the metacarpals and appeared on the 
back of the hand. The arteries and veins of the whole 
limb were enlarged ; the veins pulsated like arteries, a 
thrill was perceptible in them, and a loud buzzing was 
audible in all the vessels. The arteries and veins pulsated 
synchronously, buzzed or purred with the same note, and 
thrilled equally. The fourth and fifth fingers were 
gangrenous. I amputated the limb. The arteries and 
veins are alike in structure, and elastic tissue is deficient 
in them. 

Cavernous angiomas occur in voluntary muscles. Examples 
have been observed and recorded by C. De Morgan in the 
semimembranosus, semitendinosus, and deltoid ; Stonham 
removed one that extensively involved the gracilis, and Eve 
an angioma involving the triceps and anconeus. I removed 
a large cavernous angioma that occupied the connective 
tissue between the greater and lesser pectoral muscles of a 
woman aged 40. Clinically it resembled a tumour of the 
breast. 

In the heart primary tumours of any kind are rare. Rau 
described an angioma as big as a cherry that occupied the 
wall of the right auricle at the margin of the fossa ovalis of 
a man aged 58 ; and Manifold described one that grew from 
the fossa ovalis. (See p. 4.) 



ANGIOMA OF THE LARYNX 

Cavernous angiomas are of very rare occurrence in the 
larynx. They have been observed springing from the vocal 
cord (Kidd, Mollison), the ventricular band, the ventricle, 
and in the sinus pyriformis. Usually such tumours are 
sessile, but they are occasionally pedunculated ; they may 




Fig. 87. Cavernous angioma of the palm of a man aged 25. E.A., Eadial artery. 
IT. A., Ulnar artery. (Museum of the Royal College of Surgeons.') 

be bright-red or purple. Laryngeal angiomas may be 
smooth, or nodulated like a mulberry ; they are rarely 
larger than a haricot bean. The colour of these tumours 
is the most striking clinical feature. 

Salivary glands, especially the parotid, are liable to 



PLEXIFORM ANGIOMA 171 

capillary angiomas, remarkable from the pathological and 
interesting from the clinical point of view. The cases have 
been collected and skilfully reviewed by Shattock. 

Extremely rare situations for a cavernous naavus are 
the subperitoneal tissue (Lane) ; the synovial membrane of 
the knee-joint, simulating tuberculous disease of that joint 
(Eve); and the pelvis of the kidney (Swan). 

The liver is not an unusual situation for cavernous 
use vi of small size. Nsevi are not uncommon in the livers 
of cats and feline mammals in general, but they appear to 
be harmless tumours. It has been suggested that some 
angiomas of the liver are splenic rests (Berard). 

The brain is an unusual situation for a cavernous angioma, 
but such a tumour has been observed and described in the 
temporo-sphenoidal lobe of the brain of a boy (an idiot) 
aged 8 (Dobson), and in the left second and third frontal 
convolutions of a woman aged 45 (Sweasey Powers). 

3. Plexiform angioma. The angiomas which will be 
included under this denomination are those usually desig- 
nated "aneurysms by anastomosis," or "cirsoid aneurysms." 
The former term appears to have been introduced by John 
Bell, but the expression " aneurysm by anastomosis " has 
come to be used so vaguely that its suppression is a matter 
of necessity. 

A plexiform angioma consists of a number of abnormal 
blood-vessels of moderate size arranged parallel to each 
other, as in the rete mirabile of the fore-limb of the sloth 
or the tail of a spider monkey. Such angiomas may 
consist of arteries only (arterial retia), or of veins (venous 
retia), or of arteries and veins in equal proportions (duplex 
retia). In some the vessels are very tortuous, a disposition 
more common with arteries than veins. Tortuous vessels 
are not infrequent in retia for example, the arterial retia 
in the intercostal spaces beneath the pleura of cetaceans, 
and the rete in the pituitary fossa of oxen and sheep ; and 
the renal glomerulus. 

Plexiform angiomas are very rare; the largest that has 
come under my notice occurred in the perineum of a lad 
aged 19 : the corpus spongiosum was surrounded by a num- 
ber of arteries as large as the coronary branches of the facial, 



172 PLEXIFORM ANGIOMA : TREATMENT 

and veins as big as the cephalic. The arrangement resembled 
that of a duplex rete. 

Miiller has recorded the clinical history and an account 
of the subsequent dissection of an unusual example of 
plexiform angioma. The patient, a man aged 20, stated that 
his parents noticed a red spot on the left half of the forehead 
when he was a year old ; this gradually increased in size, 
and at the age of 12 it had become an obvious tumour. 
When he was 16 it not only grew rapidly but began to 
" buzz." Four years later the tumour exhibited all the char- 
acters of a plexiform angioma, the pulsation being attended 
by a whirring sound. P. Bruns ligatured the right external 
carotid and the left common and external carotid. The 
patient became hemiplegic on the second, and died on the 
third day after the operation. Death was due to embolism 
and thrombosis of the left middle cerebral artery. The 
parts were injected and dissected (Fig. 88); the angular 
arteries were large and very tortuous. 

Plexiform angiomas occur in connexion with the cere- 
bral arteries. They have been observed on the surface of 
the right anterior lobe of the cerebrum, fed mainly by 
the anterior and middle cerebral arteries. In two cases 
reported by Drysdale, one patient was a lad aged 17, 
and the other a woman aged 26. The woman was an 
epileptic. In another patient, a man aged 20, the angioma 
was situated over the angular gyrus : the patient died from 
haemorrhage from the tumour, which produced the typical 
signs of pressure on the motor region of the cortex (D'Arcy 
Power). A plexiform angioma arising in the posterior spinal 
vessels, in the region of the ninth and tenth thoracic vertebrae, 
caused symptoms referable to a spinal tumour (Elsberg). 

Treatment. Naevi come under observation almost daily ; 
in such cases it is usual to watch the patients in order to 
ascertain whether the naevi are growing or not : many naevi 
disappear ; but when they become active and grow, they 
need prompt treatment. No method is so safe and effectual 
as excision, whenever it can be carried out, remembering 
always to cut the ncevus out, not cut into it. This method 
is preferable to treatment by electrolysis, nitric acid, ethylate 
of sodium, or the ligature. The chief reason for excising 



PLEXIFORM ANGIOMA: TREATMENT 173 

nsevi when they evince signs of activity is to prevent them 
from assuming such proportions as to pass beyond the 
limits of justifiable surgery. Many examples have been 
recorded in which a nsevous fleck in an infant has become 
a formidable tumour in the adult. The nsevi known as 
"stains" disappear under the influence of radium and 
nitrous-oxide snow. 




Fig. 88. Dissection of a plexiform angioma of the forehead. 
(H. Mutter.} 

In the treatment of plexiform angiomas, each case 
exhibits special features which will modify the operation, 
and the particular method employed will depend on the 
enterprise, experience, and skill of the surgeon in charge 
of the case. Several cases of plexiform angioma of the 
limbs have been recorded in which it has been necessary 
to resort to amputation. The operative difficulties and 
dangers in connexion with large plexiform angiomas of the 
head and orbit are very great. 



174 LYMPHANGIOMAS 

Lymphangiomas. These have the same relation to 
lymphatics that an angioma bears to haBmic capillaries. 
There are three species of lymphangiomas : 1. Lymph- 
atic nsevus. 2. Cavernous lymphangioma. 3. Lymphatic 
cyst. 

1. Lymphatic naevus. This species of lymphangioma 
is, as a rule, colourless, but when it contains a fair 
number of h&emic capillaries, then the nsevus appears as 
a pale pink patch slightly raised above the level of the 
surrounding skin. When composed entirely of lymphatics 
it is yellowish-white ; when it is pricked, lymph (sometimes 
mixed with blood) issues from it. Occasionally several 
naevi occur in the same individual; they vary greatly in 
size some are as small as shot, others may have a 
diameter of 2 cm. or more. In many instances they are 
noticed a few months after birth ; occasionally they seem 
to be acquired. This is probably explained on the ground 
that during infancy they are small, and their want of 
colour saves them from detection until their increase in 
size later in life makes them conspicuous. Lymphatic nsevi 
may occur in the skin on any part of the trunk or limbs, 
and they have been especially studied in the mucous mem- 
brane of the tongue and lips. 

In connexion with the tongue the affection may be 
localized to a definite area and give rise to a lingual 
lymphangioma; this takes the form of a pale-pink papilla, 
or clusters of smooth papillse, projecting from the mucous 
membrane. Sometimes one half of the dorsum of the 
tongue will be beset with small rounded bodies consisting 
of clusters of dilated lymphatics. 

There is a very rare disease of the tongue to which 
the name macroglossia is applied. Clinically the condition 
manifests itself as a congenital enlargement of the tongue 
implicating mainly its anterior two-thirds. As the child 
grows the tongue increases so disproportionately that the 
mouth accommodates it with difficulty, and at last the 
tip of the organ protrudes from the mouth and, in severe 
examples, becomes so big as to extend far beyond the 
margins of the lips (Fig. 89). 

The increase in the size of the tongue is not due to 



LYMPHANGIOMAS 175 

an overgrowth of its muscular substance, but is caused, as 
Virchow pointed out, by the formation of a lymphangioma 
in connexion with the lingual mucous membrane. 

Recent observations have shown that there is another 
cause of macroglossia, namely, plexiform neuroma affecting 
the lingual and hypoglossal nerves (p. 155). 




Fig. 89. Macroglossia in a girl aged 11. (Humphry.} 

2. Cavernous lymphangioma. This species in its naked- 
eye characters resembles a lymphatic nsevus, but on micros- 
copical examination it will be found to be identical in 
structure with the cavernous neevus, with the difference 
that its cavities are filled with lymph instead of blood. 

Treatment of lymphangiomas, This is conducted on 
the same lines as for angiomas. In the case of macroglossia, 
excision of the enlarged and protruding parts of the organ 
has been followed by permanent good consequences. 



176 



LYMPHATIC CYSTS 



3. Lymphatic cyst. This appears as a congenital swelling 
in the neck, axilla, and adjacent parts of the thoracic wall ; 




Fig. 90. Child with a lymphatic cyst on the side of the thorax, which 
probably arose in an angioma. 

it was formerly classed under the title " hydrocele of the 
neck." 



LYMPHATIC CYSTS 177 

Lymphatic cysts are easily recognized. They are always 
congenital ; even at birth they are sometimes of very large 
size, and exhibit a- preference for the anterior triangle. In 
some instances they extend into the axilla and superior 
mediastinum, or project into the posterior triangle. Their 
upward limit is, as a rule, indicated by the hyoid bone, 
but they have been known to reach as high as the parotid 
gland. The cyst may be unilateral or bilateral ; it may 
consist of a single cavity, or be rnultilocular with intercom- 
munication between the various chambers. In size the cysts 
vary greatly : some equal a fist, others are bigger than the 
head of the patient. When the walls of the cyst are thin and 
the overlying skin is stretched, the tumour is as translucent 
as a thin- walled hydrocele of the tunica vaginalis testis. 

These cysts originate below the deep cervical fascia, 
but a portion may make its way through this membrane 
and become subcutaneous. A remarkable fact in connexion 
with them is the tendency they exhibit to shrivel and 
disappear ; they are exceptionally liable to inflame, and 
several cases have been recorded in which the cyst has 
been ruptured and cured by the child falling upon it. Their 
proneness to spontaneous cure explains the rarity of such 
cysts after puberty. 

It has been many times observed that the spontaneous 
effacement of these cysts is preceded by a sudden increase 
in their size ; they become hot and tender, and pass into a 
state of inflammation, and as this subsides they slowly 
disappear. 

The walls of lymphatic cysts are often composed of tissue 
so vascular as to merit the term nsevous ; it is probable that 
some of them have arisen in large cavernous nsevi which 
have been converted into cysts (Fig. 90). 

It is important to remember that lymphatics are often 
abundant in the ordinary forms of cavernous nsevi. It is 
also a fact of some interest that a lymphatic cyst in the 
neck and well-marked macroglossia may coexist. 

Barker, A. E., " Cavernous NEGVUS of the Rectum proving Fatal, in an Adult, 
from Haemorrhage." Med.-Chir. Trans., 1883, Ixvi. 229. 

Barker, A. E.,"A Case of Macroglossia, so-called Lymphangioma Caverno- 
sum." Trans. Path. Soc., 1890, xli. 77. 
M 



178 REFERENCES 

Bland-Sutton, J., '-' A Case of Erectile Tumour of the Male Breast." Trans. 
Clin. Soc., 1889, xxii. 187. 

Bland-Sutton, J., " Spolia opima." Brit. Med. Journ., 1918, i. 593. 

Dobson, Margaret B., "A Cavernous Angioma of the Temporo-Sphenoidal Lobe 
of the Brain." Ibid., 1907, ii. 144. 

Drysdale, J. H., " Angioma Arteriale Eacemosum : two cases." Trans. Path. 
Soc., 1904, Iv. 66. 

Elsberg, C. A., "Experiences in Spinal Surgery." Surg. , 6yn.,and Obstet., 
Chicago, 1913, xvi. 117. 

Fitzwilliams, D. C. L., "The ^Etiology of Nsevi." Brit. Med. Journ., 1911, 
ii. 489. 

Humphry, G. M., "Hypertrophy and Prolapse of the Tongue." Med.-Chir. 
Trans., 1853, xxxvi. 113. 

Image, W. E., "A Case of Enlargement of the Left Mamma. To which is 
added an Anatomical and Pathological Description of the Tumour by 
T. G. Hake, M.D., and W. E. Image." Communicated by Robert Listen, 
F.R.S. Ibid., 1847, xxx. 105. 

Kidd, Percy, " Cavernous Angioma of the Larynx." Trans. Clin. Soc.Lond., 
1892, xxv. 307. 

Lane, W. A., " A Case of Extensive Nsevus of the Peritoneum." Ibid., 1893, 
xxvi. 5. 

Manifold, R. F., "Cavernous Angeioma in the Wall of the Left Auricle." 
Lancet, 1915, ii. 102. 

Mollison, M. M., "Hoarseness." Clin. Journ., 1921, 1. 244. 

De Morgan, Campbell, " Remarks on some Cases of Vascular Tumour seated 
in Muscle." Brit, and For. Med. and Chir. Rev., 1864, xxxiii. 187. 

Mtlller, H., "Bin Fall von arteriellem Rankenangiom des Kopfes." Beit. 
z. Wn. Chir., 1892, viii. 79. 

Nicory, C., and Shattock, S. G., "Capillary Angiomatosis of the Parotid Gland." 
Brit. Journ. of Surg., 1921, viii. 481. 

Power, D'Arcy, "Angioma of the Cerebral Membranes." Trans. Path. Soc., 
1888, xxxix. 4. 

Powers, W. J. S., " Ein Fall von Angioma cavernosum des Gehirns." Zeit. f. 
die gesammte Neurologic und Psychiatrie, 1913, xvi. 487. 

Rau, F., " Casuistische Mittheilungen von der Prosectur des Katharinenhos- 
pitals in Stuttgart (Cavernoses Angiom im rechten Herz-Vorhof)," 
Virchow's Arch. /.path. Anat., 1898, cliii. 22. 



CHAPTER XVI 
UTERINE FIBROIDS 

FIBROIDS of the uterus are common tumours, and often cause 
much trouble to women, whether married or single, barren 
or fertile. Fibroids have no parallel among tumours in this 
important feature they only arise in the uterus during 
menstrual life. After the cessation of menstruation many 
cease to grow, and some diminish in size. The growth, 
development, and atrophy of uterine fibroids so closely follow 
the natural development and atrophy of the uterus that it is 
worth while briefly to review some points in the natural 
history of the organ which acts as host to these remarkable 
tumours. Until the advent of puberty the uterus is function- 
less ; on the establishment of menstruation it becomes the 
seat of regular monthly change, interrupted occasionally by 
pregnancy, which alters its rhythm from a period of 28 days 
to one of 280 days. This change is accompanied by an extra- 
ordinary alteration in the condition of the uterus, for previous 
to conception it is in shape somewhat like a compressed fig, 
7*5 cm. long and 2 '5 cm. thick. In the middle of the organ 
there is a cleft known as the cavity of the uterus ; the 
anterior and posterior walls of the normal unirnpregnated 
uterus are in contact. This cavity, from the os uteri to the 
fundus, measures 6*5 cm., and the whole organ weighs 2 to 
8 oz. At the end of pregnancy a uterus is 32'5 cm. long ; the 
walls are nearly 1'5 cm, thick; it weighs 2 to 3lb.; and the 
capacity of the uterine cavity varies from 1 to 1^ gallons. 
These weights and measurements afford some notion of the 
great changes produced in the uterus by pregnancy. In the 
uniinpregnated condition the uterus is sheltered in the pelvis ? 
its fundus reaching to the level of the pubic symphysis, but 
as pregnancy advances it ascends into the abdomen and be- 
comes the most conspicuous organ in this cavity, and liable, 

179 



i8o DISTRIBUTION OF FIBROIDS 

in consequence of its size, to external violence. At the ter- 
mination of a successful pregnancy the uterus in a few weeks 
returns to nearly the virgin size. 

When the capacity for child-bearing ceases, menstruation 
gradually stops; about the forty-eighth year the uterine 
tissues atrophy, and in old age the uterus becomes small 
and flattened. At the sixtieth year it may be only half the 
size of its representative in a virgin of 16, and in extreme old 
age weigh only half an ounce. 

In considering the behaviour of the uterus when it is 
occupied by fibroids, it is helpful to keep in mind the changes 
produced in it by pregnancy, for the gradual increase in size, 
the efforts made by the uterus to extrude the tumours, and 
the changes which follow their extrusion are like those which 
ensue on normal pregnancy, parturition, and the puerperium ; 
moreover, they are attended with similar complications and 
dangers. 

The distribution of fibroids in the uterus. Although 
the uterus is an organ with no sharp divisions between its 
various parts as mapped out by anatomists, it is convenient 
to use their arbitrary boundaries for descriptive purposes. 
Fibroids arise in any part of the uterus, but they are more 
common in the body of this organ than in its neck, and they 
sometimes grow in the uterine ligaments. 

Fibroids that grow from the body of the uterus are, for 
clinical purposes, divided into three sets intramural, sub- 
mucous, and subserous (Fig. 91). The distinction between 
the three sets is arbitrary, but useful, especially in relation to 
subserous and submucous tumours. The fate of subserous 
fibroids is intimately bound up with the age-changes of the 
uterus. The changes in submucous fibroids are chiefly influ- 
enced by the function of the uterus ; and the natural history 
of a cervical fibroid corresponds to that of the neck of the 
uterus. 

Fibroids arise as solid knots in the tissue of the uterine 
wall, and at a very early stage are enclosed in a vascular 
capsule from which they receive their blood supply. In the 
earliest stages they are round like mustard-seed; when the 
uterus is divided, these rounded bodies are often bisected 
and appear in sections like split peas, and, being pale-yellow 



UTERINE FIBROIDS 



181 



or white, stand out in contrast to the redness of the uterine 
tissue in which they are embedded. It is probable that the 
majority of fibroids which arise in the body of the uterus, or 
its neck, are at first intramural, and as they increase in size 
some remain intramural, but others bulge outwards into the 




Fig. 91. Uterus in sagittal section, showing intramural and submucous 
fibroids. Of the intramural set, one is shown in section, one de. 
prived of its capsule, and one is an empty capsule. One of the 
submucous set is extruded through the mouth of the uterus. 

peritoneal cavity and become subserous, or project into the 
uterine cavity and become submucous fibroids. 

Fibroids growing near the uterine cavity tend to invade 
it, and such submucous tumours acquire an investment of 
endometrium, and, as will be shown later, some of them pro- 
duce effects in the shape and disposition of the uterus like 



182 



UTERINE FIBROIDS 



those accompanying pregnancy. A uterus may contain one 
fibroid ; as a rule, several are present : a dozen or even a score 
may be counted. I have seen 140 fibroids in a uterus ; the 
tumours varied in size from a dove's egg to that of a duck- 
There is no limit to the number or size of fibroids; as 
a rule, when numerous they remain small or of moderate 
dimensions. A solitary fibroid has been reported to weigh 
100 Ib. ; one weighing 30 Ib. is a formidable tumour. When 
multiple, some may be intramural, others subserous, and one 




Fig. 92. Fibroid of the left broad ligament. The uterus rests upon but 
is not involved in the tumour. A process of the fibroid bulges 
between the ovary and the tube. The right ovary is cystic. From 
a married woman aged 52. 

or more submucous. It is also to be borne in mind that 
the complications produced by the three varieties differ in 
many important particulars, especially the manner in which 
they distort the uterus. Each variety requires consideration. 
Fibroids which arise in the neck of the uterus (cervix- 
fibroids) demand a special chapter. The term extra-uterine 
fibroids may be applied to those that arise in the tissues of 
the broad (Fig. 92), round (Fig. 93), and utero-sacral liga- 
ments. Fibroids grow in double uteri (Fig. 94); also from 



STRUCTURE OF FIBROIDS 183 

the rudimentary horn of the so-called unicorn uterus, and in 
the uterus of a pseudo-hermaphrodite. A bifid uterus is 
more liable to fibroids than one of normal shape. Disease 
makes distinctions where anatomists fail to discern them. 
Fibroids are unknown in the Fallopian tubes. 

Structure of fibroids. These tumours differ much in 
texture ; many are hard like cartilage, others tough as 



Ovary. 



Tube. 



Round 
ligament. 




Fig. 93. Fibroid growing from the round ligament. (Natural size.) 

leather. A completely calcified fibroid resembles pumice, 
and some are as soft as jelly. Between these extremes every 
degree of hardness or softness occurs, and the differences in 
texture account for the variety of names applied to them. 

The typical tumours consist of tissue like that of the 
uterus ; thus they contain smooth muscle-fibre and a small 
proportion of connective tissue, the whole being surrounded 
by a fibrous capsule in which blood-vessels ramify. A tumour 



LIPOMATOUS FIBROIDS 

of this type of structure is a myoma, and will have the same 
consistence as the walls of an unimpregnated uterus. When 
the muscle-tissue is largely mixed with fibrous tissue the 
tumour is called a fibromyoma ; it will be very dense and 
display on section a peculiar whorled appearance, due to the 
arrangement of the tissue in bundles running in different 
planes ; the centre of each whorl is usually occupied by a 
blood-vessel. The very soft tumours are composed of tissue 
like that of the common nasal polypus such are called 
myxomas ; when the only solid part of the tumour is its 




Fig. 94. Cornua of a bicornate uterus in section ; 
each cornu contains an intramural fibroid. 
From a woman aged 32. 

capsule, and the contents are gelatinous and structureless, it 
is called a fibrocystic tumour. Even among the moderately 
firm encapsuled tumours of the uterus there is difficulty in 
deciding between a myoma and a fibromyoma. A method 
is needed for the detection of the most dangerous of all 
the varieties, the sarcomatous fibroid, for an encapsuled 
tumour occasionally arises in the uterus with naked-eye and 
microscopic characters like a simple fibromyoma ; such a 
tumour sometimes recurs rapidly after removal, disseminates, 
and quickly kills the patient. 

Lipomatous fibroids. The museum of the Koyal College 
of Surgeons contains a submucous fibroid as big as a turkey's 
egg, in which the myomatous tissue is almost entirely re- 



SARGOMATOUS FIBROIDS 185 

placed by fat (see also p. 25). I removed a degenerate 
fundal fibroid from a spinster aged 67: the tumour consisted 
mainly of fat ; there were cystic spaces in it containing fluid 
sparkling with cholesterin. 

Sarcomatous fibroids. The uterus may contain a score 
of fibroids, some hard, some soft, and others calcified; on 
rare occasions a typical spindle-celled sarcoma will be found 
among them. It is for this reason preferable to classify them 
under the generic term fibroids. The differences in the tex- 
ture of fibroids are usually ascribed to degenerative changes. 
Some surgeons believe that a sarcomatous change may arise 
in uterine fibroids ; I do not share this opinion, preferring to 
believe that many tumours reported as fibroids which have 
undergone sarcomatous degeneration were in all probability 
sarcomatous from the beginning. They should be called sar- 
comatous fibroids : for a sarcoma will sometimes arise in a 
uterus already occupied by common hard fibroids, and mock 
all the clinical varieties, appearing as a submucous polypus 
protruding at the mouth of the womb ; as an interstitial 
tumour; or as a subserous fibroid with a thin stalk. 

A comprehensive study of the question indicates that 
sarcomas may arise in the tissue of the uterus during intra- 
uterine life, infancy, and at any period up to extreme 
old age, but in comparison with the common fibroid they 
are fortunately rare tumours. They agree in structure with 
sarcomas arising in other organs, and consist of round cells, 
oat-shaped cells, or spindle cells. A sarcomatous fibroid 
occurs usually as a solitary tumour in the uterine wall, it is 
enclosed in a capsule, and consists of compact tissue resem- 
bling that of a hard fibroid. In many instances both the 
naked-eye and the microscopic characters of a sarcomatous 
fibroid clearly pronounce malignancy, but some are so like 
the common innocent fibroid that, with our present methods, 
it is impossible to distinguish between them, and the malig- 
nancy of the tumour is not suspected until the patient comes 
under observation with signs of local recurrence. 

Sarcomas of the uterine Avail are rare before 40, and are by 
no means infrequent after the menopause, so that a solid 
tumour arising in the uterus of a woman over 50, and 
especially if it grows quickly, is sure to be regarded with 



i86 



MYOSARGOMA 



suspicion. As a rule, such a tumour resembles in its clinical 
features a rapidly growing ovarian tumour. 

Keference has been made (p. 35) to the occurrence in 
the uterus of the variety known as myosarcoma, in which the 




Fig. 95. Uterus in section ; it is occupied by a yellow, pulpy, sarcoma- 
tous fibroid composed mainly of round cells. The tumour is nowhere 
encapsuled, and invades the uterine wall. From a woman aged 40. 

spindle cells are transversely striated. It is a rare tumour, and 
occurs at any age, the recorded extremes being 2J and 75 
years. The physical signs are indistinguishable from those 
associated with an infected fibroid. The nature of the 
tumour can only be determined by a microscopic examina- 



SARGOMATOUS FIBROIDS 187 

tion, and the transverse striation is not easy to demonstrate- 
Myosarcoma of the uterus is especially malignant, and the 
operative removal of the tumour attended with unusual risk ; 
and of those who survive operation life is rarely prolonged 
more than two years. (Blair Bell and Glynn.) 

There are very few complete records of uterine sarcomas, 
complete in the sense of furnishing an account of the minute 
structure of the tumour and the subsequent history of the 
patients who survived operation. Sarcomas are so prone to 
disseminate that a woman dying of such a tumour in the 
uterus would be expected to have secondary nodules in the 
lungs. 

Sarcoma of the endometrium also assumes a polypoid 
form, and protrudes through the os ; this is removed, and a 
few weeks later another polypus is extruded; then a more 
thorough investigation is made, and the true nature of the 
trouble is appreciated. Here histology fails us, for it is often 
difficult to decide whether the tissue of an oedematous polypus 
extruded from the uterus is innocent or malignant, especially 
when, as is frequently the case, the tissues are septic and 
invaded by exudation products. It occasionally happens that 
the surgeon removes a soft pedunculated growth from the 
endometrium of the cervical canal, which he lightly regards 
as a septic polypus. In a few weeks the patient returns on 
account of the continued bleeding; an examination is made, 
and, distressed to find the cervix converted into a hard, 
resistant, nodular mass, which bleeds freely on examination, 
he realizes that he has to deal with a sarcomatous uterus. 

In general terms it may be stated that the common age 
for sarcoma is from 40 to 60, and women who have had 
children are more liable to it than those who are barren. The 
leading signs of this disease are bleeding from the vagina, 
purulent discharge, and pain ; haemorrhage, the predominating 
sign of all malignant uterine growths, is due to the invasion 
of the tumour by pathogenic micro-organisms. Death in the 
majority of cases is due to septic poisoning. In a few life is 
prolonged sufficiently to allow of generalization of the growth. 
Then secondary deposits occur in the abdomen and in the 
lungs. The only treatment available is early and complete 
removal of the uterus. Unfortunately it is rarely successful. 



r88 



AGE-CHANGES IN FIBROIDS 



No uterine operation is attended with so little success as 
hysterectomy for sarcoma. 

Lymphatics. It is not uncommon, when removing large 
fibroids, to find huge lymph -vessels in the broad ligaments. 
Sometimes a firm fibroid will present on section irregular 
tortuous channels (Fig. 96). These are probably lymph- 
spaces. Polano finds that such spaces can be filled with fluid 
injected into the lymphatics issuing from the uterus. 




f 

Fig. 96. Body of uterus in coronal section, showing a large fibroid 
traversed by narrow tortuous canals probably lymph-spaces. 

Age- changes in fibroids. The texture of fibroids is in a 
measure an indication of their age. Old fibroids undergo two 
remarkable changes. Some become intensely hard and are 
often calcified ; this happens to the subserous and submucous 
varieties especially, but it may occur in any kind of fibroid 
uterine, mesometric, or ovarian. The subserous fibroid is 
especially liable to soften, its tissues becoming gelatinous. 

In general terms it may be stated that soft fibroids grow 
quickly and the hard varieties slowly. When a hard tumour 
degenerates and softens it will occasionally increase in size 
very rapidly. 



CALCIFIED FIBROIDS 189 

Calcification in a tumour is a sure indication that it has 
existed many years. This change, rare before 40, occurs in 
two forms. In some tumours the capsule calcifies and en- 
closes the fibroid in a more or less complete shell ; fibroids 
in this condition are dead, and on section exhibit the dirty 
yellow appearance of chamois leather and equal it in tough- 
ness. In such a case the uterus may be described as the 
grave of the fibroid. When the proper tissue of a fibroid 
calcifies, the earthy matter is not deposited in an irregular 
manner, but follows the disposition of the fibres, and their 
whorled arrangement is obvious on the sawn surface of such 




Fig. 97. Calcified uterine fibroid in section. (Museum of the Middlesex 

Hospital.} 

a tumour (Fig. 97). When incompletely calcified fibroids 
are macerated, the material that remains is a coherent skele- 
ton of the tumour. This sometimes happens during life. A 
submucous fibroid in an old woman is liable to become in- 
fected ; then the soft tissues slough, but the calcific skeleton 
of the fibroid is retained in the uterus. These are known as 
"womb stones." Calcified fibroids found in old burying- 
grounds have been mistaken for vesical calculi. Calcification 
in a fibroid can be detected by the use of the X-rays. 

Calcified fibroids sometimes cause trouble in unexpected 
ways. A spinster aged 72 was knocked down by a dog and 
fell forward on the pavement. She was seized with severe 
pain in the belly and died in thirty-four hours. At the 
autopsy a circular hole was found in a coil of ileum which 



CALCIFIED FIBROIDS 

lay between the anterior abdominal wall and a big calcined 
fibroid. (Arnott.) 

A spinster aged 44, cycling along the sea-wall at Ryde, 
rode over the edge of the wall and pitched on the sand 
5 feet below. Some hours afterwards there were signs of 
severe internal injury. Coeliotomy was performed. The 
belly contained free blood, and the surgeon found a calcified 
subserous fibroid, as big as a foetal head at term ; the 
capsule of the tumour had been torn near its attachment 
to the uterus, hence the bleeding. He removed the 
tumour with good consequences. (Turner.) 

A large calcified submucous fibroid partially extruded 
from the uterus is a troublesome body to extract if too large 
to be removed entire. Patience and ingenuity in such cir- 
cumstances will often overcome the difficulty, although the 
scalpels will be blunted and notched. 

A calcified fibroid may become impacted in the pelvis 
and cause retention of urine. I have known this happen in a 
septuagenarian. Such hard tumours may rotate, and also 
adhere to the small intestine and cause fatal obstruction. 

It was formerly imagined that a calcified fibroid was a 
harmless possession ; the few facts mentioned show that 
such tumours, even in senescence, are occasionally dangerous 
to life. 

Nothing is known in regard to the cause of uterine 
fibroids, but it has been discovered that the hypophysis 
exerts a physiological influence on the uterus. It is known 
that this co-relationship is especially manifest during 
pregnancy (Chap. LII), A fibroid in a uterus is a more en- 
during form of physiological unrest than pregnancy. 

Multiple uterine fibroids may be caused by glandular 
disturbance of the hypophysis, and stand in the same 
category as obesity, diaphysial aclasis, and neurofibro- 
matosis. 



CHAPTER XVII 
UTERINE FIBROIDS (continued) 

SUBSEROUS FIBROIDS 

FIBROIDS growing in the uterine wall near its peritoneal 
covering project on the anterior or the posterior wall; those 
which grow from the side of the uterus push between the 
layers of the broad ligament. This difference in position 
leads to a variation in the relation of the tumours to the 
peritoneum ; those which grow from the anterior or the pos- 
terior surface receive an investment from the overlying serous 
membrane and tend to become pedunculated, and, as they 
are often multiple, it is possible in one uterus to study 
various stages of the process by which subserous fibroids 
acquire stalks. There is great variation in the size of the 
peduncles, and they are independent of the size of the 
tumour. A fibroid the size of the fist may be connected to 
the uterus by a stalk an inch or more in length and half an 
inch or less in diameter. Such a pedicle confers great and 
dangerous mobility on the fibroid, for it allows the tumour 
to rotate on its axis and twist the stalk. Such a tumour 
can be incarcerated in the pelvis by a gravid uterus ; or a 
coil of small intestine may be entangled by it, causing 
fatal intestinal strangulation. The uterus is not enlarged 
by a pedunculated subserous fibroid, and it is odd to see 
such a tumour weighing many pounds attached to a uterus 
of normal size by a thin stalk. 

The biggest fibroids belong to the subserous variety, and 
many of the big tumours are pedunculated. The stalks of 
such fibroids are worth studying, as they greatly influence the 
condition of the tumour, for the blood supply passes through 
them. Some are so vascular that they resemble cavernous 
tissue (Fig. 98). When this is borne in mind, it is easy 

191 



I 9 2 



PEDUNGULATED FIBROIDS 



to understand that a larg f e mobile subserous fibroid, with a 
long peduncle, may have its nutrition interfered with when 




Fig. 98. Subserous fibroid and uterus in section, showing the vascu- 
larity of the pedicle. The tumour weighed 6 Ib. The uterus is 
of normal size. Removed from a spinster aged 40. 

the movements of the tumour lead to compression, or tor- 
sion, of the peduncle. For example, partial twists lead to 
venous engorgement of the tumour and extravasations of 



SUBSEROUS FIBROIDS 193 

blood because the veins are obstructed more easily than 
arteries, but complete torsion arrests the circulation in the 
arteries of the pedicle, and, if persistent, will starve the 
fibroid of blood and lead to quiet necrosis and atrophy. In 
a small fibroid with a thin pedicle torsion will sometimes 




Fig. 99. Pregnant uterus with subserous fibroids ; removed by operation. 
After the uterus had been removed, an incision was made in the uterine 
wall, and, as rigor mortis supervened, the embryo in its amnion was 
extruded. 

lead to its complete separation; indeed, a small fibroid 
detached in this way has been seen free in the pelvis. A 
subserous fibroid the size of a cricket-ball has been found 
completely detached from the uterus and adherent to the 
omentum. This admits of another explanation (see p. 230). 
On the whole, the troubles caused by subserous fibroids 

N 



I 9 4 



TORSION OF THE UTERUS 



are in the main mechanical, and it is in this aspect that 
they interfere with the functions of the uterus. A subserous 
fibroid does not disturb menstruation nor hinder conception 
(Fig. .99), but if it grows near the neck of the uterus it may 




Fig. 100. Sessile subserous fibroid which had undergone axial rotation 
involving the uterus and appendages in the twist. From a spinster aged 67. 

become impacted under the promontory of the sacrum and 
form an effectual bar to delivery. 

Rotation of fibroids occurs in two forms : A pedunculated 
fibroid may twist its stalk, but when rotation occurs in a 
sessile subserous fibroid the uterus serves as a pedicle ; 
such a movement is facilitated when the supravaginal 



ROTATION OF FIBROIDS 

cervix is long and narrow. In some specimens the neck 
of the uterus has been tightly twisted and reduced to the 
dimensions of a quill at the point of greatest torsion. Thus 
we must distinguish between torsion of the pedicle of a 




Fig. 101. Same specimen as iii preceding figure. The tumour is shown 
in section and the pedicle is untwisted 

fibroid and torsion of the uterus ; in the latter condition 
the ovaries, tubes, and ligaments are involved in the twist 
(Figs. 100 and 101). 

The accident in either form is rare. Schultze collected the 
cases to 1906. Axial rotation of an ovarian cyst with a short 
pedicle will sometimes involve the uterus (see Chap. LVIII). 



ig6 SUBSEROUS FIBROIDS 

When the uterus is enlarged by fibroids of the intra- 
mural (interstitial) or submucous varieties it is rare to 
find it adherent to the surrounding viscera ; indeed, the 
uterus exhibits the same relationship in this respect to 
the abdominal organs as when it is pregnant. Subserous 
pedunculated fibroids, on the other hand, often contract 
adhesions to the intestines, mesentery, and especially the 
omentum, and 1 have found a large fibroid of this kind 
firmly adherent to the liver. It is. however, the adhesions 
to the omentum which are important. When a large sub- 
serous fibroid adheres to the omentum, and especially if the 
stalk of the tumour be narrow, the epiploic arteries, veins, 
and lymphatics increase enormously in size. Some of the 
arteries are as big as the radial and very tortuous ; the 
veins are proportionate in size to the arteries; the lymph- 
atics are conspicuous, some being equal in size to the 
median cephalic vein, and filled with straw-coloured fluid. 
The contrast of the maroon tint of the blood in the arteries, 
the deep blue of the engorged veins, and the pale-yellow 
tint of the lymphatics forms an anatomical picture not 
likely to be forgotten by surgeons who have had to remove 
tumours where these conditions existed. 

In the patients who have come under my care with 
a complex rete mirabilis of this kind the tumour impli- 
cated was always of the subserous variety. Each patient 
also furnished a history of a troublesome miscarriage or 
labour which was followed by a tedious convalescence. In 
some the Fallopian tubes were in the condition known as 
hydrosalpinx sure sign of antecedent sepsis. It is a fair 
inference that the termination of the pregnancy in such 
cases was followed by septic peritonitis which involved the 
tumour and led to adhesions between it and the omentum. 
These adhesions became vascularized from the omental 
vessels, and eventually a free anastomosis arose between the 
vessels in the capsule of the fibroid and the epiploic arteries 
and veins. In nulliparous women the adhesions may be the 
legacy of a gonorrhceal peritonitis. 

The veins on the surface of a big subserous fibroid are 
sometimes large and conspicuous. Severe bleeding into the 
belly happens when one bursts spontaneously or from 



SUBSEROUS FIBROIDS 197 

accident. For example, a spinster aged 43 fell heavily on 
an asphalted walk and felt severe pain in the belly. An 
operation was performed, and a pedunculated fibroid weigh- 
ing 6 Ib. removed. The bleeding came from a vein on the 
surface of the tumour: it had been lacerated by the fall. 
(Littler.) 

Intraperitoneal bleeding from laceration and rupture ol 
veins on the surface of fibroids is an extremely rare acci- 
dent. The history of some of the cases shows that the life 
of a woman from this cause may be gravely imperilled, 
and some women have been saved from bleeding to death 
by prompt surgical intervention. (Wallace.) 

Large subserous fibroids sometimes exert pressure on 
the veins at the brim of the pelvis. A spinster aged 43 
had a fibroid rising above the navel, and oedema of both 
legs, which had existed many weeks and kept her confined 
to bed; it was unassociated with cardiac, renal, or hepatic 
disorders, and appeared to depend on pressure in some form 
on the veins at the brim of the pelvis. Hysterectomy was 
performed ; after removal, the uterus, which contained 
several subserous and interstitial fibroids, weighed 20 Ib. 
On the posterior surface of the uterus there was a sessile 
tumour, the size of a tennis-ball, in such a position that 
it rested on the inferior vena cava, immediately above the 
junction of the iliac veins. This small tumour could do 
no harm, but the uterus, with its tumours resting on it, 
made the venous stasis fairly complete. The oedema dis- 
appeared within forty-eight hours of the operation. 

Littler, R. M., "Rupture of Uterine Myoma, due to a fall, with Intraperi- 
toneal Haemorrhage." Journ. Obstet. and Gyn. Brit. Empire, 1910, xvii. 
423. 

Schultze, B. S., " Die Axendrehung (Cervixtorsion) des myomatosen Uterus." 
SoMimlung ltlin. Vort., Leipzig, 1906, No. 410 (GynaJwL, No. 152, 
505-554). 

Wallace, A. J., " Intraperitoneal Haemorrhage in Cases of Fibromyomata of 
the Uterus." Journ. Obstet. and Gyn. Brit. Empire, 1910, xviii. 357. 



CHAPTER XVIII 
UTERINE FIBROIDS (continued) 

INTRAMURAL (INTERSTITIAL) AND SUBMUCOUS " 

FIBROIDS 

ALTHOUGH it is arbitrary to arrange fibroids arising in the 
walls of the uterus into intramural, submucous, and subserous 
sets, the division is useful because typical examples of these 
three topographical varieties of fibroids differ sufficiently in 
their effects on the uterus to justify the classification. 

An intramural fibroid, in addition to its capsule, is com- 
pletely invested by the muscular tissue of the uterine wall. 
The uterus may contain a solitary fibroid, or there may be 
many. Often when the uterus is occupied by a large fibroid, 
if the" organ be systematically sectioned, small fibroids will be 
found embedded in its walls. A fibroid growing in the wall of 
the uterus not only distorts it, but leads to hypertrophy of the 
uterine tissues, so that, apart from the tumour, the uterus is 
increased in size. For example, the normal uterus weighs 
about 2J oz. The uterus and tumours represented in Fig. 102 
weighed 80 oz. ; after enucleating the tumours the uterus 
weighed 16 oz. This increase in the tissue of the uterus is 
accompanied by increased vascularity, and helps to explain 
the troublesome bleeding that attends the operation of 
enucleation. 

A common condition is the presence of one fibroid in the 
posterior and another in the anterior wall of the uterus ; 
the slow simultaneous growth of paired fibroids of this kind 
leads to misplacement of the uterus in its efforts to find 
accommodation in the pelvis. When two fibroids occupy 
the uterus in this manner, so long as the antero-posterior 
diameter of the organ with its tumour does not exceed 
10 cm. it may occupy a normal position, but long before 

198 



TWIN FIBROIDS 

this measurement is attained the uterus has been tilted 
backwards, especially when the tumour in the posterior 
exceeds in size the fibroid in the anterior wall. As they 
increase in size, the anterior tumour attracts notice by 
causing a prominence in the hypogastrium ; the posterior 
tumour occupies the pelvis and is felt on vaginal exarnina- 




Fig. 102. Uterus containing twin fibroids. 

tion. Slowly and insidiously both increase in size until the 
available space in the pelvis is utilized; then turgescence 
of the uterus, the prelude to menstruation, leads to impac- 
tion, retention of urine, and discovery of the tumour. 

These dumb-bell-shaped uteri with twin fibroids are 
sometimes discovered in a dramatic fashion. Occasionally 
a woman marries in ignorance of the presence of tumours 
in her uterus, and in due course conceives (Fig. 103), for 
intramural, like subserous fibroids, neither interfere with 



200 



TWIN FIBROIDS 



menstruation nor hinder conception, but the increased vascu- 
larity of the uterus and its actual increase in bulk coinci- 
dent with the growth of the foetus and its placenta soon 
culminate in serious pelvic disturbances (see Chap. xx). 

When the tumours are big, the uterine cavity lies at 
right angles to its normal position. 




Fig. 103. Gravid uterus with twin fibroids; one fibroid was in the 
condition of red degeneration. The arrow lies in the cervical 
canal. From a woman aged 28. 

Intramural fibroids rarely calcify or become cystic, but 
their capsules calcify : this starves the tumours and causes 
them to become converted into yellowish tough stuff resem- 
bling chamois leather. They are liable to red degenera- 
tion, especially in association with pregnancy (see p. 223), 
but less prone to infection than the submucous kind. 
They do not influence menstruation, and are sometimes 



FLJNDAL FIBROIDS 



201 



so permeated with blood-vessels as to resemble cavernous 
nsevi. 

Fundal fibroids. -A large solitary intramural fibroid some- 
times occupies the fundus of the uterus, and when not too 
large it is apt to become impacted and lead to retention 
of urine (Fig. 104). I removed from a spinster aged 45 the 
uterus containing a large fibroid that had the usual appear- 







Fig. 104. Uterus in sagittal section with a globular intramural 
fundal fibroid. From a nullipara aged 45, in whom it frequently 
became impacted and caused retention of urine. 

ance of a fundal tumour. When the organ was hardened 
and divided it proved to be an intramural fibroid growing 
.between the horns of a bifid uterus (uterus bicornis uni- 
collis). Intramural fibroids also arise in a double uterus 
(Fig. 94). 

Latent fibroids. If a number of uteri be examined, from 
women between the twenty-fifth and fiftieth years, by the simple 
means of sectioning them with a knife, in a large proportion 
of them numerous small rounded fibroids resembling knots 



202 IMPACTED FIBROIDS 

in wood will appear, their whiteness being in strong contrast 
with the redness of the surrounding muscle-tissue. A uterus 
may contain ten or more of them without the least distor- 
tion of contour or alteration in size. These seedling fibroids 
may never cause trouble, never pass beyond this stage, and 
often calcify in old age ; but they may at any time grow and 
become formidable tumours. 

A careful consideration of the great frequency of seedling 
fibroids, and their multiplicity when compared with the num- 
ber of fibroids which attain a size sufficient to render them 
clinically appreciable, makes it undeniable that a large pro- 
portion of them remain latent. They may be compared to 
latent buds in trees (knurs) and plants : they may remain 
quiescent for a number of years and then assume active 
growth without any known cause. 

Latent fibroids have an important practical bearing ; it is 
not an uncommon experience for an operator to dilate the 
uterine canal and abstract two or more submucous fibroids. 
However carefully the procedure may be conducted, and how- 
ever thoroughly the walls of the cavity may be examined 
for minute fibroids, no honest assurance can be given to the 
patient that other fibroids will not grow. 

Impaction and its effects. A fibroid is said to be impacted 
when it fits the true pelvis so tightly that the tumour cannot 
rise upwards into the belly. All varieties of fibroids may 
become impacted. 

A solitary intramural fibroid may be small enough to rest 
in the true pelvis without pressing unduly on the urethra or 
ureters. Presently it increases to such a point that the 
turgescence which precedes the menstrual flow will cause it 
to stretch the urethra and lead to retention of urine. When 
menstruation occurs the turgidity of the tumour subsides, 
and the urethra is set free. Frequent recurrence of this 
pressure permanently damages the bladder and kidneys. 

When a woman between 35 and 45 years of age seeks 
relief because she suffers from retention of urine for a few 
days preceding each menstrual period, it is almost certain 
that she has a fibroid in her uterus. 

Incarceration of a fibroid. It is customary to use the 
terms impaction and incarceration as if they referred to the 



SUBMUGOUS FIBROIDS 203 

same condition. This is not the case. Impaction is, as a 
rule, slow, insidious, and painless, and occurs with interstitial 
and submucous fibroids. Incarceration is associated with 
pedunculated subserous fibroids, and it happens in this 
way: A woman with her uterus enlarged by pregnancy, or 
by a submucous fibroid, has a stalked subserous fibroid lying 
in the pelvis below the uterus; as the organ enlarges, the 
tumour is incarcerated by it and can be felt as a lump in 
the pelvis. Sometimes a tumour of this kind lies above 
the pelvic brim, but a jolt in getting out of a vehicle, or 
a slip when walking or in going downstairs, causes such 
a fibroid to slip below the uterus and become jammed 
between it and the pelvic wall. This is known as acute 
incarceration of a fibroid. 

It is useful and correct to make a distinction between 
impaction and incarceration, not only in relation to uterine 
fibroids, but also in regard to ovarian tumours. This use of 
the term is etyrnologically correct. A thing forcibly fixed 
is impacted, but when imprisoned, incarcerated. 

Submucous fibroids. When a fibroid arises in the 
uterine wall near the endometrium it tends to project into 
the uterine cavity. All fibroids in their early stages are 
sessile ; those growing near the endometrium receive a partial 
investment from it, and, as they increase in size, the contrac- 
tions of the uterus tend to push them more and more into 
the uterine cavity. The uterus endeavours to expel the 
growing tumour. The first result of this uterine action is 
the conversion of a sessile into a stalked or pedunculated 
tumour. At first the stalk is broad and short, then it 
lengthens and becomes thin or cord-like. When the ex- 
pulsive efforts are successful the tumour is extruded through 
the os uteri, the length of the stalk varying according to 
the position of the tumour : if it grows from the fundus the 
stalk is longer than when the fibroid grows in the neck of 
the uterus. A stalked fibroid, or polypus, is surrounded with 
endometrium, and the stalk consists of an axis of fibrous 
tissue containing blood-vessels, and a covering of mucous 
membrane. Often a fibroid will be so firmly embedded in 
the wall of the uterus that the contractions cannot detach it, 
but they mould the tumour, as it grows, to the shape of the 



204 



INVERSION OF UTERUS 



uterine cavity. As a submucous fibroid grows, the walls 
of the uterus thicken ; this adds to their expulsive power ; 
the cervical canal becomes shortened as the uterine cavity 
enlarges to accommodate the growing fibroid, and dilates in 
response to the contractions. In some instances, where the 
conditions are favourable, a sessile polypus at the fundus will 
become engaged in the cervix, and its attachments being 
too firm to allow of its detachment, the uterus is gradually 




Fig. 105. Partial inversion of a uterus due to a fibroid. 

inverted, and the fibroid, with the fundus uteri, appears in 
the vagina. (Fig. 105.) 

When many submucous fibroids are present, the con- 
tractions of the uterus and the mutual pressure of the fibroids 
mould their apposed surfaces ; gall-stones are faceted under 
similar conditions in the gall-bladder. When six or seven 
submucous fibroids are present, if the uterus be hardened 
and divided, the cut surface resembles a horizontal section 
through the wrist-joint, and the cut fibroids look like divided 
carpal bones. Twenty submucous fibroids is not an un- 
common number to find in one uterus. When numerous, 
they are invariably small ; some of them are no larger than 
mustard-seeds, and others may be as big as ripe gooseberries. 



SUBMUGOUS FIBROIDS 205 

The condition of the endometrium on these tumours is 
of interest. A conical fibroid, the size of a gooseberry, pro- 
jecting in the uterine cavity, will be invested with normal 
endometrium. If the tumour be extruded through the os 
uteri into the vagina the epithelium covering the fibroid 
becomes converted into squamous epithelium : this change 
in the shape only affects the surface epithelium ; that which 
lines the recesses not only remains columnar but retains its 




Fig. 106. Microscopic characters of the epithelium covering the protruded 
portions of a submucous fibroid; it shows the mutation of columnar 
ciliated into stratified epithelium as a result of pressure. (Gcrvis.) 

cilia (Fig. 106). If a woman with a submucous fibroid con- 
ceives, the endometrium investing the tumour takes its share 
in forming the decidua. When the uterus succeeds in ex- 
truding a fibroid, the stalk may become completely detached, 
but this is rare; usually the fibroid will be found hanging 
in the vagina. Although this spontaneous action is, in a 
measure, curative, the changes which sometimes occur in an 
extruded fibroid often lead to complications that place the 
patient's life in the gravest danger, and occasionally end in 
death. Moreover, the act of expulsion is accompanied with 



206 SEPTIC FIBROIDS 

haemorrhage ; when the tumour is large for example, as 
big as a fist the signs are like those accompanying a mis- 
carriage, for which I have known it to be mistaken. In 
such circumstances the bleeding is abundant and sometimes 
dangerous. Sepsis is the greatest danger to which extruded 
fibroids are liable; it is a serious complication even when 
it does not cause death. 

Infection of a fibroid arises in a variety of ways : when the 
tumour remains within the uterine cavity, the constant efforts 
made by the uterus to expel it lead to dilatation of the os 
and exposure of the fibroid, or the lower pole of the tumour 
becomes nipped in the cervical canal and this leads to O3dema 
of the endometrium. Normally the uterus and its cervix are 
sterile, but in married and, especially, parous women patho- 
genic micro-organisms are often present. If the surface of 
the endometrial covering of a fibroid is damaged either by 
instruments, normal labour, or in the process of extrusion, 
the epithelial protecting barrier is broken down and micro- 
organisms gain access to it and set up septic changes. The 
fibroid, instead of remaining a compact body, swells, softens, 
becomes gangrenous, and sloughs. These changes are accom- 
panied by great constitutional disturbance, haemorrhage, and 
stinking discharges. The polypus, when large, becomes de- 
tached piecemeal. The mode in which death occurs from 
the sloughing of a large submucous fibroid is the same as 
in puerperal infections. The effects are illustrated by the 
following case : 

A woman sought relief on account of excessive and per- 
sistent bleeding from the vagina. On examination, a soft 
dark-red mass 'as big as a fist occupied the vagina; its stalk 
could be felt running upwards into the uterus. She was 
ill, sallow, with a rapid pulse, fever, and a distended belly. 
Under anaesthesia the sloughing mass was removed from the 
uterus, but she died in a few days with the usual signs of 
septic peritonitis. After death putrid fluid was found in the 
recesses of the pelvis. The uterus was removed and examined. 
(Fig. 107.) It resembled in many respects the uterus of a 
woman recently delivered and which has become septic. The 
cervical canal was dilated inconsequence of the delivery of 
the fibroid, and the stalk of the tumour could be seen near 



SEPTIC FIBROIDS 



207 



the fundus. The endornetritim and portions of the capsule of 
the fibroid were loose in the uterine cavity as sloughs. The 
ccelomic ostia of the Fallopian tubes were unclosed, and stink- 
ing fluid oozed from them, indicating the route by which the 




Fig. 107. Section of a uterus from which a sloughing fibroid had been 
removed. The mucous membrane was gangrenous, and infective 
material had leaked into the belly through the unclosed ostium. 

septic fluid had travelled from the uterine to the peritoneal 
cavity, and thus destroyed the woman's life. 

This specimen is of interest to me, because it was the first 
occasion on which I had an opportunity of satisfying myself 



208 SEPTIC FIBROIDS 

that septic material could pass from the uterine cavity into 
the abdomen through the tubes. 

The baneful effects which follow the infection of fibroids 
vary with the agent ; a submucous fibroid may become septic 
without destroying life, but it sets up changes which are not 
to the patient's advantage. 

It is established that septic infection of the endometrium 
of a mild type following delivery at term, or abortion, or due 
to gonorrhoea, extends into the Fallopian tubes and causes 
pelvic peritonitis ; occlusion of the ccelomic ostia follows, the 
tubes becoming converted into sacs filled with pus (pyo- 
salpinx). All varieties of acute and chronic tubal disease 
complicate submucous fibroids. 

Women with submucous fibroids can contract gonorrhoea, 
and if they conceive they are more liable to miscarry than 
other women, and they share the same liability to puerperal 
infections. In many instances a submucous fibroid acts like a 
piece of retained placenta and serves as a focus for septic 
infection. Even more serious imputations are made against 
submucous fibroids, for the chronic changes they incite in the 
endometrium probably render it more vulnerable to cancer 
(see p. 466). 

The natural history of a submucous fibroid resembles 
that of a uterine pregnancy, and occasionally the two con- 
ditions simulate each other so closely as to render diagnosis 
uncertain. A submucous fibroid grows slowly ; many women 
with such a tumour in the womb are ignorant of its exist- 
ence until it causes complications which lead to its detection. 
When nothing unpleasant happens during the growing stage 
of the fibroid, the enlarging uterus rises out of the pelvis 
into the abdomen, and its fundus may reach a point mid- 
way between the pubes and the umbilicus before attract- 
ing attention. The time a submucous fibroid requires to 
enlarge the uterus to a size as big as a man's head is about 
ten years, but a soft (myxomatous) tumour will attain such 
proportions in five years. When a submucous fibroid is so big 
that the uterus containing it can be easily felt in the hypo- 
gastrium, and especially when the fibroid is soft, the resem- 
blance to a gravid uterus at the fourth month is very close. 
The contour of the uterus is smooth, and the tumour painless 



OBSOLESCENT FIBROIDS 209 

and often soft. On auscultation, a hum like the placental 
souffle is occasionally heard, especially a few days before 
a menstrual period. When the fibroid has arrived at this 
stage the condition of the uterus is instructive. On several 
occasions, after removing a uterus containing a very soft 
submucous fibroid, I have placed the organ before m}' 
assistants and asked them to decide from manipulation 
whether the uterus was gravid or contained a fibroid. 
On incising the walls of such a uterus and enucleating the 
tumour, the uterine tissue contracts as rapidly as after a 
normal labour, although the tumour may have been growing 
in the uterus several years. 

The corpus luteum of pregnancy is a familiar object ; when 
the uterus contains a rapidly growing submucous fibroid a 
large corpus luteum will be found occasionally in one of the 
ovaries. The largest corpus luteum I have ever seen was 
associated with such a tumour. 

When a submucous fibroid of moderate size ceases to grow, 
and the uterus fails to expel it, and micro-organisms do not 
succeed in colonizing it, then, with the cessation of menstrua- 
tion, the tumour dies. The period of obsolescence is associated 
with some interesting changes. During menstrual life sessile 
submucous fibroids enjoy an abundant blood supply ; some 
are as vascular as nsevi. After the menopause there is an 
abatement of the blood supply to the tumour, which shrinks, 
gradually dies, and sometimes calcifies. A dead interstitial 
fibroid may remain for many years sequestered in the walls of 
the uterus ; so may a submucous fibroid, but if putrefactive 
micro-organisms gain access to it the results are often serious 
for the patient. When a uterus contains a dead submucous 
fibroid it attempts to extrude the dead mass, and sometimes 
succeeds, although it failed to do so when the tumour was 
quick and growing, for as the fibroid dies it shrinks. The 
expulsive efforts of the uterus dilate the cervical canal and 
facilitate the ingress of micro-organisms, then putrefactive 
changes ensue with all the woes which follow in their train. 
Thus, even in obsolescence a submucous fibroid is often a 
mischievous thing. 

Sometimes fibroids rapidly increase in size after the meno- 
pause, but this is often due to septic changes in the tumour, 
o 



210 DEAD FIBROIDS 

A submucous fibroid has a malicious influence in delaying the 
menopause, and a woman with such a tumour in her womb 
may have the monthly fluxes of blood beyond the age at 
which menstruation normally disappears. These issues of 
blood from a uterus containing an obsolescent fibroid are not 
to be accounted menstruation in its true meaning; they are 
the result of the septic invasion of the 'dying fibroid, and 
sometimes they announce the supervention of cancer in the 
corporeal endornetrium. 

The fact that a fibroid may shrink after the menopause is 
in itself occasionally a source of danger, for the tumour, when 
growing actively, may be so big that it cannot fall into the 
pelvis, but the shrinking coincident with the cessation of 
menstruation will allow the uterus with the fibroid to settle in 
the true pelvis and become impacted. Sometimes a tumour 
settling in this way will fit the pelvis so tightly that it 
squeezes the urethra and causes retention of urine. In 
performing hysterectomy in women of 55 years and onwards, 
the tumour will sometimes be found so tightly impacted as 
to need the expenditure of much force for its extraction. 



CHAPTER XIX 
UTERINE FIBROIDS (continued) 

CERVIX-FIBROIDS; EXTRA-UTERINE FIBROIDS 

BEFORE 1897 fibroids arising in the neck of the uterus 
received scanty attention at the hands of systematic writers ; 
in that year I exhibited a series of such tumours at the 
Obstetrical Society, London, and showed that cervical 
fibroids are not rare ; they possess characteristic features, 
often attain a large size, and produce serious symptoms. 
They constitute in my series 5 per cent, of uterine fibroids. 

In its early stage a fibroid growing in the neck of the 
uterus is globular, but on attaining the size of a fist becomes 
ovoid, the long axis of the tumour being vertical, so that on 
section it exhibits an elliptical outline (Fig. 108). The 
ovoid shape of a large cervix-fibroid is determined by the 
osseous boundaries of the true pelvis. 

In a normal woman the pelvic diameters at the level of 
the middle of the cervix measure, with the soft parts in 
position, about 10 cm. (4 in.). The lower segment of a large 
cervix-fibroid is a solid cast of the true pelvis. In one of 
my specimens the minor (transverse) axis of the tumour 
measured 12'5 cm., this excessive measurement being due to 
the expanding effects of the tumour on the walls of the 
pelvis. The oval condition of the vaginal pole of a large 
cervix-fibroid corresponds with the shape of the occiput of a 
recently delivered foetus at term, or the presenting shoulder 
of a foetus which has been expelled in the process known as 
spontaneous evolution. When a cervix-fibroid has attained 
a horizontal diameter equal to that of the true pelvis, it 
increases in length and gradually pushes the body of the 
uterus out of the pelvis, and the fundus of the uterus will 
sometimes reach above the umbilicus. In such a specimen 

211 



212 



CERVICAL FIBROIDS 



the body of the uterus remains of normal size, perched on the 
upper pole of the fibroid. The relations of the tumours to 
the cervix vary and are of practical interest; like fibroids 




Fig. 108. Intracervical fibroid in sagittal section. 

which grow in the body of the uterus, they may be sub- 
mucous or subserous. 

A submucous and an intracervical fibroid expand the 
cervix equally (Fig. 108), although only attached to a por- 
tion of its circumference; but a subserous cervical fibroid 



CERVICAL FIBROIDS 213 

growing from the posterior wall of the cervix will have the 
whole of the neck of the uterus in front of it, and a covering 
of peritoneum posteriorly ; such a tumour will, like an intra- 
cervical fibroid, be ovoid. Fibroids growing from the anterior 
aspect of the cervix do not, as a rule, distort it, and often 
remain globular ; when of large size they push their way 
upwards between the peritoneum and the abdominal wall, 
and can sometimes be removed without opening the peri- 
toneal cavity. Fibroids growing from the posterior wall 
of the neck of the uterus, and the intracervical variety 
when they become large enough to stretch it, cause the 
vaginal portion of the cervix to assume the shape of the 
broad end of an egg ; then the os appears as a mere dimple 
(Fig. 109). The appreciation of this change is useful, for on 
making a vaginal examination the rounded globular mass 
feels like a subserous fibroid impacted in the pelvis, and the 
surgeon will hunt about for the cervix, expecting to find it 
drawn up behind the pubic symphysis. The discovery of the 
dimple-like os is the clue to the nature of the fibroid. 

The cervix-fibroid is usually solitary, but it may be 
associated with a fibroid in the body of the uterus. In 
structure it agrees with fibroids in other parts of the uterus 
and is liable to the same forms of degeneration and infec- 
tions, but it differs from them in its relations to the bladder, 
ureters, and rectum. 

When a cervix-fibroid attains sufficient size to block the 
outlet of the pelvis it will exercise injurious pressure on 
the urethra. A fibroid grows in the neck of the uterus so 
insidiously that one of the first symptoms connected with its 
presence is retention of urine. This may be due to direct 
pressure of the tumour on the urethra, or to the bladder 
being drawn upwards as the uterus rises into the abdomen. 
The displacement, enlargement, thickening, and disorganiza- 
tion of the bladder, ureters, and pelvis of the kidney caused 
by large cervix-fibroids greatly add to the risks of operative 
interference. 

The museum of the Royal College of Surgeons, England, 
contains some well-preserved and admirably prepared cer- 
vical fibroids, including the Hunterian specimen in which 
the tumour is 30 cm. long and 12 cm. wide, but it lacks a 



214 



CERVICAL FIBROIDS 



history. The largest specimen of cervical fibroid in my series 
weighed 13 Ib. 

Cervix-fibroids are insidious tumours, and this is in a 
measure due to the slight disturbance they cause to men- 
struation; a fibroid growing from the anterior or posterior 




Fig. 109. Uterus and fibroid in sagittal section. The tumour grew from the 
posterior surface of the neck of the uterus and occupied the pelvis. From 
a woman aged 49. 

wall of the cervix behaves like a subserous fibroid and does 
not interfere with the corporeal endometrium. A sub- 
mucous cervix-fibroid will not interfere with menstruation, 
because the endometrium lining the cervical canal does not 
share in the menstrual process; but a fibroid growing in 



EXTRA-UTERINE FIBROIDS 215 

the cervical canal, like a submucous fibroid in the body of 
the uterus, is liable to be extruded : when this happens the 
tumour becomes septic and the infection involves the cor- 
poreal endometrium ; menorrhagia and metrorrhagia are then 
inevitable consequences. 

When a woman has a fibroid in the neck of the uterus 
and the os is a mere dimple, menstruation remains unaffected. 
Such women are, as a rule, nulliparous. When a woman with 
an in tracer vical fibroid complains of bleeding, this fibroid is 
either extruded, or she has borne children, or the os is widely 
patulous and the tumour has become septic, It should also 
be borne in mind that cervical fibroids, though commonly 
solitary tumours, are occasionally associated with a submucous 
fibroid, and such a tumour is a notorious agent in producing 
metrorrhagia. 

When a fibroid grows from the anterior aspect of the 
cervix it sometimes encroaches on the vagina and prevents 
coitus. I have operated on two patients who sought relief 
for this impediment. 

Although a fibroid in the neck of the uterus is unfavour- 
able to conception, it by no means prevents it, and the 
pregnancy may go to term, a combination very dangerous 
for mother and child, as the following case proves : A woman 
aged 33 was delighted to find herself pregnant, but it dis- 
turbed her happiness when she was informed that she had 
a uterine tumour. When pregnancy had advanced to the 
thirtieth week, labour ensued, and, delivery being impossible, 
I removed the ^uterus and its neck (Fig. 110). This is the 
first recorded instance of total hysterectomy during labour. 
Two years later the woman was in good health. 

Extra-uterine fibroids. In addition to the walls of the 
uterus, fibroids arise in the various strands and strata of 
unstriped muscle-tissue connected with it. Of these, the 
three most important are the broad ligament, the round 
ligament, and the utero-sacral ligament. 

The mesometrium, or broad ligament, contains between 
its layers a large quantity of loose connective tissue which is 
continuous with that directly underlying the peritoneal in- 
vestment of the uterus. This tissue is occasionally the source 
of fibroids. The tumours are oval, encapsuled, and often 



216 



BROAD-LIGAMENT FIBROIDS 



bilateral ; they do not cause much inconvenience until they 
attain the size of coco-nuts. Sometimes they grow with great 




Fig. 110. Gravid uterus in sagittal section. The patient miscarried at the 
thirtieth week, and the arm presented. Delivery being impossible on 
account of a large cervical fibroid, the uterus with its cervix was 
removed. The oedema of the presenting arm is well shown. 

rapidity, and in a few months become tumours weighing 
20 Ib. or more, and as they rise into the abdomen drag the 






ROUND-LIGAMENT FIBROIDS 217 

uterus and its appendages out of the pelvis. Clinically they 
are indistinguishable from subserous fibroids, but they are 
easily recognized when the abdomen is opened, because, 
instead of projecting freely into the general peritoneal cavity 
like subserous fibroids, they are covered with a thin trans- 
parent layer of peritoneum representing the expanded broad 
ligament. When the tumours are bilateral the uterus lies 
anteriorly to the tumours and usually slightly sunk in a 
valley between and unconnected with them. (Fig. 92, p. 182.) 

Doran described some interesting cases and collected the 
literature: he has found records of broad-ligament fibroids 
occurring as early as the twentieth year. According to my 
observations they are most frequent after the thirty-fourth 
year. They are formidable tumours to remove, but the}- 
enucleate easily. The largest example in my own practice 
weighed nearly 30 Ib. Big tumours seriously interfere with 
the bladder. On first becoming acquainted with fibroids of 
this variety I regarded them as sarcomatous. Having been 
able for several years to watch some patients from whom I 
removed huge tumours of this kind, and who have remained 
healthy and free from recurrence, I have become satisfied 
that these tumours are non-malignant. 

Mesometric fibroids are greyish white. Large specimens 
are honeycombed with irregular cavities due to degeneration 
of the tissue ; calcareous patches are not uncommon. Large 
rapidly growing tumours are cedematous and exude a yellow 
albuminous fluid in great quantity. With rapidly growing 
tumours the health of the patient suffers, and the pressure 
they exert on the vessels in the pelvis causes oedema of the 
lower limbs. 

The tumours most commonly mistaken for broad-ligament 
fibroids are fibroids arising from the neck and side of the 
uterus, burrowing between the layers of the mesometrium. 

Tumours also arise in the round ligament of the uterus and 
exhibit the same structure as a subserous or an interstitial 
fibroid. They arise not only in the part of the ligament that 
lies between the layers of the mesometrium, but also in the 
terminal portion which traverses the inguinal canal. Fibroids 
of this kind in the canal have often been described as desmoid 
tumours, and sometimes as sarcomas. 



218 EXTRA-UTERINE FIBROIDS 

Fibroids in the niesometric portions of the round liga- 
ment, though unusual tumours, sometimes attain the size of 
a tennis- or a cricket-ball. They occur as solitary tumours 
or they appear in association with uterine fibroids. (See 
Fig. 93, p. 183.) 

Fibroids also grow in the utero-sacral ligament; in this 
situation they have a peculiar relation to the peritoneum, for, 
as they grow, they burrow under its posterior layer and form 
a flattened tumour lying on the side of the pelvis. When such 
a fibroid is enucleated it is found to be attached by a tendon- 
like stalk to the side of the uterus. Such tumours are rare, 
and usually assume the shape of a disc 3 in. in diameter and 
2 in. in thickness. It is unsafe to enucleate them without 
removing the uterus at the same time, because the sac must 
be drained, and often leaves in consequence a troublesome 
sinus. 



CHAPTER XX 
UTERINE FIBROIDS (concluded) 

FIBROIDS IN RELATION TO MENSTRUATION, CON- 
CEPTION, AND PREGNANCY ; RED DEGENERA- 
TION ; DIAGNOSIS ; TREATMENT 

IT is beyond dispute that fibroids arise in the uterus during 
menstrual life. In Great Britain this period has an average 
of thirty years, from the fifteenth to the forty-fifth. There 
are few reliable observations in which fibroids have been 
found in the uterus before the twentieth year of life. Many 
examples have been observed between the twentieth and the 
twenty-fifth years. Between the ages of 25 and 35 fibroids 
are common, but they are observed most frequently in women 
between the thirty-fifth and forty-fifth years. The interval 
between the twenty-fifth and thirty-fifth years is the great 
child-bearing period. In relation to pregnancy and fibroids 
the menstrual epoch of a woman's life may be divided into 
three periods : 

(1) From 15 to 25. In this period, if the environment be 
favourable, she is infinitely more liable to conceive than to 
grow fibroids. 

(2) From 25 to 35 her chances of pregnancy are as great 
as in the preceding period, but her liability to grow fibroids is 
increased. 

(3) From 35 to 45 the liability to conception diminishes, 
but to fibroids it is greatly increased. 

It is obvious, from a consideration of the above facts, that 
when pregnancy and fibroids coexist the subjects of this 
combination should be women past 30. This is true, and 
many of them have either married late in life or, if they 
married early, have remained for many years barren. 

Submucous and intramural fibroids are unfavourable to 

219 



220 FIBROIDS AND PREGNANCY 

conception. A fibroid of either variety, or one in the neck of 
the uterus, by no means prevents conception, but this com- 
bination is often very dangerous to the mother as well as to 
the child. A large subserous fibroid does not hinder con- 
ception, but it is occasionally a serious complication of 
pregnancy, and may hinder or obstruct delivery, or cause 
trouble during the puerperium. Pregnancy and fibroids are 
inimical to each other ; thus, when pregnancy and fibroids co- 
exist the association is doubly harmful, for the alterations in 
the physiological condition of the uterus induce pathologic 
changes in the fibroids, and in many instances the fibroids 
exert hindrances of an obstructive character on the uterus. 
Some of these occur quite early in the course of pregnancy. 

Attention has already been drawn to the condition known 
as impaction, and some of the difficulties which happen were 
described at p. 202. 

Impaction occurs when a sessile subserous tumour the size 
of an orange grows from the posterior wall. Even small sub- 
serous tumours on the posterior wall of the uterus may, by 
becoming hitched under the sacral promontory, prevent the 
uterus rising out of the pelvis, especially near the time of 
quickening, whilst a large stalked tumour, or even a sessile 
tumour weighing several pounds growing from the fundus, 
will offer no impediment to the ascent of the uterus during 
pregnancy or its descent after delivery, although it may 
cause difficulty in other ways. The question at once suggests 
itself, what would happen to an impacted gravid uterus con- 
taining fibroids if surgical relief were not available ? The 
answer is not difficult : miscarriage happens, and the patient 
recovers, but she runs great risk from haemorrhage, and also 
the chances of sepsis, especially if the uterus contains a sub- 
mucous or an intramural fibroid, for such tumours during 
pregnancy are especially prone to necrosis and red degenera- 
tion (see p. 223). Fibroids in this condition are very liable 
to become septic. Another inconvenience connected with 
impaction is retention of urine. 

Occasionally a uterus may contain several fibroids and be 
large enough to occupy all the space available in the pelvis 
before the patient becomes pregnant ; in such an event symp- 
toms occur early. Such a condition is presented in Fig. Ill 



FIBROIDS AND PREGNANCY 



221 



the uterus may be described as a "constellation" or a "pleiad" 
of fibroids. It is true that pregnancy when complicated with 
fibroids often goes successfully to term. At the same time a 
fibroid in the neck of the uterus, or a subserous fibroid of 
moderate dimensions projecting in its lower zone, will offer a 
serious obstacle to delivery, and unless surgical aid be afforded 
promptly the child will die. A large cervix-fibroid offers an 




Fig. 111. Uterus distorted with fibroids, and containing a foetus of four 
months' development. From a woman aged 42. 

impassable barrier to the transit of the child. Sometimes it is 
expelled during labour. Bennett attended a woman who had 
been ten hours in labour (her eighth confinement), when a 
fibroid the size of a big lemon was forcibly expelled from the 
vagina and fell on the floor. The foetus was stillborn ; the 
mother recovered. A large submucous fibroid extruded into 
the vagina with the placenta has been mistaken for the head 
of a twin. 

When severe symptoms arise in the course of pregnancy 



222 FIBROIDS AND PREGNANCY 

it is necessary to interfere surgically ; but it often happens 
that, with care, it can be allowed to continue to term, and 
if the tumour is in a situation where it offers an insuper- 
able obstruction to labour, the child can be delivered by 
Csesarean section. If the tumour is single and favourable 
for myomectomy, this course may be adopted, otherwise 
the uterus should be removed. When surgical intervention 
becomes necessary in the early stages of the pregnancy the 




SERJEAL). 

Fig. 112. Gravid uterus, in section, with intramural fibroids. 

same alternatives are available, for an impacted pedunculated 
fibroid may be removed, or a sessile tumour enucleated from 
its walls, without disturbing the pregnancy. A large number 
of myomectomies have been reported since I drew attention, 
in 1901, to the tolerance of the uterus to such procedures. A 
more extensive experience of myomectomy during pregnancy 
shows that in more than half the patients this operation is 
followed by abortion. The mortality of myomectomy is higher 
than that of subtotal hysterectomy for such conditions. 

It happens that a woman unlucky enough to conceive 
with a large fibroid in her uterus may be so far fortunate 
that the pregnancy goes to term and she becomes the mother 



FIBROIDS AND PREGNANCY 223 

of a healthy baby, but her risks are by no means ended, for 
a submucous fibroid may become extruded, degenerate, or 
septic; and anyone who cares to follow the subject can find 
in periodical obstetric literature many sad cases, for a septic 
fibroid in a puerperal woman entails a long illness and often 
a fatal ending. 

There is one matter connected with fibroids and pregnancy 
which merits careful consideration. If a single woman with 
fibroids in her uterus indulges in sexual intercourse she runs 
the same chance as a married woman in the same circum- 
stances of becoming pregnant. When pregnancy and fibroids 
coexist in a married woman, and cause pain or pelvic disturb- 
ance, she seeks medical aid when she suspects herself to be 
pregnant ; but a spinster in similar circumstances, although 
she seeks aid on account of pain, pelvic disturbance, or a 
swelling in the abdomen, often carefully conceals the fact 
that menstruation is suppressed, and if deliberately ques- 
tioned she will wilfully mislead in this important matter. 
Moreover, she will further lead the doctor astray by stating 
that the tumour has greatly increased in size. In the case of 
an early pregnancy in a uterus containing a large fibroid, the 
tumour will so predominate as to obscure the softer uterine 
fundus, and it is astonishing how often pregnancy in these 
circumstances is overlooked until the uterus has been re- 
moved. Pregnancy is also likely to be missed when it occurs 
in a woman known to have fibroids in her uterus, and who 
has lived for a long time in barren wedlock. 

An examination of the breasts often yields valuable 
evidence, in spite of the fact that mucoid fluid can some- 
times be squeezed from the nipples when the uterus of a 
young woman contains a soft submucous fibroid the size 
of a cricket-ball. 

Red degeneration '(necrobiosis). When the walls of 
the uterus are occupied by fibroids and pregnancy ensues, 
these tumours, depending on the circulation of the uterus 
for nutrition, are often influenced by the altered conditions- 
The changes wrought in them by pregnancy have been 
described by many writers as consisting in the softening and 
flattening out of interstitial fibroids; also it has been said that 
the muscle-tissue of fibroids multiplies with the enlargement 



224 RED DEGENERATION 

of the uterus coincident with pregnancy. This supposed 
active growth of fibroids in the walls of a gravid uterus 
appeared to receive support from the fact, noted by many ob- 
servers, that fibroids in a "pregnant uterus often become red, 
or flesh-coloured, and this change of colour was attributed 
to an increase of the muscular tissue of the tumour, or to its 
increased vascularity consequent on the pregnancy. 

The usual colour of a uterine fibroid is pale yellow (very 
hard fibroids are white) ; in degenerate and necrotic fibroids 
the colour deepens. In the course of pregnancy a fibroid 
often becomes deep red ; sometimes the colour is like that 
of fresh beef-steak. In the early stages the colour appears 
in streaks, but as the pregnancy advances the tumour 
reddens and softens ; occasionally it becomes diffluent ; the 
fibroid is converted into a cyst filled with chocolate- 
coloured fluid, the cyst-wall being the original capsule of 
the tumour. All the topographical varieties of fibroids are 
liable to red degeneration, but interstitial and submucous 
tumours are most affected. A gravid uterus may contain 
many fibroids, and none of them changes, or it may con- 
tain two fibroids, and one becomes red and quickly liquefies. 
Cervix - fibroids are not exempt from this change. The 
softening of the tissues composing a fibroid sometimes 
takes place with great rapidity and reduces even a hard 
fibroid to the consistence of soft soap. A microscopic ex- 
amination of the reddened tissue shows that the colour is 
due to the diffusion of blood pigment through the necrosed 
tissues. This change is not due to bacterial action nor 
to thrombosis. Micro-organisms are occasionally found in 
these disorganized fibroids, but such infection is an epi- 
phenomenon a sequence, not a cause. This metamorphosis 
of fibroids is described as autolysis, and is probably an ex- 
aggeration of the process that leads to involution of the 
puerperal uterus. The unpleasant odour emitted by some 
red fibroids is due to amines produced by decomposition of 
muscle -tissue. Autolysis is a term signifying the trans- 
formation of insoluble tissue into soluble nitrogenous extrac- 
tives. The change occurs without the aid of bacteria. Red 
fibroids occur in spinsters near the menopause, but are more 
common in pregnant women. 



FIBROIDS AND PREGNANCY 225 

Other important features associated with degenerative 
fibroids complicating pregnancy are pain and tenderness. 
I appreciated this in the first examples of the condition 
which came under my notice, and have persistently called 
attention to its significance. The remarkable feature of 
the pain is the suddenness of its onset, for it resembles 
the pain caused by an ovarian tumour that twists its 
pedicle; or the pain and shock produced by the bursting, 
or abortion, of a gravid Fallopian tube. These things show 
that red degeneration is of interest outside the pathological 
laboratory, and it is of clinical importance to remember 
that fibroids undergoing this change are often painful and 
extremely tender. The tenderness is a valuable diagnostic 
sign. When pain and tenderness are present in a mild 
degree, they generally subside if the patient be kept at rest 
in bed ; it is only the very severe cases which call for surgical 
treatment. 

Fibroids and tubal pregnancy. This is a rare com- 
bination, but it occurs, and the coexistence of a gravid 
tube and some uterine fibroids as big as tennis-balls makes 
diagnosis a matter of difficulty. 

Modes in which fibroids impair health and imperil 
life. A uterus containing one or many fibroids may cause 
neither inconvenience nor suffering ; indeed, the woman 
owning them is often ignorant of the existence of tumours 
in her womb : but it is equally true that they are often 
the source of much suffering and occasionally cause death, 
directly or indirectly, in a variety of ways. 

Uterine fibroids often remain for many years without 
producing more than temporary inconvenience, but those 
that remain harmless form a small minority. The most 
obvious disturbances caused by fibroids may be conveniently 
considered in connexion with haemorrhage, pelvic com- 
plications (when these tumours interfere with the bladder, 
rectum, or the big blood-vessels), and obstructive effects 
(when they become impacted in the pelvis, or undergo axial 
rotation and twist their pedicles). Disastrous consequences 
arise when fibroids interfere with the function of the uterus. 
A woman with a large fibroid' is debarred from marriage ; 
a small fibroid in the neck of the uterus will hinder con- 



226 FIBROIDS AND MENORRHAGIA 

ception ; a large cervix-fibroid sometimes prevents convenient 
coitus, and, if pregnancy ensue, an embarrassing and occa- 
sionally perilous combination is the consequence. Many 
puzzling symptoms are produced when morbid swellings 
connected with the ovaries, uterine tubes, and broad ligament 
coexist with fibroids ; and abnormal conditions of the viscera, 
such as cancer of the rectum, a pelvic kidney, or a displaced 
spleen, all help to make combinations which render accurate 
clinical work difficult. 

Among important changes associated with the presence of 
submucous fibroids, there is reason to believe that they pre- 
dispose the endometrium to cancerous changes (see Chap. XL). 

Hemorrhage. This is a very frequent inconvenience caused 
by fibroids, but it is confined to those which implicate the 
endometrium. The bleeding assumes two forms. Commonly 
it occurs as an excessive loss at the menstrual periods 
(menorrhagia) ; it may be irregular, or almost continuous, so 
that all relationship to a monthly loss disappears. It is an 
important fact that the size of a fibroid bears no relation to 
the amount of bleeding which it may cause. A subserous 
fibroid weighing many pounds will not interfere with menstru- 
ation, but a fibroid polypus the size of a chestnut will cause 
profuse menorrhagia. The condition of the endometrium in 
such a uterus varies. In a normal uterus the endometrium 
is 2 mm. thick : when it has been irritated by a fibroid and 
the patient is profoundly ansemic from severe menorrhagia, 
the endometrium sometimes measures a centimetre, or more, 
in thickness. This increase in thickness is due to oedema; 
when osdematous endometrium is examined microscopically 
the cell elements will be found spread out and the acini of 
the glands widely separated. 

The most severe form of uterine bleeding connected with 
fibroids is the result of septic infection. Submucous fibroids 
become septic in many ways. A fibroid extruded into the 
vagina is exposed to micro-organisms such as the colon 
bacillus, the staphylococcus, and the streptococcus. These 
pathogenic agents not only colonize the tumour and convert 
it into a putrescent foetid mass, but, the cervical canal being 
wide and patulous, the micro-organisms invade the endo- 
metrium and the uterine tissues generally. In some cases 



UTERINE FIBROIDS: DIAGNOSIS 227 

the sloughs which escape with the offensive discharges are 
not merely fragments of tumours but are gangrenous strips 
of endometrium. A woman with a sloughing fibroid of this 
kind is like a patient suffering from pyaemia after a wound. 
Until surgeons were taught to appreciate the importance 
of cleanliness in examining patients, a fibroid was often 
infected as a consequence of being injured by a dirty sound 
or dilator. Infection of a submucous fibroid was a common 
sequel of childbirth or miscarriage, because its soft and 
degenerate condition in these circumstances rendered it 
peculiarly liable to sepsis. It is quite probable that in 
nearly all instances where excessive uterine haemorrhage is 
due to a fibroid the endometrium is septic, and the severity 
of the bleeding varies with the degree of virulence of the 
micro-organism present. 

Sepsis is a powerful factor in producing bleeding from 
wounded surfaces. All septic wounds bleed, and hemorrhage 
from this cause is the most intractable of all ; and an infected 
endometrium, like a septic wound, bleeds profusely. 

Some writers believe that uterine fibroids cause degenera- 
tive changes in the muscular tissue of the heart. Women 
with fibroids may have valvular lesions of the heart, and 
the profound arisemia frequently associated with submucous 
fibroids is often accompanied by hsemic murmurs, but I 
have never been able to satisfy myself that there is any 
special lesion of the heart caused by uterine fibroids. 

Diagnosis. The various changes in the consistence of 
fibroids have a remarkable effect on diagnosis. Until surgeons 
displayed great activity in removing them, the diagnosis of 
uterine fibroids was regarded as a simple clinical exercise. 
It is often difficult to differentiate clinically between cystic 
fibroids and big cystadenomas of the ovary; or between 
ovarian fibroids and subserous uterine fibroids. Occasionally 
it is impossible to decide between a soft submucous fibroid 
and pregnancy on physical signs solely ; time alone enables a 
decision to be made. Gynaecologists have operated under the 
expectation of removing a fibroid, but have found a calcified 
foetus (lithopaedion). A dead foatus in the rudimentary horn 
of a so-called unicorn uterus has been removed in the belief 
that it was a fibroid; the error was discovered when, from 



228 AGUR'S APHORISMS 

curiosity, the operator or his assistant cut into the mass. 
Olshausen had an odd experience in 1902. He removed a 
gravid uterus from a woman aged 38, under the impression 
that it contained a cystic fibroid. The mass proved to be a 
large sacral tumour growing from the buttocks of an intra- 
uterine foetus. A pelvic spleen has been mistaken for a sub- 
serous fibroid; a freely movable fibroid lying high in the 
belly has been diagnosed as an enlarged spleen; and some, 
with long stalks, as movable kidneys. Such errors are rarely 
serious. A cancerous mass in the pelvic colon, lying behind 
the uterus, is often mistaken for a subserous fibroid. This is 
always an unfortunate error, because operative interference, 
undertaken on the idea that the mass is a benign fibroid, 
causes chagrin to the surgeon when it ends in colostomy ; 
and especially when a gynaecologist, with overweening con- 
fidence, has assured the patient and her relatives that the 
tumour is a fibroid, and its removal simple and safe. 

As the protean manifestations and combinations of pelvic 
tumours are ofttimes puzzling, I have ventured to frame a 
few aphorisms, in the manner of Agur the Sceptic (150 B.C.). 

Two things disquieting in diagnosis : 

1. To distinguish between solid ovarian tumours 
and large subserous fibroids. 

2. And between tubal swellings and uterine fibroids. 

Three foolish things : 

3. To give opinions on pelvic swellings without 
making a vaginal examination, or (4) on hypogastric 
swellings without passing a catheter. 

5. To remove fibroids without examining the 
woman's urine for sugar until she is comatose, two or 
three days after the operation. 

Four things useful to know : 

6. When a barren woman between 35 and 45 has 
retention of urine it is almost certain that she has a 
fibroid in her womb. 

7. A fibroid that suddenly becomes painful during 
pregnancy is probably in a state of red degeneration. 
The signs simulate tubal pregnancy, axial rotation of 
an ovarian tumour, and acute appendicitis. 



FIBROIDS : ; TREATMENT 229 

8. Errors in the differential diagnosis of fibroids and 
pregnancy are usually made before the beating of the 
foetal heart is audible. 

9. A cancerous mass in the pelvic colon, in contact 
with the uterus, imitates the signs of a subserous 
fibroid. 

Four things that are wise : 

10. When in doubt whether a big uterus in a young 
woman contains a child or a fibroid, wait for a month 
and re-examine the patient. 

11. Remember that ovarian tumours give much 
trouble to pregnant and lying-in women, but fibroids 
are more deadly, for they are liable to become septic. 

12. After the removal of a fibroid in the procreative 
period of life a woman is more liable to grow more 
fibroids than to conceive successfully. 

13. Remember that uterine bleeding after the meno- 
pause, in a barren woman with a fibroid, often signifies 
the existence of cancer within the uterus (see p. 464). 

" As the churning of milk bringeth forth butter, and the 
wringing of the nose bringeth forth blood," so the diagnosis 
of fibroids will continue to perplex surgeons. In the past 
women often endured unnecessary suffering from the blind 
belief that fibroids were tumours capable of easy recognition. 

Treatment. Radium and X-rays are useful in the treat- 
ment of fibroids in women between the ages of 40 and 50, 
especially when the tumour is of moderate size, free from 
degenerative changes, and uncomplicated by chronic infective 
disease of the tubes arid ovaries, or cancer of the uterus. 
Radium probably acts by obliterating the blood-vessels in the 
endometrium. 

The impotency of medical means to control uterine 
bleeding, as expressed in the famous verse, " A woman, 
having an issue of blood twelve years, which had spent all 
her living upon physicians, neither could be healed of 
any" (St. Luke viii, 43), is a thing of the past. To-day, 
hysterectomy for fibroids has become the safest major opera- 
tion in surgery. 



CHAPTER XXI 
FIBROIDS OF THE GASTRO-INTESTINAL TRACT 

FIBROIDS are so common in the uterus that many imagine 
that this organ enjoys a monopoly of these tumours. This is 
supported by a belief prevalent among gynaecologists in regard 
to fibroids found connected with the serous surface of the 
intestine, that they are uterine fibroids which have detached 
their pedicles and become attached to the intestine. Uterine 
tumours supposed to have behaved in this way are known as 
migratory fibroids. The facts now to be discussed will put a 
new complexion on this matter. 

A study of gastro-intestinal fibroids illustrates what obser- 
vation throughout the body teaches the baneful effects of 
simple tumours depend on their environment. The size of a 
tumour is not a measure of its danger to life. There are two 
clinical varieties of intestinal fibroids subserous and sub- 
mucous, and each often occurs as a surprise in the operating- 
theatre. 

Stomach. A subserous fibroid arising in the walls of the 
stomach may reach the size of a coco-nut, and though it 
may only cause uneasiness to the patient, it is often a source 
of perplexity in diagnosis. Fibroids of the stomach are not 
common tumours. In 1913 Outland and Clendinning col- 
lected records of 79 instances. I have had the opportunity 
of examining four specimens. In each patient the " lump " 
had been noticed several years and could be moved freely in 
the belly. These tumours are composed of white glistening 
tissue arranged in whorls, to the naked eye and the micro- 
scope indistinguishable from hard uterine fibroids ; and as the 
patients are almost invariably women, the tumours, especially 
on their anterior surfaces, are covered with the glistening 
cartilage-like tissue so common on the surface of abdominal 
cysts and tumours long exposed to friction. 

230 



GASTRIC FIBROIDS 231 

Occasionally subserous fibroids of the stomach are large 
enough to reach as low as the hypogascrium ; then the 
patient finds her way into the gynaecological department, 
where the tumour is almost invariably mistaken for an ovarian 
or a uterine fibroid, and serves to relieve the operative 
monotony engendered by specialism. 

Submucous fibroids have been described in the stomach, 
and they appear as hemispherical tumours usually situated 
near the pylorus. The summit of such tumours may be 
occupied by a crater-like depression, and severe and even 
fatal bleeding has happened in connexion with them. Two 
examples are preserved in the museum of Westminster 
Hospital, in which the patients, one a woman aged 50, and 
the other a man aged 39, died from haematemesis. The 
clinical histories of the patients have been published by 
Gossage and Braxton Hicks. 

Similar tumours have been observed in the duodenum. 
Hochenegg excised 6 cm. of the supra-ampullary section of 
the duodenum of a woman aged 38, who was emaciated and 
suffered severely from melsena. This portion of the duodenum 
was abnormally long and contained a sessile submucous 
fibroid the size and shape of a cherry. The summit of the 
tumour was occupied by an ulcerated crater from which blood 
issued. The woman recovered. (Lismayer.) 

The occurrence of severe and fatal bleeding associated with 
ulceration of submucous gastric fibroids is important, as it 
brings them into clinical relationship with submucous uterine 
fibroids, for they are liable to become abraded, and infected, 
and to cause death by septic infection or haemorrhage. The 
clinical pictures of gastric and uterine submucous fibroids 
are parallel. The subsequent histories of patients who have 
had submucous fibroids removed from the stomach will be 
valuable because some of these tumours may be spindle-cell 
sarcomas. 

Intestines. Fibromyomas of the intestine may for clinical 
purposes be arranged as subserous and submucous. They 
possess a capsule and are, as a rule, hard, and the cut surface 
presents the familiar whorls. A fibroid growing from the wall 
of the small intestine is liable to produce torsion of the gut, 
ending in fatal obstruction. (Fig. 113.) 



232 INTESTINAL FIBROIDS 

Subserous intestinal fibroids are occasionally so big that 
they are mistaken clinically for fibroids of the uterus. Dujarier 
and Khan described a pedunculated tumour of this character 
attached to the sigmoid flexure (pelvic colon) of a woman aged 
40. The tumour had undergone mucoid degeneration. A 
subserous fibroid weighing 7 lb., removed from the intestine 
of a man, is preserved in the museum of University College. 
Microscopically it is indistinguishable from a fibromyoma of 
the uterus. 




Fig. 113. Fibroid of the small intestine, in section, that led to volvulus. 
* At this point all the coats of the gut, except the serous, yielded under 
torsion. From a man aged 48. (Museum of the Royal College of 
Surgeons. ) 

Whilst removing an ovarian cyst from a woman, I found 
and removed a fibroid as big as a ripe plum from the caecum 
near the base of the vermiform appendix. The uterus had 
been flattened by the impaction of the cyst in the pelvis, but 
it was otherwise normal. The tumour on the caecum had all 
the naked-eye and microscopic characters of a pedunculated 
subserous uterine fibroid. 

Submucous intestinal fibroids have long attracted the 
attention of physicians and surgeons on account of the 
frequency with which they are responsible for intestinal 
obstruction. A submucous fibroid of the intestine is in- 



INTESTINAL FIBROIDS 



233 



variably solitary, and as it projects into the lumen of the gut 
the propulsive movements of the muscular coat relentlessly en- 
deavour to extrude it. Sometimes the pedicle is lengthened, 
and in extremely rare instances snaps. Commonly the per- 
sistent muscular contraction of the gut drives the tumour 
forward and leads to intussusception with its attendant evil 




Pedicle. 



Abscess cavity. 



Tumour. 



Fig. 114. Portion of jejunum in section; a fibroid had invaginated the 
bowel and produced fatal intestinal obstruction. From a man aged 35. 

intestinal obstruction, which unrelieved ends in death. 
(Fig. 114.) There are cases on record in which a tumour of 
the small intestine has caused intussusception and the intus- 
suscepted portion has sloughed and been voided at the anus 
the patient recovering. The chance of an intussuscepted 
section of gut sloughing is so small that it is the rule 
to interfere surgically, and with promptitude. In many 



234 



SARGOMATOUS FIBROIDS 



instances the surgeon has no idea that a polypus is the cause 
of the trouble until he has completed the operation ; on 
unravelling the implicated section of intestine he finds a 
fibroid, perhaps no bigger than a ripe grape. 

It is not uncommon for a fibroid (commonly called a 
polypus) growing from the wall of the ileurn to be propelled 
through the ileo-caecal valve into the csecum, dragging a coil 

of ileum with it. Jefferson 
successfully excised the csecum 
of a woman aged 24, and 
found a fibroid growing from 
the csecal wall, in the region 
of the upper lip of the ileo- 
caecal valve. As is so usual 
in such conditions, the mu- 
cous membrane covering the 
tumour had ulcerated. The 
terminal part of the ileuin 
was slightly invaginated in- 
to the caecum. Submucous 
fibroids of the intestine bear 
the same relation to the 
mucous membrane as sub- 
mucous fibroids to the endo- 
metrium ; they possess a 
covering of mucous membrane 
and, in most, the surface of 
the tumours is ulcerated. 

Sarcomatous fibroids. 
It is admitted by histologists 
that, in minute structure, some uterine fibroids so closely 
resemble spindle-cell sarcomas that it is impossible to decide 
whether such tumours should be called sarcomas or fibromas. 
One way out of the difficulty is to call tumours of this kind 
sarcomatous fibroids. This also is true of intestinal fibroids. 
The piece of small intestine represented in Fig. 115 contains 
a tumour the size of a walnut. Shattock examined it critic- 
ally and believes it to be a spindle-celled sarcoma with nuclei 
of striking size in some of the cells. In such cases the clini- 
cal course and the postoperative sequence alone decide. 




Fig. 115. Segment of small intestine 
in vertical section containing a 
fibroid. Excised from a woman 
aged 45. (Museum of St. Thomas's 
Hospital.') 



FIBROIDS AND INTUSSUSCEPTION 235 

Intestinal like uterine fibroids compromise the organ in 
which they arise. The subserous tumour leads to volvulus 
(torsion) of the small intestine by its weight and movement, 
setting up acute and dangerous complications which often 
demand prompt and bold surgery. Submucous fibroids 
of the intestine induce propulsive movements in the 
muscular stratum of the gut, and these efforts almost 
invariably lead to intussusception comparable to inversion 
of the uterus. This propulsive movement will slowly, but 
surely, force a subserous liporna through the muscular 
coat of the intestine into the lumen of the gut merely clad 
with mucous membrane. This leads to dimpling of the 
serous coat overlying the tumour. The same movement, 
continuing, will ultimately cause intussusception of the gut 
with a fatal ending. For example : A girl aged 16 died 
in the Middlesex Hospital, in 1879, after an operation for 
intestinal obstruction. A lipoma of the ileurn had been 
propelled through the ileo-csecal valve and dragged with 
it a yard of ileurn. At that date a lipoma of the intestine 
was a novelty. The operation was performed by Hulke, 
and the particulars were reported by Coupland. There is 
nothing peculiar in the fact that a submucous fibroid, or a 
lipoma, leads to intussusception of the gut; it occurs with 
secondary deposits of malignant disease (p. 362), primary 
cancer (p. 364), and an inverted Meckelian diverticulum 
(Chap. LXII). 

Coupland, S. Clin. Soc. Trans., 1879, xii. 216. 

Dujarier et Khan. Bull, et Mem. de la Soc. Anat. de Paris, Jan., 1920. 
Gossage, A. M. Proc. Roy. Soc. of Med., 1913, Surg. Sect., vii. 33. 
Jefferson, J. C.rit. Med. Journ., 1920, ii. 819. 
Lismayer, H. Arch.f. Min. Chir., 1920, cxiv. 235. 
Outland, J. "EL. Ann. of Surg., 1913, Iviii. 812. 

Steiner, R. Bruns' Beit. z. Min. Chir., 1898, xx. 1. (This contains the 
literature of gastro-intestinal rnyomas.) 



GROUP IL TUMOUR-DISEASES OF TEETH 

CHAPTER XXII 
ODONTOMES AND DENTAL CYSTS 

ODONTOMES 

AN odontome is a tumour composed of dental tissues in 
varying proportions and different degrees of development, 
arising from teeth-germs, or from teeth still in the process 
of growth. 

The species of this genus are determined according to 
the part of the tooth-germ concerned in their formation : 

1. Epithelial odontome : from the enamel-organ. 

2. Follicular odontome "\ 

3. Fibrous odontome JFrom the tooth- 

4. Cementome [ follicle. 

5. Compound follicular odontome J 

6. Radicular odontome: from the papilla. 

7. Composite odontome: from the whole germ. 

1. Epithelial odontomes. These tumours occur, as a 
rule, in the mandible, but they have been observed in the 
maxilla. They have a fairly firm capsule, and in section 
display a congeries of cvsts of various shapes and sizes ; 
but the loculi rarely exceed 2 cm. in diameter (Fig. 116). 
The cysts are separated by thin fibrous septa, sometimes 
ossified. The cavities contain brown fluid. The growing 
portions of the tumour have a reddish tint. 

Histologically, an epithelial odontome consists of branch- 
ing and anastomosing columns of epithelium, portions of 
which form alveoli (Fig. 117). The cells lining the alveoli 
vary in shape: those of the outer layer are columnar; the 
central cells degenerate and give rise to tissue resembling 

236 



EPITHELIAL ODONTOMES 



237 



the stellate reticulum of an enamel-organ. These tumours 
probably arise in persistent vestiges of enamel-organs (Falck- 
son and Bryck). 

A careful re-examination of a few of the specimens 
described as multilocular cystic epithelial tumours of the 




Fig. 116. Epithelial odontome. (Natural size.) 

jaws, and a study of the descriptions of others, especially 
those occurring in individuals past middle life, indicate that 
many of these tumours are carcinomas. 

This view of the matter is confirmed by the fact that 
some of these cystic tumours of the jaw supposed to arise 




Fig. 117. Microscopic characters of an epithelial 'odontome. 

in belated rudiments, or vestiges, of enamel-organs recur after 
removal. Moreover, these tumours occur in individuals at 
or after, mid-life, whereas if they arise in epithelial vestiges 
of the enamel-organ they ought, theoretically, to be met with 
in the young ; this is not the case. In typical cases the 



238 



EPITHELIAL ODONTOMES 



tumour grows slowly; in some patients it has been noticed 
for ten years and remained painless. A large tumour is a 
source of inconvenience, producing great deformity and dis- 
comfort (Fig. 118). The tolerance exhibited by patients to 
these tumours is remarkable ; indeed this applies to odon- 
tomes in general, as the observations contained in this 
chapter will prove. 




Fig. 118. Epithelial odontome. It had been slowly growing for ten years. The 
tumour and the right half of the mandible were removed, but the patient, a 
Hindu woman aged 30, died two hours after the operation. (Tirumurti.} 

The removal of epithelial odontomes is usually attended 
with good consequences. In the past, many needlessly 
severe operations have been performed. If patients come 
under observation when the tumour is small, the odontome 
can be removed in its capsule without excision of the jaw. 
In some instances the surgeon has found thorough erasion of 
the soft parts of the tumour an effectual method of treatment. 



FOLLIGULAR ODONTOMES 239 

An excellent description of the epithelial odontomes 
preserved in the London museums is contained in the 
Report on Odontomes drawn up by a committee appointed 
by the British Dental Association, 1914 

2. Follicular odontomes. This species comprises the 
swellings often called dentigerous cysts a term that has 
come to be used so very loosely that it should be discarded. 
Follicular odontomes arise commonly in connexion with 
teeth of the permanent set, and especially with the molars ; 
sometimes they attain large dimensions, and produce great 
deformity, especially in the upper jaw. They also occur 
in relation with supernumerary teeth, and are sometimes 
bilateral. 

The tumour consists of a wall of varying thickness, which 
represents an expanded tooth-follicle ; in some cases it is thin 
and crepitant, in others it may be 1 cm. thick. The cavity of 
the cyst usually contains viscid fluid and the crown, or the 
root, of an imperfectly developed tooth; occasionally the tooth 
is loose in the follicle, sometimes inverted, and often its root 
is truncated (Figs. 119 and 120), or represented by an ill- 
shaped denticle. The walls of the cyst usually contain calcine 
or osseous matter; the amount varies considerably. Some 
observers have noted the presence of an epithelial lining to 
the inner walls of follicular odontomes : it is a point which 
requires further elucidation. 

These tumours are not unknown in other mammals; I 
have seen them in sheep, pigs, and porcupines. In sheep 
they are common, and generally affect the incisors, and are 
thus limited to the mandible ; as a rule they are bilateral. 

The amount of fluid in a follicular odontome varies, and 
the size of the tumour depends in the main upon this. Occa- 
sionally the fluid may measure as much as 2 oz., and leads 
to the wide separation of the inner and outer plates of the 
body of the mandible. 

Hope well Smith found that a tooth from a follicular 
odontome had no Nasmyth's membrane, and suggests that 
the fluid within these tumours is probably formed from the 
degeneration and liquefaction of the stellate reticulum. 

3. Fibrous odontomes. In a developing tooth a portion 
of the connective tissue in which it is embedded is found to 



240 



FIBROUS ODONTOMES 



be denser and more vascular than the rest ; it also presents a 
fibrillar arrangement. This condensed tissue is known as the 
tooth-sac, and, when fully developed, presents an outer firm 
wall and an inner looser layer of tissue. At the root of the 





Fig. 119. Follicular odoutomes from the mandible. 

tooth the follicle-wall blends with the dentine papilla, and is 
indistinguishable from it. Before the tooth cuts the gum, 
it is completely enclosed within this capsule. Under certain 
conditions the capsule becomes greatly increased in thickness, 
and so thoroughly encysts the tooth that it is never erupted 
(Fig. 121). Such thickened capsules are mistaken for fibrous 
tumours, especially if the tooth be small and ill-developed. 
Under the microscope they present a laminated appearance, 




Fig. 120. Follicular odontome ; 
from a boy. (Museum of the 
Royal College of Surgeons.) 




Fig. 121 . Fibrous odontome ; from 
goat. (Natural size.) 



with strata of calcareous matter. To these the term fibrous 
odontomes may be applied. They are more common in rumin- 
ants than in other mammals, and are especially frequent in 
goats. As a rule they are multiple, four being by no means 



GEMENTOMES 



241 



an unusual number. They occur in marsupials, bears, and 
lions, as well as in man. 

Rickets may be responsible for some of these thickened 
capsules. The most typical examples are found in rickety 




B 



Fig. 122. Odon tome (cementome) from the mandible of a rickety 
youth aged 19. A, Denticle ; B, portion of the outer wall of 
the jaw. 

children ; bilateral tumours of this kind have been erroneously 
described as myeloid sarcomas. 

4. Cementomes. When the capsule of a tooth becomes 
enlarged, as in the specimens just considered, and these 




Fig. 123. Cementome weighing 25 oz. , from a horse. (Half 
natural size.) (Museum of the Royal College of Surgeons.} 

thick capsules ossify, the tooth will become embedded in a 
mass of cernentum ; such tumours are called cementomes 
(Fig. 122). Tumours of this character occur most frequently 
in horses, and sometimes attain a large size (Fig. 123). 
Q 



242 RADIGULAR ODONTOMES 

5. Compound follicular odontomes, If the thickened 
capsule ossifies sporadically instead of uniformly, a curious 
condition is brought about, for the tumour will then contain 
a number of small fragments of cementum, or dentine, or 
even ill-shaped teeth (denticles) composed of three dental 
elements cementum, dentine, and enamel. The number of 
teeth or denticles in such tumours varies greatly, and may 
reach a total of 400. 

Many of these tumours have been observed and care- 
fully described. Tellander found one in a woman aged 27, 
and Mathias in a Hindu aged 20 ; Windle and Humphreys 
described one removed from a boy aged 10. Similar cases 
have also been reported by Hildebrand and De Roaldes. 
Cousens removed 100 denticles from a tumour that grew 
in the jaw of a boy aged 11. An odontome of this kind has 
been found in the maxilla of a horse; it contained 400 
denticles (Logan). I obtained one in a Himalayan goat; it 
grew in the maxilla, and held nearly 300 denticles : the 
jaw and denticles are preserved in the museum of the 
Royal College of Surgeons. 

6. Radicular odontomes. The crown of a tooth once 
formed is unalterable. The root of a tooth continues to 
grow after the completion of the crown. When a root 
develops an odontome, enamel does not enter into its 
composition ; it contains dentine and cementum in varying 
proportions : these tissues are derived from the dentine 
papilla. A radicular odontome (Fig. 124) described by 
Salter is a good example of this species. The outer layer 
consists of cementum ; within this is a layer of dentine, 
and the nucleus is calcined pulp. The odontome shown 
in Fig. 125 has a similar structure. Many radicular odon- 
tomes are probably due to inflammatory changes affecting 
the roots of incompletely developed teeth. I think this may 
explain the specimen (Fig. 126) that I removed from a boy 
aged 15. The tumour consists of bone like that forming 
the alveolar borders of the jaw. The roots of the tooth 
seem to expand and gradually blend with the tumour- 
mass. Odontomes are usually detected during adolescence. 
I removed one with some difficulty from the mandible of 
a man aged 62 (Fig. 127). The ball of tissue around the 



ENAMEL-NODULES 



243 



roots of the tooth consists of irregularly formed dentine 
and cementum. 




Fig. 124. Radicular odontome from human subject. (A Represents the 
natural size of the specimen.) (Salter.} 

Radicular odontomes have been observed .in rodents 
such as the porcupine, agouti, marmot (Fig. 128), boar 
(Fig. 129), and elephant. It is probable that in teeth grow- 




Fig. 125. Radicular odontome, removed from the upper jaw of a mail 
aged 41. (Natural size.) (Sir John Tomes.} 

ing from persistent pulps these tumour-like masses are of 
inflammatory origin. 

Enamel-nodules. This name is applied to small enamel- 
covered excrescences of dentine projecting from the normal 



244 



ENAMEL-NODULES 



outline of the dentine o*f a tooth, the nodule being separated 
from or only slightly connected with the normal enamel. 




A B 

Fig. 126. A, Odontome surrounding the second mandibular molar of a 
boy aged 15. B, The odontome in section, showing the relation of 
the roots to the tumour-tissue. 

Enamel-nodules vary in size, but are rarely bigger than 
a mustard-seed ; they may attain a circumference of half an 




Fig. 127. A, Lower jaw with a radicular odontome in situ. The 
outline of the mandible was sketched from a radiograph. B aud 
C, The tumour of natural size and in section. 

inch or more. The dentinal core of an enamel-nodule is 
continuous with the dentine of the tooth (Fig. 130). The 



ENAMEL-NODULES 



245 



enamel-cap is often granular. In the dentine subjacent to 
the nodule there may be some irregular spaces or a pro- 
longation of the pulp cavity, but it only enters the nodule 

in large specimens. Irregu- 
larities in the calcification of 
the tooth are frequently asso- 
ciated with enamel-nodules, 
the result of aberration in the 
development of the tooth, but 
the cause is unknown. 

Enamel-nodules are com- 
mon, and, when small, often 
overlooked. They are almost exclusively confined to upper 
molars, and grow from the surface, between the roots, close 
to the gum margin. 

Nearly fifty years ago Salter described the minute struc- 
ture of enamel-nodules, and mentioned that they were not 
known to occasion symptoms. This observation is nearly 




Fig. 128. Odontome connected 
with the incisor of a marmot. 
(Natural size.) 




Fig. 129. Eadicular odontome connected with the mandibular canine 
of a boar. 

true to-day. Enamel-nodules are only discovered when the 
teeth are removed. 

Some of the larger varieties of enamel-nodules resemble 
radicular odontomes. A remarkable example was extracted 
from a Chinese student in Hankow by Mr. Davenport 



246 



COMPOSITE ODONTOMES 



(Fig. 131). A swelling around the tooth was supposed to 
be an abscess. 




Fig. 130. Tooth showing an enamel-nodule, with a magnified view of a 
section of a nodule. (Warwick James.) 





B 



Fig. 131. Second right mandibular molar of a Chinaman aged 19, with 
a large enamel-nodule. A and B, The tooth of natural size ; 0, the 
tooth enlarged and the tumour shown in section. 

7. Composite odontomes. This is a convenient term to 
apply to those hard tooth-tumours occurring in the jaw and 



COMPOSITE ODONTOMES 247 

bearing little or no resemblance in shape to teeth; they 
consist of a disordered conglomeration of enamel, dentine, and 
cementum. Such odontomes may be considered as arising 
from an abnormal growth of all the elements of a tooth- 
germ enamel-organ, papilla, and follicle. 

It was long believed that composite odontomes occurred 
only in the mandible ; now that we know more about them, 
it is clear that they arise as frequently in the maxilla, 
and that they attain a far larger size in the upper than in 
the lower jaw. In the mandible, however, these tumours 
may attain to a large size. One of the biggest (Fig. 132) was 
removed by Mr. Brothers of Cape Town from a Kaffir boy 




Fig. 132. Composite odoutome from the mandible of a Kaffir boy aged 14. 
(850 grains. ) (Museum of the Royal Dental Hospital, London.} 

aged 14. The parents of the boy stated that they " noticed 
a swelling when the boy was 6 months old." He ran about 
the village with part of the tumour sticking out of his 
mouth : it was extracted with a strong elevator. 

Many large odontomes removed from the antrurn have 
been described as exostoses. Thus, M. Michon removed from 
the antrum of a Frenchman aged 19 (without an anaesthetic) 
an odontome which weighed 1,080 grains. The operation 
lasted upwards of an hour and a quarter. The tumour is 
described as an exostosis, but fortunately Michon's account 
is accompanied by some excellent figures which show clearly 
enough that the tumour is of dental origin. The cut sur- 
face exhibited a laminated disposition. Microscopically, it 



248 COMPOSITE ODONTOMES 

was composed of tissue presenting many parallel tubules 
having the appearance of exaggerated dentinal tubules. 

A tumour almost parallel with this has been de- 
scribed by Dr. T. Duka, by whom it was removed from a 
Mohammedan woman aged 26, at Monghyr, Bengal. The 
woman had for six years suffered from a muco-purulent 
discharge from the right nostril, and was anxious for relief. 
The case was regarded as one of necrosis, but after a " sur- 
gical struggle" lasting nearly an hour (without chloroform) 
the tumour (Fig. 133) was withdrawn from the antrum. 
It had no connexion with the surrounding tissues. The 




Fig. 133. Composite odontome from the upper jaw. (Natural size. ) 
(Museum of St. George's Hospital.) 

tumour, which was regarded as an exostosis, was sub- 
mitted to a committee of the Pathological Society. In its 
report the committee states that the osseous tissue differs in 
character from that ordinarily seen in exostoses. An examin- 
ation of the tumour, which is preserved in St. George's 
Hospital museum, and inspection of the figures illustrating 
the report mentioned show that it is an odontome. 

The largest odontome known to have grown in the human 
antrum, and which Hilton described as an exostosis, is pre- 
served in the museum of Guy's Hospital. It has an extra- 
ordinary clinical history: 

A man aged 36 had a large osseous tumour occupying 
the antrum. The pressure of this tumour had caused the 











Fig. 134. Group of odontomes. 

A. Upper jaw. 

B. Lower jaw (Rushton Parker), 
c. Upper jaw (Jordan Lloyd). 

D. Lower jaw (Windle). 

E. Radicular odontome (J. GL Turner). 

249 



250 COMPOSITE ODONTOMES 

front wall of the antrum, with the integument and soft 
tissues covering it, to slough. The trouble was first noticed 
thirteen years before; as the cheek enlarged, the eyeball 
became displaced, and finally it burst. For a long time the 
surface of the tumour was exposed, the suppuration being 
copious, and occasionally pieces of bone irregular in shape 
came away ; at last, to the man's astonishment, the bony 
mass dropped out, leaving an enormous hole in his face. 
It weighed nearly 15 oz., and measured 27'5 cm. (11 in.) in 
its greatest circumference. I have had an opportunity of 
investigating this tumour ; it is remarkably hard, presents on 
section an ivory-like surface, and, on close scrutiny, a number 





A B 

Fig. 135. Composite odontome from the mandible : A, the upper, 
B, the lower view. From an inmate of a workhouse. (Museum 
of the Middlesex Hospital.} 

of closely arranged concentric laminae. Sections ground thin 
and examined under the microscope show large numbers of 
lacunae and canaliculi arranged in a very regular manner. 

On looking over a long series of composite odontomes it 
is curious to note the great variety in shape and disposition 
of the hard dental tissues which they present (Fig. 134). 
The specimen represented in Fig. 135 is one of the oddest in 
this respect, for it in no way recalls in its shape a tooth. 
This tumour came from an old woman, an inmate of a 
workhouse ; she had been troubled with it for very many 
years, and one day she "spat it .out." 

More than one tooth may be involved in a composite 
odontome. Mummery decalcified and sectioned one from a 
child, and found the germs of several teeth in the tumour. 



ODONTOMES: TREATMENT 251 

Clinical characters. The germ of any permanent tooth 
may develop into an odontome, and, as already stated, 
odontomes occur with equal frequency in the upper and 
lower jaws. The follicular species is very apt to be multiple, 
and four have been found concurrently in the jaws of the 
same patient. The composite species ranks next in fre- 
quency. In the upper jaw an odontome may invade the 
antrum and attain the size of a child's fist; in the man- 
dible it rarely exceeds a dove's egg in size, but some are 
bigger. 

There is a clinical point in the natural history of odon- 
tomes which is of some importance. A careful examination 
of the clinical history shows that in nearly all cases the 
tumours have remained for a time quiescent ; then, like 
teeth, they erupt and make their way above the gum, and 
often cause profound constitutional disturbance, mainly of a 
septic character. In some reported cases it is stated that 
the patients have been so ill as to be near death. This 
phenomenon usually happens between the twentieth and 
twenty-fifth years, but it has been deferred until the sixty- 
third year (Fig. 127). Odontomes, like teeth, are occasion- 
ally shed spontaneously, especially those growing in the lower 
jaw. This accident has been reported in a septuagenarian 
(Davidson). 

The diagnosis of these tumours has been a matter of 
great difficulty in the past. The tumour has been regarded 
as a myeloma, as a sarcoma, and as dead bone ! Radiography 
ensures a correct diagnosis. 

Treatment, A study of the literature relating to the 
treatment of odontomes is very instructive, because it re- 
veals that operations unnecessarily severe have been under- 
taken, in ignorance of the nature of the disease, by surgeons 
of high reputation and wide experience. In several instances 
it is known that a great portion of the mandible has been 
excised under the impression that the tumour was malig- 
nant in nature. In some of the cases dentists succeeded 
in removing the tumour with forceps, thinking they were 
dealing with unerupted teeth. 

In the case of a tumour of the jaw the nature of which 
is doubtful, particularly in a young adult, it is incumbent 



252 DENTAL CYSTS 

on the surgeon to satisfy himself, by means of radiography, 
before proceeding to excise a portion of the mandible or 
maxilla, that the growth is not an odontome, for this kind of 
tumour only requires enucleation. In the case of a follicular 
odontome it is very essential to remove the sac completely. 

DENTAL CYSTS 

It occasionally happens, in extracting permanent teeth, 
that a small fibrous bag is found at the apex of the root, 
usually no larger than an apple-pip, though sometimes 
it may be as big as a bantam's egg, filled with fluid, 
and often containing crystals of cholesterin. These sacs, 
or dental cysts, occur in connexion with the 
dead roots of molars and premolars (Fig. 
136). They sometimes attain a considerable 
size in the upper jaw, and some of these 
cysts simulate an abscess of the antrum. 
Dental cysts are often bilateral, and occa- 
sionally multiple. 

The constant association of these cysts 
with the dead roots of permanent teeth has 
led many observers to regard them as pus- 
sacs with thick, fibrous walls. Mr. J. G. 
Turner has carefully investigated their struc- 
ture, and demonstrated the existence of 
an epithelial lining in many dental cysts, 
cysts at the roots He belie ves that they arise in the " rests " 
of a dead lower detected by Malassez and known as para- 
dental epithelial remnants. They are de- 
rived from a prolongation of the enamel-organ which pre- 
cedes and determines the formation and shape of the dentine 
and the root of the tooth. 

I have had many dental cysts examined microscopically, 
and can confirm Turner's observation that they possess an 
epithelial lining. The epithelium is usually stratified, but 
columnar cells occur, especially in cysts associated with the 
first permanent molar. 

The restriction of these cysts to the roots of the 
permanent teeth is explained by the fact that the roots 
of temporary teeth as well as their alveoli are absorbed. 




DENTAL GYSTS 



253 



The majority of dental cysts are met with accidentally 
in extracting dead permanent teeth or their roots. Large 
specimens, however, resemble in their clinical signs tumours 
of the jaws or antrum (Fig. 137). Even cysts of the size 




Fig. 137. Large cyst connected with the mandible ; it is probably an 
unusually large dental cyst. (Museum of St. George's Hospital.} 

of a dove's egg in relation with the lower molars and pre- 
molars will so expand the outer plate of the mandible as 
to yield parchment-crackling on being firmly pressed with 
the finger. When a painless smooth tumour of the jaw is 
associated with a carious tooth, especially of long standing, 
a dental cyst should be borne in mind. The association of 



254 DENTAL CYSTS: TREATMENT 

these cysts with carious" and dead teeth is sufficient to pre- 
vent them from being mistaken for follicular odontomes. 

Treatment. The roots must be extracted, the cyst-wall 
thoroughly enucleated, and the cavity stuffed with sterilized 
gauze and allowed to granulate. If any part of the cyst- 
wall be allowed to remain it will lead to a persistent and 
usually troublesome sinus. 

Blaud-Sutton, J., "A very Large Odontorae from a Horse." Trans. Odont. 
Soc. of Gt. Brit., 1891, xxiii. 215. 

Bland-Sutton, J., " On a Radicular Odontoma from the Mandible." Ibid., 1906, 
xxxviii. 19. 

Bland-Sutton, J., "A Clinical Lecture on an Odontome in a Man aged 62." 
Med. Press and Clre., 1912, cxliv. 296. 

Broca, Paul, " Odontomes." " Traite des Tumeurs," 1869, ii. 350. 

Cousins, J. W., "A Case of Compound Follicular Odontoma." Brit. Med. 
Journ., 1908, i. 1352. 

Duka, T., "A Bony Tumour of the Nasal Fossa." Trans. Path. Soc., 1866, 
xvii. 256. 

Gabell, D. P., James, W. W., and Payne, J. L., "Report on Odontomes by the 
Committee appointed by the Brit. Dental Assoc., 1914." 

Harborow, G., " A Compound Odontome," with a histological report by 
J. H. Mummery. Proc. Roy. Soc. of Med., 1921, xv., Odont. Sect, p. 8. 

Hilton, J., "A Large Bony Tumour in the Face." Guy's Hosp. Repts., 1836, 
i. 493. 

Hopewell- Smith, A., "Two Odontoceles and some other Cysts." Proc. Roy. 
Soc. of Med., 1910, iii., Odont. Sect., p. 121. 

Michon, " Exostose eburnee du Sinus Maxillaire." Bull. Soc. de Chir., Paris, 
1850, i. 608. 

Tirumurti, T. S., Brit. Dental Journ., 1913, xxxiv. 1206. 

Tomes, Chas. S., "Description of an Odontome." Trans. Odont. Soc. of Gt. 
Brit., 1872, iv. 81. 

Tomes, Chas. S.lbid., 1872, iv. 103. 

Tomes, J., "A Group of Supernumerary Teeth. "--Hid., 1863, iii. 365. 



GROUP IIL EPITHELIAL TUMOURS 



CHAPTER XXIII 

PAPILLOMAS (WARTS); ADENOMAS; CAR- 
CINOMA (CANCER) 

IN this group of tumours epithelium is the essential and 
distinguishing feature. It is so disposed in the bodies of 
complex animals as to serve many functions : in some situa- 
tions it acts as a protective, e.g. the epidermis, where it 
becomes modified into hair, nail, horn, or into the hardest 
of all animal tissues enamel; in others, epithelial cells dip 
into the underlying connective tissue to form secreting 
glands ; some of them are simple, such as the tubular glands 
of the intestine ; others, like the liver, mamma, and kidney, are 
complex. Whether a gland is simple or complex, the principle 
of its construction is the same and consists of narrow chan- 
nels, lined with epithelium, resting upon a connective-tissue 
base, in which blood-vessels, lymphatics, and nerves ramify. 

Each epithelial recess of a gland is known as the acinus, 
and each acinus is in communication with a free surface, 
either directly by its own duct, as in the case of seba- 
ceous and mucous glands, or indirectly by means of a 
number of main ducts, as in the case of the mamma; 
or by a common duct, as in the pancreas. To this rule 
there are exceptions : the thyroid gland, the hypophysis, 
and the ovary. It is important to bear in mind the fact 
that, with the three exceptions mentioned, secreting glands 
are in direct communication with free surfaces and there- 
fore accessible to micro-organisms. 

The various members of the epithelial group of tumours 
fall readily into three genera : 1, Papillomas (warts) ; 2, Ade- 
nomas; 3, Carcinomas (cancers). 

255 



256 PAPILLOMA ADENOMA 



PAPILLOMA 

A papilloma, or wart, consists of an axis of fibrous tissue 
containing blood-vessels surmounted by epithelium projecting 
from an epithelial surface. It may be simple, or so covered 
with secondary processes as to look like a mulberry. When 
the processes are long and soft a papilloma is said to be 
villous. The chorionic villi are good physiological types of 
villous papillomas, such as occur in the kidney, bladder, 
occasionally on the endometrium, and almost as rarely in 
the plexuses of the cerebral ventricles. Papillomas arise 
from any surface covered with epithelium : they are com- 
mon on the skin, but less frequent on mucous surfaces, 
especially the tongue, larynx, intestinal tract, and gall- 
bladder, and in the ducts of secreting organs. 

Warts often arise in response to irritating discharges, 
especially in the neighbourhood of the genital orifices : here 
micro-organisms are responsible for their growth. In other 
situations they appear without an assignable cause. Warts 
are innocent structures in the young, in whom they appear 
suddenly, and disappear almost as suddenly ; but in adults 
they may persist for years, and then, without any obvious 
reason, change their character and become the starting-points 
of cancer; and this happens in all situations where warts 
are found. The evil consequences of warts are many and 
various, and it will be convenient to discuss them when 
considering epithelial tumours of special organs. 

ADENOMA 

An adenoma is a tumour constructed upon the type of, 
and growing in connexion with, a secreting gland. 

Adenomas occur as encapsuled tumours in such organs 
as the inarnma and liver, and in glands like the parotid 
and thyroid. A single adenoma may be present, but two 
or more may exist in the same gland. In the case of the 
intestine a score or more may grow in the same individual. 
In size the}' vary greatly : some are no larger than peas, 
whereas in the mamma an adenoma will occasionally attain 
the dimensions of a man's head. 

The effects of adenomas depend mainly upon the situation 



GANGER 257 

in which they grow. The following statements are true 
for all: When completely removed there is no recurrence; 
they do not infect neighbouring lymph-nodes, nor give rise 
to secondary deposits. When an adenoma causes death it 
is in consequence of mechanical complications, depending on 
the situation and size of the tumour. 

When the spaces in an adenoma are distended with 
fluid the tumour is called an adenocele. The source of 
the fluid is of interest, for it often corresponds to that 
secreted by the gland in which the adenoma arises. Thus, 
in an hepatic adenoma it is bile; in the breast it will be 
an emulsion ; thyroid cystic adenomas contain colloid stuff. 
In typical examples it is easy to distinguish between an 
adenoma and a cancer in a gland, but there are inter- 
mediate conditions in which even skilled histologists 
hesitate to offer an opinion. Adenomas exhibit peculiar 
characters and occasion disturbances varying with the glands 
in which they arise : it will therefore be convenient to 
consider the varieties in the chapters devoted to special 
glands. An adenoma and a cancer sometimes coexist in 
the same gland, and an adenoma does not become trans- 
formed into a cancer. The breast and the thyroid gland 
are common situations for adenomas. 

CARCINOMA (CANCER) 

This term, in the strict sense in which it is used by patho- 
logists, signifies a malignant tumour arising in epithelium. 
The disease is of very great importance on account of its 
frequency, insidious onset, and, in the earliest stages, pain- 
lessness ; its progressive and irresistible destructiveness ; the 
manner in which it infects lymphatics; the extraordinary 
effects produced in different organs on account of the dis- 
semination of the growth in the form of secondary nodules ; 
the helplessness,* misery, and pain it produces when fully 
advanced; and the inability of medical and surgical art 
to deal effectively with it, save in the earliest stages. 
Although this disease was recognized in the dawn of 
medicine, we not only remain ignorant of its cause, but, 
in many instances, the diagnosis of the malady is uncertain 
in the living. This is not due to supineness on the part of 
B 



258 GANGER 

investigators, but to the absence of what is called "specific 
symptomatology." Cancer causes no symptoms until it is big 
enough to set up mechanical troubles, or becomes septic. 

When carcinoma arises from a surface covered with epi- 
thelium of the protective variety it is called squamous-celled 
cancer ; and when it arises in the epithelium of glands it is 
termed gland-cancer. 

The microscopic structure of a carcinoma is very simple 
and consists of columns of cells, so that when the columns 
are cut at right angles the section has the appearance of a 
number of alveolar spaces filled with epithelium. The walls 
of these alveoli are composed of fibrous tissue, presenting 
various degrees of density, in which blood- and lymph-vessels 
ramify. 

The softness or hardness of cancer depends on the 
amount of fibrous tissue between the columns of cells. 
This plan of structure underlies all varieties of malignant 
epithelial tumours. The cells composing the columns de- 
pend for their shape upon the character of the epithelium 
in which the cancer originates ; this feature is constant, 
and histologists can often state with certainty the gland in 
which a cancer arose, merely by studying properly-prepared 
sections under the microscope. 

In the appearance of a cell from a cancer there is nothing 
characteristic of the disease, nothing that would lead a patho- 
logist to identify it as a malignant cell. Cancer can only be 
identified in sections showing the relation of the cells to 
each other in a group ; then the features of the normal gland 
are often reproduced so well that the decision can be made 
with certainty. 

Stroma and parenchyma. Every tumour, whether it 
he innocent or malignant, except chorionic carcinoma 
(Chap. XLIII), presents a stroma and a parenchyma. These 
two elements are particularly observable in adenomas and 
carcinomas on account of the striking difference in the 
characters of the connective tissue and the epithelium. In 
the case of carcinoma, as the epithelial cells multiply and 
intrude into the adjacent tissue the intrusion is answered 
by a formation of fibrous tissue : this response is less marked 
in the rapidly growing tumours than in those which grow 



VARIETIES OF GANGER 259 

slowly. This response of the tissues to irritation has been 
termed the specific tissue-reaction, but it is as obvious in 
many of the common forms of tissue-irritants, such as 
micro-organisms, and especially foreign bodies. In the case 
of sarcomas a kind of investment is furnished for each cell, 
but in a carcinoma it is furnished for groups of cells, pro- 
ducing in reality a fibrous-tissue maze. 

Varieties of cancer. Since nothing is known as to the 
actual cause of cancer, it is customary, and convenient, to 
classify the varieties of cancer according to the prevailing 
type of epithelium. The two chief varieties, as we have seen, 
are (a) squamous-celled cancer and (6) gland-cancer. 

Squamous - celled cancer. This variety, formerly called 
epithelioma, arises on surfaces covered with squamous epi- 
thelium. It occurs on any part of the skin, mouth, tongue, 
pharynx, larynx, and O3sophagus. It also attacks the urethra 
in both sexes, the vulva, vagina, and vaginal aspect of the 
neck of the uterus. 

Gland-cancer. This variety arises in the epithelium of 
secreting glands ; it is exceedingly common in some and rare 
in others. It will be convenient to discuss the liability of 
the various glands separately, but the general features of this 
disease are the same in whatever gland it arises. 

General features of cancer. A striking feature of cancer 
is the fact that it does not form a circumscribed tumour. 

, When examined clinically it is rarely possible to define the 
limits between the tumour and the surrounding tissues, and 
this indefiniteness is more obvious when, in the course of an 
operation, the surgeon cuts into it ; but, what is more signi- 
ficant, when the periphery of a cancer is subjected to micro- 
scopic scrutiny the eye of a competent pathological histologist 

-,js unable to discern the precise limitation of the cancerous 

, territory. This illimitation of cancer constitutes one of the 
greatest obstacles in dealing with it surgically ; for if with 

- the aid of a. microscope there is difficulty in defining its 
limits, how uncertain the surgeon must be in determining 
its extent with only fingers and eyes to guide him during an 
operation ! This has led to the practice, in recent years, of 
complete extirpation, whenever possible, of cancerous organs. 

, Although a cancer is for a time limited to the gland in which 



260 MICRO-FLORA OF GANGER 

it arises, we have no means of distinguishing with any reason- 
able certainty, when the individual comes under observation, 
whether the cancer is limited to the gland, for its outrunners 
quickly involve surrounding structures, whether skin, fat, 
mucous membrane, muscle, or bone. When adjacent parts 
are infiltrated or permeated in this way, it is convenient 
to describe them as being implicated in the cancer. This 
implication of organs is a grave feature, and a common cause 
of death, and it is often a bar to operative intervention. 

Although cancers, like all epithelial structures, are in 
free communication with the lymph-system, they are poorly 
supplied with blood : this leads to retrograde changes, which 
it is customary to describe as degeneration. The commonest 
of these is known as colloid degeneration, in which the 
epithelium in the cell-columns becomes changed into a 
structureless material resembling jelly : this change is 
common in cancer of the stomach and colon. It is well 
known that a primary cancerous lesion may undergo retro- 
gressive changes and almost disappear. The variety known 
as " withering cancer " or " atrophic cancer " of the breast is 
an example of this. Patients with this kind of cancer have 
lived ten, fifteen, and even twenty years. The not un- 
common form of cancer found in the pelvic colon, where 
the growth encircles and narrows the gut so tightly that 
it seems as if a piece of cord were tied around it, is really 
a primary carcinoma undergoing spontaneous cure; but it 
surely destroys life, either by obstructing the colon or by 
infecting the liver and peritoneum. 

The micro-flora of cancer. Cancer varies in malignancy 
not only in regard to the organ in which it arises, but also 
in respect to the same organ. Cancer in the breast of a 
suckling woman will sometimes run its course in a few 
months, but in an older woman it may require ten, twelve, 
and even twenty years to destroy life. Cancer of the caecum 
in exceptional instances will grow slowly and require five or 
more years to kill its victim ; this is true of cancer of the 
rectum, if the mechanical obstruction caused by the growth 
be obviated by colostomy. 

Observation teaches that cancer occurring in situations 
easily accessible to pathogenic micro-organisms runs its 






TERMINAL INFECTIONS 261 

course more rapidly than in sheltered organs. Thus, cancer 
of the tongue or pharynx, as a rule, kills within two years ; 
this is true also of cancer of the neck of the uterus, but 
cancer of the body of the uterus runs a slower course. The 
rapidity with which cancer in some situations ends fatally 
depends on the celerity with which the cancerous tissue 
becomes septic. This is a matter of great importance. 

An innocent differs from a malignant tumour in the pos- 
session of an investing capsule, and as long as this remains 
intact the tumour is protected from pathogenic micro- 
organisms. When the capsule is injured, or sloughs, in- 
fecting agents gain access to the tumour-tissue and cause 
general disturbance of the patient's health. Besides pos- 
sessing no capsule, cancer, as a rule, is situated on epithelial 
surfaces where it is exposed to micro-organisms for example, 
the lips, the gullet, tongue, larynx, stomach, intestines, and 
cutaneous surfaces. The exuberant tissue formed by the 
growth of the cancer, being poor in blood-vessels, and there- 
fore of low vitality, is easily infected by pathogenic micro- 
organisms and decomposes ; the products of these changes 
are cast off as offensive discharges, the infective agents gain 
access to the blood-stream, set up general disturbance of the 
patient's health, and produce the peculiar sallow complexion 
that was formerly called " cancerous cachexia," but which is 
due to the absorption of the products toxins brewed by 
the micro-organisms. Systematic examinations show that 
cancers of the lips, tongue, and pharynx, and of the neck of 
the uterus, teem with micro-organisms, especially the strepto- 
coccus. Fungating cancers of the large intestine and rectum 
swarm with colon bacilli. Non-ulcerating cancers of the 
breast are invariably sterile. 

In a sense it is true that the malignancy of a cancer is 
often an expression of its septicity. In many of its forms 
cancer is a chronic disease, death being determined by what 
are known as terminal infections, such as uremia, pneu- 
monia, peritonitis, and meningitis, due to the activity of 
pathogenic micro-organisms. 

The septicity of cancer has also a relation to the lymph- 
nodes. The systematic examination of these bodies enlarged 
in association with cancer shows that in some instances the 



262 DISSEMINATION 

increase in size of a node is due to cancer, in others it 
is the result of infection from micro-organisms which have 
colonized the primary focus. There is no way of deciding 
accurately between the two forms of enlargement, without the 
assistance of the microscope. 

The septicity of cancers influences in a high degree the 
results of operations. For example, the removal of a can- 
cerous breast, often a severe and extensive operation, has an 
extremely low mortality. The removal of the uterus for 
cancer of its neck, or the resection of a cancerous segment 
of the colon, is attended with a high mortality. The differ- 
ence is due to the sterility of the breast and the fertility of 
the uterus and colon in regard to infecting micro-organisms. 

Dissemination. Cancer is extremely prone to disseminate 
and give rise to a crop of cancerous nodules in parts of the 
body remote from that in which it started. The original seat 
of the disease is called the primary focus, and the nodules 
arising from its dissemination are called secondary deposits. 
This remarkable process is sometimes called metastasis. The 
structure of the secondary deposits is precisely that of the 
primary tumour, and the reproduction of its histologic features 
is so faithful that the nature and often the seat of the primary 
tumour can be correctly inferred from a microscopic exami- 
nation of a secondary nodule. (Fig. 138.) Dissemination is 
effected by three methods: 1. Transportation by the blood- 
stream. 2. Permeation by lymphatics. 3. Implantation. 

1. Transportation by the blood-stream (embolic dissemina- 
tion). In this method outrunners from the primary focus 
invade the veins of the cancerous organ, and, becoming 
detached as minute emboli, are transported by the blood- 
current and carried into the pulmonary vessels: they are 
filtered from the blood by the capillaries of the lungs, 
and, after their arrest, find in this vascular tissue an excel- 
lent soil in which to grow. When the primary growth is in 
organs in the domain of the portal circulation the cancerous 
emboli are strained from the blood by the capillaries in the 
liver, and this organ will be occupied by secondary deposits. 
Minute particles of cancer also enter the blood-stream by 
the lymphatics. 

Schmidt made some valuable observations on the coloniza- 



PERMEATION 263 

tion of the blood by cancer-emboli, and succeeded in detecting 
them in the pulmonary vessels (Fig. 139). When cancerous 
particles enter the blood-strearn they excite thrombosis, 
and the thrombus, contracting on the emigrant cells, may 
ultimately destroy them. This defending or prophylactic 
power of the blood is important, as it prevents the blood- 
stream from being colonized. The thrombosis excited by 




x 130 



Fig. 138. Section through a portion of an inguinal lymph -node infected 
with cancer: the primary disease was in the rectum. (Foulerton.} 

invading cancer-particles is capable of another explanation : 
'cancerous tumours are often colonized by pathogenic micro- 
organisms, especially streptococci, notorious agents for coagulat- 
ing blood. A malignant tumour, free from pathogenic micro- 
organisms, if it invades veins, does not induce thrombosis. 

2. Permeation by lymphatics. The surfaces of our bodies, 
whether skin or mucous membrane, are rich in lymphatics, 
and, as secreting glands are primarily derived from these 
surfaces, it comes about that they are in free communication 
with the lymphatics and lymph-nodes. The lymphatics in 



264 



PERMEATION 



relation with a cancerous focus become implicated, and the 
cells involve the walls of the lymphatics and invade the lumen 
of these minute canals, and gradually creep along them to the 
corresponding lymph-nodes. This progression of cancer along 
lymphatics is known as permeation. The cells are not pas- 
sively conveyed to the nodes as emboli, but the lymphatic 
channel is converted into a solid rod of cancer. This method 

can be occasionally studied 
in the thoracic duct (Fig. 
140). The ducts leading 
to the receptaculum chyli, 
the receptaculum itself, and 
the thoracic duct are some- 
times permeated by cancer 
until they become solid 
cords. Solidification of the 
thoracic duct in this way 
has been described in con- 
nexion with cancer of the 
gastro-intestinal tract, the 
uterus, and the testicle. 
Careful descriptions of this 
condition have been pub- 
lished by Unger, Weigert, 
Troisier, Hillier, and others. 
It is a remarkable feature 
that cancerous obstruction 
of the thoracic duct does 
not lead to chylous ascites. 
The implication of the thoracic duct in cancer of the stomach 
explains the enlargement of the left supraclavicular lymph- 
nodes late in the course of the disease, a diagnostic sign 
of great value. An example of the spread of cancer from 
the testicle to the cervical lyrnph-nodes by way of the 
thoracic duct is described in Chap. LIX (p. 652). 

The extent to which lymphatic permeation has occurred 
is a matter that cannot be accurately defined in a given 
case of cancer ; this adds an additional factor of uncertainty 
in estimating the result and value of surgical interference. 
Masses formed by enlarged lymph-nodes are sources of danger. 




Fig. 139. Cancerous embolus in a pul- 
monary capillary embedded in a 
thrombus. (Schmidt. ) 







# 

Fig. 140. Thoracic duct, receptaculum, and some lymph-nodes. The recep- 
taculum and duct are permeated with, cancerous material secondary to 
cancer of the rectum. (Hillier.) 



266 IMPLANTATION 

In the neck they sometimes interfere with the trachea or the 
ossophagus or adhere to the jugular vein. When these masses 
are colonized by micro-organisms and ulcerate, the implicated 
vein is sometimes opened by ulceration and the patient rapidly 
bleeds to death. The same accident occurs in the groins. 

Cancerous lymph-nodes are sometimes so stuffed that they 
burst their capsules and adjacent nodes blend in a common 
mass. As a rule, cancerous lymph-nodes remain separate, 
but when they become septic the nodes burst and form a 
conglomerate mass; the implicated skin sloughs, and leaves 
an open stinking ulcer. 

Often a primary cancerous focus is so small and incon- 
spicuous that the patient takes little notice of it until 
enlargement of the neighbouring lymph-nodes leads him 
to seek advice, and this involves a search for the primary 
focus. (See especially the so-called branchiogenous carci- 
noma, p. 334.) 

3. Implantation. The power of independent growth pos- 
sessed by cancerous epithelium is a dangerous feature, and 
does not always need blood- or lymph- vessels for its mani- 
festation. It sometimes happens, when an abdominal viscus 
is the seat of cancer, that a small outgrowth makes its way 
through the peritoneal covering and sheds its cells into the 
general peritoneal cavity ; these are distributed by the peri- 
toneal fluid and the ceaseless movements of the intestines. 
In a few weeks the whole of the serous membrane will be 
beset with a multitude of nodules, each reproducing a type 
of the parent tumour. Epithelial infection of this kind 
occurring in connexion with cancer of the gall-bladder, the 
body of the uterus, and the gastro-intestinal tract gives rise 
to innumerable secondary nodules and demonstrates the 
remarkable power of epithelium to engraft itself, to live 
and to grow. 

All cancer-cells which fall into the peritoneal cavity do 
not live, in spite of their vitality : many are destroyed, and 
some are hindered from doing much harm by becoming 
encysted, but under certain conditions implanted cancer 
will form huge tumours (pp. 637-8). 

An instructive form of cancer- implantation can sometimes 
be studied in connexion with the pleura, when a bronchial 



GANGER-INFECTION 267 

lymph-node, stuffed with cancer, bursts on the pleural 
surface of the lung. The cancerous particles are spread by 
the movements of respiration ; many become implanted on 
the surfaces of the pleura and grow into secondary knots. 

It is maintained by most writers that cancer invariably 
arises from a single focus of infection. From time to time 
observations are reported in opposition to this opinion. For 
example, it occasionally happens in the intestinal tract that 
two or more foci are found in the mucous membrane at 
such a distance from each other, and separated by so long a 
tract of healthy mucous membrane, as to preclude the idea 
that they arose by extension from a single focus. When a 
primary cancer of the bowel fungates into its lumen, can- 
cerous particles are frequently detached; it is not incon- 
ceivable that some of these particles may become implanted 
on the mucous membrane and grow into a patch so big as 
to give rise to the idea that it is a primary focus of cancer 
(see p. 366). The particles detached from the surface of 
a fungating cancer are, as a rule, dead tissue, but it must 
happen occasionally that clusters of living cells, capable of 
acting as grafts, are shed into the lumen of the intestine, 
and that some of them may find a suitable attachment. In 
this respect they are comparable to eggs : only a small pro- 
portion of those fertilized attain maturity. 

Cancer-infection. When normal cutaneous epithelium is 
accidentally engrafted in the subcutaneous tissue, the cornea, 
or the iris, it will live and grow (Chap. XLIX). When can- 
cerous organs are removed from the abdomen, the edges of 
the wound in the abdominal wall are sometimes soiled with 
epithelial fragments; after the operation a tumour some- 
times appears in the cicatrix, with the same histological 
structure as the primary tumour. The careful examination 
of tumours of this kind has satisfied me that they arise from 
what may be correctly called cancer-infection of the wound. 

It is a fact that, when the breast has been removed for 
cancer by a carefully planned but very extensive operation, 
it sometimes happens that the disease returns within a few 
months and converts the whole of the skin covering the area 
involved in the operation into a hard leather-like mass, leaving 
the patient in a condition far worse than if the disease had 



268 SECONDARY GANGER 

been allowed to run its course unchecked. This undesirable 
condition is due to the soiling of the connective tissue, opened 
up in the course of the operation, by cancerous cells set free 
by the division of blood-vessels, lymphatics, and lymph-nodes 
permeated with cancer. 

When an operation for mammary cancer has been carried 
out imperfectly, the cicatrix, a few months afterwards, will 
present a double row of nodules corresponding to the stitch- 
holes. The nodules are sometimes cheloid nodules, but 
many are cancerous knots due to infection by the needle 
and thread used at the operation. 

Anxious relatives living with or in actual attendance on 
patients suffering from cancer often ask if the disease is 
infectious. The reply is invariably No. Macewen has recorded 
an instructive experience : An elderly woman with advanced 
cancer of the rectum was attended by a woman who lived 
in an adjoining house; this woman also had an inoperable 
cancer of the rectum. The maidservant, aged 25, of the 
first patient had an early cancer of the rectum. The elder 
woman used regularly an enema-syringe to relieve her con- 
stipation ; this syringe had been used by the neighbour and 
by the maid. 

Distribution of secondary cancer, Secondary deposits 
of cancer may occur in any organ and tissue of the body ; 
they vary greatly in number in different individuals and 
with the variety and situation of the primary focus. The 
rarest of all tissues in which to find them is voluntary muscle, 
and the rarest of all organs the heart. Metastatic deposits 
of cancer in the walls of the heart are usually secondary 
to this disease in the resophagus or stomach. Secondary 
deposits are sometimes found in the eye, and the majority 
of the reported cases occurred in association with mammary 
cancer; in exceptional instances both eyes have contained 
deposits. Ocular deposits have been found when the primary 
disease attacked the stomach and thyroid gland. (Rowan 
and Marshall.) 

Secondary cancer of the lung, The lungs are very 
frequently depositories of secondary cancer, and this is due, 
as has been explained, to the arrest of minute cancer-emboli 
by the pulmonary capillaries ; but the lungs are often invaded 



SECONDARY GANGER 269 

as the result of permeation. Handley has made a very care- 
ful investigation of the mode in which cancer of the mamma 
disseminates, and shows that it spreads in the thoracic wall 
by permeation, a slow, progressive, centrifugal, serpiginous 
process, which is an actual growth of the cancer along one 
or other lines of the parietal layers in continuity with the 
primary growth. He believes that visceral deposits of mam- 
mary cancer occur through the fine anastomotic lymphatics 
which pierce the parietes, and infect the subserous lymphatics 
of the pleura and peritoneum. Cancer-cells then escape into 
the thoracic and abdominal cavities, implant themselves on 
the surface of the viscera, and there give rise to deposits 
which help to terminate the life of the patient. 

It has been mentioned that cancer-particles reaching the 
blood-current through venous channels, or lymphatics, are 
filtered from the blood by the pulmonary or the hepatic 
capillaries, according to the position of the primary cancerous 
focus; but patients now and then come under observation 
in whom secondary deposits of cancer appear in uncountable 
numbers over the body. In such conditions the cancer- 
em boli are distributed by the systemic arterial system. 
Universal distribution of this kind is due to a secondary 
cancerous nodule in the lung invading a pulmonary vein ; 
the cells, detached by the blood-current, are conveyed into 
the left side of the heart and distributed throughout the 
body by the systemic arteries. 

Dissemination varies widely in degree. In some cases 
secondary deposits will be found only in the liver or the 
lung; in other and apparently similar cases, so far as the 
situation and structure of the primary tumour are concerned, 
secondary knots appear in almost every organ. 

The vitality and power of independent growth possessed 
by cancer- cells is very remarkable. These minute epithelial 
emigrants not only live and grow, but reproduce the pecu- 
liarity of the primary cancer. It is astonishing to find a 
secondary cancerous deposit in the humerus with all the 
characters of the glands of the rectum ; a multitude of 
secondary nodules in the skin with the structural features 
of gastric glands, or in the lungs exactly reproducing that 
peculiar form of hepatic carcinoma which arises in the biliary 



270 SECONDARY GANGER IN BONE 

ducts; the familiar closed follicles of the thyroid gland 
reproduced in the body or spinous process of a vertebra ; 
deposits resembling the structure of a mammary carcinoma 
in the ovary, brain, or choroid coat of the eye; and a mass 
growing from the frontal bone with all the characters of the 
prostate gland, secondary to cancer of that organ. It is a 
triumph of pathological histology to have demonstrated that 
carcinoma takes its type of epithelium from the gland in 
which it arises. 

Secondary cancer of such organs as the liver, the ovaries, 
and the bones occasionally forms large masses. Cancer is 
characterized by ceaseless cell - proliferation, and, save for 
accidental infection, is a chronic disease. 

Secondary deposits of cancer in bone. Metastatic cancer 
in bone occurs especially in association with the mammary, 
prostate, and thyroid glands ; it also occurs in connexion with 
cancer of the gastro-intestinal tract, oesophagus, and uterus. 
The deposits may be due to cancer-emboli, to direct extension 
from the primary focus, or to permeation. Until Handley 
detected and described the spread of cancer by permea- 
tion, all secondary deposits were attributed to the embolic 
process, but he carefully studied the centrifugal spread of 
cancer from the primary focus, analysed the situation of 
the secondary deposits, and showed that they appear in a 
near neighbourhood of the primary focus, and as the disease 
advances the nodules occur at greater distances from the 
primary focus until at last, if death is unduly delayed, they 
appear in the trunk ends of the limbs. Hence the distal 
halves of the limbs enjoy an almost invariable immunity 
from the cancerous nodules. Secondary cancer of bone is 
often a distressing complication, especially when the nodules 
occupy the vertebrae; in this situation it causes agonizing 
pain by pressing on the roots of the spinal nerves, and on 
the nerves as they issue from the intervertebral canals. 
As the deposit enlarges, the cord becomes involved, leading 
to paraplegia and the common sequence retention cystitis, 
pyelitis, and uraemia. In cases of paraplegia in elderly women 
with little to account for the symptoms an examination 
should always be made of the breasts : in such cases it is 
not uncommon, to find in one of them a cancerous lump that 



CONJUGAL GANGER 271 

has existed for years and, being painless, has been tolerated. 
When a long bone of the limbs becomes permeated with 
cancer a slight effort will break it. The patient may raise 
her hand to scratch her head, and break the clavicle; or 
break a humerus in getting out of bed, or the femur when 
trying to scratch one foot with the toes of the other. 
The fragments, when kept in apposition, sometimes unite. 
Secondary deposits of cancer in bone rarely attain a large 
size, but this is not a universal rule. Tumours containing 
epithelium in long bones are always secondary. 

Transference of cancer by contact. Many cases have 
been reported which are supposed to prove that cancer may 
be transplanted by the direct contact of a cancerous surface 
either with another part of the infected person's body or with 
another person. The examples of the first condition usually 
mentioned are the infection of the skin of the arm from contact 
with an ulcerating carcinoma of the breast, and the infection 
of a labium by a squamous-celled cancer in the opposite 
labium; and in the case of the bladder, a primary tumour 
infecting that part of the vesical wall with which it comes 
in contact when the viscus is empty. It is a matter of 
common observation that even in extensive cancer of the 
tongue, jaws, or pharynx, quantities of cancerous particles 
find their way into the stomach, but the mucous membrane 
of the gastro-intestinal tract escapes. Surgeons who are 
engaged almost daily in performing operations for cancer 
frequently cut or prick their fingers, but a cancer trans- 
planted in this way is unknown ; in contrast to this, it may 
be mentioned that there is probably no surgeon who has 
not infected himself in this way with some form of septic 
disease. This should make us careful in accepting evidence 
in regard to what is sometimes called conjugal cancer, in 
which a cancerous ulcer appears on the penis of a man 
cohabiting with a woman suffering from cancer of the neck 
of the uterus, or vice versa. 

Heredity. This is a vexed question in regard to cancer 
and malignant disease generally, because so much that appears 
to be affirmative is founded on false facts, that is, on cir- 
cumstances that cannot be tested or proved. The statement 
that the father died of cancer of the prostate, and the 



272 GANGER AND HEREDITY 

mother of a sarcoma of the humerus, is scarcely a good 
explanation of the appearance of an embryoma in their 
daughter. When several members of a family die from 
cancer of the breast it will be found, on careful inquiry, that 
they have lived in the same environment. The question of 
cancerous inheritance bristles with difficulties, many of which 
are at present insuperable. 

Handley, W. Sampson, " The Centrifugal Spread of Mammary Carcinoma in 

the Panetes."Arc7i. of Middx. Hosp., 1904, iii. 27. 
Hillier, W. T., "Carcinoma of the Thoracic Duct; with many references." 

Trans. Path. Soc., 1903, liv. 153. 

Macewen, J. A. C., "Carcinoma Kecti." Clin. Journ., 1913, xlii. 506. 
Rowan, J., " Met astatic Carcinoma of the Choroid from a Primary Carcinoma 

of the Lung." Trans. Ophthal. Soc. of U.K., 1899, xix. 103. 



CHAPTER XXIV 
THE CAUSE AND TREATMENT OF CANCER 

THE cause (pathogenesis) of carcinoma has for many years 
been a fascinating subject of inquiry and has led to much 
speculation, some of which has had great influence in directing 
research along particular lines. Obscurity surrounds the 
cause of this disease, because our knowledge depends on 
observation alone ; all attempts to elucidate the problem by 
experiment have failed, and observation has been supple- 
mented by theory. Among the hypotheses or guesses at 
truth in connexion with this matter there are two which 
require consideration : 1. The Embryonic. 2. The Parasitic. 

1. The embryonic theory. Cohnheim attempted to 
ascribe the origin of malignant tumours to cells, or groups 
of cells, which are not utilized in the development of the 
body in its early or embryonic stages, and he assumed that 
these residues or "rests" retain potential power of growth, 
and later in life suddenly and without obvious provocation 
assume active growth and become tumours. The argument 
against it was to the effect that unutilized embryonic tissue 
or rests had not been demonstrated ; but it suggested a 
line of inquiry in which observation proved the existence 
of tissue-islets which, in some instances, could be regarded 
as potential sources of tumours. Experimental inquiry did 
not support the theory, and as an explanation of the origin 
of malignant tumours it has signally failed. 

Cohnheim's theory has commanded much attention; it 
is in itself a brilliant generalization, and served a valuable 
purpose in leading to a great extension of knowledge 
concerning vestiges and rests. 

In regard to congenital defects of tissues as the sources 
of malignant tumours, the most obvious are those known as 
birth-marks or moles. Many hundreds of these blemishes 

8 273 



274 TRAUMA AND GANGER 

come under the notice of trained observers yearly, but 
not one black mole in a thousand becomes the source of 
a melanoma. 

Trauma in relation to malignant tumours. Injury as 
an etiological factor has only been seriously advanced in 
the case of the breast and the testicle two organs particu- 
larly exposed to injury and bones. 

The majority of women receive in the course of their 
lives an accidental blow upon the breast, and the frequency 
with which women attribute the cause of a cancerous tumour 
within the breast to an injury is largely due to the belief, 
deeply rooted in their minds, that such injuries are the 
common cause of cancer. About 10 per cent, of patients 
with this disease in the breast can, and do, assign a specific 
injury as the starting-point. 

Sarcomas are unusual tumours of the breast and form 
10 per cent, of the malignant tumours of this organ ; they 
occur at an earlier age than cancer, but sarcoma may attack 
the breast even in extreme old age. As in the case of 
cancer, patients often attribute the cause of the tumour to a 
blow, and especially to what may be called an intensive 
injury (see p. 93). 

Surgeons see many patients with sarcoma and carcinoma 
who cannot recall an injury to the affected part ; and of the 
enormous number of contusions and injuries, only a small 
proportion is followed by malignant tumours. Although the 
number is small, the circumstances relating to these sequences 
are such as to lead surgeons to believe that a single " in- 
tensive " injury may occasionally induce the growth of a 
sarcomatous tumour, and place it outside the category of 
mere coincidence. The attitude of surgeons, as reflected in 
their writings, towards physical insult as an etiological factor 
in the production of malignant tumours in the breast, justifies 
the following statement : 

In regard to cancer (carcinoma), all surgeons of experience 
admit that there is a 'definite history of intensive mechanical 
injury in about 10 per cent, of the patients. They are very 
careful not to express a definite opinion as to the causal 
relationship of such injuries to the formation of cancer in 
the breast. In regard to sarcoma of the breast, there are 



PARASITES AND GANGER 275 

many carefully reported cases in which primary sarcoma of 
the breast has supervened on a single intensive injury. The 
sarcomatous nature of such tumours has been ascertained by 
a microscopic examination at the hands of a competent 
pathologist, and their malignant nature has been confirmed 
by the early death of the individual. It is undeniable that 
a single intensive blow on the breast is occasionally followed 
by a sarcomatous tumour. This also holds for sarcomas of 
bones (see p. 93). 

There is diversity of opinion among surgeons as to the 
exact conditions under which a sarcoma may be regarded 
as of traumatic origin. All agree that its situation must 
correspond to the site of the injury, but there is no agree- 
ment among them as to the length of the interval that 
may elapse between the injury and the appearance of 
the tumour in order that they may be regarded as cause 
and effect. This can only be decided by a careful study 
of individual cases. The matter is extremely debatable, 
and the question of trauma as an etiological factor in 
causing malignant disease is frequently argued with success 
in courts of law. 

2. The parasitic theory. Many who are thoroughly 
acquainted with the clinical and pathological features of 
carcinoma feel strongly that this disease will ultimately come 
to be defined as a chronic infective disease due to a micro- 
paro.site which selects an epithelial cell. The brilliant results 
of microscopic inquiry into the causes of disease during the 
last thirty years have added to the number of parasitic 
diseases previously known to us. 

It has become customary, in describing the vegetable and 
animal parasites infesting man, to speak of the flora and 
fauna of the human body. This application of a natural- 
history expression is useful, perhaps even picturesque ; more- 
over, the expression is true. 

As the living things in a brook thrive best in certain haunts, 
so the vegetable and animal forms infesting animal bodies 
exhibit a marked preference for certain organs and tissues in 
which to live and grow. For example, the demodex prefers 
the hair-follicles, and has been found in the ducts of the 
nipple ; ankylostomum selects the mucous membrane of the 



276 PARASITES AND CANCER 

duodenum ; the malaria parasite finds its way into an 
erythrocyte; filarise swim freely in the liquor sanguinis; 
Goccidium oviforme finds its way into the epithelium of 
the biliary passages ; and the embryo of Tcenia echinococcus 
prefers subserous areolar tissue, whilst the adult form of 
this tapeworm chooses the mucous membrane of the dog's 
duodenum. 

Protozoa are widely diffused through the world : they 
are minute resistant bodies which occur in the faeces of all 
kinds of animals and insects, and are easily transported in 
dust and water : they gain entrance to the alimentary canal 
with food, and especially uncooked vegetables. In Uruguay 
and the Argentine Republic cancer of gullet, stomach, and 
intestines is very frequent. Bosc thinks this is due to the 
great consumption of fish, protozoa being abundant in fishes. 
The gastro-intestinal tract is constantly subject to small 
injuries from fish-bones, fragments of the shells of molluscs, 
and the like ; these things not only inflict the injuries but 
convey the infection. 

There are several tumour-like conditions known to 
pathologists that are caused by parasites. Among them 
are the thickenings and polypoid processes produced in the 
intestine of man by the bilharzia (schistosoma), a trema- 
tode. In the bladder the masses of tissue formed by this 
parasite often resemble malignant tumours. The distinc- 
tion is made by finding the ova of 'the parasite in the tumour- 
tissue. 

A remarkable example of the pathogenic significance of 
nematodes is furnished by Fibiger's observations on gastric 
tumours in rats. A nematode lives in the squamous epithe- 
lium of the rat's stomach, also in the gullet, and sometimes 
in the tongue, where it matures; its eggs are thrown off 
with the epithelium and escape with the faeces. Cock- 
roaches eat the faaces, and the eggs contained therein 
develop. The embryos find their way into the muscles 
of the extremities and prothorax of the cockroaches, where 
a few weeks later they can be detected as trichina-like 
bodies. When infected cockroaches are eaten by a rat the 
embryos escape from their capsules, migrate to the fundus 
of the stomach, and in about two months the females lay 



PARASITES AND GANGER 277 

eggs. The parasites are only found in the part of the 
stomach that is lined with squainous epithelium. 

The lesions in the stomach take the form of papilloma- 
tous masses, but some of them infiltrate the gastric wall, and 
some of the rats had deposits in the lungs, but no parasites 
were detected in the secondary nodules. 

Among infectious diseases, the most extraordinary and 
some of the deadliest are those in which the infecting agent 
gains access to the body by inoculation, that is, through 
abrasions, cuts, or punctures of the skin or mucous membrane. 
Familiar examples of this are tetanus, hydrophobia, leprosy, 
glanders, actinomycosis, and syphilis. The point of inoculation 
is known as the primary focus of the disease, and at this 
source the parasites multiply, enter the circulation and lymph- 
stream, whence they may be distributed throughout the body, 
often to form secondary foci of disease that interfere with 
the functions of the organs in which they may chance to 
grow, as well as with the nutrition of the body by means of 
the toxins they brew and discharge into the blood, producing 
a form of slow poisoning. 

The facts which support the parasitic theory of cancer may 
be summarized in the following way : In its initial stages the 
disease is purely local, then gradually spreads to the adjacent 
tissues, and at the same time infects the lymph-nodes which 
receive the lymphatics from the affected area, and general 
infection of the body (dissemination) follows. 

In many instances cancer seems to have a period of 
quiescence, and then to enter on a period of recrudescence 
exactly like a chronic infectious disease such as syphilis. The 
primary focus in this disease disappears after a time and 
leaves but little trace of its existence; so occasionally in 
carcinoma the primary focus may atrophy, or become in- 
conspicuous. The infectiveness and vitality of the cancer-cell 
have been already discussed, and form a strong argument for 
those who are seeking for a parasite ; but to my mind the 
most valuable evidence is supplied by the distribution of 
the initial lesions of cancer. 

When cancer arises on those parts of the body easily 
accessible to observation, such as the lips and tongue, it is 
always preceded by a wound, chronic inflammation, and 



2 7 8 CAUSE OF GANGER 

especially chronic syphilitic lesions. It is also recognized that 
the disease occurs most frequently in situations where there is 
access of air, and on free surfaces, as in the case of the intes- 
tinal tract ; and it is clearly established by a careful study of 
death-returns that in more than half the cases in which death 
is attributed to cancer the primary seat of the disease is in the 
digestive organs. The distribution of cancer in that part of 
the alimentary canal which occupies the belly is somewhat 
remarkable (see Chap. xxx). The importance of chronic 
bacterial irritation as a cause of cancer is not properly 
appreciated. 

The strongest argument against the parasitic theory is 
the failure to cultivate the cancer-cell outside of the body. 

When men and women are impatient at our ignorance in 
regard to the cause of cancer, it is well to remind them that 
the part played by the spermatozoon in fertilizing the ovum 
has only been known about sixty years. Need we complain 
that it has been so difficult to find the cause of cancer ? It is 
most probably a micro-parasite which stimulates the normal 
epithelial cells of adult individuals to multiply and produce 
cancer in the same way that the male gamete or spermato- 
zoon initiates reproductive changes in the female gamete 
or ovum. 

The feature which distinguishes carcinoma from all 
infective diseases is its property of causing secondary 
deposits which reproduce the structural details of the organ 
primarily affected. This remarkable vitality of epithelium 
is, of course, exhibited in its highest form by the ovum, 
which is an epithelial cell, and one which, under certain con- 
ditions, exhibits malignancy in a very extraordinary form 
(Chap. LV). 

In order to emphasize the difficulty of what for conveni- 
ence may be termed the cancer problem, it is necessary to 
mention that competent pathological and bacteriological 
investigators, who have conducted the most painstaking and 
laborious researches with the hope of discovering the cause 
of carcinoma and sarcoma, are divided into two camps, namely, 
those who strongly believe that it is due to a micro-parasite, 
either a bacterium or some lowly animal form such as a 
protozoon ; and those who think the disease is due to some 



TREATMENT OF GANGER 279 

altered conditions of the cells independent of parasites. The 
position for the non-expert in this matter is illustrated by the 
following lines from " Ernpedocles on Etna " : 

" The gods laugh in their sleeve 

To watch man doubt and fear, 
Who knows not what to believe, 

Since he sees nothing clear, 
And dares stamp nothing false 

Where he finds nothing sure." 

Whilst investigators are hunting for the cause of ma- 
lignant tumours, practical surgeons have to deal with the 
concrete disease, and it is possible that the actual elucida- 
tion of the cause of cancer may come from clinical pathology. 

The conviction is growing among practical surgeons that 
the micro-flora of the body renders defective areas of the 
epithelial covering of the alimentary tract vulnerable to the 
agents of cancer. 

The treatment of cancer and sarcoma may be either 
surgical or therapeutic. The operative treatment is that in 
common use, and it has long been customary to speak of 
cancer from the surgeon's point of view as being operable or 
inoperable. 

An operable cancer is one that can be removed by a knife 
or by an electric cautery. Malignant growths that cannot be 
removed in this way are said to be inoperable. Some small 
operable malignant growths occur in patients who have the 
greatest repugnance to operative treatment. These can be 
sometimes efficiently destroyed by chemical or physical 
means : they may be destroyed by the application of strong 
acids or caustic alkalis, carbon- dioxide snow, electrolysis, or 
diathermy. Small nodules of growth sometimes disappear 
under injections of absolute alcohol. The use of radioactive 
substances, especially radium, sometimes causes malignant 
tumours to disappear. It is possible that chemiotherapy may 
prove useful ; but serumtherapy is so far valueless. 

With our present limited knowledge, the only method 
which affords any hopeful prospect to patients affected with 
cancer or sarcoma is early and thorough removal of the affected 



280 TREATMENT OF GANGER 

part ; and in the case of cancer it is also necessary to remove 
the associated lymphatics and lymph-nodes. 

This mode of treatment can be adopted when the patients 
seek advice at an early, and operable, stage. There are many 
organs in the body which have been extirpated for this 
disease : e.g. the breast, the eyeball, tongue, larynx, parts of the 
lung, oesophagus, thyroid gland, stomach, long sections of the 
intestine, the caecum, and rectum ; the kidney, penis, testicle, 
prostate, segments of the bladder, the ovary, and uterus ; 
the gall-bladder and portions of the liver, and the entire 
spleen. There is nothing in the way of surgical ingenuity 
and enterprise that has been left undone, with the hope of 
affording relief to those suffering from malignant tumours. 
Yet they baffle surgical art by their insidious modes 
of growth, their indefinite limitations in the tissues, and 
the infection of the lymphatic system, and, above all, 
by their property of quiescence, often for many years, and 
then of suddenly undergoing recrudescence and growing 
rapidly. 

Inoperable malignant disease. When cancer and sar- 
coma recur locally after operation, or, in their incidence, 
involve vital parts which cannot be subjected to operative 
interference, or affect an area of the body too wide to permit 
of removal, much can be done to make the patient's life 
tolerable, and many methods have been devised with the 
object of checking their growth. 

In the treatment of inoperable cancer it is useful to 
remember that this disease, especially in its late stages, is 
attended with pain and many discomforts caused by ulcera- 
tion, septic infection, and mechanical interference with the 
functions of the respiratory, urinary, or alimentary organs. 
Mental disturbances due to secondary deposits in the central 
nervous system are by no means rare. Pain is caused by the 
involvement of nerve-trunks by metastatic nodules. The 
normal exercise of such functions as swallowing, respiration, 
urination, and defsecation is attended with great distress when 
the mouth, tongue, pharynx, larynx, gullet, bladder, or rectum 
is involved in a cancerous ulceration. The distress caused by 
such conditions is often relieved by a judicious tracheotomy, 
cystotoiny, or colostomy, as the case may be. Further details 



TREATMENT OF GANGER 281 

of such procedures will be given in the chapters devoted to 
individual organs. 

Apart from any hope of cure, in inoperable malignant 
diseases, various other palliative measures may be carried 
out. Fungating tumours should be kept clean by frequent 
dressing ; oozing is checked by absorbent and styptic powders, 
and by the use of antiseptic solutions. The careful use of 
purgatives and variations in diet are useful. Alcohol given in 
a lavish manner is a grave mistake, and the unrestricted use 
of morphia is equally objectionable. 

Treatment by X-rays and radium. Great interest was 
aroused when it was discovered that the application of X-rays 
has a deterrent effect on the growth of cancer. This matter 
has been tested in the most determined way by competent 
men. The effect of this mode of treatment on cancer and sar- 
coma is local, and only affects deposits of malignant growths 
that are exposed, such as cancer of the skin, lips, breast, and 
the like. It is impossible without injury to the skin to ad- 
minister a sufficiently strong exposure to influence malignant 
tumours of the viscera. 

Radium. The use of radium in the treatment of cancer has 
attracted great attention. It is used chiefly against inoperable 
cancer. In many instances it reduces bleeding and dimin- 
ishes discharges, and it leads occasionally to the disappearance 
of the tumour. In some cases such changes are, in a large 
measure, due to the destructive effects of the gamma rays of 
radium on the micro-organisms in the cancerous tissues. It 
also destroys the epithelial elements of cancer and leads to 
the formation of tough fibrous tissue. Nodules of cancer 
occasionally shrivel in a remarkable manner after being ex- 
posed to radium emanations. A microscopic examination of 
malignant tumours affected by the action of radium shows 
that in the tissues and epithelial elements of tumours the 
gamma rays find distinctions imperceptible to the microscope. 

Occasionally a tumour that has been submitted to the 
action of radium grows very rapidly, and the application of 
radium in mucous canals like the gullet or the vagina leads 
to the formation of fistulse. , Knowledge of the effects of 
radium on tumour-tissue is empirical: occasionally a start- 
ling success is reported, but the experience of the majority of 



282 TREATMENT OF GANGER 

surgeons in the use of radium against malignant tumours is 
disappointing. 

Experience teaches that radium and X-rays may cure 
superficial and early malignant tumours, but their range is 
limited and their action uncertain. At present they are aids 
to surgery. Whenever possible, excision is the safer method. 

Drugs and nostrums. No drugs are known which in any 
way retard the growth of cancer. Periodically, remedies are 
vaunted and claimed as specifics in this disease, and are tried 
extensively, but no real and permanent good has so far been 
recorded. 

The list of things recommended as remedies by lay persons 
to their friends who suffer from cancer is almost inexhaust- 
ible, and includes powdered oyster-shells, violet-leaves, and 
things unmentionable, as well as incongruities such as the 
witches add to the stew in the famous cauldron in the 
opening scene of the Fourth Act of Macbeth. 

In regard to the various methods advocated for the relief 
and " cure " of inoperable cancer, it may be stated that all the 
methods hitherto proposed are unreliable and uncertain. In 
the majority of cases they have no effect whatever, and even 
in the few instances in which the treatment has done good 
there has been no reliability as to the permanency of the 
improvement. 

It is clear to the minds of all thoughtful men that no 
permanent advance can be made in the treatment of this 
dire disease until we know the cause of it, and then it is 
highly probable that we may learn how to prevent it. The 
cause of cancer and sarcoma remains a riddle, but let us 
hope that this riddle is one which will be read, and read 
speedily; until then some enthusiasts lean with great hope 
to the production of a serum with sufficient cytolytic power 
to induce rapid degeneration of the specific cells of these 
destructive tumours, and others look hopefully forward to 
assistance from chemiotherapy. 

Cytocides. This term, invented by Shattock, is used to 
designate certain organic and other solutions which will kill, 
or render inert, the cells of cancer. It is established that cells 
detached from cancers will under favourable circumstances 
engraft themselves on mucous, serous, or connective tissues 



GYTOGIDES 283 

and grow into independent tumours. This matter is dis- 
cussed in relation to the ovary (Chap. LVII), the colon (p. 266), 
and connective tissue (p. 267). When a cancerous mass is 
removed by operation the cells detached by manipulation 
are dispersed over the tissues ; some of them may become 
implanted and lead to recurrence. With the view of ren- 
dering such detached cells harmless, Shattock carried out 
a series of experiments for the purpose of finding some 
solution that will kill the cancerous cells, or render them 
innocuous in the same manner that antiseptic reagents 
destroy pathogenic micro-organisms. He found sulphate of 
zinc, 1 in 240, corrosive sublimate, 1 in 500, and aqueous 
solutions of iodine, 2 per cent., to be efficient cytocides. 

Bosc, F. J., " Les Protozoaires du Cancer et leur Culture." Presse Med., 

1913, xxi. 961. 
Cohnheim, " Vorlesungen iiber allgemeine Pathologic." Berlin, 1882. 

Fibiger, "Nematodes in the Production of Cancer." Brit. Med. Journ., 
1913, i. 400. 

Shattock, S. G., and Dudgeon, L. S., " Wound- Inoculation in Carcinoma, 
with Experiments upon the Action of Local Cytocides as a means of 
dealing with it." Proc. Roy. Soc. of Med., 1915, viii., Path. Sect., p. 1. 



CHAPTER XXV 
EPITHELIAL TUMOURS OF THE SKIN 

WARTS, HORNS, AND CANCER 

SKIN is a compound organ with several functions. Chiefly 
it is a protective covering, not only against external injury, 
but also for moderating the effects of heat and cold. It 
plays an important part in regulating the temperature of 
the body. In man the chief organs contained in the skin 
are sebaceous and sweat- glands, touch-corpuscles, and the 
modifications of the epithelium known as hair and nails. 
The glandular elements 'are specialized in some parts of the 
skin, such as the external auditory meatus, the palpebral 
conjunctiva, and the vulva. The niammse are often regarded 
as modified sebaceous glands. In some parts the surface 
layer (epidermis) of the skin is opaque and thick, as in the 
palms and soles; thin and red, like mucous membrane, on 
the lips and vulva; in others, thin, delicate, and, in the case 
of the cornea, transparent. The skin covering the eye of 
snakes is transparent, and this is true of the lower eyelid 
of the snake-eyed lizard Ophiops, some water tortoises, and 
the third eyelid of crocodiles. These variations are more 
fully described in dealing with special organs. It should be 
remembered that the essential cells of the organs of special 
sense, such as the eye, ear, and nose, are modifications of 
cutaneous epithelium. 

WARTS 

Warts are most common on the skin, but they also arise 
from mucous surfaces covered with squamous epithelium. 
They occur singly or in multiples ; occasionally they are 
thickly crowded on a restricted area of the skin, and form 
a wart-field. Warts are rarely painful unless irritated then 
they are apt to ulcerate and bleed. Crops of warts often 

284 



WARTS-HORNS 285 

grow on the hands of children. They are common around 
the orifice of the anus, and on the glans penis and vulva as 
a complication of gonorrhoea. 

Warts sometimes appear on the hands and on the scalp 
suddenly, and after persisting many weeks, or perhaps 
months, disappear as if by magic. When warts are thickly 
crowded upon a limited area of skin as, for example, the 
glans penis they may be mistaken for a more serious dis- 
ease, such as warty carcinoma. 

Skin-warts are overgrown papillae, and on section the 
epithelium will be found to pass from one papilla to another 
in an unbroken line without invading the fibrous frame- 
work. A solitary wart may occur on any skin-covered surface 
and persist. A wart of this character sometimes attains the 
size of a walnut, and in some cases is mottled with black 
pigment. Such warts, late in life, may become the starting- 
points of melanomas. Occasionally one or two sparse hairs 
may be detected on a wart ; and some fun is made out of 
this fact by Cressida when her uncle Pandarus says con- 
cerning the glabrous chin of Troilus: 

" And she takes upon her to spy a white hair on his chin." 
Cressida replies: 

"Alas, poor chin! Many a wart is richer." 

Solitary warts sometimes grow rapidly, and become so 
large that they are apt to be mistaken for malignant 
tumours. They are red, like the comb of a cock, and 
smeared with purulent foetid fluid. Billroth described such 
soft, rapidly growing tumours arising in warts of the face 
as plexiform sarcomas : they are infected warts, and teem 
with staphylococci. 

Rare situations for warts are the small cysts formed by 
the dilatation of a sweat-gland in the axilla (Robinson), 
the cheek (Rolleston), the face (Adams), and the vulva 
(Outerbridge). 

HORNS 

Warts growing from skin are covered with squamous 
epithelium, and the surface cells are liable to be transformed 
into horn. 

Cutaneous horns in the human subject are of four 



286 



HORNS 



varieties : 1, Sebaceous horn. 2, Wart-horn. 3, Cicatrix- 
horn. 4, Nail-horn. 

1, 2. Sebaceous and wart- horns. It is impossible to 
decide from an examination of a large horn whether it grew 
from a sebaceous cyst or from a wart. Cutaneous horns 
sometimes attain great proportions, especially in the aged 
(Fig. 141). Sebaceous horns are more frequent on the scalp 
than elsewhere, whilst wart-horns are most frequently found 
on the penis, and are not rarely seen on the pinna. It is 




Fig. 141. Horn which grew from a wart on the cheek of a very old 
Welsh woman ; it measured 21 cm. along its greater curve. 

important to bear in mind that carcinoma is apt to originate 
in the skin around the bases of wart-horns, especially in 
old men and women. 

Cutaneous horns are extremely tough, and present a 
longitudinal fibrillation; when soaked in a weak solution 
of liquor potassse they quickly soften, and the horny material 
comes away in flakes. 

The only means of deciding between a wart-horn and a 
sebaceous horn is by dividing it longitudinally, and ascer- 
taining the existence or otherwise of a cyst at its base. 
In the case of the mouse (Fig. 142), some pathologists 



HORNS 287 

who examined the horn were of opinion that it was a wart- 
horn, but on dissection a large sebaceous cyst was found to 
occupy its base. Horns of this character are not rare in 
mice, and have been seen on a mouse which lived in a 
church, and on one which was caught in Westminster 
Abbey (W. G. Spencer). 

The most elaborate collection of cases illustrating cuta- 
neous horns is contained in a small work published by Dr. 
Hermann Lebert. He gives accounts of 109 cases, with 
references, the earliest dating from the year 1300. The horns 




Fig. 142. Sebaceous horn in a mouse. 

were found on the scalp, temple, forehead, eyelid, nose, lip, 
cheek, shoulder, arm, elbow, thigh, leg, knee, toe, axilla, thorax, 
buttock, loin, penis, and scrotum. In length they varied from 
1 to 20 cm. Lebert, however, makes no attempt to dis- 
criminate between the varieties of horns. 

The most curious situation in which cutaneous horns 
occur is in ovarian dermoids. The conversion of epithe- 
lium into horn in cases of sebaceous cysts and warts is 
something more than desiccation from exposure ; it is doubt- 
less akin to the change by which nail and horn are formed 
under normal conditions. 

A good physiological type of a cutaneous horn is pre- 
sented by the nasal horn of the rhinoceros. This formidable 



288 HORNS 

cutaneous appendage is composed of agglutinated hairs. 
Professor Flower exhibited at the Zoological Society, London, 
a portion of the skin from the head of a rhinoceros (shot 
by Sir John Willoughby in Central Africa) furnished with 
three horns. The accessor}' horn was 12 cm. high and 42 cm. 
in circumference (Fig. 143). 

A physiological type of sebaceous horns is to be seen in 
the curious patch of spines on the forearm of the hapalemur 
(Hapalemur griseus). It is present only in the adult male. 
The spines are formed of hardened secretion furnished by a 
multitude of glands in the skin immediately underlying the 




Fig. 143. Head of an African rhinoceros with a large wart posterior to 
and in a line with its nasal horns. 

patch of spines. The male ring-tailed lemur (Lemur catta) 
has a curious horn-like spur upon its forearm near the wrist ; 
beneath this horny patch I found a collection of glands of 
sweat-gland type. 

Cutaneous horns are sometimes found on cows, sheep, 
and goats. They may attain a large size. The museum of 
the Royal College of Surgeons contains a very large horn 
that grew from the flank of a ram; it is nearly a metre 
in length, and in the dried condition 28 cm. in circum- 
ference at the base. This specimen is described, with others, 
by Sir Everard Home in an interesting paper (Phil. Trans., 
1791). Rabelais tells us that the mare on which Gargantua 
rode to Paris had .a little horn on her buttock. 



GIGATRIX-HORNS 289 

Birds are liable to cutaneous horns; they grow very 
rapidly, and sometimes attain great lengths. They follow 
the rule with regard to the epidermic structures in this class 
generally, and are cast off when the birds moult. 

A good physiological type of wart- horn among birds is 
furnished by the American white pelican, P. trachyrhynchus 
(Fig. 144). The beak of this bird is furnished with a horn 
structurally resembling tho wart-horns occasionally seen on 
other birds. The horn is shed in the autumn when the 




Fig. 144. American white pelican, P. trachyrhynchus. 

pelican moults, and is rapidly reproduced with the feathers. 
Mr. Spencer F. Baird states that Mr. Ridgway visited the 
breeding-ground of these birds on an island in Pyramid 
Lake, Nevada, and found the pelicans nesting by thousands. 
Towards the end of the season the ground became so strewn 
with these shed horns that they could be gathered by the 
bushel. 

3. Cicatrix-horns. These are rare, and grow generally 
from the scar left by a burn. Such scars, when extensive, 
are liable to ulcerate and then slowly heal again, but as they 
heal they become covered with a mass of scales composed of 
hard desiccated tissue, often laminated like a pie-crust. 
T 



290 GANGER OF THE SKIN 

-' ' 

Cruveilhier described a very remarkable example of this 
kind of horn growing from a hand, probably deformed in 
consequence of a burn ; the horny processes vary from 2 to 
20 cm. in length. Cruveilhier states that horns of this kind 
came under his notice on the thighs of an old woman at the 
Salpetriere ; they grew from the scars of old burns caused 
by chaufferettes. When the horns were detached they left 
painful ulcers. Later observations show that as these ulcers 
heal, new horns form. Edmunds and Neve have published 
similar observations. 

4. Nail-horns do not call for much consideration. They 
are extremely common on the toes of bedridden patients, 
especially old women and those who are dirty. Although 
nail-horns may grow on any of the toes, they are most 
frequently met with on the big toe. The horns may attain a 
length of 7 cm., and become twisted so as to resemble rams' 
horns. Curious examples are also found on the fingers of 
Hindu religious mendicants (Fig. 145). 

Treatment. Cutaneous horns are easily removed. In 
rare instances amputation of the hand has been performed. 
When cancer attacks the skin at the base of a horn, it should 
be excised with the surrounding skin, and the lymph -nodes 
connected with it carefully dissected out. 

CANCER OF THE SKIN 

Squamous-celled cancer of the skin arises as a wart, 
an ulcer, or a fissure. These clinical varieties look very 
different, but they are the same in structure. Micros- 
copically, long, simple, or ramified columns or cones of cells 
are displayed, invading the underlying connective tissue. 
When the cones grow rapidly the cells become flattened 
and cornify. In this way the epithelial pearls or nests 
are produced. When lateral pressure is made on a fresh 
specimen of squamous-celled cancer, whitish plugs are forced 
out : these plugs are the cellular cones. The three clinical 
varieties of squamous-celled cancer occur in all the situations 
liable to this disease, such as the lips, tongue, cheeks, pharynx, 
vulva, glans penis, and neck of the uterus. This kind of 
cancer arises, too, in the urethra, the pinna, and in the con- 
junctiva, especially when it has been injured with lime ; also in 



GANGER OF THE PINNA 



291 



the larynx and its recesses. Intralaryngeal cancer abounds 
in " cell-nests." 

Cancer of the pinna is a rare disease, and this is surprising 




Fig. H5. Fakir with long thickened nails on his fingers. (From the 
"National Geographic Magazine" 1914.) 

considering the frequency with which it is pierced and then 
irritated, sometimes with very uncouth kinds of earrings, 
especially among savage races. It usually attacks the edge 
of the pinna, and prefers the helix. 



292 PREGANCEROUS CONDITIONS 

Cancer occasionally arises in the external auditory meatus 
in association with chronic ulceration. For a time the disease 
is overlooked, until enlargement of the associated cervical 
lymph-nodes serves as a stern reminder. The disease may 
remain concealed in the meatus but luxuriate in the tympanic 
cavity, and invade the cranial cavity by eroding the tegmen 
tympani (see p. 335). 

A squamous-celled cancer, when left to follow its own 
course, may extend and involve extensive tracts of tissue, or 
fungate and form huge granulating dendritic masses. In both 
cases the superficial parts are continually cast off in a foul, 
foatid discharge containing sloughs of tissue, cellular detritus, 
and blood. Vascular tissues, such as skin, muscle, and mucous 
membrane, are quickly infiltrated and destroyed ; even bone is 
rapidly eroded. Cartilage resists invasion : this is seen in a 
striking way in those rare instances in which cancer attacks 
the pinna ; the skin and soft tissues quickly disappear, whilst 
its cartilaginous framework stands prominently out amid the 
surrounding ruin. 

In whatever situation squamous-celled cancer occurs, it 
destroys life rapidly. The quickness with which it ulcerates 
and overcomes all resistance enables it to open large blood- 
vessels, should any lie in its way ; hence death from haemor- 
rhage is frequent. When the cancer is near the air-passages, 
foul material is inspired and initiates septic pneumonia. 

A rare situation, but one which emphasizes the lethal 
characters of squamous-celled cancer, is the matrix of a nail 
on a finger or a toe. A small ulcer that refuses to heal is 
noticed in the bed of the nail ; this slowly increases. The 
associated lymph-nodes in the axilla or the groin enlarge, 
ulcerate, and gradually the patient's health fails, or life is 
quickly terminated by furious bleeding when the ulceration 
broaches an artery in the axilla or groin. Cancer of the nail- 
matrix of a finger is sometimes called malignant onychia. 

Observation has taught surgeons that no case of cancer of 
the skin has been reported which did not arise in a pre-exist- 
ing lesion. Local changes preceding cancer are termed pre- 
cancerous conditions. Many will be considered in succeeding 
chapters. It has been known for many years that chronic 
ulcers, especially of the leg, are liable to become cancerous, and 



KANGRI-GANCER 293 

the change supervenes so gradually that patients disregard it 
until the disease becomes widespread; then amputation is 
needed to make the presence of the patients bearable to those 
who live with them. An ulcer may exist on the leg for 
twenty years before becoming cancerous. Ulcers that become 
cancerous are more common in old persons. A man aged 69, 
whilst washing telegraph cups in a solution of caustic soda, 
splashed his forearm with the solution : this left an ulcer 
which did not completely heal. Two years afterwards the 
back of the forearm was the seat of a large, cancerous, stinking 
ulcer. The lymph-node at the elbow and the axillary nodes 




Fig. 146. The kangri, a basket containing an earthenware pan for hold- 
ing burning charcoal. The Kashmiri wear it strapped to the waist 
beneath their garments. 

were enlarged. The limb was amputated and the nodes 
were excised. 

A notable contribution to this question has been fur- 
nished by Neve. During twenty years 4,902 tumours were 
removed at the Kashmir Mission Hospital : of these 1,720 
were malignant. Of the malignant tumours 1,189 were 
classed as carcinomatous, and of these 848 arose on the 
thighs and abdomen. 

The frequency of skin-cancer among the Kashmiri is due 
to the use of a peculiar portable -fire-basket called a kangri 
(Figs. 146 and 147) ; it consists of an earthenware pan con- 



294 KANGRI-GANGER 

tained in a basket. Burning charcoal is placed in the pan, and 
the kangri suspended from the waist, under the loose robes 
worn by the Kashmiri, as a means of keeping them warm 
for the hills of Kashmere are cold. The kangri, like the hot- 
water bottle and the old-fashioned warming-pan, is apt to 
burn the skin and cause a chronic ulcer ; such an ulcer often 
becomes cancerous. The use of the kangri by the Kashmiri 
is akin to that of the chaufferette by the poor old folk of 




Fig. 147. A group of Kashmiri with the portable fire-basket known as 
the kangri. (Neve.) 

France. Neve also mentions the occurrence of horns at the 
edges of kangri burns ; and sometimes at the base of a horn 
cancer arises. 

It is admitted by all who have carefully studied squa- 
mous-celled cancer supervening on ulcers left by burns that 
the process is extremely slow, and this is true also of the 
closely allied condition known as soot cancer (see Chap, 
xxxvni). In a remarkable instance of this disease under my 
own observation, a man aged 50, in prosperous circum- 
stances, had a mass of enlarged inguinal lymph-nodes 
associated with an ulcer the size of a split pea on the 



AUXETIGS 295 

scrotum ; on looking closely at the scrotum I saw small 
spots which looked like soot marks, and he admitted, in 
reply to my question, that as a boy he, had climbed and 
swept chimneys, but he had had no dealing with soot for 
thirty-five years. The disease was soot cancer, and the man 
died in about twelve months. The relation of soot to this 
disease is difficult to explain. 

Although chronic ulcers the result of burns are apt to 
become cancerous, Neve states, in regard to his extraordinary 
series of cases, that the burns more liable to this sinister 
change are those due to actual contact of the sooty pan 
with the skin. Such contact happens when the basketwork 
of the kangri is partially burnt. 

This matter has received some elucidation from Legge's 
inquiry into Avhat is known as pitch and tar cancer: he 
found a consensus of opinion among medical men, and the 
pitch workers, that those workmen who kept themselves 
clean and changed their clothing frequently did not suffer 
from irritation of the skin, nor from warts, which are 
regarded by the men as precancerous conditions. It seems 
clear that the chronic dermatitis which precedes the cancer 
is caused by prolonged contact of the skin with the dust 
and dirt. Many of the flat-topped, brownish-looking eleva- 
tions on the skin of elderly persons who do not keep them- 
selves clean are little heaps of senile dirt. 

Pitch and tar cancer has been investigated by H. C. Boss 
and Bayon : they find that pitch cancer is more com- 
mon among men who work with pitch obtained from 
gas- tar than among those who use pitch prepared from 
blast-furnace tar. The result of their inquiries led them 
to the opinion that gasworks- tar contains a substance irri- 
tating to epithelial cells. Substances capable of stimu- 
lating epithelial cells to unwonted activity are known as 
auxetics. 

Arsenic-cancer. It is known that arsenic taken inter- 
nally acts as an auxetic when administered for the cure of 
chronic affections of the skin, especially psoriasis, and Sir 
Jonathan Hutchinson showed (1887) that patches of psori- 
asis sometimes become cancerous after the prolonged use of 
arsenic, and that this may happen many years after the 



296 



ARSENIC-GANGER 



administration of arsenic, has been discontinued. Hutchinson's 
observations have been confirmed by K J. Pye-Smith, who 
found that the prolonged administration of the drug induces 
keratosis ; the hard skin cracks and allows bacteria to enter and 
infect the skin. Ulcers arising in this way become chronic 
and finally cancerous. The microscopic study of these lesions 
indicates that the auxetics initiate in the epithelium and 
subepithelial tissue inflammatory changes that act as pre- 
cancerous conditions. In one of Pye- Smith's patients a 
squarnous-celled cancer appeared on the skin of the finger 




Fig. 148. Cancer arising in a patch of psoriasis on the leg of a woman 
aged 60. She had taken arsenic "on and off" for thirty years. 

under the wedding-ring. This form of cancer does not infect 
the lymph-nodes. 

A woman aged 60, under my care, had a large cancerous 
ulcer below the left knee; it arose in a patch of psoriasis 
(Fig. 148); she had taken liquor arsenicalis at intervals for 
thirty years. In 1913 a pimple at the lower border of the 
psoriasis-patch slowly ulcerated, and would not heal in spite 
of scraping and cauterizing. In 1916 it became a typical 
cancerous ulcer. The leg was amputated and some enlarged 
lymph-nodes were removed from the groin. The tissue at 
the edge of the ulcer had the microscopic characters of 
cancer, but there were no cell-nests. The lymph-nodes were 



X-RAY GANGER 297 

free from cancer : their enlargement was due to septic 
infection. The patient quickly recovered. 

Among other auxetics, mention must be made of malignant 
tumours of the bladder in aniline- workers (Chap, xxxvn). 

Betel nut and cancer. Betel nut is the fruit of the betel 
palm (Areca catechu), and betel leaf is obtained from the 
betel vine (Ghavica betel), allied to the black-pepper plant. 
Betel nut is a masticatory : slices of pulp are dried, and a 
small piece is wrapped in a leaf of the betel vine with a 
pellet of lime (obtained by burning the shells of molluscs) 
and an aromatic like cardamom or turmeric. This mixture 
is called by the Philippines buyo. Mastication of the nut 
causes a copious flow of brick-red saliva that dyes the 
lips and gums but blackens the teeth ; it is supposed to 
sweeten the breath and stimulate digestion. 

The practice of chewing the betel nut is extremely common 
in the Philippine Islands. Davis draws attention to the fre- 
quency with which cancer attacks the mucous membrane 
of the cheeks of those who chew buyo. Buyo cheek-cancer 
occurs more frequently in women than in men, and the 
natives attribute it to buyo-chewing. Davis considers the 
lime to be the essential cause. 

X-ray cancer. Since the X-rays have been employed for 
the detection and cure of certain diseases it has been 
discovered that they sometimes produce changes in the 
skin known as X-ray burns, or X-ray dermatitis, which are 
extremely difficult to treat and, in some instances, become 
cancerous. 

The alterations in the skin covered by the term X-ray 
dermatitis may affect not only those who receive the rays 
designedly for the cure of local disease but also those who 
apply them, and the latter appear to be the greater sufferers. 
The earliest changes consist of an erythema around the 
base of the nails, which become brittle arid degenerate into 
shapeless masses. The skin reddens and small warts appear ; 
cracks and ulcerated patches occur and refuse to heal. The 
ulcers and cracks are extremely painful, and in a small 
proportion of cases become malignant. While these changes 
are progressing in the skin, the deeper tissues undergo 
nutritional changes and the bones of the fingers waste. The 



298 SKIN-GANGER IN NEGROES 

precancerous stage the stage of chronic dermatitis is pro- 
longed, and the transition to carcinoma is effected by slow 
and insensible gradations. These changes have been carefully 
studied by Rowntree. 

Skin-cancer in negroes. Curiosity prompted me to ascer- 
tain if the cells of skin-cancer in the black races of mankind 
contain more pigment than in the white races, or in any 
way approached the blackness of a melanoma. This is not 
the case. The pigin exited normal skin ends sharply at the 
margin of the cancer, and the microscopic characters of a 
squamous-celled cancer in a white man and in a negro agree. 

Cancer of the skin covering the trunk is unusual ; it is 
more common on the skin of the face and limbs, and always 
arises in a pre-existing lesion, especially a chronic ulcer. 
Some day the origin of cancer in a chronic ulcer, a wart, 
or a patch of psoriasis may receive a simple explanation. 
Probably a better knowledge of symbiosis will teach surgeons 
how chronic sepsis tills the soil in the human body to make 
it receptive of the germs of cancer. 

Bayon, H., " Epithelial Proliferation induced by the Injection of Gasworks- 
Tar." Lancet, 1912, ii. 1579. 

Bland-Sutton, J., " Parable of the Gooseberry-Bush." Brit. Ned. Journ., 
1916, ii. 788. 

Davis, G. G., " Buyo Cheek- Cancer." Journ. Amer. Med. Assoc., 1915, Ixiv. 711. 
Pye-Smith, R. J., "Arsenic Cancer." T Proc. Roy. Soc. of Med., 1913, vi., 

Clinical Sect., p. 229. 
Rowntree, C. W., "Contribution to the Study of X-Ray Carcinoma." Arch. 

Middx. Hosp., 1908, xiii. 182. 



CHAPTER XXVI 
EPITHELIAL TUMOURS OF THE SKIN (concluded) 

SEBACEOUS-GLAND TUMOURS; RODENT 
CANCER 

TUMOURS connected with the sebaceous glands are 1, Seba- 
ceous cysts, or wens ; 2, sebaceous adenomas. 

1. Sebaceous cysts (wens). The sebum resulting from 
the activity of a sebaceous gland escapes, as it is formed, on 
to the free surface. Should the orifice of the follicle become 
occluded, the secretion is retained, and the glandular acini, 
becoming distended, give rise to an appreciable swelling 
known as a sebaceous cyst. This is the usual description of 
the mode by which these cysts arise; but even a superficial 
examination of a number of sebaceous cysts will serve to show 
that in many there is no obvious obstruction indeed, the 
duct may be widely open and the sebum exuding, so that 
obstruction of the duct is not an explanation that will cover 
all cases. Shattock has shown that the common " wen," in 
most instances, arises in a hair-follicle. 

Cysts can be obtained experimentally by implanting 
cutaneous glands or hair-bulbs into the subcutaneous con- 
nective tissue (Chap. XLIX). 

Sebaceous follicles often contain one or more examples of 
the Demodex folliculorum. These arachnids are harmless, 
and their presence merely an epiphenomenon (Thudichum). 
Such cysts occur in all situations where sebaceous glands 
abound; an exceptionally common place is the scalp. The 
cyst may be single; sometimes many are present indeed, 
16 or more may be counted on one scalp. In size they vary 
greatly : many are as large as walnuts, others of the size of 
peas, and some as big as a golf-ball. 

On the surface of sebaceous cysts occurring in any part of 

299 



300 SEBACEOUS CYSTS 

the trunk and head save the scalp, close scrutiny will reveal 
either a black dot or a small dimple. This is the orifice of 
the follicle, and on picking off the black spot and squeezing 
the cyst sebum will exude, and thus furnish positive evidence 
of the nature of the cyst. In wens of the scalp the orifice is 
rarely seen, except in those which occur along the junction of 
the skin of the forehead with the hairy scalp. A sebaceous 
cyst, unless it has been inflamed, is easily shelled out of its 
matrix. It then presents a capsule and contents. The capsule 
may be exceedingly thin and pliant, the inner surface present- 
ing an epithelial lining ; or it may be laminated, thick, and 
hard. The contents of the cyst may be pultaceous material, 
consisting of shed epithelial scales, fat, and cholesterin ; or 
laminae of firm, yellowish- white material, arranged like the 
layers of a bulb. These laminae represent the epithelium of 
the lining wall that has been shed in successive layers. In 
rare instances the contents of sebaceous cysts calcify. 

It has already been mentioned that the contents of a 
sebaceous cyst sometimes ooze from the orifice of the follicle. 
In some instances such cysts give rise to an extremely offen- 
sive odour. This is due to decomposition of the cyst-contents 
by micro-organisms, and, as the material within the cyst 
contains a large proportion of fat and epithelium, the odour 
evolved is not difficult of explanation. 

When sebaceous cysts grow in situations where they are 
exposed to injury they are apt to become infected. An 
inflamed sebaceous cyst has a characteristic colour, and 
resembles the deep red of a ripe plum. Such inflammation 
may subside and recur. These recurrent attacks of inflam- 
mation cause firm adhesion between the capsule of the 
tumour and the skin, which renders its removal somewhat 
tedious. When it suppurates the wall thins, and at last 
bursts, unless this result is anticipated by the timely use of 
a scalpel. The suppuration often ends in cure; but frag- 
ments of capsule may be retained and lead to the formation 
of a sinus. In some instances the cyst bursts, the pus escapes, 
and the point of rupture heals, the cyst-wall being retained. 
When this is the case the cyst refills with sebaceous matter. 
Thus, in dealing with these cysts surgically, it is an important 
thing to remove thoroughly every particle of the cyst-wall. 



SEBACEOUS ADENOMA 301 

Occasionally, especially in old persons, a sebaceous cyst sup- 
purates and fungates, producing a foul offensive mass which 
is often mistaken clinically for a cancer (Fig. 149). 

Sebaceous cysts occur in the "velvet" covering the 
growing antlers of deer. The velvet of a growing antler 
is covered with fine downy hair furnished with large seba- 
ceous glands (Fig. 150). 

2. Sebaceous adenoma. It has been so customary to 
regard all tumours arising in connexion with sebaceous glands 




/v. 



\ 



Fig. 149. Fungating wen on the scalp of a woman aged 83. 

as wens or sebaceous cysts, that it is quite an exceptional 
event for them to be submitted to microscopical examination. 
It has already been pointed out that there are two varieties of 
sebaceous cysts one in which the cyst contains sebum and 
epithelial debris, and another in which the contents are 
arranged in thick laminae. In addition to these, tumours 
occasionally occur in the skin and furnish the usual clinical 
signs of wens ; but when removed and examined micro- 
scopically they are found to be composed of lobules, which 
structurally resemble the exuberant masses upon the nose 
that used to be called lipomas, but are now known to be due 
to overgrowth of the large sebaceous glands that occupy the 



302 SEBACEOUS CYSTS 

skin in this situation (Shattock). These tumours are seba- 
ceous adenomas, and they are liable to ulcerate, and excep- 
tionally to calcify (Eve). 

Treatment. A sebaceous cyst is easily removed; when 
the skin covering one is incised and the capsule exposed, the 
cyst usually shells out quite easily. When the cyst has been 
inflamed and is firmly adherent to the skin, some little 
dissection will be necessary to effect its removal. 

Before surgeons appreciated the importance of extreme 
cleanliness, the removal of sebaceous cysts was often followed 





Fig. 150. Sebaceous glands in the velvet of the antler of a stag 
(Cervus elaphus). 

by septic inflammation. An excellent notion of the fears 
which surgeons entertained in regard to secondary compli- 
cations after the removal of wens is furnished by the case of 
George IV, who had a sebaceous cyst on the top of his head. 
This formed the subject of a serious consultation. Eventually 
Astley Cooper, with Cline's assistance, removed the wen ; and 
his anxiety lest erysipelas should supervene, seems scarcely 
compensated by the baronetcy which the King bestowed upon 
him as a reward for the successful issue of the operation. 

Brodie refers to this case thus: i( Eventually the opera- 
tion was performed by Sir Astley Cooper, in the presence 
of Sir Everard Home, Mr. Cline, Sir William Knighton, the 



RODENT ULCER 303 

King's physicians, Sir Henry Halford, Sir Matthew Tierney, 
and myself; making a very large assembly for so small a 
matter." 

Cancer of sebaceous glands (rodent ulcer). In British 
writings on Surgery it has been customary for many years to 
describe under the name of rodent ulcer a form of cancer 
which exhibits extraordinary clinical characters. In its 
common form a smooth, rounded knob of about the size of a 
split pea is noticed on the skin of the face, either on the nose, 
eyelids, orbital angles, or cheek. This knob may remain for 
years (seven, eight, or even twelve), and cause no inconveni- 
ence save unsightliness ; then, without obvious reason, it may 
ulcerate and destroy the surrounding skin and underlying 
structures, involving all tissues in its vicinity skin, muscles, 
fat, cartilage, eyeball, and bone and producing horrible 
destruction of the face, in some cases even destroying the 
base of the skull and meninges, and exposing the brain. To 
produce such terrible effects the disease requires sometimes 
five, ten, or even more years. In its course it destroys every- 
thing, never cicatrizes, and is painless. This disease was 
described by Jacob of Dublin, in 1827. It is often called 
Jacob's ulcer. 

In recent years the histology of the early knobs which 
mark the beginning of the disease has been investigated with 
great care. All observers agree that the disease begins as a 
solid growth beneath the epidermis. If in this stage the 
nodule is excised and sections are examined microscopically, 
it will be seen to consist of gland-ducts filled with epithelium, 
though sometimes they take the form of solid cylinders. In 
the later stages, when ulceration is in full sway, these appear- 
ances are lost. 

The origin of the initial knob has been ascribed to the 
following sources : 1, sebaceous glands ; 2, sweat-glands ; 
3, the hair-follicle ; 4, the outer layer of the root-sheath of a 
hair ; 5, epithelial remnants in the course of the facial 
fissures ; 6, vestiges of the tear-pits of ruminants ; and occa- 
sionally (7) a hairy mole. My own investigations induce me 
to ascribe its origin to the sebaceous glands. 

Although rodent cancer arises mainly in the facial fissures 
already mentioned, it occurs elsewhere. It has been observed 



304 RODENT ULCER 

on the neck, abdomen, vulva, and the limbs. On any part 
of the body, except the face, it is rare. 

Rodent cancer attacks, as a rule, persons advanced in 
life ; it is not uncommon between the thirtieth and fortieth 
years, and Sequeira has reported a case in the twelfth year. It 
is more common in men than in women. The features that 
distinguish it from the ordinary variety of cancer are the 
following : It does not infect lymph-nodes, nor disseminate ; 
as a rule it is solitary, but multiple ulcers are not unknown. 
The disease runs a very chronic course ; in some persons 
it has existed twenty years. 

Treatment. When a rodent ulcer exists in a situation 
favourable for removal it should be excised. No other 
form of treatment gives such good results. When the 
wound is soundly healed a course of radium treatment is 
desirable. A rodent ulcer in a situation unfavourable for 
surgical treatment should be submitted to radium emana- 
tions. X-rays are dangerous for treating rodent ulcer : there 
is good ground for the belief that some treated in this way 
have been converted into squamous-celled cancer. Carbon- 
dioxide snow heals a rodent ulcer, but ulceration often recurs 
after this treatment. 

Brodie, Sir Benjamin, "Autobiography." (Works, Vol. I., 1865.) 

Eve, F. S., "Adenoma of the Sebaceous Glands partially Calcified." Trans. 

Path. Soc., 1882, xxxiii. 335. 
Jacob, Dublin Hasp. Repts., 1827, iv. 232. 
Sequeira, J. H., quoted in Morris's "Diseases of the Skin," 1917, 6th Edit., 

p. 713. 
Shattock, S. G., " Sebaceous Adenoma of the Scalp." Trans. Path. Soc., 

1882, xxxiii. 290. 
Shattock, S. G., " Keratinizing Epithelial Tumour from the Scalp." Ibid., 

1897, xlviii. 224. 
Thudichum, J. L. W., " The Demodex Folliculorum." Med. Press and Circ. t 

1894, ii. 103. 



CHAPTER XXVII 
EPITHELIAL TUMOURS OF THE BREAST 

TUMOURS of the breast are common, and have been known 
for many centuries. Atossa, the daughter of Cyrus and 
wife of Darius, had a tumour on her breast. As long as 
it was but small she kept it hidden for shame and told 
no one ; but when it became troublesome she sent for 
Democedes and showed it to him (Herodotus). Modesty in 
these matters is no new thing. 

The breast is so open to observation that it is the organ 
from which the knowledge of the natural history of cancer 
was primarily derived. In regard to this Rindfleisch per- 
tinently remarks : " The tumours of the female mammary 
gland have been so often, and already at so early a period, 
the subject of earnest histological investigation, that in this 
we might not improperly call the mammary gland the nurse 
of pathological histology." 

In order to appreciate the nature of tumours arising in the 
glandular elements of the mammary gland, it is useful to 
review briefly its essential tissues and age-changes. A fully 
developed mammary gland consists of a stroma and a 
parenchyma ; the latter is composed of a number of lobes, 
each of which is practically a separate gland and subdivided 
into lobules beset with alveoli, or spaces, lined with a single 
layer of secreting epithelium. The ultimate recesses are 
known as acini, and each acinus ends in a duct lined with a 
single layer of epithelium ; these ducts converge and open 
into neighbouring ducts ; finally they fuse to form a number 
of excretory ducts which traverse the nipple and open in- 
dependently on its summit. These large excretory canals ? 
named galactophorous ducts, become dilated during lactation 
and form ampullae or sinuses. The walls of the ducts, composed 

u 35 



306 MAMMARY TUMOURS 

of areolar tissue and elastic fibres, are beset with columnar 
epithelium. The lobes are embedded in areolar tissue. The 
size of the breast varies according to the proportion of the 
glandular tissue it contains and the amount of areolar tissue 
and fat in which it is embedded. 

The age-changes of the mammary gland are important. 
During infancy, as a rule, there is no difference between the 
breasts of a boy and of a girl, but at puberty the glandular 
tissue multiplies rapidly and the whole breast increases in 
size. During pregnancy the epithelium is extremely active, 
but as the function of the gland declines with age the secret- 
ing epithelium in the acini atrophies, and this change is 
accompanied by an increase in the fibrous tissue. 

This brief outline indicates that before puberty abnormal 
changes connected with the mammary glandular tissue would 
be rare ; after the accession of puberty they would be common, 
and special changes will be associated with the atrophy coin- 
cident with the resting stage. 

During the active or functional period, aberrations of the 
epithelium of the acini would be expected, but it is essential 
to remember that the excretory system of the mammary gland 
is in relation with the surface of the skin by its excretory 
ducts, and it is extremely vascular. 

The aberrations of the mammary gland specially con- 
nected with tumours are of two kinds : 

Those which arise in connexion with the ducts and acini, 
and those arising in perversions of the epithelium. 

Tumours which involve the ducts and acini are known as 
adenomas ; and the second group, special to the epithelium, 
are papillomas and cancers. 

In addition, tumours arise in the areolar tissue in which 
the gland elements are embedded, such as lipomas and 
sarcomas ; and the overlying skin is liable to the same 
tumours as skin in other regions of the body. 

ADENOMA OF THE BREAST 

There are two varieties of mammary adenoma : 1, fibro- 
adenoma ; 2, cystic adenoma. 

1. Fibro-adenomas. These occur as spherical or oval 
tumours furnished with capsules. As a rule, they are firm 



CYSTIC ADENOMAS 307 

and elastic to the touch, and slip about under the examining 
finger. It is not rare to find a fibro-adenoma in each mamma, 
nor is it unusual to find more than one tumour in the same 
gland. When occupying a superficial position they will, 
even when small, cause an irregularity in the contour of 
the breast. Although the majority of mammary adenomas 
do not exceed the dimensions of a walnut or of a golf-ball, 
some are as big as coco-nuts. They consist of fibrous tissue 
in which glandular acini are embedded ; the tumour itself 
is isolated from the surrounding gland-tissue by a capsule. 

Tumours of this character are commonly met with 
in the years succeeding puberty. It is rare to meet with 
them before the age of 15, but Pattesoii has published a 
careful description of two cases met with in girls aged 13. 
These are probably the youngest cases yet recorded. The 
great rarity of fibro-adenomas of the breast before puberty 
is due to the simple construction of the breast in the 
non-pubic girl. The gland-elements are represented by 
epithelium-lined tubes, which branch slightly, embedded in 
fibrous tissue. After puberty the gland-elements multiply, 
and this activity is accompanied by a corresponding active 
growth of the fibrous tissue in the breast. 

Paul holds the opinion that encapsuled adenomas of the 
breast arise in the periacinous tissue. As this tissue grows, 
the epithelial elements increase with it, and, if they keep pace 
with the abnormal growth of the connective tissue, the result 
is an adenoma (Fig. 151). When the connective tissue out- 
grows the epithelial elements the result is a fibro-adenoma, in 
which the acini appear as slit-like spaces lined with epithelium. 

2. Cystic adenomas. As women increase in age, and 
especially if the breast has an opportunity of fulfilling its 
function, then adenomas which arise in the gland contain 
much more epithelium and far less connective tissue. The 
epithelial cells are larger, and approach in character those of 
the active mamma. Adenomas of this kind form far larger 
tumours than those to which the term fibro-adenoma is usually 
applied. Occasionally the glandular acini become dilated with 
fluid and form cystic spaces; the -tumour is then termed a 
cystic adenoma (or an adenocele). At times a cyst of this 
kind will retain its communication with the galactophorous 



308 



CYSTIC ADENOMAS 



duct, and the secretion will sometimes escape at the nipple. 
Indeed, it is possible, when examining the breast, by gently 
squeezing the tumour to force a jet of fluid through the 
nipple. This is a diagnostic sign of great value. It some- 
times happens, after removal of a large cyst of this kind, that 
a bristle can be passed from the cyst along a galactophorous 




Fig. 151. Breast in section containing an adenoma that had been 
slowly growing for thirty years. The nipple is inverted. From 
a spinster aged 59. 

duct. In some adenomas the cystic portion largely pre- 
ponderates, the glandular element merely projecting as 
a bud into the cyst. A sharp distinction, however, must 
be drawn between a cystic adenoma and a dilatation of a 
duct with intracystic growth. This variety is closely allied 
to duct-cancer and duct-papilloma. Cystic dilatation of a 
milk-duct during lactation is known as a galactocele. 



MAMMARY PAPILLOMAS 



309 



Some of the rarer but larger and more formidable kinds 
of mammary adenomas are those which combine all the 
characters of the preceding varieties ; that is, they contain 
much fibrous tissue, and numerous and fairly large cystic 
spaces, many of which are also almost completely occupied 
by intracystic processes. Mammary tumours of this kind 
sometimes attain very large proportions, weighing upwards of 
5 or even 10 Ib. These tumours have received a variety of 




Carcinoma. 



Adenoma. 



Fig. 152. Mamma in section containing a nbro-adenoma surrounded by 
cancer. From a woman aged 46, who had been aware of the exist- 
ence of a tumour for twenty years. (Museum of the Royal College 
of Surgeons.} 

names, such as Brodie's tumour, sero-cystic tumours, adeno- 
sarcomas, and so on. Clinically they are innocent, and do 
not recur after removal. 

Although adenoma and carcinoma occasionally coexist in 
the same breast (Fig. 152), an adenoma never becomes trans- 
formed into cancer. 

Papillomas of the breast. It is an established fact that all 
epithelial surfaces are especially prone to produce crops of warts, 



3io MAMMARY PAPILLOMAS 

and the epithelium lining the galactophorous ducts, the ducts 
of the acini, and the acini themselves are liable to papillomas, 
and such papillomatous surfaces with fair frequency become 
the sites of cancer. This occurs in a galactophorous duct, and 
the duct becomes dilated into a cyst ; as the warts are vas- 
cular and bleed freely, the patients become disturbed and 
distressed by irregular discharges of bloodstained fluid issuing 
from the nipple ; the fluid is occasionally so abundant as to 
soak their clothes. An example of such a cyst is shown in 




Fig. 153. Nipple dissected to show a dilated duct filled with a soft 
papillomatous mass. From a woman aged 48. 

Fig. 153, in which a cyst the size of a cherry contains a vas- 
cular clump of warts the size and colour of a ripe mulberry. 
When such a cyst arises near the base of the nipple, the over- 
lying skin may be plum-coloured. When the ducts deeper 
in the breast are implicated, two or more cysts are produced, 
and they may reach the size of an orange. Usually, when the 
cyst is deep in the breast the fluid is abundant and the solid 
portion small. Patients occasionally come under observation 
with a discrete tumour in the breast ; it may be of the size of 
a walnut or as big as a tennis-ball, and yield bloodstained 
fluid on pressure. The surgeon regards it as a papillomatous 



PAPILLOMATOUS CYSTS 311 

cyst, but, on removing it and examining the intracystic growth, 
finds it cancerous. On such evidence he completely removes 
the breast. This condition is known as duct-cancer of the 
breast. The specific characteristic of duct-cancer is this : the 
cancer nodule is contained in a cyst. In the rare instances in 
which recurrence follows operation the recurrent nodules are 
cystic, of the size of cherries, and each cyst contains a sessile 




Fig. 154. Section of a mamma containing a papillomatous cyst. The 
nipple is inverted, not retracted. From a woman aged 68. 

purple wart bathed with pink fluid. When exposed in the 
course of an operation they resemble in colour melanotic 
nodules ; this, is due to the reflection of light through the 
thin cyst -wall. 

Dissemination in duct-cancer is rare. Shattock found, in 
the museum of St. Thomas's Hospital, a rib containing a 
secondary nodule of cancer which had the microscopic 
characters of duct-cancer of the breast. The clinical notes 



312 



DUCT-CANCER 



were consulted, and contained the statement that the patient, 
a woman aged 60, had suffered amputation of the breast a 
few weeks before her death. It was recorded that the breast 
was generally believed to be scirrhous, but some who saw it 
had doubts on the matter. In the majority of instances duct- 
cancer appears as a solitary tumour in the breast, near the 



i 




Fig. 155. A'/breast in section ; it contains a globular tumour. The over- 
lying skin is smooth and the nipple is not retracted. From a woman 
who stated that the tumour had been growing two years. 

nipple, usually of the size of a walnut, but it may be as big as an 
orange, and there is no implication of the skin. The women 
are usually over 35, and the nipple is not retracted but may 
be inverted (Fig. 154). The tumour grows slowly, is softer 
than the common forms of cancer, and the disease shows 
little tendency to disseminate, or infect lymph-nodes. It is 
the least malignant form of mammary cancer. 



PERITHELIOMA 



There is a rare form of tumour of the breast which occurs 
in adults and is encapsuled like an adenoma, but in struc- 
ture resembles carcinoma. It does not infiltrate surrounding 




Fig. 156. Microscopic character of a perithelioma. (Ziegler.) 

parts, nor lead to retraction of the nipple (Fig. 155). The 
cells grow in such a way as to form a cell-mantle round 
the blood-vessels (Fig. 156). Such tumours are sometimes 
called peritkeliomas. 



CHAPTER XXVIII 

EPITHELIAL TUMOURS OF THE BREAST 

(Concluded) 

CANCER OF THE BREAST 

CANCER occurs in any part of the breast, from the nipple to 
the ultimate recesses of the gland. The common form arises 
in connexion with the secreting elements, and a rarer variety 
arises in the galactophorous ducts and has been already de- 
scribed. It has been customary to call the common form of 
this disease acinous cancer, under the idea that it actually 
originated in the epithelium of the acini. Cheatle, after careful 
research, prefers to believe, and his sections justify his belief, 
that cancer arises, as a rule, in the epithelium lining the duct 
of an acinus. If this be confirmed, it will be inconsistent to 
use the term acinous cancer, for all forms will be duct-cancer, 
but the common kind arises in a primary duct, and the 
uncommon and less malignant kind in a secondary duct. 

This will bring clinical classification into line with histo- 
logical findings. It must be admitted that the histological 
diversity presented by cancer of the breast has led to great 
confusion in surgical writings, but the investigations into the 
epithelial changes to be observed in the mammary gland in 
the conditions termed chronic mastitis, and the treatment of 
this change by surgical measures, have enlarged our knowledge 
of the early stages of cancer. 

Mammary cancer in its typical form is found as a solitary 
hard tumour situated at the base of the nipple, but it may 
occupy any part of the gland, even its periphery, or one of the 
outlying prolongations. When the tumour is near the areola 
it will induce retraction of the nipple ; in other parts of the 
breast it will lead to dimpling and puckering of the overlying 
skin. 

314 



CHRONIC MASTITIS 315 

Chronic mastitis. This name is applied to an abnormal 
condition of the mammary gland closely associated with the 
incidence of cancer. The leading feature of this change is an 
increase in the fibrous tissue of the breast in close association 
with the acini and their ducts : the tissue specially concerned 
is often called periacinous tissue, and when the change is 
widely diffused the gland shrinks and resembles the atrophic 
condition of the breast characteristic of old age. This form 
is called in consequence atrophic mastitis the fibrous tissue 
is in excess, the gland-elements shrink, and the breast be- 
comes hard. Both breasts are usually affected. In another 
form, the increase is accompanied by epithelial activity, the 
ducts of the acini are distended with fluid, become lobulated, 
and on section present a number of cystic spaces which appear 
to be independent but are really sections of the same con- 
voluted duct (Cheatle). This is the cystic form (Fig. 157). 
Chronic mastitis may affect both breasts uniformly, or the 
change may be more or less isolated to an area of the 
breast : then it is often difficult to determine its nature, for 
the indefinitely localized thickening so resembles a cancerous 
area that its nature can only be determined by microscopical 
examination. 

Chronic mastitis has been studied for many years with 
great care, not only on account of its simulation of the clinical 
signs of cancer, but also from its constant association with this 
disease. Mitchell Banks insisted on the importance of this 
association, and his views are now accepted. Surgeons to- 
day agree that chronic mastitis is a universal precursor of 
mammary cancer, and that the breast, like other secreting 
glands, is more liable to become cancerous when the seat of 
pre-existing disease. 

Cheatle has shown that the ducts of the acini in chronic 
mastitis occasionally become dilated and so convoluted that, 
when cut across, a section of such a duct often resembles a 
colony of cysts. He has also found signs of unusual activity 
in the epithelium of the ducts, and that papillomas are 
common on the walls of the ducts. The acini are often 
converted into cysts. Acinous cysts, like the dilated and 
convoluted ducts of the acini, sometimes contain papillomas. 
There are differences in papillomas arising in ducts and those 



CHRONIC MASTITIS 

arising in acini. An acinus-papilloraa is covered with elon- 
gated feathery epithelium. Duct-papillomas have coarse 
fibrous stalks. Cheatle holds the opinion that cancer often 




Fig. 157. Microscopic appearances of the atrophic and the 
cystic form of chronic mastitis. 



GANGER OF THE BREAST 317 

begins in the ducts and in duct cysts of the mamma, and he 
believes that cancer-like papillomas may affect extensive 
epithelial surfaces in one or more ducts. Cancer may arise 
primarily in different parts of the same breast. Columnar 
epithelium may change its shape and become spheroidal in 
simple duct-papilloma, and this change invariably occurs 
when the cells of duct-cancer reach the lymphatics: here 
they also lose their papillomatous formation. 

These observations have an important bearing on the 
nature of cancer ; they show that the recesses of the acini by 
means of its duct, and the galactophorous duct, are in com- 
munication with the surface of the skin at the tip of the 
nipple, and thus a potential channel is offered for the invasion 
of the recesses of the mammary gland by pathogenic micro- 
organisms. 

Clinical features. Cancer of the breast in its typical form 
occurs as a solitary hard, ill-defined tumour at the base of the 
nipple ; but it may occur in any part of the breast. When 
the tumour is near the areola it induces retraction of the 
nipple. When situated in other parts of the breast it will 
lead to dimpling or puckering of the overlying skin. 

On section such a tumour has the appearance and consist- 
ence of an unripe pear ; microscopically it will be found to 
consist of columns of epithelial cells, disposed like the lobules 
of the gland, and embedded in dense fibrous tissue. The 
tumour has no capsule, and fades away indefinitely into the 
surrounding tissues. When the parts beyond the tumour are 
examined, nodules of cancer will often be detected. 

In many examples of mammary cancer the tumour, when 
bisected, appears to the naked eye merely like a tract of cica- 
tricial tissue, and feels as hard as cartilage ; when examined 
microscopically it will be found to consist of strands of fibrous 
tissue enclosing here and there a few epithelial cells. This 
variety is sometimes spoken of as " wittering" or contracting 
cancer ; it runs a much slower course than the preceding 
kinds, and gradually, by its contraction, causes the gland to 
shrivel, so that at length the patient presents an appearance 
as if the breast had been removed. Women have been known 
to live twenty years with this variety of cancer. 

Among unusual forms of cancer of the breast may be 



3i8 CANCER OF THE BREAST 

classed the rare condition in which it arises in an axillary 
mamma. Before the invention of the microscope, tumours 
could only be classified by their physical characters texture, 
density, and colour. Hard tumours were called scirrhus ; 
and soft tumours medullary, on account of their likeness to 
marrow, or encephaloid, from a semblance to brain tissue. 
Melanoma, a name applied to certain tumours on account of 
their blackness, is a good term and persists. 

Mammary cancer does not occur before puberty, and 
is rare before 30 ; it is very common between 40 and 50. 
After 50 it decreases in frequency, and, though rare after 
70, it occasionally occurs in extreme old age. It attacks 
single as well as married women, the barren and the 
fertile being equally liable. It also attacks the male breast, 
but mammary cancer is a hundred times more frequent in 
women than in men. Concurrent cancer of the breasts is 
rare both in women and in men. 

Cancer usually attracts attention as a circumscribed hard 
lump in the mamma ; it never forms a large tumour indeed 
a mammary cancer rarely exceeds the dimensions of a fist. 
The rate of growth may be slow, is often extremely slow, 
especially in the old. When cancer appears during lactation 
it progresses with frightful rapidity. 

As the tumour increases in size it infiltrates surrounding 
tissues, becomes adherent to the fascia of the pectoral muscle, 
and even implicates the muscle. These infiltrated tissues 
shrink (Fig. 158) and cause the cancerous breast to become 
smaller, often much smaller, than its fellow. The general 
shrinking of the breast is an important factor in diagnosis, 
and must not be confounded with retraction of the nipple, 
which is rarely of diagnostic import, as it occurs under a 
variety of conditions. Occasionally a cancerous nodule in 
the breast feels as discrete and movable as an adenoma. 

There is a delusive form of breast-cancer that resembles 
in its clinical features an acute abscess. Mammary cancer 
until it ulcerates is sterile. In exceptional cases a cancerous 
focus near the base of the nipple becomes infected, inflames, 
and looks like an abscess ready to burst. The unsuspecting 
surgeon incises it, and is surprised that only thin purulent 
fluid escapes, but the hardness of the tissue raises his sus- 



PERMEATION 



319 



picion and he excises a portion of the wall. On microscopic 
examination the typical characters of mammary cancer are 
revealed. Such a breast should be promptly excised. 

Permeation (lymphatic infection). This occurs early in 
mammary cancer, and is an important clinical sign. The 
lymph-nodes lying parallel with the free border of the great 




Fig. 158. Cancerous breast in section : the dotted line indicates the 
extent to which the nipple and areola have retracted. 

pectoral muscle are first involved ; the infection then extends 
to the whole axillary group, and finally involves those in 
the posterior triangle of the neck immediately above the 
clavicle. 

It by no means follows that .because a tumour of the 
breast is unassociated with large lymph-nodes the tumour is 
not a cancer. By the time the nodes are sensibly enlarged 



320 FACETS DISEASE 

the tumour has made its way towards the surface, and at 
last the involved skin ulcerates. The advent of ulceration is 
heralded by a purplish or bluish appearance of the skin, which 
sometimes resembles a recent cicatrix with veins radiating 
from it, or the surrounding skin may be dotted with small 
knots of the size of a split pea, or even larger. 

After the skin breaks, the ulcer tends to spread, and 
soon assumes the typical appearance of a cancerous ulcer : its 
edges are raised and rampart-like, and surround an irregular 
depression, the floor of which is formed of firm granulations 
discharging a foul ichorous or bloodstained fluid. 

Paget's disease of the nipple. In 1874 Sir James Paget 
described a peculiar dermatitis affecting the nipple and areola 
which he regarded as having some intimate connexion with 
cancer of the breast. Although it is a rare condition, there 
has been much speculation in regard to the relationship of 
the so-called chronic eczema of the nipple with cancer of 
the breast. 

Handley has investigated the pathology of the condition. 
He makes it clear that the thickened eczematous condition of 
the nipple is not the precursor but the result of a subjacent 
cancer commencing near the nipple. For example, a carci- 
noma starts in the smaller ducts of the breast and, without 
producing a palpable tumour, permeates the breast lymphatics 
widely. The rich plexus of lymphatics around the ducts form 
an easy and convenient channel for permeation, and the 
lymphatic block extends along them to the subareolar plexus 
beneath the nipple, causing oedema and necrosis of the over- 
lying cutaneous structures. 

Pain. There is no symptom more variable in mammary 
cancer than pain. A large proportion of patients experience 
no painful sensations whatever, and are absolutely ignorant of 
the presence of any disease in the breast until their attention 
is arrested by some irregularity in its outline, or some marked 
difference in the comparative size of the two breasts. In some 
the pain is localized, but in others it radiates from the tumour 
to the surrounding parts. The pain in mammary cancer is 
usually a concomitant of the late stages of the disease, and 
is caused by the involvement of nerves in the growth. 
When cancerous deposits occupy the vertebrae and press on 



SECONDARY DEPOSITS 321 

nerve-roots or nerve-trunks, pain is severe and difficult to 
control. 

Secondary deposits. Concurrently with, but more often 
subsequently to, infection of the lymph-nodes, secondary 
deposits occur in the viscera, especially the liver and lung ; 
but any organ may be the seat of deposit. 

When the liver is attacked it enlarges, and there may be 
hydroperitoneum, rarely jaundice ; deposits in the lungs and 
pleurae set up pneumonia and pleurisy. When effusions occur 
in the pleurae, peritoneum, or pericardium, as a result of 
cancerous infection, the fluid is often bloodstained. 

Secondary deposits in the brain give rise to mental disturb- 
ance and coma. Deposits in the bones cause " spontaneous " 
fracture, and when the vertebral column is implicated para- 
plegia is the usual consequence. Enlarged lymph-nodes and 
secondary deposits may so involve large blood- and lymph- 
vessels in the axilla as to produce solid oedema of the arm. 

In the late stages of the disease the tissues covering the 
thorax may be infiltrated, and this local extension often 
implicates the ribs and directly infects the pleura. In some 
patients, secondary deposits of mammary cancer occur as a 
multitude of small nodules in the skin covering the front of 
the chest and both breasts, and the skin becomes so rigid as to 
resemble a firm leather shield, a condition which has earned 
for it the name of " cancer en cuirasse." In this extreme 
condition the skin is so firm and hard (pig-skin) that it is 
impossible to wrinkle it. This peculiar condition is probably 
due to cancerous invasion of the cutaneous lymphatics. 

As the cancer extends locally and ulcerates, and more 
especially when there is evidence of secondary deposits, the 
patient's health begins rapidly to decline and the tissues 
to waste. It is astonishing how women with breasts in- 
filtrated with cancer, or eroded by large and foul ulcers, 
will sometimes be able to get about and busy themselves 
with household matters ; and this state of things will con- 
tinue for many months, until the supervention of pleurisy, 
pneumonia, or some complication due to the dissemination 
of the cancer incapacitates them and extinguishes life. 

Lymphatic 03dema. This occasional complication of 
mammary cancer must be considered, on account of the 
v 



322 GANGER EN GUIRASSE 

inconvenience and distress it produces. It is a condition 
which cannot be mistaken. The oedema is usually manifested 
in the skin about the shoulder, gradually extends to the skin 
of the arm, and in due course involves the forearm and hand ; 
the skin covering the scapula is also implicated. The limb in 
typical cases has a swollen appearance, as though cedematous ; 
but when the skin is pressed, instead of pitting on pressure it 
will be found firm, brawny, and unyielding. 

The lirnb grows extremely heavy, arid the patient finds it 
necessary to support it in a sling. Exceptionally, the weight of 
the limb prevents the patient from taking walking exercise ; 
it usually produces a moderate degree of lateral curvature 
of the spine. The connective tissue may be so infiltrated 
with lymph that the skin becomes sufficiently tense to 
prevent movement at the wrist, elbow, and shoulder : under 
such conditions the arm resembles a wax cast rather than 
a living limb, and is absolutely useless. 

When the tissues of such a limb are examined immediately 
after death, it will be noticed that the increase in size is due 
to infiltration of the subcutaneous tissue with lymph, which 
causes the cut surface to resemble in colour and in texture 
the pulp of an orange, and large quantities of lymph flow 
from the incisions. The muscles are smaller than natural 
and infiltrated with fat. This condition is the consequence 
of the destruction of the axillary lymphatics secondary to 
their permeation by the cancer. 

Treatment. Although investigations carried out upon 
tumours of the mammary gland have failed to throw any light 
upon the cause of such disorders, the study of their minute 
anatomy has thrown much light on their natural history, 
clinical course, and the modes in which they destroy life, and, 
most important of all, the discovery that chronic mastitis is 
such a constant precursor of cancer has considerably increased 
the opportunities of hopeful surgical treatment. 

Diffuse chronic mastitis is often a source of pain and 
distress, and it is sometimes necessary to remove the breast 
though there be no obvious sign of cancer. Chronic mastitis 
with general cystic disease frequently requires the removal 
of one breast, and sometimes both. 

The practice of removing tumours such as fibro-adenomas 



TREATMENT 323 

and adenomas is a proper proceeding. All tumours of the 
breast lacking a capsule are suspicious conditions, and as a 
rule justify a radical operation. 

Duct-papillomas are often so clearly defined that it may 
be sufficient to excise the nipple with the cyst, but if on 
microscopic examination the mulberry-like mass is proved 
to be clearly malignant the whole breast should be removed. 

With our present knowledge, the only method of treatment 
which offers any hopeful prospect to patients affected with 
mammary cancer is the removal of the whole breast with its 
outlying lobules, the skin covering the breast, the pectoral 
muscles with the fascia and the lymphatics which run from the 
breast to the axilla, and the axillary lymph-nodes. Handley, 
who has carefully investigated the serpiginotis way in which 
the cancer- cells permeate the lymphatics in the deep fascia, 
advises the removal of this fascia, especially in the direction 
of the epigastric region, in order to prevent cancerous invasion 
of the abdomen. 

Unfortunately, the chief difficulty the surgeon finds in 
recommending this very clumsy though appropriate remedy 
arises from the circumstance that patients so often conceal 
the fact that they have a tumour until compelled by pain, 
discomfort, and often actual misery, induced by ulceration 
and sloughing of the cancer, to seek advice. There is, of 
course, a small proportion of women who absolutely refuse to 
submit to operation in the early hopeful stages, and wait until 
the skin becomes involved before they realize their unfor- 
tunate condition. When the tumour has been allowed to run 
its course and infect the axillary lymph-nodes or ulcerate, the 
chance of doing good by operation is seriously diminished. 

Careful observations show clearly enough that those 
patients do best who have the cancerous mamma extirpated 
at the earliest possible date after the tumour is perceived. 
There is a consensus of opinion among surgeons who have 
had the largest experience in cancer, that when a patient 
comes under observation with a nodule in the mamma which 
it is reasonable to regard as cancerous, it is the duty of the 
medical attendant to advise the removal of the breast. It 
is, however, a remarkable fact that while mammary tumours, 
innocent and malignant, have been subject to observation for 



324 CANCER OF THE BREAST 

centuries, there is no organ in the body in which tumours 
give rise to more doubt or difficulty in diagnosis than in 
the mamma. This is so generally recognized that it is the 
duty of every surgeon, before amputating a breast, to make 
an incision into the swelling, in order to assure himself that 
he is really dealing with a malignant tumour, and not a 
simple cyst or an abscess. 

The most favourable cases are those in which the cancer is 
limited to the breast, does not involve the skin, and has not 
produced any appreciable enlargement of the axillary lymph- 
nodes. In such a case the removal of the whole breast, with 
the underlying fascia, lymphatics, and lymph-nodes, is a pro- 
ceeding which, if properly carried out, is devoid of operative 
risks ; recurrence or dissemination is indefinitely delayed, and 
the patient may enjoy many years (five, ten, or even fifteen) 
of useful life. 

When the cancer has been allowed to implicate the skin, or 
has ulcerated, and there is extensive infection of the lymph- 
nodes, then very wide removal of the tissues is imperative. 
This necessarily adds to the risks of the operation ; and though 
in many instances patients have allowed the disease to 
advance in this way before coming to the surgeon, yet a fair 
proportion enjoy some years of immunity from recurrence, 
but their expectation of life is not great. The difficulty the 
surgeon has to contend with 'in this stage is uncertainty as 
to the presence of secondary nodules in the viscera. 

When cancer of the breast extensively involves the skin 
and has ulcerated deeply and especially if it implicates 
the pectoral muscle and chest-wall then an operation is 
useless. 

This also applies when the supraclavicular lymph-nodes 
are enlarged; in cuirass cancer; and when there are signs of 
dissemination. 

Perhaps one of the most extraordinary facts connected 
with mammary cancer is this : Two patients may have their 
breasts removed for cancer ; they may be alike in age, habit of 
body, and circumstances ; the tumours may be alike as far as 
eyes, fingers, and microscope can determine ; the operations 
may be conducted by the same surgeon and by the same 
method ; yet one patient may die in a few months with wide 



RECURRENCE A FALSE TERM 325 

dissemination, and. the other may be spared ten or even fifteen 
years. Herein lies all our difficulty, for the surgeon, however 
wide his experience, cannot forecast from the clinical character 
of the tumour the future of his patient; neither can the 
morbid histologist predict the course of the case. Even when 
a competent knowledge of surgery and pathology is combined 
in the surgeon, he rarely ventures to prophesy. It may be 
truly said that some cases for which surgery seemed to 
promise much have been tragic failures, and that some which 
seemed almost hopeless have given admirable results after 
operation. 

Although cancer rarely attacks both breasts simul- 
taneously, it is not uncommon, after one cancerous breast 
has been removed, for this disease to appear in the other ; 
under these conditions it is usually of the massive kind. 

Recurrence. It is now clearly established that local 
recurrence after removal of a cancerous breast is due to two 
causes, namely, incomplete removal and cancer-infection. In 
respect to imperfect operations, Sir Benjamin Brodie, many 
years ago, wrote in regard to the removal of the whole breast : 
" You may imagine this is a very easy thing to be done, but it 
is not so easy in reality ; for in amputating the breast you will 
be very apt, in a thin person, if you are not very careful, to 
leave small slices of the gland of the breast adherent to the 
skin, and I have no doubt that the part or parts thus left 
behind in some cases have formed the nidus of future disease." 
We now know this to be perfectly true. Recurrence is a 
false term. The nodules that appear around and in the 
cicatrix, or in any part of the area disturbed by the surgeon's 
knife, grow in cancerous tracts missed in the operation. 

Sometimes the surgeon removes a cancerous breast, takes 
every care to keep wide of the tumour in making the skin- 
incision, dissects out the gland- tissue, removes the major and 
minor pectorals, and clears the lymph-nodes, with the sur- 
rounding fat, from the axilla. He closes the wounds, and 
congratulates himself on the completeness of the operation. 
Occasionally his industry is rewarded, but now and then 
these extensive enterprises are followed by rapid and wide 
recurrences, which often take the form of infiltration of the 
skin raised in the operation and of the underlying chest-wall. 



326 GANGER OF THE BREAST 

This dire result is due to the distribution of cancer- cells 
in the course of the operation; in short, to cancer-infection 
(see p. 267). 

Broadly reviewing the whole subject of operation for the 
relief of cancer of the breast, it must be admitted that to cut 
out the diseased breast, though extremely clumsy, is the only 
useful method yet devised. 






CHAPTER XXIX 

EPITHELIAL TUMOURS OF THE ALIMENTARY 
CANAL, LARYNX, AND LUNG 

CANCER OF THE LIPS 

IN the lips squamous-celled cancer is common between the 
thirty-fifth and sixtieth years ; it has been recorded as early 
as the twenty-fifth year and as late as the hundred-and- 
third (Jalland). A remarkable feature is the preference it 
shows for the lower lip. Thus, out of 565 cases tabulated 
by Loos in Brims' clinic at Tubingen, 534 arose in the lower 
lip. Of these, 467 of the patients were men and 67 women. 
It is also remarkable that though men are so much more 
liable to cancer of the lower lip than women, yet the lia- 
bility is equal for both sexes in regard to the upper lip. 
Out of the 31 cases of cancer in the upper lip in Loos' total 
of 565, 16 occurred in men and 15 in women. 

The increased liability of men to cancer of the lip as 
compared with women is attributed to the greater frequency 
of tobacco-smoking among men. In connexion with this 
matter it may be mentioned that cancer of the lip is some- 
times spoken of as "countryman's cancer," on account of 
the frequency with which it occurs among agricultural 
labourers, who use short-stemmed dirty pipes. The clay 
pipes with short stems are very convenient, as they can be 
carried in the pocket. In London hospitals some patients 
with cancer of the lip are farm-labourers, but many are 

tmen who come under the term " labourers," and their cus- 
tom in regard to the short pipe is the same as the farm- 
hand's. The stem of a short clay pipe soon becomes hot 
when in use, and burns or scorches the lip. Chronic ulcers 
caused by burns are prone to be the starting-points of 
squamous-celled cancers. (See p. 293.) 
327 



328 GANGER OF THE LIPS 

Women, too, who* work in the fields acquire the habit 
of smoking short clay pipes, and, as far as ray observations 
go, in Germany more women work in the fields than in 
England. This may account for the greater prevalence 
of cancer in the lip in women of that country, as shown in 
the tables prepared by Loos, than we find from an analysis 
of the hospital lists of London. 

Chronic syphilitic ulcers of the lips become cancerous 
and account for a certain number of cases which occur in 
non-smokers. This is true of the tongue. Cancer is occa- 
sionally seen in the lips of patients who do not smoke 
tobacco, and who are not tainted with syphilis. It is also 
worth bearing in mind that cancer of the lip is a common 
disease among those whom we regard as the "working class," 
but this set of men and women do not monopolize tobacco. 
Many professional men, including the vicar of the parish, 
smoke as hard as the labourer, yet it is excessively rare to 
find a case of cancer either of the upper or lower lip among 
them. The preference of cancer for the lower lip is not 
easily explained. 

Cancer of the lip, when left to run its course, soon infects 
the lymph-nodes in the submaxillary region. Occasionally it 
will attack the right side of the lower lip, but infect the lymph- 
nodes in the left submaxillary region, and vice versa. No 
anatomical explanation of this anomaly is forthcoming. The 
tissues of the lip are gradually destroyed, and the mucous 
membrane covering the mandible is implicated and the bone 
itself eroded. In the late stages the lymph-nodes in the neck 
form huge masses, which gradually implicate the overlying 
skin, causing it to ulcerate, and at last the ulcer in the neck 
and the primary ulcer on the lip join ; and as the underlying 
tissues slough a horrible chasm is formed in the neck, on the 
floor of which large vessels may be seen pulsating. Death is 
due to asthenia from repeated haemorrhage, or to a profuse 
haemorrhage, septic pneumonia, or oedema of the glottis. 
The average duration of life in untreated patients is twelve 
months from the time they come under surgical observation. 

Treatment. Cancer of the lip in the early stages is easily 
removed by the V-shaped method, or some one or other of 
its many modifications. The submaxillary and submental 



GANGER OF THE TONGUE 329 

lymph-nodes should be dissected out. When the disease has 
been allowed to extend until it involves the underlying bone 
and extensively infiltrates the cheek and neck, operative 
interference can rarely be undertaken with good prospects. 

After the excision of cancer of the lip, recurrence may 
take place along the edge of the scar, but more frequently 
in the cervical tissues. There is a form of recurrence which 
begins near the angle of the mandible, and spreads on each 
side of the body of this bone in such a way as to resemble 
a periosteal sarcoma. 

Early removal in cancer of the lip is more likely to be 
fpllowed by good results than in any other part of the body. 
Occasionally the operation is followed by quick recurrence, 
even when the primary lesion was very small ; but in a 
large proportion of cases recurrence is delayed two, three, or 
more years, and in a few cases a cure is brought about. 

CANCER OF THE MOUTH AND TONGUE 
Squamous-celled carcinoma arises in any part of the 
mucous membrane of the mouth. It is common on the 
anterior two-thirds of the tongue that is, the part lying in 
front of the circumvallate papillae. It is often found on the 
floor of the mouth, especially in the folds around the openings 
of the submaxillary glands. Cancer often starts in the gums, 
especially near the neck of a carious tooth, and it is occa- 
sionally seen on the mucous membrane of the cheek. Cancer 
of the mouth and tongue is ten times more frequent in men 
than in women. The disease is often preceded by chronic 
lesions of the tongue such as leucoplakia, cracks in the 
mucous membrane, and chronic syphilitic ulcers. 

Cancer of the tongue. In this situation cancer is most 
frequent after the fortieth year, but it has been recorded in 
patients as young as 25 and as old as 75 ; it is commoner in 
men than in women. The predilection of this disease for the 
tongues of men is usually attributed to the habit of smoking, 
but a very common forerunner of cancer of the tongue is a 
chronic syphilitic ulcer, or what appears to be a simple 
papilloma, and bacterial irritation due to septic teeth and 
chronic oral sepsis. Cancer generally attacks one side of the 
tongue, near its tip; in a fair proportion of cases it starts 



330 CANCER OF THE TONGUE 

on the dorsum, but always distinctly to one side of the 
middle line. 

Leucoplakia. In a fair proportion of cases cancer of the 
tongue is preceded by chronic inflammation of the mucous 
membrane of the tongue, which leads to the formation of 
white patches of greatly thickened epithelium. Such patches 
are raised above the general level of the normal mucosa. 
This condition and its relation to cancer of the tongue were 
described by Hulke, in 1868, as ichthyosis glossse : it is now 
generally known as leucoplakia, and no one doubts that it 
is a precancerous condition. At the same time it must be 
borne in mind that not every patch of leucoplakia become^ 
cancerous. Leucoplakia of the vulva is also a precursor of 
cancer (Chap, xxxvin). 

When cancer attacks the tongue it is manifested in various 
ways. Sometimes the disease declares itself as a superficial 
patch of ulceration that does not extend below the mucous 
membrane. Often it is seen as a deep crack or fissure in the 
tongue, with raised edges ; or as an ulcerating warty patch ; 
and it is occasionally difficult to decide, without a microscopic 
examination, whether the lesion is cancerous or papillomatous. 
In some patients an ulcer appears in a leucoplakic patch ; and 
often an ulcer is seen that has existed on the tongue for many 
months, and the surgeon is puzzled to decide whether it is 
tuberculous, or a chronic syphilitic patch that has become 
cancerous. It is an important matter to remove cancerous 
ulcers as soon as they appear; therefore it is necessary to 
decide their nature promptly by means of a microscopic 
examination. This is the only sure method in the early 
and hopeful stages. The deep fissures in cancerous lesions 
of the tongue are due to the action of pathogenic micro- 
organisms, for cancers in exposed situations are rapidly 
destroyed by bacteria. The raised, everted edges of can- 
cerous ulcers are caused by the infiltration of the tissues 
around the edges of the patch with inflammatory cells, the 
response to the irritation set up by the pathogenic micro- 
organisms that invade the cancerous tissue. 

Lingual cancer often destroys life very quickly. The 
lymph-nodes in the neck are soon infected, and the disease 
frequently runs its course within a year of coming under 



GANGER OF THE TONGUE 331 

observation, The average duration of life varies from six to 
twenty-four months from the time the cancer is recognized. 
Death ensues from exhaustion, pain, or difficulty in taking 
food. In many it occurs from septic pneumonia, the result 
of inhaling the foetid discharges from the mouth ; a few die 
early from haemorrhage when the ulceration opens up the 
lingual or the carotid artery. Death is occasionally due to 
asphyxia. This arises from two causes : the cancer may 
extend to the base of the tongue and infiltrate the epiglottis 
and its folds, producing oedema of the glottis ; or a mass of 
enlarged lymph-nodes in the neck may press upon the 
trachea and cause suffocation. Dissemination occurs, but 
is unusual. Lymphatic invasion is the most constant and 
the gravest feature of cancer of the lips and tongue. (For 
cancer of the posterior part of the tongue, see p. 336.) 

Treatment. The results of the operative treatment of 
cancer of the tongue stand in striking contrast to those which 
follow operations for this disease when affecting the lower lip. 

The manner of removing a cancerous tongue is modified 
according to the situation and extent of the disease. The 
excision of the anterior portion of the tongue, or the right or 
left anterior fourth of the organ when the disease is localized 
to one side, is an operation devoid of risk or difficulty. If 
the cancer deeply invades the tongue, involves the floor of 
the mouth, or extends so far backwards that, in order to get 
beyond the limits of the disease, the surgeon interferes with 
the pillar of the fauces, then the operation is often hazardous. 
The chief difficulty is connected with haemorrhage, and in 
order to obviate it a variety of methods have been advocated 
for the excision of the tongue. A careful selection of cases, 
wide removal of the diseased tissues, and extirpation of the 
infected lymph-nodes are the points to bear in mind. 

It is important in operating upon the tongue to avoid 
the entrance of blood into the trachea, as it is then drawn, 
during inspiration, into the lungs, and gives rise to septic 
pneumonia. Should blood in considerable quantity get 
into the trachea, it may cause suffocation. To avoid these 
complications it is useful, in extensive operations on the 
tongue, to perform laryngotomy and administer the anaes- 
thetic through a laryngotomy-tube ; and in order to prevent 



332 GANGER OF THE GUM 

blood from running into the trachea, the pharynx is plugged 
with a sponge. 

Trotter has drawn attention to the manner in which 
teeth influence the result of operations for cancer of the 
tongue. Septic teeth in these patients lead to unfavourable 
postoperative sepsis, but such complications rarely give rise 
to serious anxiety in edentulous patients; the intractable 
sloughing so common in cancerous tongues is due to micro- 
organisms, companions of the teeth. An operation for cancer 
of the tongue is attended with better consequences in an 
edentulous patient than in one rendered edentulous for the 
purpose of an operation. 

The mortality of operations for the removal of cancerous 
tongues is not less than 10 per cent. ; the chief causes of 
death are hsemorrhage and sepsis. 

After excision of the tongue, recurrence in the neck 
within a year of the operation is the rule, nevertheless it 
is in some cases delayed for five or even seven years. 

Cancer of the gum, Squamous-celled cancer arises in 
any part of the gum, but is more common in the mucous 
membrane covering the lower than the upper alveolar pro- 
cesses. It often starts near the neck or stump of a carious 
tooth, and quickly infiltrates the mucous membrane; thus, 
whilst eroding the bone, it is creeping along the mucous 
membrane towards the cheek on one side and the tongue 
on the other. Similar effects may be observed when the 
disease attacks the gum in relation with the maxilla; as 
the alveolar process is destroyed the cavity of the antrum 
is exposed, and becomes a foul ulcerating cavity. Although 
in the majority of instances in which the maxilla is attacked 
by squamous-celled cancer the disease begins in the gums 
there are cases in which it arises in the mucous membrane 
of the antrum. The victims of this variety of cancer are 
usually persons past middle life. They complain of pain 
in the jaw for which no adequate cause can be assigned. 
Gradually a slight fullness is observed in the infra-orbital 
region, with perhaps oedema of the eyelid, the skin becomes 
brawny, and at last a cancerous ulcer appears in the skin 
of the cheek, and the antrum is then found to be filled 
with a tumour. When such a case is submitted to operation 



GANGER OF THE ANTRUM 333 

and the skin of the cheek is reflected, the inroads the 
disease has been silently making on the surrounding parts 
are seen to be truly extraordinary. The greater part of the 
maxilla will be found destroyed, and outrunners from the 
growth invade the orbit and the pterygoid muscles. The 
skin of the cheek is usually so infiltrated that it must 
be removed. The successful treatment of such cases de- 
mands much boldness on the part of the operator, as he 
will find it necessary to sacrifice the eye and the orbital 
contents, the palatine plate of the maxilla, and a portion 
of the skin covering the cheek : as a result, a large yawning 
cavern is left. Life is rarely prolonged, but the patients 
are spared much pain and discomfort. 

Bolam has carefully studied the histology of primary 
epithelial tumours of the antrum, and satisfied himself that 
some of them arise in the glands of the antral mucous 
membrane. My independent examination of some cases 
leads me to take the same view. Actinomycosis in its 
clinical course resembles and is often mistaken for squamous- 
celled cancer of the buccal and nasal mucous membrane. 

Cancer of the cheek. This is an uncommon situation 
for cancer. It may start near the angle of the mouth or 
in the vicinity of the orifice of Steno's duct. It leads to 
closure of the jaws. Occasionally cancer at the angle of 
the mouth arises in a chronic syphilitic ulcer. 

Cancer of the mucous membrane of the cheek is common 
among the natives of the Philippine Islands who chew betel- 
nut, especially women (see p. 297). 

Lymphatic infection in cancer of the mouth, pharynx, 
and larynx. In all forms of squamous-celled cancer, no 
matter in what part of the body it arises, early involvement 
of the adjacent lymph-nodes is a most serious feature. It 
is well known that a primary and often inconspicuous focus 
of cancer in a recess of the pharynx, or the larynx, will 
give rise to a mass of enlarged lymph-nodes in the neck 
as big as a fist (Fig. 159). When the nodes just above the 
clavicle are enlarged, especially on the left side, the oaso- 
phagus, stomach, rectum, and testicles should be carefully 
examined, for a primary carcinoma in any of these organs 
can infect the supraclavicular lymph-nodes by way of the 



334 



BRANGHIOGENOUS CANCER 



thoracic duct (see p. 264) . The presence of enlarged lymph- 
nodes in the neck of a person, at or after middle life, 
always leads the surgeon to make a thorough examination 
of the lips, rnouth, tongue, larynx, and pharynx for a small 
inconspicuous ulcer. 

Much has been written about branchiogenous cancer, 
or, as it is sometimes called, malignant cyst of the neck. 




Fig. 159. A mass of cancer in the neck of a man aged 56. The tumour 
was secondary to a primary focus in the sinus pyriformis. During 
life it was regarded as branchiogenous cancer. 

This tumour is commonly observed after the fiftieth year 
of life ; it is deeply seated in the neck, usually near the 
fork of the carotid artery. The tumour grows quickly, 
softens in the centre, and the overlying skin becomes brawny 
and red. In its clinical features it so resembles an abscess 
that an incautious surgeon is induced to incise it, much to 
his discomfiture. Left to itself, the implicated skin sloughs 
and leaves a cancerous hole in the neck. Some surgeons 



GANGER OF THE PHARYNX 335 

believe a tumour of this kind to be primary cancer arising 
in remnants of branchial clefts. In many instances the 
mass is secondary to cancer originating in a recess of the 
pharynx, naso-pharynx, oro -pharynx, or the sinus pyriformis. 
The idea that this variety of cancer arises in remnants of 
branchial clefts is pure fiction. A man died in the Middlesex 
Hospital (1903) with a malignant mass on the right side of 
his neck, regarded during life as a branchiogenous cancer. 
At the post-mortem examination a primary squamous-celled 
cancer was found in the external auditory meatus. The 
cancer had perforated the tegmen tympani, and a small 
rounded bud projected into and indented, but did not pene- 
trate, the temporo-sphenoidal lobe of the brain. In rare 
instances a cancerous mass may arise in an accessory thyroid. 
Some of these malignant epithelial tumours of the neck are 
supposed to arise in the carotid gland (see Chap. LIII). 

This variety of cancer runs a rapidly fatal course ; the 
average duration of life is about six months : it resents 
surgical interference, and, in a few cases where patients have 
survived operation, quick recurrence and a rapidly fatal 
ending have baen the rule. 

CANCER OF THE PHARYNX AND LARYNX 

The distribution of cancer in the pharynx and larynx, and 
its peculiarities in the different situations in which it occurs, 
are of great importance to the surgeon. A knowledge of 
these peculiarities will help in the clinical recognition of the 
disease in the early and hopeful stages. Trotter has studied 
carefully the distribution of cancer in the pharynx and 
larynx. He distinguishes, so far as the mouth and larynx 
are concerned, five groups : (1) Naso-pharyngeal tumours, 
(2) oro-pharyngeal tumours, (3) epilaryngeal tumours (laryn- 
geal cancer), (4) tumours of the sinus pyriformis, and (5) hypo- 
pharyngeal tumours. 

Naso-pharyngeal tumours. The naso-pharynx is often 
the seat of tumours, but the common form of malignant 
tumours is of a peculiar type and is usually regarded as 
sarcomatous. Squamous-celled cancer in this situation is 
rare, and causes very few symptoms until it infects the 
cervical lymph-nodes ; even then the existence of a primary 



336 LARYNGEAL WARTS 

focus in the naso-pharynx often remains unsuspected, and 
the mass of infected lymph-nodes in the neck is miscalled 
branchiogenous cancer. 

Oro-pharyngeal tumours. The tumours in this group 
arise in the tonsil, the anterior pillar of the fauces, and the 
pharyngeal portion of the tongue that is, the part behind 
the circumvallate papillae. Squamous- celled cancer arising 
in the pillar of the fauces and the tonsil is not uncommon ; 
the disease spreads downwards along the groove between the 
tongue and the lateral pharyngeal wall and tends to invade 
the tongue. Carcinoma arising in the posterior third of the 
tongue begins generally in the middle line. It invades the 
substance of the tongue and runs for some time a symptom- 
less course; this fact and the ambiguity of the symptoms 
when they arise make it a grave form of cancer, and the 
extirpation of the disease, even in the early stage, is a 
formidable and dangerous proceeding. 

Oro-pharyngeal cancer runs a more rapid course than the 
purely laryngeal variety. It not only extends more quickly 
and infects the lymphatics at a very early period, but it ex- 
tensively implicates surrounding parts. The duration of life 
is therefore shorter. 

Laryngeal warts. In the larynx, warts most commonly 
spring from the mucous membrane covering the true cords ; 
frequently they grow immediately beneath the cords, and a 
not uncommon situation is immediately below the point of 
attachment of the vocal cords to the thyroid cartilage. Ex- 
ceptionally, a large mulberry-like wart has been detected 
growing from the floor of the sinus pyriformis. In number 
laryngeal warts vary greatly often but one is present; in other 
cases ten or more will be found (Fig. 160). In size there Is 
great difference : some warts are not larger than the head of 
a pin ; they rarely exceed the dimensions of a small cherry, 
and as a rule are no bigger than split peas. The warts may 
be sessile or pedunculated ; in the latter case they sometimes 
possess great mobility, and get nipped between the vocal 
cords and give rise to urgent dyspnoea, occasionally ending 
in suffocation. In colour they are of a delicate pink 
resembling that of the healthy cords. 

Laryngeal warts occur in children and adults. A curious 



GANGER OF THE LARYNX 337 

feature connected with them in children is their disappear- 
ance after tracheotomy. This is similar to the suddenness 
with which warts on the skin sometimes vanish. 

Cancer of the larynx. When this disease attacks the 
mucous membrane of the ventricles, vocal cords, ventricu- 
lar bands, the interarytenoid fold, or the subglottic area, it 
is said to be intrinsic. Cancer arising in the aryteno-epi- 
glottic folds, the mucous membrane covering the arytenoids, 
or the pharyngeal surface of the cricoid, is called extrinsic. 
This clinical classification, introduced by Krishaber, has 




Fig. 160. Larynx of a child opened posteriorly; it is full of warts. 
The child died from suffocation. 

proved useful, but Trotter prefers to reserve the term in- 
trinsic laryngeal cancer for this disease when it arises in 
and about the vocal cord. Cancer starting in or near the 
margin of the upper laryngeal opening is now distinguished 
as epilaryngeal cancer. This term should be applied to 
growths arising from an aryteno-epiglottic fold or the epi- 
glottis. Carcinoma beginning in this fold or in the epiglottis 
has no great tendency to invade the larynx. Intrinsic 
cancer of the larynx usually starts in one of the cords ; 
it is often of the warty variety and rich in cell-nests which 
are exceptionally horny. The papillomatous character of 
w 



338 GANGER OF SINUS PYRIFORMIS 

intrinsic laryngeal cancer should be borne in mind, or it 
may lead to grave errors in diagnosis. The laryngeal wart is 
essentially a disease of children ; cancer is a disease of adults, 
especially men who have passed the meridian of life. A 
warty growth in the larynx of a patient over 40 should be 
viewed with suspicion. Lymphatic infection and dissemina- 
tion are not marked features of intrinsic laryngeal cancers. 
The disease is usually rapid in its progress ; death occurs 
in twelve or eighteen months, and is rarely postponed to 
two years. The fatal result is due to asthenia, intensified 
by the difficulty in swallowing, and pneumonia. Actual 
suffocation is obviated early in the course of the disease 
by tracheotomy. 

Cancer of the sinus pyriformis. In this situation cancer 
is not uncommon, and is in remarkable contrast to the 
disease when it attacks the epilaryngeal structures, on 
account of its latency. Another difficulty in regard to 
cancer arising in this recess is its inaccessibility to laryngo- 
scopic examination, but it can be felt by the finger. Cancer 
in the sinus pyriformis runs a latent course, and is rarely 
suspected until a mass of enlarged lymph-nodes appears 
in the neck. It is often betrayed by hoarseness and copious 
frothy, bloodstained sputum. 

Cancer of the hypopharyngeal region. Cancer belong- 
ing to this group arises in the small section of the pharynx 
lying below the opening of the larynx. In this situation it 
produces symptoms early ; this being the narrowest part of 
the pharynx, difficulty in swallowing soon arises, and diag- 
nosis is possible at an early stage of the disease. It is not 
easy to distinguish between cancer of the sinus pyriformis 
and cancer of the terminal portion of the pharynx, but this 
disease, in the latter situation, tends to involve the oesopha- 
gus widely. Cancer in this situation is usually described as 
cesophageal. 

Treatment of laryngeal cancer. It is of great import- 
ance to recognize early this grave disease of the larynx. As a 
rule, there is little difficulty in appreciating the extrinsic variety, 
but the papillomatous nature of intrinsic cancer of the larynx 
makes the diagnosis somewhat dubious in the early stages. 
Thus it is customary, when there is an element of doubt 



CANCER OF THE LUNG 339 

as to the nature of a laryngeal growth in an adult, to remove 
a fragment by means of laryngeal forceps and submit it to 
microscopical examination. 

Acting on the principles that prevail in the treatment of 
cancer in other parts of the body, surgeons (following the 
lead of Billroth, 1873) have attempted to cure cancer of the 
larynx by excision. Unfortunately, there is very little to 
urge in favour of complete extirpation of the larynx; it 
has been abandoned by most surgeons in the extrinsic form 
of the disease, and even for the intrinsic form laryngectomy 
has fallen into disfavour. The operation has an excessively 
high mortality: a very large proportion of the patients 
succumb to septic pneumonia, and the few that recover are 
often in a miserable and pitiable condition. 

Excision of the diseased half of the larynx for intrinsic 
cancer is a more successful operation ; and this is also true 
of the operation known as thyrotomy, in which the thyroid 
cartilage is divided in the median line and the diseased 
soft tissues are dissected out. 

Thyrotomy is more successful than laryngectomy because 
the laryngeal cartilages are not very liable to be infiltrated by 
carcinoma. It is therefore a comparatively simple operation 
to split the thyroid cartilage in the middle line, thoroughly 
expose the interior of the larynx, and remove the affected 
tissues. In view of the great improvement in the details of 
this operation, its risks have been reduced almost to a 
vanishing point. In cases too advanced for thyrotomy, the 
needs of the patient are in most cases best satisfied by a 
simple tracheotomy. 

For admirable summaries of the operative treatment 
of laryngeal carcinoma, see Gluck and Semon, and StClair 
Thomson. For the surgical treatment of pharyngeal cancer 
Trotter's excellent Lectures should be consulted. 

CANCER OF THE LUNG 

The comparative immunity of the conduits of the body 
to primary cancer is well exemplified in the case of the 
windpipe. The lungs are rarely the seat of primary cancer ; 
when the reports of such cases are strictly examined we find 
that the lungs are liable to be invaded by malignant disease 



340 GANGER OF THE LUNG 

arising in the tissues of the mediastinum : these are usually 
sarcomas. Cancer of the thoracic portion of the gullet invades 
the lung, and malignant tumours arising in the pleura also 
implicate the pulmonary tissues. An insidious but rare form 
of cancer arises in the mucous glands of the bronchi and 
spreads into the lung. 

Adler has collected the reported cases of primary cancer 
of the lung and bronchi ; he is of opinion that it arises in 
the lung-substance distinct from -the hilum, and expresses 
the opinion that a cancer of the lung is strictly a bronchial 
carcinoma. In extremely rare cases cancer arises in the 
pulmonary tissue and is composed of cylindrical epithelium. 
Bronchial cancer arises in the bronchial mucous glands and 
in the surface epithelium. 

Primary cancer of the lung will be more carefully studied 
in the future, now that attempts are being made to deal 
with it surgically. Cancer of the lung, whether primary 
or secondary, produces symptoms long before it furnishes 
clinical signs. The symptoms consist of prune-juice expec- 
toration containing numerous large spherical cells with club- 
like or tail-like projections (Lenhartz). On a radiographic 
examination the tumour casts a shadow. 

Some attempts have been made to remove these tumours. 
Morriston Davies succeeded in extirpating the lower lobe of 
the lung for primary cancer of the bronchus. The vessels in 
the pedicle were ligatured separately, and the stump of the 
bronchus was stitched over and covered with an adjacent 
portion of lung. The patient, a man aged 44, developed an 
empyema, and died on the eighth day. The tumour was a 
squamous-celled carcinoma of bronchial origin. 

Wolf (1895) published some cases of pulmonary cancer 
in which he emphasized the distinction between cancer of 
the lung and cancer of the bronchus, the latter being more 
common ; it is liable to arise in places most subject to chronic 
irritation, especially at the points of bifurcation of medium- 
sized bronchi. The causes of irritation are due to inspiration 
of dust and smoke. Pigmented nodules often form at the 
points of bifurcation of bronchi, especially in the right lung, 
and Wolf contends that these nodes are apt to become the 
starting-points of tuberculosis as well as cancer. The interest 



GANGER OF THE (ESOPHAGUS 341 

of the observation centres in the detection of what may be 
called precancerous lesions in the bronchi. There is nothing 
inconsistent in the opinion that cancer may arise in the walls 
of a chronic tuberculous pulmonary cavity. The observations 
of Wolf have not been confirmed ; this may be due to a cer- 
tain amount of apathy concerning primary cancer of the 
lung a rare affection, and one almost outside the scope 
of practical surgery. 

CANCER OF' THE (ESOPHAGUS 

The gullet is liable to two varieties of cancer : that which 
attacks its upper two-thirds is squamous-celled, whereas 
cancer of the lower segment is of the glandular type. This 
disease appears to be four times more frequent in men than 
in women, and is common between the fortieth and sixtieth 
years. It has been observed as early as the thirtieth year, and 
my oldest patient was 84. Certain parts of the oesophagus are 
more liable to be attacked than others : the usual situations 
are (1) at the level of the cricoid cartilage; (2) where it is 
crossed by the left bronchus ; and (3) at its termination. 

Nothing is known of the early stages of cancer of the 
oesophagus, as it produces few symptoms until neighbouring 
structures, such as the larynx, trachea, pleura, etc., become 
implicated. 

The disease runs a very rapid course ; most cases terminate 
fatally within a year from the time the patient comes under 
observation. Death occurs in a variety of ways : inanition 
and exhaustion are the results of obstruction to the passage 
of food ; pleurisy and septic pneumonia are due to perforation 
of the pleura and trachea. In very rare instances an cesopha- 
geal perforation into the pleura may establish a well-marked 
pneumothorax. A fistula between the trachea and oesophagus 
is common in this disease. Mediastinal abscess, which may 
perforate the pleura or pericardium, sometimes forms, and 
ulceration has been known to broach the aorta. When cancer 
begins in the cervical segment of the oesophagus the recurrent 
laryngeal nerve is apt to become entangled; this will cause 
paralysis of the laryngeal muscles. 

When the disease occupies the middle and lower parts of 
the oesophagus, the lymph-nodes of the mediastinum and 



342 



GANGER OF THE (ESOPHAGUS 



lumbar region enlarge. When the upper third of the tube 
is implicated, the mediastinal lymph-nodes and those at the 
root of the neck are infected. The supraclavicular lymph- 
nodes, especially of the left side, are often enlarged when 




Mucous 

membrane. 



Circular- 
muscle layer. 



Longitudinal- 
muscle layer. 



Cancer. 



Diaphragm. 



Fig. 161. Cancer of the cardiac orifice of the oesophagus, from a man 
aged 48. The gullet has been dissected to show the great enlarge- 
ment of the muscular layers. (Museum of the Middlesex Hospital.') 

cancer arises in any part of the gullet and stomach. This 
fact is an occasional aid in diagnosis (see p. 264). Dissemina- 
tion is rare. 

When cancer attacks the oesophagus where it passes 
through the diaphragm, the tumour assumes the shape of 



GANGER OF THE OESOPHAGUS 343 

a spool, and, as the orifice becomes contracted, the muscle- 
fibres of the gullet markedly hypertrophy (Fig. 161). This 
explains the great force with which patients under these con- 
ditions eject food and drink when they attempt to swallow. 

Treatment. Cancer of the oesophagus has been removed 
when situated high enough to be accessible in the neck. 
Attempts have been made to remove a contracting spool- 
shaped cancer at the gastric end of the oesophagus through a 
median abdominal incision. The excision is easily performed, 
but the oesophagus is not resilient enough to allow the cut 
end to be securely sutured to the stomach. The results are 
not encouraging. When the disease so obstructs the gullet 
as to render the patient liable to starvation, gastrostomy has 
been found useful, and this is especially serviceable when the 
cancerous mass is high in the oesophagus and causes liquids 
to trickle into the larynx in the act of swallowing. In ex- 
cising the middle of the oesophagus it is difficult to avoid 
injuring the vagi. In contracting cancer at the lower end 
ot the oesophagus the nerves are invaded and destroyed. 

Efforts have been made to treat cancer of the oesophagus 
with radium. The oesophagoscope has also been of signal 
service in this disease, for it allows the surgeon to see the 
growth and obtain fragments for diagnostic purposes. The 
oesophagoscope is an ingenious instrument requiring for its 
successful use a surgeon with the instincts of a sword- 
swallower and the eye of a hawk. 

Adler, J., " Primary Malignant Growths of the Lungs and Bronchi." New 

York, 1912. 
Davies, H. M., " Kecent Advances in the Surgery of the Lung and Pleura."- 

Brit. Journ. of Surf/., 1913, i. 228. 
Gluck, T., and Semon, Sir Felix, " Operative Treatment of Malignant Diseases 

of the Larynx." Brit. Med. Journ., 1903, ii. 1113, 1119. 
Hulke, J. W., " A Case of Extreme Hypertrophy of the Epithelial and Papillary 

Elements of the Mucosa of the Tongue, Ichthyosis Glossre, where, after 

twenty years, Epithelioma supervened." Trans. Clin. Soc., 1869, ii. 1. 
Krishaber, "Cancer du Larynx." Gaz. Hebd., 1879, xvi. 518. 
Thomson, Sir StClair, " Intrinsic Cancer of the Larynx." Brit. Med. Journ., 

1912, i. 355. 
Trotter, W., "Operative Treatment of Malignant Disease of the Mouth and 

Pharynx." Lancet, 1913, i. 1075. 

Trotter, W., "Prognosis in Cancer of the Tongue.' 5 Ibid., 1914, ii. 989. 
Wolf, K., " Der primare Lungenkrebs.'' Fortscli. der Mad., 1895, xiii. 725, 



CHAPTER XXX 

EPITHELIAL TUMOURS OF THE GASTRO- 
INTESTINAL TRACT 

THE distribution of cancer in the gastro-intestinal tract is 
significant, the disease being extremely common in the 
stomach, rare in the small intestine, but very common in 
the large intestine and rectum. These are facts of great 
interest in relation to the etiology of cancer ; they favour 
the view that cancer is due to a micro-parasite, probably 
something taken into the alimentary canal with uncooked 
food or water. From 1881 to 1886 I paid almost daily visits 
to the Zoological Gardens for the purpose of making post- 
mortem examinations of the bodies of animals dying in the 
menagerie. The frequency with which their viscera were 
invaded with parasitic worms astonished me, as well as the 
uncountable number of these parasites in some animals. This 
experience impressed me with the value of cooked food for 
human beings as a safeguard against infection; it should 
induce us to agree with Metchnikoff that entozoa may 
convey the parasites of cancer. There are many channels 
by which minute but not invisible invertebrate animals gain 
an entrance into the alimentary canal of man. Food and 
water are frequent conveyers of disease, and it is undeniable 
that minute animal parasites are our daily messmates and 
companions, though their presence we sublimely ignore. 

A striking observation pointing to uncooked vegetables 
as the probable vehicle by which man is infected with cancer 
we owe to Behla concerning the town of Luckau in Ger- 
many. This town contained 5,000 inhabitants, the majority 
being concerned in agriculture. The town consists of a 
central portion surrounded by a moat. Joining it on the 
east and on the west are two straggling suburbs, Kalauer 

344 



VEGETABLES AND GANGER 345 

Vorstadfc and Sandoer Vorstadt, each of them with 1,000 
inhabitants. Behla practised in Luckau twenty-two years, 
and during that period the number of the inhabitants re- 
mained practically stationary. Cancer did not occur among 
the inhabitants of Sandoer Vorstadt, but was very common 
in the Kalauer Vorstadt. Reckoning for the whole town, 
only one death out of every 25 or 30 was due to cancer ; 
whereas in the Kalauer Vorstadt, from October 1st, 1875, 
to April 1st, 1898, 663 deaths occurred, 73 of these being 
from cancer, an average of 1 in 9 a very high proportion. 
In this suburb the houses were similar in size and arrange- 
ments, and, as a rule, damp. A large ditch encircled the 
central town and contained foul and stagnant water in which 
the people washed their vegetables, many being eaten raw. 
The western suburb was sandy, dry, elevated, and remote 
from the ditch, and free from cancer during the period 
investigated by Behla. He believes that his microscopical 
investigations support the view that cancer is due to a 
micro-parasite, and that it is a vegetable organism which 
enters the blood through skin or mucous membrane : its 
spores penetrate epithelial cells and cause enlargement of 
their nuclei and asymmetrical mitoses, and, later, prolifera- 
tive irritation ; finally, a sporangium is found within the 
cell, or close to it in the infected tissues. The vulnerability 
of the various sections of the alimentary canal to cancer is 
instructive in relation to the etiology of the disease, for 
those parts of the digestive tube are most prone to become 
cancerous where food makes the longest sojourn. The oeso- 
phagus, or gullet, is merely a conduit for food. The stomach 
is a churn, and in this viscus there is much mixing of the 
ingested material and prolonged contact of the food with 
the gastric mucous membrane. The digested mass, hurried 
through the small bowel, is retained for many hours in the 
caecum and deprived of the main part of its fluid. The 
undigested residue (faeces) remains for many hours, and in 
some ill-conditioned individuals for days, in the descending 
colon and the rectum. This retention favours invasion of the 
epithelial covering of the gut by an infective agent. Abra- 
sion of the walls of the intestine by foreign bodies accidentally 
ingested, and hard faeces, would also favour infection. 



RECTAL WARTS 



PAPILLOMAS AND POLYPI 

The alimentary canal from the lips to the anus is about 
30 feet long, and papillomas may arise in any part of it, and 
differ in character according to the region in which they 
arise and the variety of epithelium that prevails. 

A wart growing on the lips resembles a raspberry in shape 
and colour. On the tongue a wart is often an exaggerated 

C 




Fig. 162. Microscopic features of a rectal polypus from a child. 

filiform papilla, or cluster of papillae. In the rectum warts 
may be sessile or stalked ; sometimes they are club-shaped 
tags of mucous membrane ; occasionally they resemble chori- 
onic villi ; but in all cases, remote from the anal canal, they 
are covered with columnar epithelium. The tag-like processes 
in the large intestine are often beset with the familiar colic 
follicles (Fig. 162). 

The liability of the various sections of the alimentary canal 
to papillomas and polypi varies widely. Papillomas are not 
uncommon on the tongue, but rare on the mucous membrane 



(ESOPHAGEAL PAPILLOMAS 



347 



of the oesophagus and the stomach. They are unusual in the 
small but frequent in the large intestine, especially in the 
pelvic colon and the rectum. A single polypus may exist, or 
the number may exceed a thousand. 




Fig. 163. Portion of the oesophagus of the green turtle, Chelone mydas. 
Opened to show the mucous membrane crowded with processes resem- 
bling papillomas. (Museum of the Royal College of Surgeons.') 

The oesophagus of the edible or green turtle is beset with 
processes which in structure resemble papillomas; some are 
pointed and 3 cm. long, with the points directed towards the 
stomach ; others are merely low, flat-topped cones. Each 
spine has an axis of loose connective vascular tissue covered 
with a layer of polygonal cells and overlaid with a layer of 



348 



OESOPHAGEAL PAPILLOMAS 



epidermis almost as hard as horn. Edible turtles are strictly 
vegetable feeders, and their chief food is the turtle-grass, 
Zostera marina; it has long tape-like leaves with algse 




Fig. 164. Segment of the oesophagus of an ox, inverted. The mucous 
membrane bears a crop of papillomas. (Museum of the Royal College 
of Surgeons.} 

attached to them, and grows abundantly in the shallow water 
and lagoons of the Old and the New World (Fig. 163). Papil- 
lomas are rare in the oesophagus, but may occur in crops (Fig. 
164). The ancient name polypus, applied to benign tumours 



SOLITARY PAPILLOMA 



349 



attached to mucous membrane by means of a stalk (Fig. 165) 
has merely a clinical value. The stalk is a fold of mucous 
membrane induced by the drag of the polypus. Polypoid 
tumours of the intestinal canal may be fibro-myornas, fibroids 
(see p. 233), lipomas (see p. 21), dermoids (see p. 519), 
adenomas, or papillomas. The two last have been studied in 
recent years very carefully by 
surgeons, for there is the same 
close relationship between papil- 
lomas and cancer of the intes- 
tines as exists between warts 
and cancer of the skin. Intes- 
tinal warts sometimes disappear 
spontaneously a fact that has 
been established since the in- 
vention of the sigmoidoscope. 
Polypi may be solitary, or 
multiple, and sometimes exist 
in vast numbers on the gastro- 
intestinal mucous membrane, 
from the termination of the 
gullet to the anus. They present 
themselves in various forms : 
some as flattened processes of 
mucous membrane beset with 
glands. Many are long and 
narrow, others have club-shaped 
ends (Fig. 166). Some are true 
warts and villous in appearance^ 
and as delicate as the familiar 
villous papillomas of the blad- 
der ; occasionally, clumps of 
warts resemble cauliflowers. 
Often, polypi and warts are 
attached by broad bases, and so clustered together as to 
recall barnacles on a rock. Such clumping favours the oc- 
currence of intussusception. This is proved by an extraor- 
dinary set of specimens in the museum of the Koyal College 
of Surgeons, in which an abundant crop of polypi and 
papillomas grew from the mucous membrane of the stomach, 




Fig. 165. Solitary polypus of the 
pelvic (sigmoid) colon. The head 
of the polypus is crowded with 
intestinal glands. (Museum of the 
Middlesex Hospital.) 



350 MULTIPLE PAPILLOMAS 

duodenum, jejunum, and ileum of a man aged 21. He died 
after an operation for intussusception set up by a cluster of 
polypi in the jejunum. (W. Colyer.) 




Fig. 166. Multiple polypi of the large intestine. They occupied the 
colon from a short distance from the ileo-csecal valve, and ended 
at a cicatrix 3 in. above the anus. From a man aged 46. (Museum 
of the Middlesex Hospital) 

Polypi are uncommon in the stomach. One that grew from 
the mucous membrane near the oesophageal orifice had a 
pedicle 6 cm. long ; this allowed the head of the polypus to 



POLYPI OF COLON 



35i 



pass through the pylorus ; it lay in the first part of the 
duodenum after death. The subject was a woman aged 69. 
(Breschet.) 

A woman aged 75, a dissecting-room subject, had a polypus 
that grew from the margin of the pylorus and adjacent part 




Fig. 167. Cylinder of the pelvic colon inverted to show polypi and papil- 
loraas on the mucous membrane. The orifices of the colic crypts are 
conspicuous. (Museum of the Middlesex Hospital.) 

of the duodenum ; it was involved in an intussusception which 
had dragged the pylorus into the duodenum. The mucous 
membrane covering the polypus contained gastric and duo- 
denal glands. (Thompson.) 

Cancer and papillomas are sometimes found associated 



352 RECTAL POLYPI 

in the stomach, as in bther regions of the alimentary tract. 
The association is rare in the stomach. In an example 
reported by Stewart, cancer occurred in the oesophageal region, 
and the polypi were described as multiple adenomas. 

Polypi of the intestines occur in any part of the intestinal 
tract. The most serious features in their clinical history are 
these : They simulate colic cancer, but are more chronic and 
set up recurrent attacks of pain, diarrhoea, and bleeding from 
the bowel, anaemia, and loss of weight symptoms suggestive 
of cancer. The common age for intestinal papillomas is from 
the fifteenth to the thirty-fifth year. 

Frequent situations for multiple polypi are the rectum and 
colon, especially the pelvic colon, and in this situation they 
are discoverable by the sigmoidoscope. 

Treatment. The removal of a localized patch of warts 
from the rectum is a simple proceeding, but when an abun- 
dant crop of polypi implicate a large tract of intestine it is a 
serious matter. 

In the Middlesex Hospital (September, 1900) I excised 
from a German woman aged 41 the whole of the pelvic colon 
(sigmoid flexure), which was crammed with warts set as 
closely as the bloom of a cauliflower. The lower end of the 
colon was closed with sutures and dropped into the pelvis, and 
the upper end implanted into the incision permanent col- 
ostomy. She survived the operation eight years, and her death 
was attributed to intestinal obstruction caused by cancer. 

In 1917 Ligat successfully excised the rectum and the 
colon as high as the splenic flexure from a man aged 36. 
They were beset with warts (Fig. 167). This man died two 
years later from acute pneumonia. 

Lockhart- Mummery in 1918 excised the caecum and colon 
(29 inches) from a spinster aged 24, for multiple polypi, and 
joined the cut end of the ileuru to the stump of the pelvic 
colon, subsequently clearing the rectum of polypi with the 
aid of the sigmoidoscope. This woman was in satisfactory 
health two years later. 

Breschet, G.-Bull. de la Fac. de Med. de Paris, 1817, No. 5, 375. 
Collier, W. Trans. Path. Soc., 1896, xlvii 46. 
Stewart, M. J. Journ. of Path., 1913, xviii. 127. 
Thompson, P Journ. of Anat. and PJiys , 1897, xxxi. 392. 



CHAPTER XXXI 

EPITHELIAL TUMOURS OF THE GASTRO- 
INTESTINAL TRACT (continued) 

CANCER OF THE STOMACH 

THE stomach, the female breast, and the uterus are the 
three most common situations in which cancer arises 
primarily. Cancer arises in the glands which are so abund- 
ant in the gastric mucous membrane, and the cells com- 
posing it are either spheroidal or cylindrical. The amount 
of connective tissue in the growth varies greatly, being 
abundant in the hard and scanty in the soft varieties. 
One of the special features of gastric cancer is the readiness 
with which its cells undergo colloid change, especially when 
they are of the columnar type. When well advanced, cancer 
of the stomach may appear as an ulcer with raised indurated 
edges, or as a large fungating mass. 

We have no precise knowledge of the manner in which 
cancer of the stomach begins, but we know that in the 
majority of cases it starts in the pyloric segment. The 
frequency of cancer in the vicinity of the pylorus gives 
colour to the opinion that the disease arises in the edges 
of chronic ulcers, the pyloric half of the stomach being 
the common seat of gastric ulcer. Extensive observations 
indicate that cancer of the skin, or tracts of mucous mem- 
brane easily exposed to examination, always begins in some 
pre-existing lesion, such as a mole, a wart, a chronic ulcer 
due to a burn, syphilis, a fistula, or a sinus (see p. 292). 
Convincing evidence is accumulating to show that what is 
true of visible epithelial surfaces holds good for those out 
of sight. In the glandular tissue of the breast, in the 
mucous membrane of the gullet, colon, rectum, gall-bladder, 
uterus, and bladder, chronic lesions are common and may 
become the starting-places of cancer. 
* 353 



354 GASTRIC GANGER 

So far as the stomach is concerned, it is undeniable that 
gastric cancer is more common in men than in women ; 
this is true of gastric ulcer, and the usual situation of both 
diseases is the pyloric region of the stomach. Most of the 
surgeons who have had great experience of gastric surgery 
believe that a chronic ulcer is the common predisposing cause 
of gastric cancer. 

Cancer at the cardiac orifice of the stomach is usually 
described with the oesophagus, and the puzzling symptoms 
connected with it are, in the main, disturbances of degluti- 
tion. It is much rarer than cancer at the pylorus, almost 
invariably of the contracting variety, and peculiar in shape, 
for it roughly resembles a cotton spool or reel ; the upper end 
bulges into the gullet, the lower into the stomach, and the 
intermediate segment fits into the oesophageal opening of 
the diaphragm, whilst the channel representing the lumen of 
the oesophagus becomes so narrow that it barely permits the 
passage of a probe. The effects of the obstruction on the 
oesophagus are described and illustrated at pp. 341, 342. 

In the early stages gastric cancer is limited to the mucous 
membrane ; it then invades the muscular and, in a fair pro- 
portion of cases, the serous coats. The infiltration of the 
tissues about the pylorus leads to its obstruction, which may 
be so extreme that an ordinary probe can scarcely traverse 
it. The mucous surface of the tumour ulcerates, sloughs, and 
bleeds. Occasionally the pyloric branch of the hepatic artery 
is eroded, and the bleeding may be so profuse as to terminate 
life in patients whose strength has been reduced by small 
haemorrhages, frequently repeated, from the ulcerating surface 
of the cancer. Whilst these changes are in progress on the 
mucous aspect of the tumour the subserous tissues become 
infiltrated, the overlying peritoneum is involved, and ad- 
hesions form between it and the omen turn, the parietal 
peritoneum, liver, and the transverse colon. 

For a time the disease remains restricted to the walls of 
the stomach, but later it spreads along the adhesions to such 
structures as the liver, pancreas, gall-bladder, duodenum, 
colon, spleen, and diaphragm ; then, as ulceration follows, it 
happens that the floor of the ulcer will be formed by the liver, 
the pancreas, or the spleen. When such parts as the colon 



GASTRIC GANGER 355 

or duodenum form the base of the ulcer, perforation occurs, 
and a gastro-colic or gastro-duodenal fistula is formed. These 
fistulse are more common with cancerous than with the simple 
forms of gastric ulcer. 

Lymphatic infection. The lymphatics of the stomach 
follow the principal vessels, and their ultimate destination 
is the cluster of lymph-nodes around the cceliac axis and 
thence into the receptaculum chyli. 

Lymphatic infection occurs very early in the disease and 
spreads very quickly. In the late stages the lymph-nodes 
around the coeliac axis form large masses and infect the nodes 
in the mediastinum and in the posterior triangle of the neck, 
especially on the left side. The mode by which the infection 
reaches the lymph-nodes in these situations is described in 
Chap. XXIIL 

Dissemination is the rule with cancer of the stomach. 
The secondary nodules grow in the liver, lungs, and in one 
or both ovaries (Chap. LVII), and occasionally wide dispersal 
is noticed. 

There is a variety of gastric cancer in which the walls of 
the stomach become so infiltrated with cancerous cells that 
the viscus assumes the shape and rigidity of a leather pouch. 
This condition is of such importance to the surgeon that it 
will be separately considered. 

Leather-bottle stomach. In 1854 William Brinton de- 
scribed under the term linitis plastica this remarkable disease 
of the stomach. The precise nature of the change puzzled 
him as it had puzzled other observers. Before describing the 
leather-bottle stomach it will be useful to recall the leading 
features of the normal organ. The stomach of an adult is 
12 in. long, 5 in. wide, and its walls are about one-fifth of an 
inch thick. In the living body the stomach is pink, glisten- 
ing, soft, very vascular, and has a capacity of 40 fluid ounces. 
A well-marked example of leather-bottle stomach (Fig. 168) 
measures 4 in. in length, 2 in. in width, and in places its walls 
are an inch in thickness. Instead of being flexible the walls 
are rigid, thick, and hard like a leather pouch. When pressed 
upon, the wall does not collapse, and, as Brinton pointed 
out, it resists even considerable pressure, and returns to its 
original shape like a large artery, or a caoutchouc bottle. 



356 LEATHER-BOTTLE STOMACH 

So shrunken is the stomach that it has a capacity of 4 instead 
of 40 oz. The thickening involves the gastric walls from the 
cardiac opening to the pylorus. At the pyloric end it is 
sharply defined, and the thin walls of the duodenum are 
in striking contrast to the thickness of the walls of the 
stomach ; the thickening also involves the terminal inch of 
the oesophagus. 

When the wall of the stomach is divided, the tissues seem 
to be bloodless and the boundaries between its various coats 
are easily discernible. The cut surface, traversed by glistening 
filamentous bands, recalls the appearance of woven linen; 
this suggested to Brinton the term "linitis" (\lvov, rete ex 
lino factum). He regarded the change in the walls of the 
stomach as an " inflammation of the filamentous network of 
areolar tissue ensheathing the vessels." 

The minute anatomy of the leather-bottle stomach has 
been studied with great care, and as much uncertainty 
exists in regard to this remarkable condition as in Brinton's 
day. Some writers believe it to be inflammatory in origin; 
others regard it as a diffuse form of cancer ; a few consider 
it to be syphilitic ; and it has been described as tuberculous, 
like the hyperplastic tuberculous thickening occasionally seen 
in the small intestine, and especially in the caecum. 

The changes in the gastric tissues are sometimes limited 
to the pyloric region and convert this part of the stomach 
into a rigid funnel-shaped tube. In well-marked examples 
the gastric Avails implicated in the change will measure an 
inch or more in thickness. The change is sharply limited 
at the pyloric ring, and the pyloric orifice is thickened, but 
not obstructed though narrowed. When such a stomach is 
examined with the help of the X-rays and a bismuth or 
barium meal, the leather-bottle stomach is seen acting like 
a tube and the food drops through it into the duodenum. 

The leather-bottle stomach produced by cancer is due to 
a cancerous focus in the mucous membrane probably a 
chronic gastric ulcer that has become cancerous and allows 
the epithelial elements to permeate the connective-tissue 
planes of the stomach. Similar changes occur in the gall- 
bladder and in the colon. 

Surgeons sometimes operate on patients, expecting a 



-SPLEEN 




Fig. 168. Cancerous leather-bottle stomach. (Natural size. ) 
(Museum of the Middlesex Hospital.} 



357 



353 LEATHER-BOTTLE STOMACH 

condition suitable fof gastro-jejunostorny, but find a hard 
pylorus embedded in adhesions. Occasionally, even in this 
apparently unfavourable condition they perform gastro-jejun- 
ostomy under the impression that the alterations are due 
to cancer, and have been surprised, some years later, to see 
the patient in good health. Many such cases have been 
reported. There is often difficulty in deciding whether a 
stomach has been converted into the semblance of a caout- 
chouc bottle by cancer or by inflammation, except with the 
assistance of a microscopic examination. Surgeons who have 
had much experience of gastro-jejunostomy for tumours of 
the stomach admit that patients often make excellent and 
permanent recoveries after operation, in spite of a dismal 
prognosis. 

Clinical features. Cancer of the stomach is rare before 
the thirtieth year ; it is most common between the fortieth 
and sixtieth years ; it has been demonstrated as early as 13, 
near the cardiac end of the viscus, in a girl (Norman Moore), 
a boy aged 14 f (Ness and Teacher), and a boy aged 15 
(Laird). 

Gastric carcinoma runs a very rapid course, life being 
rarely prolonged beyond twelve months from the time the 
disease is first recognized. Its rapidly fatal course, especially 
when the pylorus is implicated, is largely due to the obstruc- 
tion offered to the escape of food into the duodenum ; hence 
the food is retained in the stomach, which often becomes 
dilated into a huge sac, sometimes reaching as low as the 
pubes. The retained and partially digested food ferments, 
and the contents of the stomach are vomited at irregular 
intervals, mixed with altered blood that escapes from the 
ulcerated surface of the tumour. 

Cancer of the stomach causes death in various ways. 
Of these the chief are exhaustion due to starvation and 
frequent haemorrhage ; perforation into the general peri- 
toneal cavity and fatal peritonitis. In exceptional instances 
the diaphragm is perforated and fatal pleurisy ensues. 

An important feature of gastro-intestinal cancer is its 
proneness to permeate the musculo-serous walls of the 
stomach or the colon. In this event the cancer-cells find 
their way into the general peritoneal cavity and settle on 









GASTRIC GANGER 359 

the ovaries, tubes, and uterus. Vagrant cells of this kind 
give rise to large masses in the ovary, frequently regarded 
as primary ovarian tumours, and often removed under this 
impression, the primary disease in the stomach or gut being 
overlooked. 

In men the cells shed into the peritoneum fall on the 
floor of the recto-vesical pouch and occasionally cause so 
much thickening that it can be detected on rectal examina- 
tion. Infection of the pelvic peritoneum by gastric cancer 
was known to Y 7 irchow. 

An X-ray examination, with the help of a barium or a 
bismuth meal, is of great use in demonstrating constrictions, 
or gross alterations in the shape and position of the stomach. 
Often by this means the presence and site of an ulcer may 
be detected, but no information is afforded as to whether 
the lesion depends on simple or on malignant disease. There 
are no signs in the early stages of cancer of the stomach, 
and when the disease reaches such a stage as to give rise to 
physical signs, medicine and surgery have little scope ; all 
treatment is then palliative. 

Treatment. The only radical method for the relief of 
gastric cancer is wide excision. When the disease attacks the 
pylorus, this part is excised (pylorectomy), and the cut edges 
of the stomach and duodenum are carefully sutured. When 
this is impracticable on account of the wide extent of the 
disease, or lymphatic infection and dissemination, then, in 
order to obviate inevitable death by starvation, a fistula may 
be established between the stomach and jejunum (gastro- 
jejunostomy). This is merely a palliative proceeding. 

In 1897 Schlatter removed the stomach of a woman aged 
56, for cancer. The patient survived the operation fourteen 
months, and died with local recurrence or dissemination. 
Since that date excision of the stomach, partial or complete, 
for cancer has been frequently performed. 

In 1906 that is, ten years after Schlatter's pioneer case 
H. J. Paterson collected a series of 436 cases of partial gas- 
trectomy by various surgeons, with a death-rate of 28 per 
cent. In 1913 he believed that the rate of mortality with 
surgeons of experience was under 15 per cent. 

Sherren, after a careful review of the facts, believes that 



360 GASTRIC GANGER 

the general operative mortality is about 25 per cent. Of the 
75 per cent, who recover, 60 per cent, will succumb to the 
disease within three years, and 15 per cent, will survive over 
five years and may possibly be cured. 

After the removal of the stomach its functions are vicari- 
ously performed by other parts of the alimentary canal. For 
example, its function as a reservoir is supplied to a limited 
extent by dilatation of the lower end of the oesophagus; 
maceration of the food is replaced by careful dieting ; the 
chemical functions the secretion of pepsin, hydrochloric 
acid, and rennin can be effectively replaced by the intestine. 
The function of rennin can be performed by pancreatic juice ; 
the antiseptic action of the hydrochloric acid is carried on by 
the bile ; and the peptones are absorbed by the small intes- 
tine (Paterson). 

The death-rate of total gastrectomy for cancer is very 
high, probably 50 per cent. It is very rarely possible to 
remove the whole stomach. In the only instance in which I 
have been able to perform total gastrectomy the patient had 
a partial leather-bottle stomach. She survived the opera- 
tion three years and a half. 

A wide study of the pathology of gastric cancer and a fair 
experience of operations performed for its relief lead me to 
regard cancer of the stomach as the most hopeless form of 
cancer. 

Brinton, W., " Disease of the Stomach." 1864. 

Laird, D. A., "Carcinoma of the Stomach of a Boy of 15." Edin. Med. 
Journ., 1921, xxvi. 98. 

Lyle, H. H. M., " Linitis Plastica (Cirrhosis of Stomach)." Ann. of Surg., 1911, 
liv. 625. 

Moore, Norman, " Carcinoma of the Stomach in a Child." Trans. Path. Soc., 
1885, xxxvi. 195. 

Ness, R. B., and Teacher, J. H., "A Case of Carcinoma of the Stomach in a Boy 
aged fourteen years and nine months." Brit. Journ. Child. Dis., 1908, 
v. 515. 

Paterson, Herbert J., " Lectures on Gastric Surgery." Lancet, 1906, i. 491, 574. 
Schlatter, C. L., " (Esophago-Enterostomy after Total Extirpation of the 
Stomach." Ibid., 1898, i. 141. 



CHAPTER XXXII 

EPITHELIAL TUMOURS OF THE GASTRO- 
INTESTINAL TRACT (continued) 

CANCER OF THE INTESTINES 

PRIMARY cancer is rare in any part of the small intestine, 
but it occurs more frequently in the duodenum, short as 
it is, than in the jejunum or the ileum. 

The duodenum. A study of the effects produced by 
cancer of the duodenum shows that the time-honoured 
division of this part of the intestine into first, second, and 
third parts is of little use for the purposes of clinical 
medicine. It is more convenient, following Sherren, to call 
the portion above the bile papilla the supra-ampullary seg- 
ment, the portion containing the bile papilla the ampullary 
segment, and the remainder the infra-ampullary segment. 

Duodenal ulcer is a common affection, and arises most 
frequently in the part of the duodenum immediately ad- 
jacent to the pylorus. The chronic indurated duodenal ulcer 
is usually situated in the first 2 cm. of the duodenum, and 
four-fifths of the patients are men. There is no evidence 
that cancer of the duodenum arises in a chronic ulcer. Malig- 
nant disease of the duodenum of any kind is rare, and very 
few specimens exist in the museums in London. The only 
example of primary malignant disease of the supra-ampullary 
segment of the duodenum that has come under my notice 
was a sarcoma, and it arose in a chronic ulcer. I excised 
it with a portion of the stomach and duodenum. 

Cancer arising in the mucous membrane around the bile 
papilla is known as circuinampullary cancer, in order to 
distinguish it from cancer arising in the ampulla. Both 
forms lead to jaundice and distension of the gall-bladder. 
There can be little doubt that cancer of this section of the 

361 



362 GANGER OF THE ILEUM 

duodenum would often escape detection if it were not for the 
obstruction it offers to the flow of bile from the common 
duct. (Cancer of the ampulla is discussed in Chap, xxxv.) 
The common place for cancer of the duodenum is in the 
infra-anipullary section, and especially at the part where 
the duodenum is crossed by the superior mesenteric ves- 
sels. Cancer in this situation is usually of the constricting 
type. Rolleston has seen the channel of the gut so narrowed 
that it would scarcely admit the point of a pencil, and the 
growth so small that it could not be seen until the duo- 
denum was opened. I have seen the duodenum completely 
obstructed by a cancerous growth in a man aged 56. When 
the infra-ampullary duodenum is narrowed in this way it 
gives rise to signs similar to those seen in pyloric obstruc- 
tion, but the vomited matter is extremely offensive, because 
it contains, in addition to the contents of the stomach, chyme 
that has been submitted to pancreatic digestion. The effects 
of the occlusion on the duodenum are also remarkable, for it 
becomes enormously dilated and like a stomach. Cursorily 
examined, the appearance produced is like that of a bilocular 
stomach, the pylorus representing the isthmus. A radio- 
graph of such a stomach and duodenum, obtained with the 
help of a bismuth or barium meal, resembles very closely 
one furnished by a bilocular stomach. 

The jejunum and ileum. Tumours of any kind in the 
small intestine are, as a rule, pedunculated. The propulsive 
movements of the intestine influence the shape of tumours 
in its walls. Thus simple tumours, such as lipomas and 
myomas, or sarcomas arising in the mucous membrane of the 
small intestine, tend to become polypoid. The danger to be 
feared from the presence of such tumours is intussusception 
of the gut, for the tumour, acting as a foreign body, is urged 
along the bowel and may lead to fatal obstruction (see p. 349). 
The peristalsis of the small intestine also exercises moulding 
effects on deposits of cancer, primary or secondary, within 
its walls. A man with disseminated melanocarcinoma was 
admitted into the Middlesex Hospital with symptoms of in- 
testinal obstruction. The widespread nature of the disease 
deterred the surgeon from an operation. A few days after 
admission the patient passed a slough of ileum with a 



GANGER OF THE ILEUM 363 

rounded deposit of melanoma in its wall. The symptoms of 
intestinal obstruction abated. 

The museum of the London Hospital contains a portion 
of ileum in a state of intussusception caused by a secondary 
deposit of melanocarcinoma. It was obtained from a woman 
admitted with signs of strangulated hernia. An operation 
was performed on the supposed femoral hernia, but it proved 
to be an enlarged lymph -node filled with black pigment. 
The woman died, and at the post-mortem examination the 
intussuscepted ileum was found. The situation of the primary 
tumour is not stated. 

It is difficult to decide the nature of a tumour in the 
small intestine from a naked-eye inspection in the course of 
an operation. For example, a man aged 50, with intestinal 
obstruction, was submitted to operation. The ileum 3 ft. 
from the valve contained a lump as big as a golf-ball. I 
excised the tumour and 15 cm. of the ileum on each side 
of it, and the corresponding segment of the mesentery with 
big lyrnph-nodes. This tumour, which had reduced the lumen 
of the ileum to a narrow strait, was a round-celled sarcoma. 

Primary cancer of the ileum is more common at the ileo- 
caBcal junction than elsewhere, but the frequency of ulcer 
and cancer at the pylorus is not repeated at the ileo-caecal 
valve. Morbid growths at the valve have rarely been classi- 
fied; they are of four kinds (1) cancer arising in the ileum; 

(2) cancer arising in the caecum and invading the ileum; 

(3) malignant growths of the vermiform appendix (see 
p. 368); and (4) hyperplastic tubercle of the ileum. 

Cancer at the termination of the ileum is often of the 
constricting type ; it may lead to complete occlusion of the 
opening, and the contraction be so extreme that it is neces- 
sary to make a careful search in order to detect it. The can- 
cerous focus is often more easily felt than seen in the course 
of an operation. The terminal portion of the ileum rests on 
the wall of the caecum for at least 4 cm., and cancer arising 
in the caecum will often infiltrate the caecal wall and involve 
the ileum (Fig. 172). 

A study of primary cancer of the small intestine shows 
that the disease presents the same features as in the colon. 
Sometimes the cancer is of the annular constricting type ; or 



364 HYPERPLASTIG TUBERCLE 

it may sprout like a Cauliflower into the bowel. There is 
also a massive form which envelops the intestine with a large 
collar of new growth. Cancer of the ileum gives rise to no 
signs which render localization of the disease a matter of 
certainty. In age-distribution cancer of the small intestine 
agrees with that of the stomach and colon. 

It has been imagined by some pathologists that cancer of 
the small intestine might arise in islands of pancreatic tissue 
occasionally found in its mucous membrane : the experience 
of the laboratory does not support this view. Nor is there 
any evidence that cancer of the duodenum arises in Brunner's 
gland, as some pathologists are disposed to believe. 

Cancer of the ileo-csecal valve is rare, especially if care be 
taken to distinguish between primary cancer of the caecum 
involving the terminal segment of the ileum, and cancer 
arising in the terminal portion of the ileum. 

In one remarkable case a cancerous ileo-csecal valve led 
to intussusception and the valve appeared at the anus. It 
was excised, and through an opening in the peritoneum the 
vermiform appendix was recognized. The patient, a woman 
aged 75, died ten hours later. (Ball.) 

The rarity of cancer, primary and secondary, in the small 
intestine is worth consideration. Cancer of the stomach 
being extremely common, it cannot be doubted that frag- 
ments are frequently detached from the cancerous surface by 
food passing over it in response to the churning movements 
of the stomach. Many of the particles are dead, but some 
contain living cells, and they pass with the chyme into the 
duodenum, where they come under the influence of the diges- 
tive action of the pancreatic juice and are destroyed. Shat- 
tock, in a suggestive paper, offers this as an explanation of 
the infrequency of cancer in the small intestine. He also 
points out that the feebleness of digestive processes in the 
colon may explain the phenomenon of multiple cancerous foci 
in that section of the intestinal tract ; some of the supposed 
multiple primary tumours being implantation nodules. 

Hyperplastic tubercle. An analysis of the growths found 
at the ileo-csecal junction reveals that some tumours met with 
in this situation and labelled " cancer" are often tuberculous 
formations. The hyperplastic form of intestinal tuberculosis 



GOLONIC CANCER 



365 



is most common in the caecum and the caecal segment of the 
ileum. It differs from the common varieties of tuberculous 
disease in that the lesion is not destructive but leads to an 
increase in the bulk of the part affected. Microscopically it is 
easily distinguished from cancer, for the new tissue contains 
clumps of giant cells and occasionally calcareous deposits. 
The cavity of the ileum is often so narrowed that a track no 
larger than a common quill re- 
mains. In rare instances the tuber- 
culous change is limited to the 
valve. Hyperplastic tuberculous 
disease of the ileum was not recog- 
nized till 1891. This disease has 
received attention from Billroth, 
Hartmann, and Pilliet. It is cur- 
able by excision. 

Cancer of the large intestine 
is very common, and may arise in 
any part of it, from the ileo-caecal 
valve to the anus. It is more fre- 
quent in some parts of the large 
bowel than in others; it is less 
frequent in the caecum than in 
the pelvic colon and the rectum. 
The distribution of cancer in the 
colon is instructive, for it increases 
in frequency in the various anato- 
mical regions from the ileo-caecal 
valve onwards, and reaches its 
maximum in the rectum. Its usual form is the columnar 
type. Little is known of the early stages, because it gives 
rise to no definite symptoms until it mechanically interferes 
with the bowel, or becomes septic. When cancer is well 
advanced it sometimes projects into the interior of the bowel 
as a cauliflower-like mass (Fig. 169); its surface becomes 
abraded and infected with pathogenic micro-organisms, espe- 
cially the colon bacillus. This exuberant form is common 
in the caecum and ascending colon. In the transverse, de- 
scending, and especially the pelvic colon, the atrophic, or 
constricting, form of cancer prevails. There is also a massive 




Fig. 169. Cancer of the pelvic 
colon. 



366 COLONIG GANGER 

variety that grows rapidly, fungates into the bowel, forms 
a large mass on its peritoneal surface, and invades adjacent 
tissues. 

One of the most remarkable features of cancer of the colon 
is the variations in its virulence. When the obstruction to 
the bowel is relieved by colostomy, or by short-circuiting, 
some patients live a few months, and die from generalization 
of the disease; others may survive the operation five years 
or more. 

In most parts of the body cancer begins in a single focus, 
but in the colon several foci have been observed in the 
mucous membrane and regarded as multiple primary foci, 
for there were sections of normal bowel between the can- 
cerous areas. These occurrences admit of another interpre- 
tation (see p. 364). 

Cancer of the intestine is very prone to travel round the 
gut, following the line of the blood- and lymph-vessels; it 
forms a zone of hard material projecting into its lumen; and 
then, as it contracts, the diseased parts, as seen from the 
outside, look as if the intestine had been girt with a liga- 
ture (Fig. 170). In the later stages the lumen of the gut 
becomes so straitened that nothing but a narrow, tortuous 
channel traverses the cancerous mass ; this allows the liquid 
fseces retained in the dilated segment of the gut on the 
proximal side of the tumour gradually to trickle through, 
but at times even this limited channel closes. Occasionally, 
after several days of complete obstruction, a portion of the 
cancer sloughs, and the obstruction is temporarily relieved. 

The constricting variety, or ring-cancer of the colon, like 
atrophic cancer in the breast, is an example of the disease 
undergoing spontaneous cure. In a few cases the hard ring 
resulting from the contraction of the cancer acts as a polypus 
and leads to intussusception. 

Whilst the cancerous mass is either growing exuberantly 
in the bowel and forming a tuberous mass, or contracting into 
a hard ring slowly narrowing its lumen, the cancerous cells 
are permeating the veins, lymphatics, and connective-tissue 
planes between its coats. In this way the lymph-nodes in 
the track of the colic vessels are infected, and the veins, 
invaded by the growth, act as channels for the conveyance of 



COLONIC GANGER 



367 



cancer-emboli to the liver. The readiness with which the 
walls of the colon are permeated by the cancerous cells leads 
to the implication of remote organs by what is known as per- 
meation. In this way the pelvic peritoneum, bladder, uterus, 
ovaries, and the walls of the intestines become infected 
(Chap. LVIL). 




Fig. 170. Constricting cancer of the pelvic colon. 

Cancer of the colon is also quickly invaded by patho- 
genic micro-organisms, and symptoms of septic infection and 
abscess are often associated with this disease. The exuber- 
ant fungating variety of colic cancer occurs most frequently 
in young patients; it grows rapidly, disseminates quickly, 
and produces septic symptoms. 

Cancer of the large intestine, as a rule, attacks patients at 
or after middle life, but it also occurs in young men and 



368 



GANGER OF THE APPENDIX 



women. Experience teaches that, in the young, cancer is more 
common in the intestines than in any other organ. Many 
cases of early cancer of the rectum have been recorded (see 
p. 373). I have resected a cancerous section of the pelvic 
colon in a girl of 16, and my efforts were not rewarded with 
success. 

The vermiform appendix. Primary cancer of this small 
segment of the intestinal tract has 
been recorded by many observers, 
but it differs pathologically and clini- 
cally from cancer occurring in any 
other region of the body. It presents 
itself as a small discrete nodule in 
the thickened wall of the appendix; 
the nodule rarely exceeds a cherry- 
stone in size. Microscopically it con- 
sists of nests of spheroidal cells. No 
special symptoms are associated with 
these little tumours. Though in 
structure they mimic cancer, there 
the likeness ends, for the nodules do 
not invade adjacent structures, nor 
recur after removal, nor disseminate. 
The patients are usually about 30, but 
these nodules are often found in 
children and adolescents. Secondary 
cancer of the appendix is rare. A 
man aged 42 was admitted into St. 

Thomas's Hospital with a large nod- 
Fig. 171. Vermiform appen- i r 

dix containing a columnar- ular mass in the epigastrium. Alter 
death this was found to lie between 
the liver and the transverse colon. 
The gut was embedded in its lower 
border, but no perforation had taken place. The gall-bladder 
contained calculi and was infiltrated with new growth. Sessile 
and pedunculated masses were freely scattered over the peri- 
toneum. The stomach and duodenum were intact, although 
the lumen of the latter was narrowed by the carcinomatous 
mass external to it. The head of the pancreas was involved 
in the new formation, and the vermiform appendix contained 




celled carcinoma. (Shat- 
tockj " Proc. Roy. Soc. of 
Med.f 1916, Path. Sect.} 



CANCER OF THE CAECUM 369 

a columnar-celled carcinoma. The various growths were 
cancerous and of the spheroidal-celled kind. In all prob- 
ability the primary disease arose in the head of the pancreas. 

Cancer of the caecum. In this situation cancer is not 
always easy of recognition, because infective conditions are 
common in this part of the large intestine ; pericsecal abscess 
is sometimes associated with cancer of the caecum. The 
matter is further complicated by infective conditions of the 
vermiform appendix and the occurrence of stercoral ulcers 
secondary to cancerous obstruction of the colon. Hyper- 
plastic tuberculous disease of the csecurn and of the colon in 
its naked-eye appearance is indistinguishable from cancer. 
On microscopical examination the presence of giant -cell 
systems affords an unerring means of distinction (see p. 365). 

The csecum has often been excised under the impression 
that it was cancerous, and an examination in the laboratory 
has shown the thickening in its walls to be of inflammatory 
origin, and in some instances actinomycotic. These mycotic 
infections of the bowel resemble cancer very closely in their 
clinical manifestations. 

The transverse colon. Cancer arises in any part of the 
transverse colon, and as this section of the large intestine 
is liable, especially in women, to be displaced, some account 
of its vagaries may be useful. Moreover, the close approxi- 
mation of the transverse colon to the gall-bladder and to 
the stomach must be borne in mind, because a primary 
cancer of the gall-bladder sometimes implicates the adjacent 
section of the colon, and it is not uncommon for a cancerous 
growth in the colon to invade the stomach, and vice versa. 
The inconvenience and distress. associated with a gastro-colic 
fistula is very great, for the intestinal gases accumulate in 
the stomach and cause offensive eructations. Normally, the 
transverse colon crosses the abdomen from the right hypo- 
chondrium to the left hypochondrium ; between these two 
points it usually forms a loop with its convexity directed 
downwards. As a rule the transverse colon crosses the 
abdomen above the level of the umbilicus, but when the 
loop is exaggerated its lowest segment sometimes dips into 
the pelvis. When the centre of the loop is occupied by 
cancer the tumour may move so freely that it is difficult to 
Y 



370 



GOLONIG GANGER 



decide, from a clinical examination, to which part of the 
large bowel the tumour belongs. It occasionally happens that 
the mass adheres to the fundus of the uterus, and in the 




Fig. 172. Caecum with vermi- 
form appendix and terminal 
portion of the ileum. The 
caecum is the seat of cancer 
that has also implicated and 
perforated the ileum. The 
parts were removed from a 
spinster aged 55. She was in 
good health 18 years after 
the operation. (Natural size.) 



PERICOLITIS 371 

course of an operation it is sometimes difficult to decide, 
without a microscopic examination, whether the cancer arose 
in the colon and implicated the uterus, or vice versa. 

A foreign body may give rise to an inflammatory mass 
(pericolitis) in the loop of an omega-shaped colon and become 
attached to the fundus of the uterus and simulate cancer 
very closely. As in other parts of the colon, cancer of the 
transverse portion is usually discovered accidentally. An 
operation is undertaken for the relief of an acute, or chronic, 
intestinal obstruction, and in its course a cancerous mass is 
found. It is difficult to fix the relative frequency of cancer 
in the transverse colon in comparison with other parts of 
the large bowel, but it is by no means rare. The mobility of 
this part of the large bowel leads to many errors of diagnosis 
when it is the seat of cancer. 

The descending colon. It has been the custom to call 
the portion of the colon between the splenic flexure and the 
limits of the false pelvis the descending colon, and the length 
between this point and the rectum the sigmoid flexure. In 
recent surgical writing the sigmoid flexure has been anato- 
mically separated into two : the portion attached to the iliac 
fossa without a mesentery is known as the iliac colon. The 
remaining portion forms a loop completely surrounded by 
peritoneum and attached by a mesentery to the side wall of 
the pelvis : this is the pelvic colon. It terminates near the 
third piece of the sacrum, and at this part the peritoneal 
investment ceases to be complete. The occurrence of cancer 
in these three sections of the colon varies widely ; it is very 
common in the pelvic colon. Sherren found that among 376 
cases of colic cancer treated at the London Hospital during 
the ten years 1901-11, 211 were of the pelvic colon and 20 
of the descending colon. 

The mobility of the pelvic colon often leads to difficulty 
in diagnosis when it is occupied by cancer, for the weight of 
the growth causes this colic loop to sink until the cancerous 
portion rests on the floor of the pelvis. This brings it into 
close relation with the rectum and the bladder in men; 
and in women, with the uterus, ovaries, and vagina. A 
cancerous growth in the colon is often mistaken for an 
enlarged ovary, a distended tube, or a subserous fibroid. 



373 RECTAL GANGER 

The inflammatory, condition covered by the term peri- 
colitis or diver ticulitis causes symptoms resembling appen- 
dicitis rather than cancer, but the thickening of the colon 
and the mesocolon associated with it is often mistaken for 
a malignant tumour of the bowel ; indeed, the resemblance 
is so close that in some cases colostomy or resection of 
the bowel has been performed under this impression (see 
Chap. LXII). A knowledge of the condition is, as a rule, 
sufficient to prevent mischievous surgery. 

CANCER OF THE RECTUM AND ANUS 

The rectum is 6 in. long, and the colon, from the 
caecum to its termination in the rectum, is nearly 6 ft., 
but cancer occurs in the rectum more frequently than in 
any other anatomical segment of the large intestine. The 
rectum lies entirely within the pelvic cavity ; its narrowest 
portion is at its junction with the pelvic colon at the level 
of the junction of the second and third sacral vertebrae, 
and ends at the pelvic diaphragm. Its terminal portion is 
dilated, and called in consequence the ampulla. In the 
male the lowest portion of the rectum is in immediate 
relation with the prostate ; in the female, with the lowest 
fourth of the vagina. 

The rectum opens into the anal canal, a passage about 
an inch long with an ischio-rectal fossa on each side of 
it. The terminal orifice, surrounded by skin, is the anus. 
In transverse sections of the empty bowel the rectum 
appears as a transverse but the anal canal as an antero- 
posterior slit. 

Cancer of the rectum. This may start in any part of 
the mucous membrane of the rectum, but a common situa- 
tion is just above the anal canal, and another favourite 
spot is at the junction of rectum and pelvic colon. The 
former situation is within reach of the examining finger, 
the latter is beyond its reach. 

'Rectal cancer consists of glandular recesses lined with 
tall columnar cells embedded in a stroma of dense con- 
nective tissue. In order to make out the nature of the 
growth, sections should be taken from the margins of the 
tumour, because the deeper parts are much altered by 



RECTAL GANGER 373 

ulcerative and necrotic changes. In many cases of rectal 
cancer, judging merely from the appearances under the 
microscope, it would be difficult to determine whether a. 
section was prepared from an adenoma or a carcinoma ; 
but it must be borne in mind that the adenoma remains 
restricted to the mucous membrane, whereas in cancer we 
find the glands with their characteristic columnar cells 
interspersed among the muscular fasciculi of the gut-wall. 
The proportion of connective tissue varies greatly. In 
some cancers the glands are closely set; in others they 
are ill formed, arranged irregularly, and embedded in an 
abundance of connective tissue. Occasionally, collections 
of lymphoid tissue are observed. 

The cancerous ulcer with raised edges, so common in 
the ampulla of the rectum, owes its shape to bacterial 
action. Cancers are rapidly destroyed by bacteria, and, the 
central parts being disintegrated whilst growth proceeds at 
the periphery, the plaque assumes a saucer-like shape. 

Cancer of the pelvic colon is often of the constricting 
variety, and this variety is common in the section of the 
rectum immediately above the ampulla. In the ampulla, 
cancer often appears as a raised patch on the mucous 
membrane, and sometimes it is in shape like a horseshoe. 

Cancer is more frequent in the ampulla than in the 
anal canal, or at its junction with the pelvic colon. Cancer 
of the rectum is very common in men and women 
between 40 and 60, but it occurs occasionally at an early 
age. Quenu has recorded an example in the rectal am- 
pulla of a girl aged 17, and in 1899 he collected a dozen 
instances of cancer of the rectum in patients under 20. 

In all forms the disease infiltrates the muscular as well 
as the submucous tissues, and extends beyond the confines 
of the bowel into adjacent parts and involves peritoneum, 
pelvic connective tissue, prostate, vagina, bladder, and sacrum. 
Ulceration occurs early. 

Cancer of the rectum is spread by lymphatics and by 
veins. The lymphatic vessels from the rectum accompany 
the hsemorrhoidal veins; they conduct the growth to the 
lymph-nodes in the pelvis, then to those at the brim 
of the pelvis along the course of the iliac vessels, and* 



374 ANAL GANGER 

onwards to the set aroXind the coeliac axis. In the last stages 
of the disease very extensive infection of the lymph-nodes 
exists, and occasionally the thoracic duct is converted into a 
solid cord (Fig. 140, p. 265), and enlarged lymph-nodes appear 
in the neck above the left clavicle. Enlargement of the 
pelvic lymph-nodes associated with cancer of the rectum 
is not always due to deposits of cancer ; often it is secondary 
to septic infection of the primary cancerous focus. 

The dissemination of rectal cancer is effected mainly by 
the portal circulation, and the liver becomes the depository 
for the cancerous emboli. Sometimes cancer in the rectum 
produces very little disturbance, and is unsuspected until 
enlargement of the liver and perhaps jaundice lead the 
patient to seek advice. The nodular condition of the liver 
prompts the surgeon to examine the rectum, and the 
cancer is discovered. 

Occasionally, widespread dissemination occurs and nodules 
of cancer appear in the liver, lungs, kidne} 7 s, and bones. Few 
things are more surprising than to find cancerous deposits 
in the liver, the lungs, or in the humerus, displaying Lie- 
berkiihn's glands with their tall columnar epithelium. It 
has happened in the course of a post-mortem examination 
that nodules have been found in the lung displaying the 
typical columnar epithelium of the colon. This has led to 
an examination of the rectum, omitted in the first ex- 
amination of the body, and a cancer unsuspected during 
life has been found. 

Cancer of the anus. The terminal portion of the 
alimentary canal, which is surrounded by the sphincters of 
the anus, may be termed the anal canal. It is an antero- 
posterior slit in the pelvic floor, its lateral walls being in 
apposition. It is 2*5 cm. in length when the rectum is empty. 

In the skin around the anus, and for about a centimetre 
from its margin, there is a zone containing large sweat-glands, 
known as the circumanal glands. At the anus the epidermis 
extends for a short distance into the aperture, but, becoming 
gradually thinner, is replaced by the columnar cells of the 
mucous membrane. The crypts of Lieberktihn do not appear 
immediately ; there is a narrow zone of mucous membrane 
destitute of glands (Quain). 



ANAL CANCER 375 

Cancer may arise either in the mucous membrane of 
the anal canal or in the skin at the margin of the anus, 
and is of the squamous-celled type. When rectal cancer 
invades the anus the anal portion becomes squamous-celled 
(Harrison Cripps). A cancerous ulcer, 3 in. in diameter, 
removed by Makins from the anus of a man aged 72, ex-- 
tended just within the rectum : the growth had the structure 
of columnar- and squarnous-celled cancer. Some chronic 
inflammatory change often precedes anal cancer, such as a 
pile, a fissure, or a patch of chronic eczema, and it has been 
known to occur at the orifice of a chronic fistula. The 
lymph-nodes in the groin become infected. 

Cancer of the anus is an uncommon disease ; rare before 
40, and more common in women than in men. Excision 
is followed by good consequences. 



CHAPTER XXXIII 

SYMPTOMS AND TREATMENT OF CANCER OF 
THE GASTRO-INTESTINAL TRACT 

Symptoms. Primary cancer of the stomach, caecum, and 
colon appeals to those who are interested in the clinical 
recognition of this disease, on account of the difficulties 
which often attend its diagnosis. Cancer has no specific 
symptomatology. A person accidentally feels a lump in 
the belly, and seeks advice : in many instances an astute 
physician or a practical surgeon will come to the conclusion 
that the lump is malignant. When situated in the neigh- 
bourhood of the right costal arch there is often difficulty 
in deciding whether it is connected with the stomach, gall- 
bladder, liver, or transverse colon. A cancerous gall-bladder 
may involve all these structures. 

When the lump is situated in the right flank, diagnostic 
obscurity is somewhat diminished, but the wisest is often 
puzzled to decide between cancer arising in the ceecum and 
some forms of chronic disease of the vermiform appendix. 
Primary cancer in the descending and the iliac colon sel- 
dom causes doubt in diagnosis, but a cancerous lump in the 
pelvic colon often lodges on the floor of the pelvis : in women 
a cancerous lump of this kind is frequently mistaken for an 
enlarged ovary or a diseased tube. A massive cancer of the 
pelvic colon impacted in the recto-vaginal fossa is occasion- 
ally mistaken for an incarcerated subserous fibroid. 

Cancer of the colon, as a rule, causes no pain until it 
has so narrowed the lumen of the bowel that the intestinal 
contents are held up : then the patient, suffering from intes- 
tinal obstruction, seeks advice. In many instances when the 
disease reaches this stage, unless surgical help is forthcoming, 
death ensues from perforation of the caecum, or of the colon 
above the stricture. 

376 



GASTROINTESTINAL GANGER 377 

The character of the disease in the early stages is un- 
known, for it grows unsuspected, unrecognized, and painlessly 
until the lumen of the colon is too narrow to allow faaces to 
pass, then pain is the sequence ; even then the disease may 
remain undetected for many months. 

In the gastro-intestinal tract, cancer often runs its fatal 
course quickly ; dissemination outside the abdomen is un- 
usual, nevertheless secondary deposits are seen in patients 
affected with gastric or intestinal cancer, especially when it 
runs a chronic course. Some of the examples are remark- 
able. Pitts amputated the upper limb of a woman on 
account of a large tumour at the higher end of the humerus. 
This tumour was regarded as a periosteal sarcoma until a 
microscopic examination showed that it contained spaces 
lined with tall columnar epithelium ; also lymphoid nodules, 
such as exist normally in the large intestine. This discovery 
led to a thorough examination of the patient, and cancer was 
found in the rectum. 

A woman aged 50 suffered from chronic discomfort in her 
epigastrium ; it was attributed to tapeworms until a swelling 
appeared in the hypogastrium. This proved to be a solid 
ovarian tumour ; and during its removal a cancerous stomach 
was detected. The microscopic features of the ovarian 
tumour were those of gastric cancer, and the disease in the 
ovary was due to implanted cancerous particles shed from 
the stomach. 

When cancer arises in the rectum there is an additional 
element of danger, because the cancerous mass is in close 
proximity to the bladder and the ureters. In the late 
stages of the disease these organs become involved, and, 
apart from the extreme misery produced by the formation 
of urinary fistulse, the patient's life is terminated by septic 
invasion of the urinary system, which leads to death by 
uraemia. 

. The comparison of cancer of the breast and cancer of 
the gastro-intestinal tract in relation to life-destroying pro- 
perties is instructive. When cancer attacks the breast it 
runs an insidious course, and only a small proportion of 
the victims die from t}he direct result of the primary dis- 
ease. When cancer attacks the stomach and large intestine 



37 GASTRO-INTESTINAL GANGER 

primarily, it so profoundly interferes either with alimentation, 
or with the escape of the gross excrementitious products 
of the body, that life soon becomes impossible. 

In anal cancer the chief symptom is pain very similar 
to that accompanying an anal fissure spasm and pain 
during and after defaecation. 

Every surgeon of experience can recall instances in which 
he has felt convinced, on examining a hard, indefinitely cir- 
cumscribed swelling in some region of the abdomen, that 
it depended on cancerous disease of the large bowel, and 
has regarded the case as inoperable and hopeless ; finally, an 
abscess has burst spontaneously, either into the bowel or 
externally, and the patient has slowly recovered. Unfor- 
tunately, the converse of this is true, for a patient may 
have a cancerous lump of moderate dimensions growing from 
any part of the large bowel, but especially in the neigh- 
bourhood of the caecum, the transverse, or the pelvic colon : 
such lumps are particularly liable to septic infection, for the 
csecal and colic segments of the intestinal canal abound in 
pyogenic micro-organisms. Infection leads to ulceration and 
often perforation of the bowel, which permits leakage of 
the intestinal contents and the formation of an abscess. It 
occasionally happens that the surgeon evacuates pus asso- 
ciated with a primary colic cancer under the impression 
that he is dealing with a pericolic abscess, and gives the 
patient satisfactory assurances; but the relief is temporary 
and a fistula discharging fsecal matter persists. Eventually, 
the chronic course of the case leads to a more thorough 
investigation of the sinus, and the unpleasant discovery of 
its dependence on a primary but septic cancer. 

To show how chronic inflammatory thickenings of the 
large bowel mimic in their clinical features colic cancer, 
and how cancer of the colon simulates chronic pericolitis, 
it is necessary to mention that foreign bodies like pieces 
of straw, needles, small chips of metal, or a piece of whale- 
bone accidentally introduced with food will perforate the 
bowel, or lodge in a colic diverticulum, or penetrate an 
epiploic appendage, and lead to local thickening of the 
bowel, which so strikingly resembles the clinical signs of 
cancer, in middle-aged and elderly persons, that colotomy 



GASTRO-INTESTINAL GANGER 379 

and resections of the gut have been performed under the 
impression that the disease was cancerous. 

In order to show how surgeons are hampered by 
the absence of a specific symptomatology for cancerous 
affections, it may be mentioned that when a suspected 
cancerous mass connected with the gastro-intestinal tract 
is exposed in the course of an operation, eyes and fingers 
are often incompetent to determine for, or against, malig- 
nancy. Hardness, indefiniteness, age of patient, enlarge- 
ment of the adjacent lymph-nodes, may all deceive. It is 
only necessary to read reports of cases published by reliable 
and conscientious surgeons, to learn that severe operations 
have been performed under the impression that the disease 
was cancerous ; subsequently a careful microscopic examina- 
tion has proved the mass to be infective in origin, and 
this opinion has been justified by the complete and permanent 
recovery of the patient. 

Since gastro-jejunostomy has been freely practised for 
the relief of obstructive affections in the pyloric region, 
believed to be cancerous by physicians in charge of the 
cases and the surgeons who performed the operation, they 
have been astonished, on seeing some of the patients months 
later, to find that the suspected cancerous lumps have dis- 
appeared. Facts of this kind may be gleaned from the 
records of any general hospital in London. 

A large proportion of patients with intestinal cancer 
succumb to the effects of obstruction; in some, death is 
brought about by other means. For example, the retention 
of the contents of the bowel leads to dilatation of the 
gut above the stricture ; this may induce ulceration and 
gangrene which terminate in perforation. In such an event 
the effect depends on the part of the gut perforated. Should 
the opening allow faecal matter to escape into the peri- 
toneal cavity, this, as a rule, kills the patient in a few hours. 
In the case of the caecum, the ascending and descending 
colon, the extravasation may take place behind the peri- 
toneum and give rise to a faecal abscess. Such abscesses 
in connexion with the right colon will point in the neigh- 
bourhood of Poupart's ligament (usually above, but some- 
times below this band), or at the crest of the ilium. Pus 



38o GASTROINTESTINAL GANGER 

from an abscess of this kind in connexion with the de- 
scending colon will travel between the muscular planes as 
far as the linea semilunaris, and the. intestinal gas cause 
the whole of the left half of the belly-wall to become 
emphysematous. 

In chronic intestinal obstruction due to cancer of the 
descending colon the caecum becomes greatly distended 
with fluid faeces; this leads to ulceration of its wall, which 
sometimes perforates and sets up rapidly fatal peritonitis. 

Cancer in the loop of an omega-shaped transverse colon, 
or in the pelvic colon, causes much misery when it per- 
forates into the urinary bladder. This complication is more 
common with diverticulitis than with cancer (see Chap. LXII). 

Briefly summarized, the modes of death in cancer of 
the intestine are intestinal obstruction, intussusception, 
peritonitis, infective nephritis when the disease attacks the 
rectum and involves the ureters, and the complications 
which ensue from general dissemination of the cancer. 

Treatment. The only satisfactory method of treating 
cancer of the intestinal tract is early and free removal; 
unfortunately the disease is so insidious that its presence is 
rarely suspected until it interferes with the lumen of the 
bowel and produces intestinal obstruction, the usual ter- 
minal event in the clinical history of cancer of the intestine. 
Sometimes the inflammatory symptoms set up by bacterial 
invasion of the growth impair the patient's health and 
lead him to seek advice, and this sometimes ends in the 
discovery of the tumour. Although there is no specific 
symptom indicating cancer of the colon, there are many 
points in the clinical history of this disease that enable 
surgeons to suspect its existence. There is often toxaemia 
due to putrefaction of the cancer, and intestinal stasis caused 
by incomplete obstruction of the lumen of the gut. Later, 
increasing constipation, attacks of colic, and emaciation are 
important signs, and they lead to careful examination of 
the bowel and rectum. Frequently a swelling is detected 
in the course of the colon by careful palpation of tho 
abdomen. Suspicions of intestinal stasis lead to the inves- 
tigation of the intestinal tract by means of bismuth or 
barium meals and an X-ray examination. Valuable informa 






GASTRO-INTESTINAL GANGER 381 

tion is often obtained in this way, and also as regards the 
pelvic colon and rectum by the use of an opaque enema. 

In many patients indefinite symptoms exist for many 
months, and occasionally, in women, secondary manifest- 
ations of the disease in connexion with implantation of 
cancer on the ovaries, or the walls of ovarian cysts, lead 
to operation, and a primary focus of cancer is accidentally 
discovered in some part of the colon. In men a similar 
implantation of cancer happens on the floor of the pelvis. 

When an attack of acute intestinal obstruction compels an 
operation, the surgeon, on opening the abdomen, endeavours 
to determine the cause, and, if it be due to a growth in the 
small or large intestine, he generally temporizes, for the 
bowel on the proximal side of the obstructive mass will be 
greatly distended with faeces, and the gut on the distal side 
narrowed. Under such conditions any effort at a radical 
operation is, as a rule, attended with great risks, for, in 
addition to the liability to infection from faecal matter, the 
septic state of the implicated bowel contraindicates resec- 
tion. In such conditions the necessities of the patients 
are usually met by a colostomy preceded by a careful re- 
connaissance of the intestinal tract. When the obstruction 
is relieved and the urgent symptoms subside, the disparity 
between the limb of intestine above and below the growth 
disappears; then a definite resection of the growth can be 
carried out with an enormously enhanced prospect of success. 
It has become a surgical axiom that no attempt should be 
made to excise a cancerous growth of the intestine and 
o^nastomose the cut ends during the phase of acute obstruc- 
tion. Occasionally, in the acute stage the surgeon will find 
an obstructing mass which he regards as irremovable ; in 
these circumstances he may feel justified in performing an 
anastomosis between the obstructed intestine above and the 
unobstructed gut below the growth. If relief of this kind 
is impossible, he will consider the best interests of the 
patient and perform colostomy, its situation being deter- 
mined by the position of the obstruction. A permanent 
colostomy happens commonly with growths situated at 
the junction of the pelvic colon with the rectum, for in 
this situation cancer permeates the wall of the bowel and 



382 GASTROINTESTINAL GANGER 

implicates the rectum", leaving no margin of healthy tissue 
available for anastomosis. 

When an irremovable cancer occupies the caecum, the 
transverse or the descending colon, the loop of the pelvic 
colon is always available for an anastomosis with a suitable 
coil of ileum. When operating for cancer of the colon the 
large bowel should be examined throughout to ensure that 
a second focus is not overlooked. In cases where the growth 
is in such a position as to admit of excision, many operative 
procedures are available. Tumours and cancers of the small 
intestine cause intussusception ; this condition lends itself to 
resection. The resection is made wide of the cancer, and the 
infected lymph-nodes are included in the triangular section 
of mesentery exsected with the diseased gut. The cut ends 
of the intestines are joined by an end-to-end, side-to-side, 
or end- to-side anastomosis, according to the fancy of the 
surgeon. Each method has its advocates. 

Excision of cancer of the colon varies with its situation, 
and this is somewhat controlled by the lymphatics. In the 
case of the csecum the lymphatics coming from the last six 
inches of the ileum join those belonging to the csecum, the 
appendix, the ascending colon, and about one-third of the 
transverse colon, to form a continuous set ; and it is customary 
in removing cancerous growths of the csecum to excise the 
terminal six inches of the ileum, the csecum, the ascending 
colon, and the beginning of the transverse colon. The ileum 
is then joined by a side-to-side or an end- to-side anastomosis 
with the middle of the transverse colon. 

The removal of a cancerous growth from any portion 
of the transverse colon is a very straightforward operation 
on account of the mobility of this part of the large intestine. 
On opening the abdomen the transverse colon is easily 
recognized as it hangs in the layers of the great omentum. 
The condition which embarrasses the surgeon most is a 
carcinomatous mass in the transverse colon, adherent to the 
greater curvature of the stomach. Such a case may require 
resection of the colon with an end-to-end anastomosis and 
excision of the implicated area of the stomach. Where the 
implication of the stomach is extensive the surgeon may 
find it undesirable to proceed with the operation. 



INTESTINAL ANASTOMOSIS 383 

Cancer of the large intestine offers to surgeons a wide 
field for the exercise of ingenuity. The methods of making 
junctions and the varieties of stitching which have been 
invented transcend those of tailors or seamstresses, and are 
bewildering in number and design. 

The simplest condition for surgical measures in the colon 
is a constricting cancer in the middle of the pelvic colon. 
It admits of wide resection, free removal of infected lymph- 
nodes, and the mobility of the parts facilitates anastomosis ; 
moreover, the fact that the pelvic colon is completely invested 
by peritoneum aids greatly in securing firm union after the 
apposed parts have been securely joined by sutures. 

The most difficult situation for resection is the portion 
of the colon at the junction of the pelvic colon and rectum ; 
the Trendelenburg position in such an operation is of great 
help, and contributes to success. 

Few operations offer so much scope for ingenuity on 
the part of surgeons as resections, anastomoses, and short- 
circuitings in dealing with intestinal obstruction set up by 
cancer of the intestine. Thirty years ago surgeons were 
generally content with a colotomy, or, as it is more cor- 
rectly called, colostomy. Surgeons do their best to avoid 
permanent colostomy by resecting the diseased part of the 
bowel and restoring its continuity by an anastomosis or by 
short-circuiting. 

In spite of great activity in devising radical and pallia- 
tive measures in the surgical treatment of colic cancer, 
the results are not gratifying. Resections of the csecum 
or portions of the colon are attended with a high rate of 
mortality, and among the survivors early recurrence or dis- 
semination is the rule. The mortality of radical operations 
for cancer of the caecum and colon in London during 1912 
was 30 per cent. In the London Hospital, during the years 
1901-11, resection of cancerous portions of the large bowel 
was performed on 95 patients ; 49 recovered and 46 died 
(Eve). 

The radical method of dealing with cancer of the colon 
is free resection of the cancerous portion in favourable 
cases; this requires a complicated operation for the reunion 
of the bowel, entailing a sutural junction that must be not 



384 INTESTINAL ANASTOMOSIS 

only water-tight but gas-tight. One of the first requisites 
for immediate union is the absence of pyogenic bacteria. 
In operations for intestinal anastomosis, success depends on 
early and firm union of the apposed surfaces of the bowel. 
There is nothing more amazing in relation to the healing 
of wounds than the rapidity with which peritoneal surfaces 
join when they are carefully sewn together with sterile 
sutures. In regions of the gastro-intestinal tract free from 
pyogenic bacteria, union occurs after surgical operations 
safely and quickly ; thus a gastro-jejunostomy in the hands 
of competent surgeons is devoid of risk from septic peri- 
tonitis. How different the picture for radical operations 
performed for cancer of the colon ! Septic peritonitis destroys 
the lives of at least 30 per cent, of those who submit to it. 
Death is due to septic peritonitis from infection during 
operation, leakage at the junctions, or failure of union due 
to the colon bacillus and its congeners. Statistics indicate 
that the risks of operations performed for cancer of the 
colon are as great as for the operations of general surgery 
in pre-Listerian days, with this difference : the mortality of 
that period was due to sepsis from infection of the wound 
through the use of dirty sponges, instruments, sutures, and 
the septic fingers of the surgeon and assistants. In opera- 
tions on cancerous viscera the diseased tissues are already 
infected, and taint the fingers and instruments of the surgeon ; 
hence the danger of such operations. In order to improve 
the results of operations for intestinal cancer, means must 
be devised for sterilizing the tissues, or a specific remedy 
found for cancer, and, from the surgical point of view, treat- 
ment to be successful must be prompt. 

The surgical treatment of cancer of the rectum has under- 
gone extensive development in the last few years. It was 
formerly difficult to localize accurately a growth in the 
rectum if it happened to be beyond the reach of the 
examining finger. The invention of the sigmoidoscope 
enables a growth in the colon to be seen even higher than 
the pelvic brim. 

The condition most difficult for the surgeon is a cancer 
in the rectum too high to be reached from the perineum and 
too low to be dealt with by means of an incision in the 



COLOSTOMY 385 

abdomen. In such a position it is now the custom to 
establish an artificial anus in the left inguinal region and 
then extirpate the cancerous portion of the rectum and 
anus. This method appeals to the patient, because when 
colostorny is performed he realizes that he has the incon- 
venience of an artificial anus and the disease persists in his 
rectum. When the rectal disease is extirpated he soon 
tolerates the disagreeableness of the inguinal anus. 

A carcinoma of the anus, anal canal, or lower end of 
the rectum, suitable for removal which means that it is 
not firmly fixed to the sacrum, and has not invaded the 
prostate, the bladder, or the uterus may be readily and 
safely removed. 

A constricting cancer at the junction of the rectum and 
pelvic colon has often been successfully excised, with the help 
of an abdominal incision, and the cut ends of the bowel 
successfully sutured end to end. A small localized chronic 
cancer low in the rectum can be exposed by resecting the 
coccyx and the two terminal sacral vertebraa. The diseased 
portion of the rectum is excised and the cut ends are 
sutured. This operation preserves the anal sphincter and 
relieves the patient of the discomfort of a colostorny. 

When cancer of the rectum is too extensive to permit 
of the removal of the growth, the disease is allowed to pro- 
gress until it interferes with the free evacuation of the bowel 
or becomes painful then the patient may be advised to 
submit to colostomy. 

The story of colotomy (or colostomy) is an interesting 
chapter in the progress of Surgery. Formerly patients with 
cancer of the rectum ended their lives miserably. The 
early attempt to relieve them was the operation, introduced 
by Littre (1710), known as colotomy ; it consisted in open- 
ing the descending colon in the left ilio-costal space (lumbar 
colotomy). Bryant (1881), by accident, in the course of a 
colotomy found the obstructing tumour in the wound and 
performed an unpremeditated colectomy. A few years later 
H. Allingham insisted on the advantages of a colostomy in 
the inguinal region. This method was also advocated by 
Harrison Cripps, and lumbar colotomy slowly fell into 
abeyance. Now, surgeons endeavour to avoid colostomy by 



386 GOLOSTOMY 

turning the ileum iuto the colon on the distal side of the 
obstruction, and with admirable results. Inguinal colos- 
tomy is useful in advanced cases of rectal cancer. For 
obstruction situated in the pelvic colon or the lower part 
of the descending colon it is often convenient for the 
patient to have the opening made in the transverse colon, 
and it is wise to remove the navel before suturing the 
colon in the wound. Some surgeons prefer to investigate 
the conditions through a median incision in the abdominal 
wall, and if a transverse colotomy is chosen they attach 
the opening of the colon to an incision through the rectus 
abdominis muscle and close the median incision. 

The short-circuiting operation in cases of cancerous 
obstruction of the colon has had a great influence in 
reducing the number of colostomies. 

Many instances are known where patients have survived 
colostomy, performed for obstruction due to cancer of the 
pelvic colon, five years or more ; the average expectancy of 
life in my experience is eighteen months. Death follows 
from secondary deposits in the liver, implication of the 
urinary organs, thrombosis from septic infection of large 
veins, general sepsis or toxaemia. 

Facts of this kind are full of interest, for they illustrate 
that even in the big bowel, where cancer is so easily liable 
to become septic, if the gross mechanical effects can be 
overcome this disease may, and does in some instances, 
pursue a chronic course. From the therapeutic standpoint 
this is hopeful, for while the bacteriologist is helping to 
limit the dire results of septic poisoning, by means of 
prophylactic sera, we are all hopeful that some cunning 
substance will be prepared which, when injected into the 
circulation, shall cause the cancerous tissue to disappear in 
the same startling, and often magical, way in which diph- 
theritic membrane dissolves after the injection of the 
appropriate antitoxin. 




CHAPTER XXXIV 
EPITHELIAL. TUMOURS OF THE LIVER 

THE liver is permeated by minute canals lined with epi- 
thelium. These canals are in communication with the 
duodenum by means of the excretory apparatus of the liver, 
and the epithelium that lines them is continuous with, and 
was in early embryonic life derived from, the cells lining 
the intestine. The bile-canals are 
invisible to the naked eye (Fig- 
173), but in certain conditions they Lymphatic.. 
become dilated and form cysts, 
some of which reach an important Biie-duct.- 

Size. Lymphatic.- 

Those forms of epithelial per- 
version known as adenoma and Artery.. 
cancer arise in any part of the 

i r ,i v Fig. 173. Transverse section of 

drainage system of the liver, in- a g portal canal> (Magnifie(L) 
ternal or external, but primary 

cancer is more common in the excretory apparatus than in 
the intrahepatic system of canals. 

CYSTS OF THE LIVER 

Two varieties of cyst are found in the liver, arising from 
the bile-canals independently of any obvious impediment to 
the flow of bile : these are multiple cysts and solitary (non- 
parasitic) cysts. 

1. Multiple cysts of the liver. This variety has been 
recognized for many years by pathologists as general cystic 
disease of the liver. It is often associated with congenital 
cystic disease of the kidney (see p. 688), and occasionally 
with cysts in the pancreas, lungs, spleen, and brain. 

In typical examples of this disease the liver is converted 

387 



388 



MULTIPLE CYSTS OF THE LIVER 



into a condition resembling a honeycomb (Fig. 174). The 
cavities vary in size : some are as small as mustard-seeds, and 
others as big as, or bigger than, ripe cherries. A cystic liver 
is enormously enlarged and may weigh 40 lb., yet its shape is 




Fig. 174. Liver shown in section. The spaces on the cut surface 
are dilated bile-canals. From a woman aged 46. (Museum of 
the Royal College of Surgeons, London.} 

preserved. The small cysts are lined with epithelium ; and 
the smallest look like sharp, definite punctures in the liver- 
substance. As the cysts increase in size and number the 
hepatic tissue is encroached upon, and appears as narrow 



SOLITARY CYST OF THE LIVER 389 

bridges between large tracts of honeycomb, but by degrees 
these become broken up by absorption, and then the rem- 
nants of the normal hepatic tissue appear as islands on the 
cut surface of the liver. 

The microscopic characters of the cysts when examined 
in the early stages prove that they arise in the bile-canals, 
but no investigator has succeeded in ascertaining the cause 
of this disease, or in associating it with obstruction to the 
escape of bile. It has been attributed to foetal cholangitis 
and pericholangitis causing obstruction to the bile-ducts 
(Forster, Rolleston). 

General cystic disease of the liver produces great enlarge- 
ment of the organ, but is painless, causes no jaundice, 
presents no diagnostic features, and comes invariably as a 
surprise, usually in the post-mortem room, and occasionally 
in the operating theatre. 

This curious disease has attracted the attention of several 
pathologists, including Virchow, Rokitansky, Bristowe. Still, 
Shattock, and Rolleston. Blackburn, in a careful and critical 
paper, has reviewed the various theories relating to the 
disease and collected the literature. 

2. Solitary (non-parasitic) cyst of the liver. This is a 
rare condition, and the general characters of such a cyst may 
be inferred from the specimen represented in Fig. 175. In 
nearly all the recorded cases the cysts grow from the free 
margin of the liver and possess thin walls which are trans- 
lucent, have no communication with the gall-bladder, and 
do not give rise to jaundice. The peritoneal investment and 
the capsule of the liver are directly continuous with the 
cyst-wall. On microscopic examination of a large solitary 
cyst, which I enucleated from the liver of a woman aged 75, 
the cyst-wall at the point where it joins the liver exhibited 
small loculi lined with epithelium ; ducts could also be 
detected, lined with cubic cells. The cyst-wall consisted of 
fibrous tissue, and its inner surface presented spaces covered 
with flattened epithelium. In some parts of the cyst-wall, 
hepatic tissue was detected. In such cysts the fluid may 
be straw-coloured bile, or blood. 

The solitary cyst of the liver is unassociated with gall- 
stones and obstruction to the main bile-ducts : it probably 



390 



SOLITARY CYST OF THE LIVER 



arises from the dilatation and fusion of bile-ducts, and, 
although it is difficult to explain its origin, attention may 
be drawn to the following points: The recorded examples 
occurred in women. It is noteworthy that the liver of 
many women presents along its free border a variable strip 
of thin atrophied tissue, which appears almost white in con- 




rig. 175. Cyst (non-parasitic) growing from the free border of the liver. 
Obtained post mortem from a woman aged 38. (Museum of the 
Royal College of Surgeons.} 

brast with the dark hue of the normal liver. This atrophy 
of the free border of the liver is attributed, and I think 
correctly, to the pressure of stays ; whether this be true or 
not, it was in this pale, thin strip of liver that the cyst 
arose in my patient, and it was due to dilatation of the 
bile-ducts in this tissue ; the dilated ducts subsequently fused 
to form larger spaces, much in the same way that cystic 
spaces arise in a cavernous nsevus from the fusion of 
adjacent blood-vessels composing the primary nsevus. 



ADENOMA OF THE LIVER 391 

Some of these solitary cysts are intrahepatic, but the 
majority project near the lower border of the liver (Fig. 175). 
A large cyst with a capacity of many pints is usually 
diagnosed as an ovarian cyst. S. Boyd has collected and 
analysed 34 reported cases. Echinococcus cysts are described 
in Chap. LXVIII. 

Treatment. Multiple cysts of the liver admit of no 
treatment and, as far as I know, have never been diagnosed. 
The solitary cyst is a clinical puzzle, but is amenable to 
surgery. When the attachment to the liver is narrow the 
cyst may be enucleated ; cysts having broad connexions with 
the liver, and those that are intrahepatic, are incised and 
drained. Burghard succeeded in anastomosing a solitary 
hepatic cyst, in a girl aged 16, to the duodenum. 

Boyd incised and drained one of these cysts, in a woman 
aged 27 ; it contained four pints of green fluid. Three 
months after the operation, offensive fluid drained along 
the track. The cavity was daily irrigated with peroxide of 
hydrogen solution. One day during the process of irrigation 
the sac burst. Coaliotomy was performed, but the woman 
died next day from acute peritonitis. 

ADENOMA AND CARCINOMA OF THE LIVER 

The histological characters of the liver render it possible 
for epithelial tumours, whether adenoma or carcinoma, to 
imitate the tubular arrangement of the bile-ducts, or the 
disposition of cells characteristic of an hepatic lobule. 

Adenoma. Fully developed adenomas of the liver are 
encapsuled tumours of a spherical shape; they may be 
situated in any part of the liver. Hepatic adenomas vary 
greatly in size : a solitary adenoma may be no larger than a 
marble; when multiple they will be as big as Tangerine 
oranges. In colour some are bright green, others are dull 
white. The peripheral parts of the tumour consist of solid 
columns of cells, but on approaching the centre they gradually 
acquire a lumen (Fig. 176). These blind ducts are lined with 
a single layer of columnar epithelium, and contain green 
inspissated material. As the ducts make up the bulk of the 
tumour, it is clear that the olive-green of the tumour is due 
to imprisoned bile. In adenomas of this kind the columnar 



392 



GANGER OF THE LIVER 



cells are so striking that some observers have described these 
tumours as columnar- celled carcinomas of the liver. In other 
specimens the cells, instead of being arranged in this tubular 
fashion, are grouped around a minute central lumen, two or 
more deep. 

So far as our knowledge at present extends, it would 
appear that hepatic adenomas as described above are of little 
clinical importance, and they have been found during the 
performance of a post-mortem examination when the liver 




Fig. 176. Adenoma of the liver. (Paul.) 

a. Section of blind duct filled with green fluid ; b, liver-cells ; 
c, connective tissue. 

has been sliced up in the course of the inspection. Keen 
successfully removed an hepatic adenoma measuring 9 by 
6 cm. from a woman aged 31. 

Carcinoma. Hepatic cancer varies greatly in its 1 'exter- 
nal appearance ; sometimes it assumes the form of compact 
nodules projecting from the surface of the liver and visible 
on every cut surface, the nodules varying in size from a 
marble, or ripe cherry, to tumours as big as the fist. Many of 
the surface nodules present a central depression or umbilicus. 

In other cases the cancer assumes the form of an irregular 
infiltration of soft growth of an olive green; some of the 
tracts are yellow. In all cases the liver is enlarged, some- 
times to twice its natural size. The surface is in most cases 
irregularly lobulated. 



GANGER OF THE LIVER 393 

Cirrhotic livers often become cancerous, and cirrhosis 
seems to bear some relationship to cancer of the liver, like 
chronic mastitis to mammary cancer. 

Dissemination of hepatic cancer is exceptional : secondary 
nodules have been found in the lung, and cancerous lymph - 
nodes in the portal fissure; when secondary nodules occur 
in the lung, the mediastinal lymph-nodes are enlarged and 
infiltrated with cancer. 

Prym (1912) examined a tumour, as big as the egg of 
a goose, removed post mortem from the skull of a patient 
who died from cancer of the liver. This secondary tumour 
had the structure of liver-cancer; its cells contained bile 
and were infiltrated with fat. 

In point of structure hepatic cancer conforms to two types, 
the tubular and the acinous, but the imitation in the case of 
cancer is not so good as with hepatic adenoma. 

Secondary cancer of the liver. The liver plays the 
same part in the portal circulation that the lungs play in 
the pulmonary circulation when any viscus or organ drained 
by them is the seat of carcinoma namely, to act as a filter 
and deprive it of cancer-emboli. Like the lungs, the liver 
offers an extremely favourable territory wherein such emi- 
grants may thrive. Secondary cancerous nodules in the 
liver attain larger proportions than in the lungs, and are 
often umbilicated. In many cases reported as primary cancer 
of the liver the nodules were multiple. This is a very 
exceptional condition in other viscera, which renders it 
important, before reporting a case as primary cancer of the 
liver, to make a thorough search of the whole intestinal tract, 
and particularly of the rectum and anus, when conducting 
a post-mortem examination for a small cancerous focus, 
perhaps no larger than a cherry, in the colon or the rectum 
will give rise to a mass in the liver as big as a coco-nut. 

Occasionally the secondary infection of the liver may 
assume the form of one large central mass of cancer, some- 
times exceeding in size the patient's head. Reference is 
made to the massiveness of secondary cancerous deposits in 
the liver, and some explanation offered as to the possible 
cause of their luxuriant growth, on p. 410. 

Clinical features. Hepatic cancer occurs equally in men 



394 CANCER OF THE LIVER 

and in women, and is most frequent between the fortieth 
and sixtieth years. It is, however, liable to arise at a much 
earlier age ; and Acland has published an excellent paper on 
this subject, and collected nine cases of primary cancer of 
the liver occurring in children under 20. All observers 
agree that primary cancer of the liver is very rare ; and, as is 
the case with many rare diseases, there is very little reliable 
evidence forthcoming concerning it. 

Cancer of the liver leads to enlargement of this gland 
and to jaundice, which may be slight and transient or of 
great intensity; in a few cases this symptom has only been 
observed towards the termination of life. Ascites occurs in 
most cases. The available facts indicate that it runs a very 
rapid course. 

An important clinical feature associated with the rapid 
growth of secondary cancer in the liver, especially when the 
primary focus is in the large intestine, is fever. In such 
conditions the body temperature may rise to 101. 103, and 
even 105 Fahr. 

Cancer of the liver is rarely amenable to art, either 
medical or surgical. In a few, very few, exceptional in- 
stances it has been possible to excise a cancerous segment 
of the liver, and with some success. 

Blackburn, C. B., " Cystic Disease of the Liver and Kidney." Trans. Path. 

Soc., 1904, Iv. 203 ; with a complete list of references. 
Bland-Sutton, J., "On Solitary (Non-Parasitic) Cysts of the Liver." Brit. 

Ned. Journ., 1905, ii. 1167. 

Boyd, S. f " Non-Parasitic Cysts of the Liver." Lancet, 1913, i. 951. 
Doran, A., "Large Bile-Cyst of the Liver." Med.-Chir. Trans., 1904, Ixxxvii. 

1 ; with literature. 

Keen, W. W., " Report of a Case of Resection of the Liver for the Removal 
. of a Neoplasm, with a table of seventy-six cases of Resection of the 

Liver for Hepatic Tumour." Ann. of Surg., 1899, xxx. 267. 
Prym, P., " Fettin filtration fin der Metastase eines primaren Leberzellen- 

k-rebses." Frankfurter ZeitscJir. f. Pathologle, 1912, x. 170. 



CHAPTER XXXV 

EPITHELIAL TUMOURS OF GALL-BLADDER, 
BILE-DUCT, AND AMPULLA 

UNTIL near the end of the nineteenth century little was 
known of cancer of the gall-bladder and the excretory 
apparatus of the liver. Cancer in these situations remained 
a pathological curiosity until the aggressiveness of surgeons 
proved it to be a common disease and clinically important. 
Moreover, the frequency with which cancer of the gall- 
bladder and gall-stones coexist has invested the association 
with pathological and practical interest. 

Cancer may arise in the epithelium in any part of the 
bile-duct system of the liver, but it is more common in 
the excretory apparatus than in the intrahepatic system of 
canals ; when this disease arises in the small intrahepatic 
ducts it is, for practical purposes, primary cancer of the 
liver, and is discussed in Chap, xxxiv. Cancer of the 
excretory apparatus of the liver is frequent in the hepatic 
duct; at the junction of the hepatic and common bile-ducts; 
in the common duct and in the ampulla ; but it arises 
with greatest frequency in the gall-bladder. 

Cancer of the gall-bladder. Any part of the mucous 
membrane of the gall-bladder may be the seat of cancer, 
which will project into its cavity as an exuberant growth, 
or infiltrate the walls and spread directly into the sub- 
jacent hepatic tissue. Cancer near the neck of the gall- 
bladder will extend along the cystic duct and invade in 
turn the hepatic and common ducts. When localized to 
the fundus of the gall-bladder, bud-like processes of growth 
will extrude through its walls and set up cancerous infec- 
tion of the abdominal cavity, or directly invade adjacent 
organs such as the stomach, dtiodenum, colon, and omen- 
turn. Cancerous cells shed into the peritoneal cavity will 

395 



GANGER OF THE GALL-BLADDER 

be deposited on the pelvic floor and, in the case of women, 
lodge on the ovaries, and form large masses of implanted 
cancer (see Chap. LVII). 

The type of cell usually found in cancer of the gall-bladder 
is columnar or subcolumnar. When the walls of a cancerous 
gall-bladder are firmly compressed on contained calculi the 
epithelium flattens and becomes squamous. Cancer in a 




CALCULUS 



Fig. 177. A gall-bladder with a primary cancer arising in its neck and 
extending into the cystic duct ; the gall-bladder was filled with pus. 
The patient, a man aged 70, died nine months after the beginning of 
his symptoms. (Museum of Charing Cross Hospital.) 

gall-bladder of this kind is squamous-celled, and cell-nests 
abound. 

The changes in the gall-bladder associated with cancer 
vary widely and depend in a large measure on the situa- 
tion of the disease. When cancer arises in the neck of the 
gall-bladder (Fig. 177), retention of mucus causes the organ 
to enlarge and resemble a simple "hydrops" of the gall- 
bladder. The common situation for cancer of the gall- 
bladder is the fundus, and here it gives rise to widely 
different effects. In some examples the gall-bladder will be 



GANGER OF THE GALL-BLADDER 397 

filled with soft growth in which many gall-stones are em- 
bedded, and the whole organ hangs freely in the abdomen. 
In such a case the cancer perforates the wall of the gall- 




rig. 178. Gall-bladder removed from a woman aged 43. The cancer 
had burst through the fundus of the gall-bladder and implicated the 
transverse colon. Eight inches of the latter was resected. Several 
hundred calculi, consisting almost entirely of cholesterin, were present. 

bladder and invades the adjacent colon (Fig. 178). Occa- 
sionally the gall-bladder is filled with a hard mass of 
cancer, and the concretions are lodged in the centre like 



398 GANGER OF THE GALL-BLADDER 



Liver. 



eggs in a nest (Fig. 1^79). Often the cancer infiltrates the 
walls of the gall-bladder and spreads into the liver so inti- 
mately that it leaves no indication of the limit between the 
gall-bladder and the hepatic tissue (Fig. 180). Calculous 
gall-bladders should be systematically examined, for it is easy 
to overlook a cancerous focus in their walls (Fig. 181). 

An aged spinster had 
an abdominal tumour 
which was regarded as a 
subserous fibroid with a 
long pedicle. In course of 
time ascites developed, 
and it was decided to 
evacuate the fluid and, 
if possible, remove the 
tumour, which reached 
to the hypogastrium. It 
proved to be the gall- 
bladder, and some nodules 
of cancer were detected 
in the right lobe of the 
liver. The gastro-intes- 
tinal tract and pelvic or- 
gans were examined, but 
no evidence of cancer was 
found. The condition of 
the gall-bladder (Fig. 182) 
is instructive : a large cal- 
culus obstructed the cystic 
duct and produced the 
condition known as hy- 
drops vesicce feliece. Its 
cavity contained two re- 
markable gall-stones arranged like an acorn in its cup. The 
lower pole of the balanoid calculus moved freely in the cup 
formed by the smaller stone ; the two bodies moved on each 
other, and the concavity of the lower calculus is polished 
by trituration. The calculus which forms the cup is a frag- 
ment spontaneously detached from the top of the larger 
stone. The relation of these two gall-stones recalls the 




Fig. 179. Squamous- celled cancer of the 
gall-bladder. From a woman aged 56. 
(Museum of the Middlesex Hospital.} 



GANGER OF THE BILE-DUCTS 



399 



glacier-mills which form such interesting objects in the 
famous glacier-garden of Lucerne. Trituration of the ap- 
posed surfaces of gall-stones is not uncommon, but this is 
the most perfect example of a gall-stone mill that has come 
under my notice (Fig. 183). The most sinister feature in this 




Fig. 180. Cancerous and calculous gall-bladder in section, showing the 
manner in which the liver is infiltrated. {Museum of St. Bartholomeiv''s 
Hospital.} 

gall-bladder was a patch of cancer infiltrating its walls, and 
the source of the nodules in the liver. 

Cancer of the hepatic duct and of the common bile- 
duct. Cancer may arise in any part of these ducts, and in 
a fair proportion of cases the disease is situated at the 
junction of the cystic, hepatic, and common ducts. As a 
rule the amount of growth is small and the effects on the 
gall-bladder vary according to the situation of the cancer, 



4oo 



GANGER OF THE BILE-DUCTS 



but the result on the liver is the same whichever part of 
the duct is implicated, for the obstruction to the escape 
of bile by the common duct leads to dilatation of the 
canals above the obstruction, which become distended with 
bile. The liver increases in size, and there exists more or 
less interstitial biliary fibrosis. 

The complete obstruction of the common duct leads to 




Fig. 181. Bilocular gall-bladder: the upper loculus contained a number 
of gall-stones faceted by pressure. * A small nodule of cancer in its 
wall that had infiltrated the liver. At the operation a large trian- 
gular piece of hepatic tissue was removed with it. From a woman 
aged 65. She recovered, but reported herself with recurrence in the 
liver sixteen months later. (Museum of the Middlesex Hospital.} 

an important change in the excretion of bile. When the 
flow of bile along the common duct is completely obstructed, 
especially by cancer, the bile drains through the lymphatics 
of the liver into the circulation and is eliminated by the 
kidneys. In the early days of the obstruction, if the common 
bile-duct be incised it will be found filled with bile. When 
the blockade of the duct has been maintained for several 



GANGER OF THE BILE-DUGTS 



401 



weeks (six or more), it happens now and then that the duct 
contains, instead of bile, a mucoid fluid. This is a sinister 
sign ; when this fluid is present, patients usually die shortly 
after the operation. On some occasions in which patients 
have been tormented with pruritus, the common sequel of 
chronic jaundice, relief is afforded by anastomosing the gall- 




Fig. 182. Cancerous "gall-bladder containing a gall-stone "mill." The 
nether stone is a fragment spontaneously detached from the top of 
the upper stone. (Museum of the Middlesex Hospital.} 

bladder and intestine. On two occasions in which this was 
carried out the gall-bladder contained only mucus. In about 
ten days the jaundice and the troublesome pruritus dis- 
appeared, and the faeces resumed a normal colour, showing 
that bile again escaped along its normal channels. Chronic- 
ally jaundiced patients are not -good subjects for surgical 
intervention. The peculiar tendency of cholsemic patients to 
2 A 



402 



GANGER OF THE AMPULLA 



bleed is notorious (see p. 408), and is a factor demanding 
serious consideration when an operation is contemplated. 

Cancer of the ampulla. It is possible to distinguish 
between cancer arising in the common bile-duct near its 
termination and cancer arising in the ampulla. This disease 
also arises in the mucous membrane of the duodenum 

around the bile papilla ; it is known 
as circumampullary cancer (see p. 
361). From a practical standpoint 
the distinction is not important, 
except that a cancerous obstruction 
just above the ampulla would block 
the common bile-duct but not the 
pancreatic duct, whereas cancer 
arising in the ampulla blockades 
both ducts. Apart from its mechan- 
ical interference with the outflow of 
bile and pancreatic juice, cancer of 
the ampulla presents exceptional 
features. It is a rare disease; it is 
usually circumscribed and shows little 
tendency to invade adjacent struc- 
tures or to disseminate. Nowhere in 
the body does so small a growth 
lead to such grave interference with 
digestion. A cancerous growth, some- 
times no larger than a small cherry, 
will block the outflow of bile and 
pancreatic juice, cause intense iaun- 

Fig. 183. A, The gall-stone V , . . T % ^ 

"mill" from rig. 182. ^ lce an( * great emaciation. It leads 
B, The nether stone, drawn to great dilatation of the bile-ducts, 
extra- and intrahepatic, and enormous 
distension of the gall-bladder. In 
spite of its local nature it quickly destroys life. When cancer 
of the ampulla gives rise to jaundice, death usually follows 
in six months. Cancer of the ampulla, like cancer of the 
common bile-duct, differs from this disease in the gall- 
bladder by being rarely associated with gall-stones. (Fig. 
184.) Very few instances of cancer of the ampulla have 
been recorded in England. Outerbridge has collected 100 




B 



GANGER AND GALL-STONES 



403 



reported cases. There are very few specimens preserved in 
the London museums. 

Relationship of gall-stones to cancer of the gall- 
bladder. The frequent association of gall-stones and cancer 
of the gall-bladder has led surgeons to regard a calculous 
cholecystitis as a precancerous condition. Naunyn's in- 
quiries seemed to prove that the cholesterin of which 
gall-stones are so largely composed is not derived from the 




Fig. 184. Cancer of the ampulla. The common bile-duct contained 
three gall-stones, and one of them had ulcerated through the 
wall of the cancerous ampulla. From a woman aged 58. 
(Museum of the Royal College of Surgeons.} 

bile, but from the epithelium of the gall-bladder, especially 
when inflamed; little masses of cholesterin mixed with 
bilirubin-calcium form the nuclei of the stones, and these 
two substances may collect about shed epithelium and 
clumps of bacilli that may happen to be in the gall-bladder. 
It is now regarded as proved that the favouring conditions 
for the formation of gall-stones are stasis of the bile in the 
gall-bladder, mild infection of the epithelium of the mucosa 
of the bile-ducts, and the presence of micro-organisms, 
.especially B. typhosns, 



404 GHOLESTER1N 

A valuable demonstration of the- origin of cholesterin 
from epithelium of the gall-bladder is afforded when the 
cystic duct is so completely plugged by a calculus, or by 
cancer, that bile no longer enters the gall-bladder. In 
these conditions the concretions formed in the gall-bladder 
subsequently to the obstruction of the cystic duct consist 
of pure cholesterin, and look like polygonal lumps of 
spermaceti. (See Fig. 320, p. 671.) 

Some new light has been thrown on the formation of 
gall-stones by Aschoff and Bacmeister. They describe two 
kinds of cells in the gall-bladder : one variety is a tall 
cylindrical cell with an oval nucleus ; the other is similar 
to the familiar goblet-cell of the intestine, and secretes mucin. 
These observers also draw special attention to the depressions 
in the mucosa in the neck of the gall-bladder, and term 
them Luschka's ducts ; they play an important part in the 
production of gall-stones. 

Naunyn recognized two factors in the formation of gall- 
stones : (1) stasis of the bile in the gall-bladder, permitting 
the constituents of gall-stones to separate from the bile ; and 
(2) infection by micro-organisms that sets up cholecystitis 
and causes an exudation of inflammatory products, increased 
secretion of mucus, and an addition of lime salts to the bile. 
Aschoff's investigations show that under certain conditions, 
especially pregnancy and diabetes, the amount of cholesterin 
in the blood is above the normal. Infection of the gall- 
bladder in such conditions will lead to the rapid formation 
of gall-stones. Normal human bile is sterile, but it is a 
ready culture-medium for many organisms. 

The solitary cholesterin stone so often found in the neck 
of the gall-bladder is of interest for several reasons. It has 
a peculiar radial structure (Fig. 185), and Naunyn described 
the origin of this stone in the following way : When the 
cholesterin nucleus of a gall-stone is coated with layers of 
bilirubin-calcium and biliverdin-calcium, it may, if no bile 
runs into the gall-bladder, become coated with cholesterin ; 
under favourable conditions the cholesterin may permeate 
the calculus and crystallize. Whilst the cholesterin is thus 
permeating the calculus through favouring cracks and fissures 
the biliverdin-calcium is dissolved out and finally replaced, 



FORMATION OF GALL-STONES 



405 



Thus, a gall-stone primarily composed of laminoe is trans- 
formed into a pure cholesterin calculus with a crystalline 
structure. Aschoff describes the formation of these radial 
stones differently. They are derived from the bile itself, and 
not from the epithelium of the gall-bladder. This solitary 
stone is only found in an obstructed gall-bladder without 
inflammation ; it increases in size very slowly. Inflammatory 
calculi are rich in calcium, are often numerous, and usually 
faceted. They grow more rapidly 
than radial stones. It is highly 
probable that the solitary cholesterin 
stone of crystalline structure (Fig. 
185) that often occupies the gall- 
bladder without causing symptoms 
is due to the combined effects of 
stasis and an excess of cholesterin 
in the bile. When a gall-bladder 
containing such a stone becomes 
infected, the lime salts in the bile 
will be deposited on the calculus and 
furnish it with a mantle of chalk. 
Few cholesterin calculi escape this 
change. 

The majority of surgeons regard 
the conditions of the gall-bladder Fig. 185. Large. solitary gall- 
favouring the formation of gall- stone iu section, showing 

.... its radial structure. 

stones as precancerous conditions. 

A gall-bladder the seat of infection and occupied by calculi 
shows, in addition to pathological changes in the epithelium 
and an increase in the glandular recesses of its mucosa, ulcers 
and cicatrices, as well as active changes in the subepithelial 
tissues. The chronic changes leading to the production of 
gall-stones increase its vulnerability to the micro-parasite of 
cancer. It is illogical to urge that gall-stones are the cause 
of cancer in the gall-bladder, when cancer arising in the 
hepatic and the common bile-duct is rarely complicated with 
gall-stones. It is now recognized by surgeons that cancer 
sometimes arises in gall-bladders many months after stones 
have been removed. Cases have been reported by Knaggs, 
Hutchinson, and Lett. 




4o6 GANGER OF THE GALL-BLADDER 

Clinical features "of cancer of the gall-bladder. This 

disease is more common in women than in men. The period 
of greatest liability is the decade between 50 and 60. Cancer 
of the gall-bladder is most insidious in its beginnings, not- 
withstanding the presence of gall-stones. Patients usually 
seek advice either on account of a local lump which they 
have detected, or for marked depreciation of health. There 
are two sets of symptoms in this disease. In one a more 
or less movable pyriform swelling exists in the right hypo- 
chondrium, associated with a slight tinge of jaundice ; this 
swelling resembles in ail particulars an enlarged gall-bladder, 
but the local signs are not so acute as in cholecystitis, 
although there is usually such an obvious impairment of the 
general health as to make one suspect the malignancy of 
the lump. In the late stages of the disease hydroperitoneum 
is present. 

In the other class the patients come under observation 
with signs and symptoms indicating serious disease and 
resembling those peculiar to the gall-bladder, mingled with 
others pointing to cancer of the liver. In many cases it 
is impossible to* decide from physical signs which organ is 
diseased until the parts are exposed in the course of an 
operation. In some instances the disease is proved to be cal- 
culous cholecystitis ; in others it is a cancerous gall-bladder ; 
in a few, primary cancer of the liver; and occasionally a 
gall-bladder will be found to contain calculi, whilst the liver 
presents nodules of cancer secondary to a primary focus of 
disease in some part of the gastro-intestinal canal. In a 
few cases a cancerous lump, supposed to be in the gall- 
bladder, is situated in the transverse colon or the pyloric 
region of the stomach. 

Primary cancer of the gall-bladder runs a rapid course, 
and usually terminates the life of the patient within six 
months of the onset of definite symptoms. Jaundice is 
present in the late stages of the disease in about one-third 
of the cases. 

Clinical features of cancer of the hepatic and the 
common bile-duct. This condition is most frequent between 
the fiftieth and sixtieth years, and occurs more often in 
men than in women. The symptoms it produces differ in 



GANGER OF THE BILE-DUCTS 407 

an important particular from cancer of the gall-bladder, 
for jaundice is an early and constant symptom painless, 
intense jaundice accompanied with great emaciation. The 
position of the cancerous obstruction has an important effect 
upon the gall-bladder : when the obstruction is in the hepatic 
duct, bile will not enter the gall-bladder ; when the obstruc- 
tion is in the common duct below the junction of the cystic 
duct, bile freely enters the gall-bladder, and, as it cannot 
escape, this receptacle becomes over-distended and can be 
detected as an oval body lying in the right hypochondriac 
or right lumbar region. This condition of the gall-bladder 
is a valuable guide in the differential diagnosis of obstructive 
jaundice. The distension of the gall-bladder is an important 
feature, for cases have been reported in which patients have 
died from peritonitis due to intraperitoneal rupture of the 
gall-bladder. (Cockle, 1883 ; Coats and Finlayson.) 

Gall-stones have been found in cancerous bile-ducts, but 
the association is uncommon. Pain is an uncertain feature ; 
it is well to remember that a gall-stone may painlessly 
obstruct the common duct, and cancer of the duct some- 
times causes attacks of pain resembling biliary colic. Itch- 
ing of the skin in jaundiced patients is often a distressing 
complication. 

Clinical features of cancer of the ampulla, The 
symptoms of this disease are homologous with those pre- 
sented by cancer of the head of the pancreas, primary 
cancer of the duodenum involving the bile-papilla, a malig* 
nant tumour of the stomach involving the bile-duct, and a 
gall-stone impacted in the ampulla. 

Treatment of cancer of the gall-bladder. Cancerous 
gall-bladders in favourable circumstances can be successfully 
removed, and in many instances a gall-bladder is excised 
without the surgeon being aware that it contained cancer. 
This matter was impressed on surgeons in 1905, when Slade 
reported that the routine examination of calculous gall- 
bladders removed by operation, and in the post-mortem 
room of the London Hospital, showed that cancer was pre- 
sent in 30 per cent. Subsequent observations show that 
the disease is more frequent than surgeons suspected, but 
Blade's estimate is excessive. 



4o3 GANGER OF THE AMPULLA 

The removal of a gall-bladder with obvious cancer is 
not an encouraging operation. Slade reported that out of 
11 patients submitted to operation in the London Hospital, 
9 died. In the year 1905, 17 patients with primary cancer 
of the gall-bladder submitted to operation in the chief general 
hospitals of London ; of these 9 died. It is an axiom among 
surgeons that by the time a cancerous gall-bladder can be 
diagnosed, the chances of successful operative treatment are 
small. 

Treatment of cancer of the common bile-duct. The 
diagnosis of this disease is difficult : occasionally the uncer- 
tainty is cleared up by an exploratory operation. 

In cases where an exploratory operation has been per- 
formed, and the surgeon finds it impossible or, in considera- 
tion of the patient's condition, imprudent to attempt a 
radical operation, it is sometimes to the patient's interest 
and comfort to anastomose the gall-bladder with the duo- 
denum, jejunum, or colon. This will certainly relieve the 
irritating minor troubles associated with the jaundice, 
although it will for a time set up biliary diarrhoea. The 
great danger of these operations in cholsemic patients is 
uncontrollable oozing, as in leukaemia. 

In a few instances, where the common and hepatic ducts 
have been dilated into large sacs behind an inoperable com- 
plete obstruction of the common bile-duct, an anastomosis 
between the sac and the duodenum has been successfully 
effected (choledochostomy). 

Treatment of cancer of the ampulla. The daring 
resourcefulness of modern surgery is well exemplified in 
attempts to deal with this singular form of cancer. Valu- 
able papers have been written on the subject by Hartmann, 
Korte, Schuler, Kausch, and Upcott. The risks are great, 
but some examples of survival after a complicated operation 
have been described. It is highly probable that some means 
for dealing with the condition successfully will be devised. 

Papillomas occur in crops on the mucous membrane of 
the gall-bladder. Though uncommon, they have been seen 
both in association with gall-stones and without them. Their 
presence is of no serious import. 



CHAPTER XXXVI 

EPITHELIAL TUMOURS OF THE PANCREAS 
AND SALIVARY GLANDS 

CARCINOMA of the pancreas is an affection of peculiar interest 
because it is in itself very insidious, and rarely becomes 
clinically recognizable except from what may be called an 
accident in its environment, namely, the disease is very 
prone to attack the head of the gland and cause jaundice 
by obstructing the common bile-duct. 

The pancreas is a compound gland, for, in addition to its 
own acini, it is occupied by the epithelial bodies known as 
the islands of Langerhans, which are at present regarded 
as ductless glands furnishing an internal secretion. The 
pancreas contains three distinct sets of epithelial structures ; 
these are its own acini, the islands, and its excretory duct. 
Hillier and Goodall have conducted a valuable investigation 
concerning the histology and general features of carcinoma 
of the pancreas, and they have come to the conclusion that 
primary cancer of this gland may arise in any of the three 
epithelial structures which it contains. (Fig. 186.) The 
common type is spheroidal-celled carcinoma with a large 
amount of fibrous tissue. It probably arises in the acini of 
the gland, and is comparable to spheroidal-celled cancer of 
the breast The second variety is columnar-celled, probably 
arises from the duct, and resembles primary cancer of the 
duodenum. 

The third variety is of interest, as there is good reason 
to believe that it arises in the islets of Langerhans : " it 
consists of cells most irregular in size and shape, but on 
the whole much larger than in the other varieties of car- 
cinoma, and possessed of nuclei which in some instances are 
enormous." 

In connexion with the relation of the islands to carcinoma, 

409 



4io 



GANGER OF THE PANCREAS 



it is pointed out that,* in the ordinary varieties of cancer of 
the pancreas, the islands remain unaffected and may be seen 
in some instances surrounded by cancerous growth ; on the 
other hand, when the pancreas is the seat of secondary 
cancer, the islands are among the first of the pancreatic 
structures to disappear. 

Cancer of the pancreas attacks the head of the gland six 
times more frequently than the tail. In one unusual case 
a cancerous deposit was found in the head and tail of the 



Islet, 



Connective 
tissue 



Duct. 




' Centro- 

acinar cell. 



_. T Duct-zone 
< of alveolar 
(. cells. . 



Fig. 186. Magnified view of a cross-section of the pancreas, showing 
the three epithelial elements concerned in pancreatic cancer. 
(Bohn and Davidoff.) 

same gland (Hale White). Hillier and Goodall observe that 
the site of origin for the head corresponds closely with the 
position of the junction of the ducts of Wirsung and 
Santorini. 

Cancer of the pancreas never forms a large mass ; this is 
a matter of interest because cancer of the liver forms, in 
some instances, enormous masses, increasing the weight ol 
the organ many pounds. This would suggest that cancer 
thrives better in some organs than in others, and that hepatic 
tissue favours the growth of cancer, the glycogen in its cells 
possibly serving as pabulum for the cancer-cells. On the 
other hand, the pancreatic secretion may be unfavourable to 



GANGER OF THE PANCREAS 411 

the growth of cancer. Waring found that the cell-elements 
of primary and secondary cancer of the pancreas can produce 
ferments identical with or similar to those furnished by the 
normal cells of the gland. The tissue of primary cancer of 
the stomach produces pepsin and rennin. It is a fact that 
under some conditions the pancreatic tissue becomes impaired 
after the ducts are infected by micro-organisms, and occa- 
sionally necrosis of the glandular tissue ensues ; this allows 
the secretion to escape and expend its fat-splitting property 
on subperitoneal fat and omentum, leading to the remarkable 
phenomenon known as fat necrosis. Whatever the reason t 
primary cancer of the pancreas can never be described as an 
exuberant process, and the suspected antipathy of pancreatic 
secretion to cancer particles may explain the rarity of primary 
and secondary deposits in the duodenum, jejunum, and ileum 
(see p. 364). 

Clinical features. The pancreas is one of the least 
obtrusive organs in the abdomen, and yet the complete 
abrogation of its functions entails death as surely as renal 
bankruptcy. The difficulty of recognizing cancer of the 
pancreas is increased by the fact that the tumour is rarely 
large enough to be appreciated by manipulation through the 
abdominal wall. Occasionally a malignant pancreatic tumour 
will attain the size of a fist, but this is uncommon. As 
already mentioned, the disease rarely becomes clinically mani- 
fest except when it attacks the head of the pancreas, as it 
usually does, and causes jaundice by obstructing the common 
bile-duct, thus furnishing one of the earliest symptoms. The 
jaundice sometimes follows a sudden attack of pain such as 
is produced by the impaction of a gall-stone in the common 
bile-duct; this leads to errors in diagnosis. The distended 
gall-bladder associated with cancer of the pancreas often 
contains mucus. 

The disease is rare before middle life, and it attacks both 
men and women. The chief manifestation, save in quite the 
late stages, is deep jaundice, often unaccompanied by pain. 
As the disease progresses and the jaundice deepens, an oval 
tumour is sometimes appreciable in the right lumbar region ; 
this is the over-distended gall-bladder, and it is painless to 
touch. In a certain proportion of cases a second swelling 



412 CHRONIC PANCREATITIS 

can be made out in the region of the head of the pancreas. 
This disease is rarely a source of pain, but in some cases 
the late stages of cancer of the pancreas are accompanied 
by much suffering. Pain occurring in severe paroxysms, 
sometimes called coeliac neuralgia, is probably due to impli- 
cation of the coeliac plexus. No symptom is constant, and 
it is uncommon for all to be manifested in one patient. 

The most characteristic feature of cancer of the head 
of the pancreas is jaundice unaccompanied by pain ; but the 
icterus in these circumstances lacks the yellowness which is 
seen when the common bile-duct alone is obstructed, for it 
has a brown tint, not unlike the hue of the skin in Addison's 
disease. In cases where the jaundice has been relieved by 
diverting the bile into the colon this brown tint persists. 

The jaundice is accompanied by irritation of the skin, 
great depression, slow pulse, and emaciation. The wasting 
depends in a measure upon the altered digestion and mal- 
assimilation due to absence of the pancreatic secretion in 
the alimentary canal. Glycosuria is an extremely rare com- 
plication of pancreatic cancer, and this has been ascribed to 
the fact that the islands of Langerhans enjoy considerable 
immunity from the disease ; Canimidge is of opinion that it 
is due to inflammatory changes in the part of the pancreas 
that is not invaded by cancer. Death as a rule results from 
coma produced by toxaemia, and not infrequently from 
septic phlebitis due to the implication of the large veins 
in the immediate neighbourhood of the cosliac axis. Cancer 
of the head of the pancreas quickly involves the common 
bile-duct, but rarely implicates neighbouring viscera such 
as the duodenum or the stomach. Lymphatic infection is 
unusual, and dissemination occasionally occurs, the secondary 
nodules being found in the liver and lung. 

Diagnosis. Chronic pancreatitis is frequently mistaken 
for cancer of the pancreas. In both diseases the head of 
the pancreas is transformed into a hard nodular mass. 
The distinction between the two conditions is of first-rate 
importance in order to spare patients the distress of an 
unnecessary operation. To this end, Cammidge elaborated 
a method of examining the urine and fseces of patients with 
obstructive jaundice, for the purpose of determining whether 



GANGER OF THE PANCREAS 413 

the obstruction depends on a concretion impacted in the 
ampulla, or on cancer. A common cause of chronic pan- 
creatitis is a gall-stone impacted in the ampulla. The " pan- 
creatic reaction" is a factor to be taken into account in 
making a diagnosis in suspected cases of pancreatic disease 
and jaundice. 

In surgery the diagnosis of cancer of the pancreas is 
often made unexpectedly : the surgeon, exploring the duo- 
denal region with the hope of finding a gall-stone impacted 
in the common duct, sometimes finds a hard mass replacing 
the head of the pancreas, and, believing it to be cancerous, 
closes the abdomen and gives an unfavourable prognosis. 
As a rule his prognostications are fulfilled and the patient 
dies within a year, but occasionally he is astonished on 
meeting his patient a year later to find him in excellent 
health and without any palpable tumour. Such cases admit 
of a simple explanation. The pancreas, like a salivary gland, 
is liable to have its main duct invaded by pathogenic 
micro-organisms, and a condition is set up comparable to 
what is known as septic parotitis. An acute swelling of the 
pancreas persists for a few weeks and then gradually subsides. 
The salivary glands are not often destroyed by infections, 
and acute pancreatitis does not always lead to atrophy of 
the pancreas. The subsidence of a pancreatic swelling is 
one form of disappearing abdominal tumour. 

Treatment, The insidious nature of cancer of the pan- 
creas and the intimate relations of the gland with the 
duodenum, blood- and lymph-vessels do not favour surgical 
enterprise. In order to secure the full benefit of an opera- 
tion upon a cancerous pancreas it is essential to remove 
the whole gland. This would be physiologically disastrous, 
because experiments on animals demonstrate that complete 
extirpation of the pancreas is followed by diabetes. Another 
factor is the frequency with which cancer of the head of 
the pancreas causes jaundice, a condition which renders 
successful surgery almost impossible on account of the 
great tendency of cholremic patients to uncontrollable bleed- 
ing after operations. 

When tumours occupy the pancreas and do not interfere 
with the common bile-duct, operations can be successfully 



414 ACCESSORY PANCREAS 

undertaken. Cysts and solid tumours have been success- 
fully enucleated from it by Finney and Korte. Portions of 
the pancreas have been excised accidentally in the course 
of splenectomy, by myself, Mayo, and other surgeons, without 
harmful results. 

When the head of the pancreas is excised the digestive 
organs are deprived of the pancreatic secretion, and a trouble- 
some fistula is the consequence. To meet this difficulty, 
Coffey has devised an operation, pancreato-enterostomy, 
whereby the cut end of the pancreas is adjusted to a loop 
of small intestine. 

Accessory pancreas. This is a nodule of pancreatic 
tissue wholly separate from the pancreas and provided with 
a duct. Such a pancreas occurs in the pyloric section of the 
stomach, the duodenum, or any part of the small intestine. 
It may be situated in the rnucosa, muscularis mucosse, or 
the muscular layer. Some of these accessory glands may 
attain a length of 4 cm. An accessory pancreas is often situ- 
ated at the apex of a diverticulum. When such a diverti- 
culum is situated within 2 or 3 ft. of the ileo-csecal valve it 
is often mistaken for a Meckelian diverticulum, but both 
varieties have been found in the same person. It is possible 
that an accessory pancreas produces the diverticulum by 
traction. These diverticula are not harmless ; they some- 
times invert, and lead to intussusception (see Chap. LXII). 
The structure of the accessory pancreas has been studied 
by Opie, Alexis Thomson, and others. It has been suggested 
that cancer of the small intestine may arise in an accessory 
pancreas. There is no evidence to support such a theory. 

Tumours of salivary glands. These tumours are a 
pathological puzzle and a source of much unsatisfactory 
speculation. Typical examples occur in the parotid gland, 
as oval, smooth, elastic swellings in its substance ; they dip 
beneath the sterno-mastoid muscle, and infiltrate the sheath 
of the carotid arteries and the jugular vein. The facial nerve 
is often involved in the tumour, and is occasionally divided 
accidentally in the course of operations for the removal of 
such tumours. Sir Charles Bell removed a parotid tumour 
from a coachman. Some time after the operation the man 



PAROTID TUMOURS 

returned to thank Bell for " ridding him of a formidable dis- 
ease, but complained that he could not whistle to his horses." 
Left to themselves, parotid tumours cause death in a 
variety of ways : they often press on the pharynx and inter- 
fere with swallowing, or ulcerate and open large vessels in the 
neck, and lead to death from bleeding, sepsis, and infection 
of the lymphatics 







Fig. 187. Parotid tumour that grew slowly for seventeen years. When 
the woman was 57 it grew quickly, infected the lymph-nodes, and 
the patient died. 

Structurally, these tumours exhibit extraordinary variety. 
Some consist of tissue resembling cartilage arranged in 
lobules bound together by loose connective tissue. The cells 
rarely possess capsules, and are often stellate, as in immature 
cartilage. Such tumours grow with extreme slowness, and 
rarely exceed a bantam's egg in size; they may require ten 
or even twelve years to attain "such proportions (Fig.. 187). 



416 



PAROTID TUMOURS 



Large, rapidly growing tumours consist of spindle cells in 
which tracts and islets of hyalin tissue are interspersed ; 
this tissue is very prone to mucoid changes, and soft, 
fluctuating spaces are formed. The connective tissue is very 
liable to undergo myxomatous change, and, as if to render 
these tumours more complex, portions of the secreting tissue 
of the gland are imprisoned in them. 




Fig. 188 Tumour of the submaxillary gland which had heen slowly 
growing for forty-four years. It was successfully removed. 

It is not unusual in sections from a parotid tumour 
to meet with spindle cells, inyxornatous tissue, glandu- 
lar acini, and fibrous tissue in an area 2 cm. square. 
Parotid tumours of such complex structure grow rapidly, 
attain a large size, and often infiltrate the surrounding 
tissue and skin. Some of them infect the adjacent 
lymph-nodes and give rise to secondary deposits in the 
lungs. 



PAROTID TUMOURS 4*7 

Parotid cartilage. The nature of the cartilage-like tissue 
so common in tumours of the parotid gland is a puzzling 
question ; it resembles immature cartilage. Outside of the 
vertebrate kingdom, hyalin cartilage is rare. The best- 
known example is the capsule that supports the nerve- 
ganglia in Octopus. Gaskell made an elaborate investigation 
into the nature of the chondral tissue of the lamprey and 
the ammoccete : he found that the cartilage of the bran- 
chial bars differs in histology, staining reaction, and chemical 
constitution from hyalin cartilage. This tissue he called 
muco-cartilage, and the skeletal cartilage hard cartilage. The 
cartilage found in the tumours of salivary glands is derived 
from the tissues of the glands ; it differs from hard cartilage 
in structure and staining reaction, and resembles rnuco- 
cartilage. 

A critical consideration of the histological features of the 
tissue called cartilage in parotid tumours convinces me that 
it is not entitled to this distinction. 

Tumours of the parotid gland occur between the fifteenth 
and thirty-fifth years, but they have also been observed in 
septuagenarians. 

In adolescents they are often encapsuled and easily and 
safely removed. Care should be taken to remove the capsule 
with the tumour. Quickly-growing infiltrating tumours are 
difficult to extirpate. 

Occasionally a tumour will arise in and remain limited to 
the socia parotidis. 

Similar tumours occur in the submaxillary gland and in 
the mucous membrane of the hard and soft palate (Chap, 
vm), but they are rare. 

The principal features of parotid tumours are these : A 
tumour may arise in the gland and grow to the size of a 
walnut and remain stationary for ten, fifteen, or twenty years ; 
then, without warning, it enlarges, infiltrates the gland, causes 
pain, and kills the patient in a few months. In another 
person a tumour arises, grows quickly, ulcerates, and causes 
death in nine months. The microscopic features in each 
case are similar. 

Radium sometimes exercises beneficial effects on parotid 
tumours. 

2B 



REFERENCES 

Bell, Sir Charles, " The Nertous System." 1844. 

Cammidge, P. J.," An Improved Method of performing the Pancreatic Reaction 

in the Urine." Brit. Med. Journ., 1906, i. 1150. 
Cammidge, P. J., " The Relation of the Pancreas to Glycosuria." Proo. of 

XVItli International Congress of Medicine, London, 1913. 
Gaskell, W. H., " The Origin of Vertebrates." 1908. 
Hillier, W. T., and Goodall, J. S., "The Pancreas in Cases of Carcinoma." 

Arch, of Middx. Hasp., 1904, ii. 1. 
Waring, H. J.. "The Physiological Characters of Carcinomata." Journ. o 

Anat. and Phys., 1894, xxviii. 142. 
White, W. H,, "Carcinoma of the Pancreas." Clin. Journ., 1900, xvi. 97. 



CHAPTER XXXVII 
EPITHELIAL TUMOURS OF THE URINARY TRACT 

THE epithelium of the urinary tract has been studied with 
such care that the cells from its various parts can be recog- 
nized with certainty when they appear in the urine; they 
serve as valuable guides in clinical investigations, and enable 
a skilled observer to localize the seat of disease in many 
morbid conditions of the kidneys, ureter, and bladder. The 
kidneys serve for the elimination of waste products from the 
blood, and irritating chemical substances, as well as patho- 
genic micro-organisms, escape with the urine. In addition 
to the microscope, the use of the cystoscope secures accurate 
observations and aids the surgical treatment of renal and 
vesical tumours. 

Papillomas. In the pelvis of the kidney and in the bladder, 
papillomas often present themselves as long, branching, 
feathery tufts resembling chorionic villi ; hence they are 
often called villous papillomas ; but sessile, soft, conical or 
flat-topped warts are by no means rare. In structure they 
do not differ from the common forms of wart ; they consist 
of a vascular connective-tissue core surmounted by epithelium 
continuous with, and of the same type as that covering the 
part of the urinary tract in which they arise. These papillomas, 
being soft and vascular, are liable to bleed spontaneously ; 
thus hsematuria, sometimes alarming in amount, is an im- 
portant clinical sign. When papillomas grow in the renal 
pelvis, blood-clot and fragments of soft tissue, detached from 
the villi, escape down the ureter with the urine and cause 
colic like a migratory renal calculus. In 1870 Murchison 
found villous papillomas in both kidneys of a man aged 65, 
and a singular feature of the case was the presence of villi 
in the bladder around the orifices of the ureters. This 

419 



420 



RENAL PAPILLOMAS 



suggested that epithelial elements from the pelves of the 
kidneys had been conveyed by the urine to the bladder, and, 
like weeds in a brook, had implanted themselves on the 
vesical mucous membrane. 

It is certain that papilloinas arising in the renal pelvis 
may extend down the ureter ; moreover, it is reasonable to 




URETER 



Fig. 189. Kidney with villous papillomas growing iu its pelvis. 
(Museum of the Middlesex Hospital.} 

believe that minute epithelial tufts detached from papillomas 
implant themselves on the mucous membrane of the 
ureter* 

A woman aged 43 complained of intermittent ha3inaturia. 
Cope, by means of a cystoscope, detected blood escaping from 
the orifice of the ureter. The corresponding kidney being 
much enlarged, he removed it. This kidney was sacculated 
and contained two pints of bloodstained fluid ; the walls of 



CLOT-COLIC 



421 



its pelvis were thickly beset with papillomas, some of which 
had extended into and completely blocked the ureter. (Figs. 
190, 191.) 

Papillomas in the pelvis of the kidney not only lead 
to exhausting haematuria, but by obstructing the ureter 
impede the escape of urine from the kidney and cause 




Fig. 190. Kidney in section showing papillomas growing from the walls 
of the pelvis. The kidney is sacculated ; it contained two .pints of 
bloodstained urine. (Museum of the Royal College of Surgeons.} 

clot-colic ; this leads to dilatation of the renal pelvis and its 
calyces, and surely destroys the cortical substance of the 
kidney. 

Papillomas occur in the kidneys of men and women. 
This disease is uncommon before 40. It is often bilateral. 
When unilateral it simulates cancer of the kidney, and 
nephrectomy has often been performed under this impression. 
In the bladder villous papillomas may have broad attachment 
to the mucous membrane, or be. so narrow that they can 



422 



URETERIG PAPILLOMAS 



be described as pedunculated. Seen with the cystoscope in 
the living bladder, tliey are exquisite objects and resemble 
sea- anemones in an illuminated tank. Vesical papillomas 
may be solitary, but often two, three, or more are present 
in the same bladder. Occasionally there is one large villous 
tuft surrounded by smaller tufts of the size of peas ; they 
often occur at or near the orifice of the ureter, and, though 




Fig. 191. Kidney showing papillomas growing from its pelvis, invading 
and blocking the ureter. Same kidney as in Fig. 190. 

small, the tumour will give rise to serious changes in the 
corresponding kidney by obstructing the flow of urine from 
the ureter. When the papilloma is situated near the neck 
of the bladder the long villous tufts will sometimes be carried 
by an overflowing current of urine into the urethral orifice, 
and cause impediment to its free escape (Fig. 192). The 
delicate character of the villi and their vascularity are 
sources of danger, because the processes are sometimes 
torn, and the haemorrhage is occasionally so severe as to 



VESIGAL PAPILLOMAS 423 

place life in great peril. The epithelium of vesical papillomas 
is very active, and can engraft itself on the mucous membrane 
of the bladder. It is by no means rare for a crop of small 
implanted villi to arise around a central clump. The vitality 
of the epithelium is sometimes proved in a curious way : 
after the removal of the villi by cystotomy, papillomas have 
appeared in the operation-scar in consequence of fragments, 
detached from the villi, soiling the edges of the wound. 




Fig. 192. Papilloma of the bladder. From a man who passed fragments 
of villi for seventeen years. 

Clinical experience teaches that the removal of vesical 
papillomas apparently benign is often followed by a malig- 
nant recurrence, and it is now the rule to regard a collec- 
tion of villous papillomas in the bladder as a precancerous 
condition. It is also certain they may retain their inno- 
cency for many years. For papillomas of the bladder in 
aniline workers, see p. 431. 

Carcinoma. All parts of the urinary organs are liable 
to primary cancer. It is common in the bladder ; the kidney 
and prostate rank next in order of frequency. Cancer is 
rarest in the conduits the ureters and the urethra. 



424 RENAL CANCER 

Cancer of the kiduey. In this organ the disease begins 
in the renal epithelium and gradually destroys the kidney 
without violently distorting its shape (Fig. 193). The can- 
cerous tissue creeps into the renal pelvis and invades the 
ureter, extending sometimes to the bladder. This relation 
of cancer to the pelvis of the kidney and the ureter explains 




Fig. 193. Cancerous kidney in section. From a man aged 54. A cancerous 
outrunner appears in the ureter. 

the frequency of hsematuria as a clinical feature of this 
disease. In a man aged 45 a cancerous outrunner from 
the kidney extended along the renal vein and the inferior 
vena cava to the tricuspid valve and obstructed it. The 
symptoms simulated abdominal tuberculosis, typhoid fever, 
cancer of the splenic flexure of the colon, and infective 
endocarditis (French). 



RENAL GANGER 



425 



The histological characters of renal cancer consist of 
tubules lined with regularly arranged columnar epithelium. 
The general arrangement of these tubules presents a rough 
resemblance to the tubular structure of the kidney (Fig. 194). 
The disease disseminates mainly by the blood-vessels, and 
large outrunners invade the renal veins. 

Secondary growths may occur in any organ or tissue. 
The lung is a common situation. Cases have been reported 




Fig. 194. Microscopic appearances of a renal carcinoma. (Hartung.) 

of amputation for what were regarded as primary tumours 
in such bones as the humerus and fibula. Subsequently 
primary cancer has been found in the kidney. 

Cancer of the kidney is sometimes associated with the 
presence of a stone in the renal pelvis ; but renal cancer 
and calculus do not complicate each other so frequently as 
to give rise to the suspicion that the two conditions stand 
to each other as effect and cause. 

Cancer of the kidney is uncommon before middle life 



426 



RENAL GANGER 



and increases in frequency after 50. It is usually limited 
to one kidney. Hsemdturia is an important symptom asso- 
ciated with malignant tumours of the kidney. As long as the 
tumour is encapsuled and restricted to the cortex no blood 
appears in the urine, but as soon as it invades the renal pelvis 
bloody urine attracts attention and leads to the discovery of 
the tumour. The unilateral character of the disease comes 
out strongly when it attacks a horseshoe kidney, for even 




Fig. 195. Horseshoe kidney. One half contains a carcinoma. From a 
woman aged 60. (Museum of the Royal College of Surgeons.} 

under these conditions it is restricted to one half of the 
compound organ (Fig. 195). 

Renal carcinoma is a deadly disease : a study of the 
records shows that many of the patients who submit to 
operation die soon afterwards. This is partly due to the 
exhausting effects of the haematuria upon individuals ad- 
vanced in life. 

Patients who recover from the operation rarely live more 
than a year. Recurrence and dissemination are the rule. 



HYPERNEPHROMA 



427 



It has been estimated that 60 per cent, of the recurrences 
happen within the first year (Legueu). 

Hypernephroma. Small yellow nodules resembling fat are 
occasionally found under the capsule of the kidney, as a rule 
near its upper pole. Such nodules, called accessory adrenals, 
occur also on the under-surface of the liver. They have been 
critically studied by pathologists since Grawitz, in 1883, con- 
ceived that they might be the source of one kind of malignant 




V, \ 



Fig. 196. Sarcoma of the kidney supposed to arise from an adrenal 
"rest." Kemoved from a woman aged 42, during pregnancy. She 
was in good health five years later, in spite of having borne a child. 

tumour of the kidney, afterwards named hypernephroma. 
The chief peculiarity of these tumours is their supposed 
likeness in structure to the zona fasciculata of the adrenal. 

The renal tumours called hypernephromas are very vas- 
cular, and irruptions of blood into their soft tissue often 
convert them into spurious cysts containing a pulp which 
consists of blood and degenerate tissue (Fig. 196). This 
also happens with the secondary deposits. 

The following case-report illustrates some of the clinical 



428 ACCESSORY ADRENALS 

features, especially the chronicity and insidiousness occasion- 
ally exhibited by these tumours : 

A medical man aged 45 had a swelling in the lower 
end of the right humerus which he attributed to an injury. 
This swelling presented the usual clinical and radiographic 
features of a central tumour of bone. In September, 1912, I 
excised the lower fourth of the humerus ; he recovered with a 
useful arm. Indeed, the hand was more useful than any 
cunning contrivance made by man. 

The tumour was extremely vascular and had the naked- 
eye but not the microscopic characters of a myeloma. In 
February, 1915, I removed a recurrent nodule from the 
end of the stump. The doctor led a useful life till 1918. 
In this year he complained of pains in his lower limbs, 
and two months later died suddenly. The post-mortem ex- 
amination revealed an extraordinary set of lesions. The lower 
half of the right kidney was occupied by a plum-coloured 
tumour like the one removed from the humerus. The lumbar 
lymph-nodes were as big as ripe grapes and plum-coloured. 
Both adrenals were converted into plum- coloured masses as 
big as a fist (Fig. 197). The heart was much enlarged ; a firm 
nodule of tissue, the size of a nut, projected from the inter- 
ventricular septum among the cords of the mitral valve. 

Shaw Dunn has critically examined the specimens, and is 
convinced that the primary tumour was a Irypernephroma of 
the right kidney with dissemination. The key to the nature 
of the tumour was the firm secondary nodule from the septum 
of the heart. 

It has been proved by several critics that hypernephromas 
do not arise in the adrenal, and that adrenal rests prefer the 
upper pole of the kidney, whereas hypernephromas occur, as 
a rule,. in the lower pole. Most pathologists who have closely 
studied these tumours regard them as carcinomas arising 
in the epithelium of the renal tubules. 

Accessory adrenals. As soon as histologists made path- 
ologists familiar with the minute structure of accessory 
adrenals attached to the kidney, the latter began to hunt for 
them in the organs and tissues in the immediate neighbour- 
hood of the adrenals during foetal life. Periodical literature of 
the last twenty years contains descriptions of yellow nodules, 



HISTOLOGIC NOVELTIES 



429 



resembling in structure adrenal tissue, found in the spermatic 
cord, the broad ligament, and in relation with ovaries and 
testes. Most of these nodules may be considered as histo- 
logic novelties. There are no grounds for associating them 




Fig. 197. Kidney and adrenal in section. The adrenal is enlarged in 
consequence of secondary deposits from a hypernephroma of the right 
kidney. (Museum of the Royal College of Surgeons.') 

with the adrenals. Before this new phase was manifest, these 
small bodies so common on, or near, the ovaries, and which 
are yellow on section, >and often cystic, were described as 
supernumerary ovaries. Many "of them are small lutein cysts. 
Attempts are now being made to exalt them as the probable 



430 VESIGAL GANGER 

source of certain rare but malignant tumours of the ovary. 
This fantastic view has been critically considered by Glynn 
(1921). 

Cancer of the ureter. The terminal orifices of ducts are 
the favourite situations for primary cancer, e.g. the duodenal 
end of the bile-duct, the urethral orifice in both sexes, and 
the vesical as well as the dilated or pelvic portion of the 
ureters. It is, however, rare for cancer to arise in any part 
of the ureter between the renal pelvis and the bladder. 
Voelcker has recorded a case in which a primary carci- 
noma arose in the right ureter at the spot where it crosses 
the brim of the pelvis. The patient, a man aged 68, came 
under observation on account of hsematuria. At the post- 
mortem examination a tumour as big as a cherry, which on 
microscopic examination furnished the characters of car- 
cinoma, was found in the ureter. The lymph-nodes on the 
corresponding side of the aorta were infected. There was a 
large secondary mass of cancer in the liver, and there were 
nodules in the right lung, which agreed in their microscopic 
characters with the tumour in the ureter. 

Cancer of the bladder. In this viscus cancer is of the 
squamous-celled variety, and arises in the mucous mem- 
brane. From what is known of the habits of this disease 
elsewhere, it might be anticipated that in a certain propor- 
tion of cases it would begin at the orifices of the ureters. This 
is actually the case; but it must not be assumed, when the 
ureteral orifices are found involved in the late stages, that 
the disease originated in these orifices. 

Cancer of the bladder occurs in both men and women, 
and cystoscopic examination of the bladder shows that it 
is sometimes preceded by leucoplakia of the vesical mucous 
membrane. The symptoms of vesical cancer are hsematuria, 
painful micturition, and cystitis. These symptoms are often 
equivocal, and cancer when present is demonstrable by the 
cystoscope. 

Carcinoma has been observed on an extroverted bladder ; 
the patient was a man aged 60, who "had always earned 
his living by cracking stones" (Newland). 

Cancer is unusual in the bladder before the age of 40, 
and it is often preceded by villous disease. Death results 



URETHRAL GANGER 43 1 

from renal complications mainly due to sepsis, exhaustion 
from repeated bleeding, bodily suffering, and frequent mic- 
turition. 

Aniline cancer. In 1895 Rehn drew attention to the 
frequency of vesical tumours in men working in fuchsin. 
Since that date other amino-compounds have been incrimi- 
nated. The chief symptoms are cystitis and hsematuria asso- 
ciated with papilloma and carcinoma of the bladder. The 
lymph-nodes become infected, but visceral metastases are rare. 
These troubles arise in workpeople after the age of 40, and 
only after prolonged occupation in the industry. 

Bilharzial cystitis also leads to papilloma and carcinoma 
of the bladder. 

Treatment of vesical cancer. Operations for this disease are 
of two kinds (1) those performed to relieve the patient of 
frequency of micturition and the attendant pain, and (2) 
those which are directed to the extirpation of the cancer. 

A permanent suprapubic opening into the bladder gives 
great relief. The urine flows away as soon as it enters the 
bladder, and the patient quickly learns to manage the neces- 
sary tube and receptacle, and is not obliged to remain 
in bed. 

The more radical treatment consists either in removal of 
the tumour with the implicated segment of the bladder, or 
in complete extirpation of the vise us. In the case of women 
the ureters have been diverted into the vagina, and in the 
case of men into the rectum. It is a fact of some value that 
the rectum will accommodate a fairly large quantity of urine 
under such conditions. The results of complete removal of the 
bladder are not encouraging. Partial resection of the bladder 
is attended with better consequences, especially when the 
tumour is situated on or near its summit. When cancer 
involves the ureteric orifice, the tumour with the terminal 
segment of the ureter has been excised and the ureter trans- 
planted into the bladder with success. 

Cancer of the urethra. This is an extremely rare situa- 
tion for cancer. Nevertheless, there are some carefully 
recorded cases. The disease is of the squamous-celled variety, 
and usually arises in that part of the urethra which is in 
relation with the bulb. The patients were between the ages 



432 PROSTATIG CANCER 

of 50 and 73. The trouble in each instance attracted atten- 
tion as a hard mass in the perineum which interfered with 
micturition, and attempts to pass a catheter provoked great 
pain and induced free bleeding. The obstruction increased 
until the urethra became impermeable and fistulas formed in 
the perineum. In many of the cases perineal section was 
performed, and the cut surface of the tumour had a greyish- 
white appearance and was extremely brittle. 

Cancer of the urethra occurs, though rarely, in women ; it 
may be of the columnar-celled or the squamous-celled type. 
The first variety may arise in the urethral recesses known 
as Skene's tubes. Whitehouse has collected the literature. 

The free removal of the urethra in women for carcinoma 
usually entails incontinence of urine. 

Cancer of the prostate. Malignant disease of the prostate 
was formerly regarded as a comparatively rare disease until 
the method of enucleation became an established practice for 
the treatment of the common form of prostatic enlargement. 
Cancer of the prostate is now recognized as a fairly frequent 
disease, and its effects on this gland are somewhat variable. 
As a rule, the precancerous prostate is enlarged, hard, fixed, 
and tender on pressure. The gland lacks the smooth contour 
of the so-called adenomatous enlargement of the prostate, 
and its fixedness is another important clinical feature. The 
most insidious variety of prostatic cancer is one that leads 
to very little alteration in the size of the gland. 

Those surgeons who have had great experience of pros- 
tatic disease agree that cancer rarely supervenes on the 
common type of prostatic adenoma. 

Prostatic cancer is especially prone to disseminate, 
secondary deposits being found in the bones, especially the 
vertebrae, pelvis, femur, the other bones of the limbs, and 
the skull. In some instances a secondary mass in a long 
bone, such as the femur, has been so large as to be mistaken 
for a primary tumour. 

The antecedents of prostatic cancer are unknown. The 
disease is common in elders, and, like cancer in other situa- 
tions, extremely insidious. Interference with urination and 
occasionally hsernaturia induce the patient to seek advice 
and lead to the detection of the disease. 



PROSTATIG GANGER 433 

Treatment. Radical interference with prostatic cancer is 
rarely attended with any advantage to the patient. In cases 
where the surgeon has succeeded in excising the gland a 
rapid increase in the growth is the usual consequence, and 
is in a measure due to septic infection of the cancerous 
prostate. The usual practice is to relieve the patient by 
suprapubic drainage when the growth obstructs the vesical 
orifice of the urethra. 

The enlargement of the prostate which is so common 
after middle life, and is often termed prostatic adenoma, is 
the result of a slow, chronic inflammatory change. This 
subject has been thoroughly handled by Ciechanowski 
(1903). 

Ciechanowski, S., "On the so-called Hypertrophy of the Prostate Gland." 

1903. 
Newland, H. S., "Extroversion of the Bladder." Brit. Mcd. Jonrn., 1906, 

i. 964. 
von Recklinghausen, F.,' 1 Festschrift Rudolf Virchowzu seinem 71 Geburtstage 

gewidmet " Berlin, 1891. 
Voelcker, A. F M " Primary Carcinoma of the Ureter." Trans. Patli. Soe., 

1895, xlvi. 133. 



2c 



CHAPTER XXXVIII 

EPITHELIAL TUMOURS OF THE GENITAL 
ORGANS 

THE external genital organs are for the greater part directly 
continuous with and derived from the skin ; they are liable 
to squamous- celled cancer. 

Cancer of the scrotum (sweep's cancer). This appears 
on the scrotum in the form of a wart or warts ; they are often 
spoken of as " soot-warts," for they not only occur on the 
scrotum of the chimney-sweep, but are met with in others who 
are brought much in contact with soot. In many cases the 
scrotal wart is harmless, but in a certain proportion of cases 
it grows slowly, or, if multiple, one becomes more prominent 
than its fellows and ulcerates. The ulceration, at first limited 
to the wart, extends to the surrounding skin and forms a 
cancerous ulcer, which will extensively involve the scrotum, 
spread thence to the skin around the anus and pubes, and 
even to the thigh. In some cases the ulceration, instead of 
spreading widely, involves the tissues deeply, so that the 
tunica vaginalis is exposed and sometimes implicated in the 
disease ; but this is rare. 

The inguinal lymph-nodes become infected and attain a ' 
large size, then slowly involve the skin, break down and ulcerate. 
This process often leads to the formation of deep excavations 
in the groin, and it not infrequently happens that the femoral 
or the external iliac artery, or both, will be seen exposed and 
pulsating on the floor of one of these deep pits. It is not 
uncommon in such cases for the ulceration to open up one of 
these large vessels, and violent, fatal haemorrhage is the result. 

It has been stated by several writers that in chimney- 
sweeps cancer may begin in the inguinal lymph-nodes. 
There can be little doubt that such views arise in imperfect 

434 



SWEEP'S CANCER 435 

observation. In some of these cases the lesion on the scrotum 
assumes the form of a small hemispherical pimple no larger 
than a split pea so small, indeed, that I have known it 
escape very vigilant eyes and yet such a small lesion will 
cause the inguinal lymph-nodes to grow into a mass as big 
as two fists. Two cases of this kind have come under my 
own notice. 

A remarkable feature connected with cancer in English 
chimney-sweeps is, that they are not more prone to it in 
other parts of their bodies than those persons who follow 
other occupations ; yet the scrotum, which in other indi- 
viduals is the part least disposed to cancer, is in sweeps so 
very liable to become the seat of this disease. No answer to 
this problem is at present forthcoming ; neither has anyone 
succeeded in assigning a reason why scrotal cancer is so 
very much more frequent in English chimney-sweeps than 
in sweeps of other nations. 

Tar and paraffin are liable to produce an affection of the 
scrotum similar to sweep's cancer (see p. 294). The litera- 
ture has been summarized by Butlin. 

Treatment. This consists in the free removal of the 
disease whenever it is practicable ; the very best results follow 
the excision of a soot-wart in its earliest stages. When the 
disease is permitted to extend deeply into the tissues of the 
scrotum, so that it is necessary to excise one or both testicles 
with the scrotum, and perhaps a portion of the neighbouring 
skin, it is not probable that lasting benefit will follow the 
operation. In cases where soot-warts have been early and 
thoroughly removed, there is good ground for the belief that 
a cure is sometimes brought about. 

Cancer of the testis, This subject is discussed in 
Chap. LIX. 

Warts and cancer of the penis. These diseases may 
attack the prepuce or the epithelial investment of the glans. 
They are rare before the age of 30, and appear to be most 
common between 50 and 70. Phimosis, congenital or acquired, 
is a condition that favours cancer of the penis. It is cer- 
tainly true that phiinosis, by leading to the retention of 
smegma, is indirectly a cause of penile warts not only in 
men but hi other mammals dogs, horses, and bulls. 



436 CANCER OF THE PENIS 

Penile warts are liable to be transformed into wart-horns, 
and cases have been recorded in which men have had a wart- 
horn on the penis for many years before its base became the 
starting-point of cancer. Cases have been reported in which 
penile cancer arose in the scar of a syphilitic lesion. Cancer 
may begin as an ulcer on the penis, but the warty variety 
is by far the more frequent, When the disease begins as 
an ulcer it is very liable to be mistaken for some mani- 
festation of primary or tertiary syphilis. On the other hand, 
very great care must be taken not to mistake a breaking- 
down gumma of the glans penis for cancer. 

The cancer, in whatever form it begins, gradually involves 
and as surely destroys the penis, implicates the scrotum, and 
infects the inguinal lymph-nodes on each side ; in many cases 
the lumbar lymph-nodes also become infected. Secondary 
deposits seem to be rare. The duration of life in this 
disease is very uncertain. As a rule, its course is short six 
months to a year; but in many cases it is much longer. 
When the urethra is involved this passage becomes narrowed? 
and not infrequently urinary fistulae add to the patient's 
misery. 

Cancer of Cowpers glands. These structures are liable 
to inflame and become cystic, and there is also reason to 
believe that the gland may become cancerous. The most 
recent contribution to the subject is by Witsenhausen. 

Treatment. Cancer of the penis is treated by partial or 
complete removal of this organ, according to the extent of the 
disease. Partial removal of the penis is a simple proceeding, 
and entails but little risk so long as the cut end of the 
urethra is stitched to the skin. When the disease is so 
extensive as to demand complete removal of the penis, the 
operation which gives best results consists in excising not 
only the corpus spongiosum and corpora cavernosa, but the 
penile crura as well, by detaching them from the pubic arch. 
The urethra is brought out and attached to the incision in 
the perineum. In all cases where it is justifiable to amputate 
or extirpate the penis for cancer the infected inguinal lymph- 
nodes should be thoroughly removed. The published results 
of this complete operation are very good, and my experience 
of it has been in every way satisfactory. The ultimate results 



GANGER OF THE VULVA 437 

of amputation of the penis are more favourable after partial 
than after complete removal of the organ, because the disease 
is not so advanced when partial amputation suffices. 

Cancer of the vulva and vagina. The variety of cancer 
which attacks the external genital organs of the female, with 
the exception of Bartholin's glands, is squarnous-celled. 

Collectively, cancer of these parts is not uncommon, but 
when each part is individually considered, then it is compara- 
tively rare. The disease is more frequent in the labia than 
in all other parts of the genital passage taken together. 

The labia majora and minora. Carcinoma may begin 
on any part of the labia, but it generally attacks the opposed, 
or so-called mucous, surfaces. In many cases this is pre- 
ceded by leucoplakia, identical in appearance and structure 
with lingual leucoplakia. 

Careful inquiries in London indicate that cancer of the 
vulva is as common as cancer of the lip in men. During 
the decade 1898-1908, 58 women were admitted into the 
Chelsea Hospital for Women and the Middlesex Hospital 
with carcinoma of the vulva, and in all the patients the 
inner surfaces of the labia majora presented the condition 
known as leucoplakia. When the social histories of these 
women are analysed they are instructive, because of the 58 
patients 16 were widows, 34 married women, and 8 spinsters. 
These observations indicate that trauma connected with 
coition and childbirth are probably factors in producing 
the changes which render the epithelial tissues of the vulva 
liable to cancer. 

The relation of leucoplakic vulvitis and kraurosis of the 
vulva to cancer has been carefully investigated by Comyns 
Berkeley and Victor Bonney. In their valuable monograph 
they point out that kraurosis is not a forerunner of cancer. 

It is a significant feature in relation to vulvar cancer that 
trauma and infections connected with the sexual act play 
the same part in connexion with the labia that the habit of 
smoking short, dirty clay pipes and syphilis exercise on 
the mucous membrane of the lips. 

The disease runs a course very similar to squamous- 
celled cancer of the scrotum. When recognized in the early 
stages, prompt and free excision and removal of the infected 



438 GANGER OF THE VAGINA 

inguinal lymph-nodes are followed by much the same suc- 
cess as that attending operations upon cancer of the lip. In 
operating for cancer of the vulva the method which has 
given me the best results, immediate and remote, consists in 
freely excising the primary disease with the scalpel. Heal- 
ing usually takes place in fourteen days. The lymph-nodes, 
large and small, are then removed from both inguinal 
regions. Dividing the operation in this way avoids the risk 
of sepsis and diminishes shock and haemorrhage. 

The clitoris. Cancer of this organ is a rare disease; the 
majority of the patients are over 50. One example has 
come under my notice, and in this the disease began at the 
free extremity of the clitoris in a woman aged 45. 

The treatment consists in free removal of the clitoris and 
its crura, and removal of infected inguinal lymph-nodes. If 
the operation is carried out before the disease has extended 
to the nymphse, labia, or mons, the outlook for the patient is 
favourable. 

Bjorkquist has collected 67 cases from the literature. He 
considers the prognosis grave : in 20 patients death occurred 
within sixteen months. 

The vagina. Carcinoma may attack any part of the 
mucous membrane lining this canal, but it is much more 
prone to begin at the vulvo- vaginal junction. In the majority 
of cases which have come under my observation the cancer 
has been in the immediate vicinity of the urethral orifice. 
In every instance the patients were past middle life, and 
one was 73. The inguinal lymph-nodes are early infected. 
The cancer quickly implicates the vesico-vaginal septum 
and leads to fistula, and when it attacks the posterior wall 
it causes a recto-vaginal fistula. In one case the urethral 
orifice became blocked with cancerous granulation, and reten- 
tion of urine was a very distressing symptom. 

In the early stages cancer of the vagina produces so 
little inconvenience that the patients do not seek advice until 
the disease is far advanced. Surgery can do little in cancer 
of the vagina, for even in the very early stages free removal 
may anticipate some of the evils of the disease by establishing 
a vesical or a rectal fistula. 

Bartholins glands. It is well known that these glands 



GANGER OF THE VAGINA 439 

are liable to become cystic and are prone to septic infection : 
they are occasionally the seat of cancer. 

Schweizer (1903) and Spencer (1914) collected the chief 
reported cases of cancer of Bartholin's glands. The disease 
appears as a small, hard, tender lump, accompanied by 
severe pain which is increased by walking, menstruation, 
and coitus. The cancerous mass softens and ulcerates. The 
inguinal lymph-nodes are early infected. 

Among the reported cases the youngest patient was 28 
and the oldest 91. The course of the disease is very similar 
to that of cancer of the vulva. 

The normal acini of the gland contain columnar cells, 
and the duct squamous epithelium. Cancer of this organ 
is either squamous or columnar-celled. 

Treatment consists in free excision of the cancerous gland 
and extirpation of the corresponding inguinal lymph-nodes. 

CARCINOMA OF THE VULVA AMD THE SCROTUM 

Berkeley, C., and Bonney, V., " Leucoplakic Vulvitis and its Relation to Krau- 
rosis Vulvas and Carcinoma Vulvas." Brit. Med. Journ., 1910, ii. 1739. 

Bjorkquist, " Festschrift gewidmet Otto Engstrom." Berlin, 1903, p. 307. 

Butlin, H. T., " Cancer of the Scrotum in Chimney-Sweeps. " Brit. Med. 
Journ., 1892, i. 1341 

CARCINOMA OF BARTHOLIN'S GLANDS 

Schweizer, F., Arch. f. Gyn., 1893, xliv. 322. 
Spencer, H. E., Proc. Roy. Soc. of Med., 1914, vii. 102. 



CHAPTER XXXIX 
EPITHELIAL TUMOURS OF THE UTERUS 

ADENOMA, PAPILLOMA, AND ADENOMYOMA 

THE endometrium of the cervical canal and body of the 
uterus is covered with columnar epithelium ; it is continued 
through the Fallopian tubes to end at their coelomic ostia, 
where there is an abrupt transition to the pavement-like 
epithelium (endothelium) of the peritoneum. The epithelium 
of the cervical endometrium undergoes transformation at the 
external mouth (or os) of the uterus into the stratified or 
squamous-celled type that lines the vagina. The columnar 
cells within the uterus and Fallopian tubes are ciliated. 
Changes occur throughout any portion of this epithelial 
tract, but the vulnerability of the epithelium varies greatly 
in the different regions. 

The endometrium of the cervical canal is furnished with 
racemose glands (Fig. 198). These are probably the source 
of the little bodies described as ova by Martin Naboth of 
Leipsic (1704), and since known as the ovules of Naboth. 
They are round cystic bodies, usually the size of coriander- 
seed, with thick walls lined with epithelium and filled with 
mucus. Occasionally the ovules are so numerous as to give 
the cut surface of the cervix an appearance like honeycomb, 
only the cavities are circular and differ in size. They have 
neither pathological nor clinical import. 

It will be convenient to study the epithelial changes which 
are non-malignant before considering those of a cancerous kind. 

Adenomas. These arise in the glands of the cervical 
endometrium and imitate them structurally. They are very 
common and may be sessile or pedunculated. 

A sessile adenoma appears as a soft velvety areola 
around the os; in colour it is like a ripe strawberry and 

440 



ADENOMA OF THE UTERUS 441 

thickly dotted with minute spots of a brighter pink. This 
pink tissue is composed of glandular acini lined with large, 
regular, columnar epithelium (Fig. 199). The glandular tissue 
often extends beyond the margins of the os and invades the 
vaginal portion of the cervix. Sometimes it is so abundant 




Fig. 198. Microscopic characters of a gland from the cervicarendometrium. 

that the apex of the cervix, instead ol being a cone, assumes 
rather the shape of the under-surface of a mushroom. The 
glandular mass is not confined to the margins of the os, but 
extends for a variable distance up the canal. When adenoma 
affects a lacerated cervix the whole of the exposed portion of 
the canal is involved. The surface of a sessile adenoma is 
covered with tenacious mucus- secreted by the abnormal 
glands. 



442 ADENOMA OF THE UTERUS 

Pedunculated adenotnas are rarely large : they may grow 
from any part of the cervical canal, but are most frequently 
found springing from its lower 2 cm. As a rule they occur 
singly, but two or more may be present. They are soft, and 
dotted with minute pores. An adenoma consists of an axis 
of fibrous and sometimes muscle- tissue, covered with mucous 
membrane continuous with that lining the cervical canal. 
If these "polypi" remain within the canal, the epithelium 
covering them and the glands they contain are of the 




Fig. 199. Microscopic characters of the pink tissue at the neck of 
the uterus, commonly called an " erosion." (Bonney.} 

same character as those of the cervical mucous membrane. 
When the tumours increase in size and project into the 
vagina, the epithelium covering the protruding portions 
becomes stratified and the glands disappear. This muta- 
tion of epithelium can be studied on extruded fibroids (see 
p. 205) 

Adenoma of the cervix, clinically familiar as cervicitis 
or erosion, is very common in married women, and especially 
in those who have had children. It is due to bacterial infec- 
tion, and occurs also as a sequence of laceration of the neck 
of the uterus caused by delivery and operations. Adenoma 



PAPILLOMA OF THE UTERUS 



443 



of the cervix is frequently seen in virgins, and is caused by 
an ascending infection from the vagina. The condition is 
apt to be very chronic and resist treatment. The epithelial 
crypts furnish an annoying muco-purulent secretion commonly 
called " whites." 

Chronic adenoma (or erosion) of the neck of the uterus 
is now regarded as a precancerous condition, and the malig- 
nant cells of a cancerous cervix arise as ingrowths from the 
active epithelium of the adenomatous tissue. The form of 
this disease most clearly associated with cancer occupies the 




fFig. 200. Tubular glands of the corporeal endometrium in transverse section. 

clefts of a lacerated cervix. This pink tissue stands in the 
same relationship to adenoma and cancer of the cervix as 
chronic mastitis to adenoma and cancer of the breast. 

Adenomas growing from the corporeal endometrium are 
pedunculated, and so soft that they are often termed mucous 
polypi. They consist of cystic spaces lined with columnar 
epithelium, the cavities being filled with mucus. (Fig. 200.) 
Adenomas of the corporeal endometrium differ from those 
of the cervix in that the cystic spaces are larger and more 
numerous. 

Papilloma of the endometrium. This is a rare change, 
and in its typical form the uterine cavity is filled with villi 



444 



ADENOMYOMA 



structurally similar to "the villous disease so common in the 
bladder, for each villus has an axis of delicate connective 
tissue covered with a layer of columnar epithelium. The 
clinical signs are similar to those caused by cancer of the 
endometriurn, for which it is often mistaken even on micro- 
scopical examination. For example: A multipara, aged 83, 
complained of uterine bleeding, and 
fragments of the endoinetrium were 
obtained and pronounced to be can- 
cerous. Hysterectomy was performed, 
on this supposition. (Fig. 201.) After 
( the operation a re-examination indi- 
cated that the growths were papil- 
lomas and non-malignant, a view con- 
firmed by the subsequent history of 
the patient ; she survived the opera- 
tion eight years, and there was no 
evidence of recurrence or dissemina- 
tion. I have seen two other examples. 
In each the patient was a multipara 
who had passed the climacteric; in 
each, too, the uterus had been re- 
moved under the impression that it 
was cancerous. 

Adenomyoma. The detection and 
isolation of adenomyoma of the uterus 
is a matter of some interest. In 1896 
Prof, von Recklinghausen described 
the leading pathological features of 
the disease. Cullen reported some 
cases in the same year, and drew 
^tention to _ its clinical importance. 
Little attention was given to it in 
Great Britain, although examples of 

the disease were observed and recorded. One of the rea- 
sons, and perhaps the chief, which militated against the 
recognition of adenomyoma is the necessity for a micro- 
scopic examination of the tissue. As this change in the 
endometrium is often associated with fibroids, and the symp- 
toms caused by it are like those set up by submucous 




Fig. 201. Uterus in section, 
showing papillomas grow- 
ing from the endome- 



the operation eight years. 



ADENOMYOMA 



445 



fibroids, the real nature of the trouble in the uterus is often 
overlooked. Nevertheless, the tissue-changes in an adeno- 
myomatous uterus are so characteristic that they cannot be 
mistaken, and the naked- eye features, though they cannot 
be relied on without the confirmation afforded by a micro- 
scopic examination, are often sufficiently marked to lead the 
surgeon to suspect the presence of this disease. The change 
may involve the whole endometrium and produce uniform 




Fig. 202. Uterus in section, showing a localized patch of adenomyoma 
in the posterior wall. The gland- spaces were cystic and filled with 
gelatinous material. From a spinster aged 32. 

thickening of the walls of the uterus, and is occasionally 
mistaken for cancer of the corporeal endometrium. When 
the disease is limited to a particular area of the endometrium 
the appearances resemble very closely those associated Avith 
a submucous fibroid, but encapsulation is lacking. (Fig. 202.) 
In a typical example of adenomyoma the uterus is 
enlarged, and when the organ is bisected longitudinally the 
walls will be found thickened, sometimes to the extent of 
6 cm. or more. This increase is due to the formation of new 
tissue between the outer wall of the uterus and the super- 
ficial stratum of the endometrium. There is no attempt 



446 ADENOMYOMA 

at encapsulation, and the term diffuse, usually applied to it, 
is thoroughly justified. The cut surface of this adventitious 
tissue differs from that shown by common hard fibroids, 
for it never presents the vortex-like arrangement seen in 
them, but, when freshly cut, the surface has a pattern not 
unlike that of the fabric known as "watered silk." When 
the cut surface is critically examined it is sometimes possible 
to detect the new tissue, for there is a marked distinction 
between it and the true tissue of the uterus. 

In many instances the adenomyomatous change is 
localized to a definite area of the endometriurn, and in 
this way causes a prominence which may bulge on the 
mucous or on the serous surface of the uterus, and thus 
closely simulate a submucous or an interstitial fibroid. 
Occasionally small bodies project under the peritoneal coat 
of an adenomyomatous uterus, and resemble sessile and also 
stalked subserous fibroids ; these are bud-like processes of 
glandular tissue. Pedunculated processes of this kind are 
more common in the immediate neighbourhood of the cornua 
of the uterus, the walls of the organ being thinner here than 
elsewhere, because they are tunnelled by the Fallopian tubes. 
Adenomyomatous tissue consists of unstriped muscle-fibre 
disposed in an irregular manner : the spaces between the 
muscular bundles are filled with the peculiar stroma of the 
uterine mucosa, in which gland-tubules lined with columnar 
epithelium are embedded (Fig. 203). The amount of glandular 
element varies widely in different specimens. Occasionally 
the gland-spaces will be found dilated into cysts, and some 
of them are large enough to be obvious to the naked eye 
on the cut surface of the tumour. 

There is great variation in the proportion of the two 
tissues concerned in an adenomyomatous formation. When 
the myomatous element is in excess the uterus will be hard, 
and sections must be made through its whole thickness in 
order to detect isolated glandular tracts. In some hard 
specimens where the uterus is scarcely enlarged the gland 
islets sometimes lack the usual stroma. When the glandular 
elements are abundant the uterus is much larger than 
normal and its fundus may rise high in the hypogastrium ; 
such a uterus may measure 50 cm. in circumference. In 



ADENOMYOMA 447 

some specimens the glandular tissue may be so predominant 
that polypoid processes project into the uterine cavity. The 
naked-eye characters of such an endometrium resemble those 
of cancer, and the illusion is sometimes enhanced when the 
parts are examined microscopically, for the tubular glands 
in the diseased tracts are occasionally lined with a double 
row of epithelium. 

In the early investigation of this disease it was thought 
that the glandular elements were mainly derived from vestiges 
of the Miillerian and Wolffian ducts; the frequency of the 




Fig. 203. Microscopic appearances of diffuse adenomyoma of the 
uterus. X 60. (F. E. Taylor.} 

glandular formations at the tubal angle of the uterus gave 
some slender support to this opinion. No one seriously 
entertains this view, and all recent histologic inquiries indicate 
that the glandular tracts are derived from the uterine mucosa. 
When isolated sections of the adenomyomatous tissue are 
examined the glandular areas appear as islets, but when a 
consecutive series of sections is examined the various tracts 
will be found to run into each other, and, if the investigation 
be conducted on a sufficiently large tract of tissue, it is pos- 
sible to follow them up until they become continuous with 
the normal endometrium. Since the disease has been more 



448 ADENOMYOMA 

widely recognized, attention has been directed to the frequency 
with which infective diseases of the Fallopian tubes are asso- 
ciated with adenomyomatous disease. Chronic tubal disease 
is an occasional complication of subinucous fibroids, but 
chronic pyosalpinx and hydrosalpinx are often found asso- 
ciated with adenomyomatous disease of the uterus, and 
evidence of chronic infection is often obvious on the peri- 
toneal surface of uteri so affected. Indeed, evidence is 
accumulating that the tissue - change which characterizes 
adenomyorna is the result of microbic infection. It is an 
epithelial overgrowth with a responsive increase of the tissue 
in which the glands are implanted. This epithelial activity 
is promoted by micro-organisms, and the frequency with 
which the relics of inflammatory action are found in con- 
nexion with adenomyomatous changes supports this view. 
Cases have been reported in which tuberculous foci occurred 
in the midst of typical adenomyomatous tissue (Fig. 204), 
and tuberculous tubes have been found in association with 
adenomyoma of the uterus. 

The leading clinical features of adenomyoma may be 
summarized thus : It is most frequent between the thirtieth 
and fiftieth years, and has been observed as late as 60. It 
occurs in nulliparous spinsters and barren women as well 
as in those who are fertile. One of my patients with this 
disease had borne fourteen children. 

The symptoms of which the patients complain are pro- 
fuse menorrhagia, and in severe cases sanguineous fluid 
may flow from the vagina, sometimes for tive or six weeks 
without intermission. Pain at the menstrual period is fairly 
common. 

On physical examination the uterus is found to be bigger 
than normal, and in some cases the enlarged fundus may 
rise high in the hypogastrium. The contour of the uterus 
may be quite smooth, but in many instances it is irregular. 
This unevenness may be due to the localization of the 
adenomyomatous tissue to one wall of the uterus, or the 
disease may be complicated by the presence of subserous 
or interstitial fibroids. 

It will be seen that these signs and symptoms are those 
which commonly accompany a subinucous uterine fibroid, 



ADENOMYOMA 



449 



and it is under this impression that operative treatment is 
most commonly recommended and undertaken. These are 
also the signs furnished by fibrotic uteri. When adenomyo- 
matous changes in the uterus are complicated by chronic 
bilateral infections of the Fallopian tubes the nature of the 
affection is very liable to be overlooked. It has been men- 
tioned already that a shrewd and experienced observer 
may suspect adenomyornatous disease before operation 




Fig. 204. Uterus laid open by a vertical incision. The endometrium on 
the anterior wall is occupied by an unencapsuled mass of tuberculous 
adenomyomatous tissue. From a spinster aged 46. She was in good 
health six years after the operation. 

even then the use of the microscope is indispensable for its 
identification. 

The uterus has been removed for what is often described 
as an adenocarcinoma of the body of the uterus ; and it is 
probable that many of the cases where the women have 
remained free from recurrence were in reality examples 
of adenomyoma. Simulation of cancer is an important 
feature of this disease 

The only effectual mode of dealing with the disease is 
removal of the uterus, either by the vagina, or preferably 

2D 



45o ADENOMYOMA 

by the abdominal route. Subtotal hysterectomy with con- 
servation of an ovary gives admirable results, immediate 
and remote. Even in those cases in which the adenomyo- 
matous mass was complicated with tubercle the patients 
made excellent recoveries, and the condition of these women 
many months after operation is stated in the reports to have 
been excellent. It is also worthy of note that no instance 
is recorded in which hysterectomy has been performed for 
this disease and the patient has again come under observation 
with recurrence. 



CHAPTER XL 

EPITHELIAL TUMOURS OF THE UTERUS 

(concluded) 

CARCINOMA 

IN preceding chapters it is clearly set out that the leading 
features of carcinoma are its undoubted origin in epithe- 
lium, its invasiveness, and its proneness to attack organs 
chronically diseased. In addition, cancer infects lymphatics, 
disseminates, and is easily infected by pathogenic micro- 
organisms. The lethal effects of cancer are retarded or 
accelerated according to the environment of the organ 
primarily affected. The natural history of uterine cancer 
is very instructive in all these matters. 

Cancer arises in any part of the epithelial investment 
of the uterus, from the squamous cells covering the vaginal 
portion of its neck to its termination at the coelomic ostiurn 
of the Fallopian tube. The vulnerability of the uterine and 
tubal epithelium varies very greatly. Cancer in the cervical 
segment of the uterus is very common, less frequent in the 
endometriurn of the uterine cavity, and rare in the tubes. 

Carcinoma of the neck of the uterus. This part of the 
uterus is liable to squamous-celled and columnar-celled cancer, 
according to the situation in which it arises. When the 
disease arises in the vaginal portion of the neck and this is 
the common situation it is of the squamous-celled variety; if 
it starts in the cervical endometrium the cells are columnar. 
Strictly, cancer arising in the epithelial cap covering the 
vaginal portion of the cervix uteri should be regarded as 
vaginal cancer, but for clinical reasons it would be an un- 
practical arrangement. Some writers fix the proportion of 
squamous-celled cancer of the neck of the uterus as high 
as 98 per cent. 

Clinical observation teaches that cancer of the cervix 

451 



452 GANGER OF THE CERVIX 

uteri is almost exclusively confined to women who have been 
pregnant, and that fecundity increases the liability. It is 
stated on p. 442 that the chronic inflammatory condition 
in the neck of the uterus known as cervicitis, or erosion, 
is particularly associated with epithelial changes. Histo- 
logical investigations show that it must be regarded as a 
precancerous condition. 

Although the ultimate results of cancer arising in the 
cervical endometrium, or on the vaginal aspect of the cervix, 
are the same, it will be advisable to discuss their pathologic 
features separately. In the majority of patients who come 
under observation, particularly in hospital practice, the disease 
has already destroyed, or eroded, the neck of the uterus to 
such an extent that it is impossible to determine whether 
it arose in the cervical canal or on the vaginal surface ; never- 
theless, patients do occasionally come under observation at 
a sufficiently early stage to enable an exact localization of 
the primary focus of the disease to be made. It may appear 
as a circular ulcer with raised and everted edges, or it 
erodes the tissues deeply at the outset ; exceptionally it 
forms luxuriant warty excrescences. The cancer infiltrates 
the cervix, extends to and implicates the vaginal wall, and 
involves the tissues of the mesometrium. Cancer also arises 
in the epithelium in any part of the cervical canal or its 
glands, but it appears to be more prone to arise in the lower 
than in the upper half of the canal. It begins either as a 
deeply eroding ulcer, or as a soft, fungating, vascular, cauli- 
flower-like outgrowth. Commonly the cancer, after infiltrat- 
ing the adjacent tissues of the cervix, spreads into the 
mesometrium and implicates the vaginal wall. It ulcerates 
early, destroys the cervix, and spreads into the body of the 
uterus ; in the late stages this organ may become hollowed 
out by ulceration until nothing remains but a thin layer 
of muscle-tissue covered by peritoneum. When a uterus 
hollowed out in this way has its cervical canal obstructed 
by cancer, the uterine cavity becomes distended with pus. 
This condition is known as pyometra. The pus sometimes 
escapes intermittently. 

The microscopic features of cancer arising in the cervical 
epithelium consist of round spaces filled with columnar epi- 



GANGER OF THE CERVIX 



453 



thelium. This depends on the fact that the invasion of the 
tissues is due to columns of epithelium, and in the micro- 
scopic sections these cell-columns are represented cut at 
right angles (Fig. 205). 

Cancer of the cervix permeates the lymphatics and infects 
the pelvic and lumbar lymph-nodes. It invades the meso- 
metrium and the walls of the vagina, so that urinary and 
faecal nstulse often complicate the late stages of the disease. 




Fig. 205. Microscopic characters of cancer of the cervix. 

Dissemination occurs in the lungs, liver, and bones, but it 
is uncommon. When the mesometria are extensively in- 
filtrated the ureters become involved ; this leads to dilatation 
of the renal pelves. Cystitis is a common complication 
of cancer of the cervix, and causes suppurative pyelitis 
and nephritis. A large proportion of patients affected with 
cancer of the uterus exhibit marked uraemic symptoms in 
the later stages of their lives. Among other complications of 
cancer of the cervix, especially when it extends to the body of 
the uterus, must be mentioned pyosalpinx and hydrosalpinx. 



454 



GANGER OF THE CERVIX 



In these cases the dilated tubes are rarely thicker than the 
thumb, but they are a source of danger, inasmuch as perfora- 
tion occasionally occurs and sets up infective peritonitis. Ex- 
ceptionally, cancer perforates the body of the uterus. When 
this happens, peritonitis may ensue and quickly cause death ; 
in some instances the carcinomatous material becomes dis- 
tributed over the peritoneum, and small knots form upon 

Infiltrated ovary. 



Uterine cavity. 



Wall of bladder. 



Cancer. 



Cervical canal. 



Vagina. 



Fig. 206. Cancerous uterus in sagittal section. 

the surfaces of the intestine, liver, spleen, etc. This distri- 
bution of the cancer may lead to an effusion of bloodstained 
fluid into the belly, sometimes in considerable quantity, or 
to agglutination of coils of intestine, each cancerous nodule 
being the focus of a limited area of peritonitis. Occasionally 
actual perforation of the uterus is prevented by a piece of 
intestine becoming adherent to the uterus at the spot where 
the disease is approaching the surface. 

Cancer of the neck of the uterus is very common between 
the ages of 40 and 50 ; many cases occur between 30 and 40. 




GANGER OF THE CERVIX 



455 



Before the age of 30 the disease is rare, but I have observed 
undoubted cases in women of 23, 25, and 26 years of age. 
It belongs especially to the latter part of the child-bearing 
period of life ; it is almost exclusively confined to women 
who have been pregnant. Critical inquiry shows that injury 
associated with coition or with child-birth (but more particu- 




Fig. 207. Pelvis and viscera in section. From a case of cancer of the 
cervix in its late stages. 

larly the latter) is a potent factor in producing the changes 
which render the epithelium in this situation liable to can- 
cer, and it is disappointing to find that fecundity increases 
this liability. 

A remarkable record bearing on this matter has been 
published by Czerwenka. A woman aged 35 had a double 
vagina and uterus bicornis bicollis. Coitus was practised 
in the left vagina. The left cervix was cancerous, the 



456 



GANGER OF THE CERVIX 



left uterus contained two fibroids, and the corresponding 
Fallopian tube contained pus and its ccelomic ostium was 
occluded. 

The signs of cancer of the cervix are bleeding, offensive 
discharges, and sometimes pain. The first two signs are those 
which usually lead women to seek advice. In the early stages 
the margins of the os will be found everted, and a fungous 

Ovary infiltrated with cancer. 



Fallopian tube. 

Ureter. 

Round ligament. 

Occluded ureter. 
Cancer-mass. 




Vesical orifice 
of ureter. 



Fig. 208. Cancer of the neck of the uterus implicating 
the bladder and the ureter. 

mass protrudes from the canal, which bleeds on the slightest 
touch. In the late stages (Fig. 207), when the neck of the 
uterus is destroyed and replaced by an ulcerating cancerous 
mass, there is no difficulty in recognizing the nature of the 
lesion. 

Cancer of the uterus terminates in a variety of ways : 
1. The uterine artery may be opened by ulceration, and 
fatal haemorrhage ensue. 



GANGER OF THE UTERUS 457 

2. Repeated bleeding due to smaller arteries being eroded 
will often lead to exhaustion and death. 

3. Implication of the bladder and one or both ureters (Fig. 
208) causes cystitis, septic pyelitis, and ureemia. Some 
observers fix the frequency of renal complications in this 
disease as high as 70 per cent. 

4. Septic changes in the uterus extend to the Fallopian 
tube and cause pyosalpinx. 

5. Peritonitis may be caused by rupture of a pus-containing 
Fallopian tube. 

6. Intestinal obstruction may follow adhesion of a piece 
of small or large intestine to the uterus, or direct extension 
of the cancer into the rectum. 

7. Hydroperitoneurn and hydro thorax may arise from the 
presence of secondary nodules of cancer on the peritoneum or 
pleura. 

8. The cervical canal sometimes becomes occluded, and 
the cavity of the uterus is thus distended with pus (pyo- 
metra). The chief danger in this complication is due to the 
Fallopian tubes becoming secondarily distended with pus, 
which occasionally leaks into the peritoneum, with lethal 
results. 

Cancer of the cervix is sometimes complicated with other 
lesions of the genital organs, such as ovarian cysts and 
tumours, fibroids, etc. 

Treatment. The only treatment available for cancer of 
the neck of the uterus is early removal of the whole uterus 
a method practicable in only a small percentage of women, 
because the disease arises and spreads very insidiously : it 
infiltrates adjacent parts such as the vagina, bladder, rectum, 
and the vesical portions of the ureters, precluding opera- 
tive interference. Operations have been introduced by Hies, 
Mackenrodt, Diihrssen, and Wertheim which enable surgeons 
to remove not only the uterus and its neck and the upper 
part of the vagina, but the Fallopian tubes, broad ligaments, 
pelvic lymph-nodes, and the para-uterine connective tissue. 
Some gynaecologists even advocate the excision of the ter- 
minal portions of the ureters and parts of the wall of the 
bladder when these parts are involved in the cancer. These 
very extensive operations are attended with a high mortality. 



458 SEPSIS AND GANGER 

The results of operations on cancer of the neck of the uterus 
are largely influenced by the septic condition of the cancerous 
tissue. 

Sepsis in relation to cancer of the uterus. The results of 
the removal of the uterus for cancer are by no means uni- 
form even when the conditions are apparently similar. The 
microscopic features of cancerous growths do not help in 
explaining variations in the clinical course of the disease. 
Patients in the advanced stages of uterine cancer, wasted 
by discharges of blood and purulent fluid, fall into a con- 
dition which used to be called the cancerous cachexia. This 
appearance has no special relation to cancer : it is due to 
the entrance into the circulating blood of toxic substances 
secreted by the bacteria and cocci which colonize cancerous 
growths. These micro-organisms influence the work of the 
surgeon very markedly. Cancer of the uterus is colonized 
by staphylococci, streptococci, and the coli group. The fate 
of a patient submitted to hysterectomy for cancer of the neck 
of the uterus depends not so much on the skill of the surgeon 
as on the nature of the infecting micro-organism. 

Many patients submitted to hysterectomy for cancer of 
the neck of the uterus die within a few days of the opera- 
tion from septic peritonitis, pulmonary embolism, or acute 
bacterisemia, when the cancerous tissues are colonized by 
streptococci. It cannot be too emphatically stated that the 
virulence of cancer, as a rule, depends on its septicity, and 
cancers in exposed situations are rapidly destroyed by bac- 
teria. It is also true that cancers, as a rule, grow and remain 
unsuspected in internal organs until they become septic ; then 
they are painful or bleed as a result of their disintegration 
by ulceration. 

Palliative treatment. In many cases where no operation is 
possible, much may be done to make the patients comfortable. 
Careful nursing keeps them clean, free from bedsores and 
fcetor a difficult matter when a woman has a fsecal or a 
urinary fistula, or both. Pain may be alleviated by phen- 
acetin or the judicious use of morphia. 

Radiology. The use of radium as an auxiliary in the 
treatment of cancer of the uterus has attracted great atten- 
tion. At present it has been used extensively in patients 



GANGER AND PREGNANCY 459 

with inoperable cancer; in many instances it reduces the 
haemorrhage and diminishes the discharges, and it leads 
occasionally to a reduction in the size of the growth. It is 
probable that such changes are, in a large measure, due to 
the destructive effects of the gamma rays of radium on the 
micro-organisms in the cancerous tissues. It also destroys 
the epithelial elements of cancer and leads to the formation 
of tough sclerotic tissue. This is a matter of some interest. 
When a patient with cervical cancer suffers from haemorrhage, 
if the cervix be submitted to radium rays the bleeding will 
be checked and the growth shrinks. Three weeks after the 
treatment, if the uterus is removed, the tissues in the vicinity 
of the neck of the uterus will be found tough and hard ; this 
makes the separation of the uterus from the bladder a matter 
of difficulty. Recurrent nodules of cancer often shrivel in a 
remarkable manner after an application of radium. Occa- 
sionally the use of radium is followed by an unusually rapid 
increase of the cancer; the injudicious and inexperienced use 
of this powerful agent may lead to sloughing of the vagina 
and the formation of a recto-vesical or a vesico-vaginal 
fistula. 

At present the results of radium in the treatment of 
uterine cancer are far from uniform. Histological inves- 
tigations indicate that radium rays find distinctions in 
cancerous tissue imperceptible to the microscope. Occa- 
sionally startling successes are reported, but the experience 
of the majority of surgeons is decidedly disappointing. 

Cancer of the cervix and pregnancy. The most appalling 
complication of pregnancy is cancer of the neck of the 
uterus. It is somewhat difficult to understand how a woman 
with cancer of the neck of the uterus can conceive, but it is 
quite certain that it happens, and the complication is not 
uncommon. Cases in which cancer in this situation obstructs 
delivery are unusual, and this is due to two circumstances : 

1. Cancer of the neck of the uterus predisposes to 
abortion. 

2. When it has advanced to such a stage as to fill the 
vagina with an obstructive mass, the disease- has such an 
effect upon the health of the mother that the life of the 
foatus is imperilled. 



460 GANGER OF THE UTERUS 

The second conditipn is of importance, because in con- 
sidering the advisability of Csesarean section in these circum- 
stances it is well to be satisfied that the foetus is alive. In 
very exceptional cases it has been found necessary to resort 
to this operation in order to deliver a dead and putrid foetus. 

The careful study of the literature relating to this compli- 
cation shows clearly enough that when a pregnant woman 
with recent cancer of the uterus comes under observation in 
the early months, her best hope lies in vaginal hysterectomy. 
In the later stages (fourth to the seventh month) very good 
consequences have followed amputation of the cervix, and 
this operation has been successfully performed without dis- 
turbing the pregnancy. In the latest stages the best conse- 
quences have followed the induction of labour and the 
immediate performance of vaginal hysterectomy for, surpris- 
ing as it may seem, the uterus enlarged by pregnancy can be 
safely extirpated through the vagina. 

These methods of treatment only apply to cases where the 
cancer is in such a condition as to afford reasonable hope of a 
prolongation of life. When the disease is in an inoperable 
stage and the foetus is dead, abortion usually occurs. Where 
there is reliable evidence that the foetus is alive, the preg- 
nancy should be allowed to go to term ; if the cancer affords 
an impassable barrier to the transit of the child, then Csesarean 
section becomes a necessity. 

Cancer of the body of the uterus. This is much less 
frequent than cancer of the neck of the uterus. It arises in 
the epithelium lining the uterine cavity. There is very little 
accurate knowledge regarding its early stages, and I have 
had only one opportunity of obtaining a cancerous uterus 
before the disease had extended to the muscular wall. The 
disease remains for a long time restricted to the body of the 
uterus, and may creep into the uterine sections of one or 
both Fallopian tubes ; it rarely invades the cervix, and then 
only in the late stages of the disease. It is apt to perforate 
the wall of the uterus and infect the peritoneum. 

It is only during the last twenty years that the importance 
of cancer of the body of the uterus has been clearly appre- 
ciated, and this is due to the fact that there were no means 
available for the proper examination of the interior of the 



GANGER OF THE UTERUS 461 

organ, and, as a result, the descriptions of diseases of the 
endometrium were obscured by a crowd of terms such as 
senile endometritis, malignant endornetritis, villous endo- 
metritis, and so on. When the plan of mechanically dilating 
the cervical canal was introduced, so that the endometrium 
could be examined and fragments obtained for the laboratory, 
it became possible to make an accurate diagnosis. 

As in other organs, cancer of the corporeal endometrium 




Fig. 209. Cancerous uterus in sagittal section. A bud-like process of 
cancer has eroded the uterine wall and protrudes on the peritoneal 
surface. The peritoneum was dotted with thousands of secondary 
nodules. 

consists of cell-columns : the cells being identical with the 
epithelial investment of the endometrium. The disease as- 
sumes two forms. Commonly it gives rise to luxuriant soft, 
succulent, vascular masses projecting into the cavity of the 
uterus ; this variety is sometimes called villous endometritis. 
The rarer form is an eroding cancerous ulcer that penetrates 
the muscular wall of the uterus. The luxuriant variety 
sometimes penetrates the uterine wall, and cancerous buds 
appear on the serous surface (Fig. 209) ; small fragments 
of cancer are detached, some of which become implanted on 



462 GANGER OF THE UTERUS 

the peritoneal surface of the bowel and ovaries. A multitude 
of such nodules are sometimes produced in this way, and 
occasionally large masses of cancerous tissue grow on the 
omentum from such implanted particles. 

In clinical work we describe very definitely cancer of the 
cervix and cancer of the body of the uterus; it is well to 
realize that after the uterus has been removed it is some- 
times difficult, on examining it, to be satisfied whether the 
disease arose in the body of the organ or in the upper 
segment of the cervical canal. 

Cancer of the corporeal endornetriurn is unusual before 
the forty-fifth year ; it is most frequent at, or subsequent 
to, the menopause. The majority of the cases occur between 
the fiftieth and seventieth years. A large proportion of the 
patients are nulliparw. 

The patient's attention is usually attracted by fitful 
haemorrhages after the menopause, followed by profuse and 
offensive discharges which are often bloodstained. The 
uterus on examination may feel scarcely enlarged ; some- 
times it is much bigger than usual. It is not uncommon, 
especially in aged spinsters, for cancer of the body of the 
uterus to cause little disturbance until it disseminates in 
the abdomen and causes hydroperitoneum. This leads to an 
investigation and the discovery of cancer in the uterus. 

Treatment. Cancer of the body of the uterus entails 
complete removal of the organ, including its neck, by the 
abdominal route. The ovaries, Fallopian tubes, and broad 
ligaments are removed with the uterus. If the lymph-nodes 
of the pelvis are enlarged and signs of dissemination are 
obvious on the peritoneum, omentum, or intestines, it is 
useless to remove the uterus. Hysterectomy for cancer of 
the body of the uterus is followed by better consequences, 
immediate and remote, than when the operation is performed 
for this disease in the cervix. 

Variations in malignancy. Cancer varies widely in its 
malignancy in nearly all the situations in which it grows. 
As a rule, cancer in the neck of the uterus runs its course 
more rapidly than the same disease inside the uterus. This 
is due in a large measure to accidental circumstances, espe- 
cially to the facility with which cancerous tissue becomes 



GANGER OF THE UTERUS 463 

septic. Observation also shows that cancer of the corporeal 
endometrium becomes septic more quickly in a multiparous 
than in a barren woman. The objective sign of sepsis in con- 
nexion with uterine cancer is haemorrhage. 

The infection of cancerous organs by pyogenic micro- 
organisms makes the labours of surgeons comparable with 
those of Sisyphus. A careful study of the results published 
by those surgeons who are making earnest and praiseworthy 
efforts to relieve, by surgical means, women suffering from 
cancer of the neck of the uterus, shows that it is not the 
technical difficulties which baffle, but the difficulty of con- 
trolling the sepsis. It is this which accounts for the high 
mortality of what is known as the radical operation for cancer 
of the cervix ; and among the various micro-organisms which 
lurk in cancerous tissues the virulent streptococcus is fre- 
quently found. 

Cancer of the uterus and fibroids. Uterine fibroids are 
very common, so is cancer of the uterus, and, as the maxi- 
mum of frequency in relation to age is very nearly the same 
in the two diseases, it is not a matter for surprise that they 
should often coexist. The subject may be conveniently con- 
sidered under two headings : 

1. Cancer of the neck of the uterus coexisting with 

fibroids. 

2. Cancer of the body of the uterus complicating 

fibroids. 

1. Cancer of the cervix and fibroids. The special danger 
of this combination depends on the fact that it is liable 
to be overlooked, because the most prominent clinical feature 
of fibroids, as well as of cancer of the uterus, is bleeding. 
When a patient with uncomplicated cancer of the neck of 
the uterus comes under observation, the disease is almost 
certainly recognized ; but when a woman known to have a 
fibroid in her uterus complains of more than usual bleeding 
she is not so likely to be made the subject of routine ex- 
amination, hence the disease remains for an indefinite time 
unsuspected and therefore undetected. There is also another 
danger : when cancer attacks the parts around the mouth of 
the womb its detection is a fairly simple act ; but there is a 
fair proportion of cases in which the disease begins a short 



464 GANGER AND FIBROIDS 

distance up the canal, and is easily overlooked ; the higher 
up the canal the disease is situated, the more probable the 
chance that it will escape detection. If the uterus contains 
fibroids the chances are very great that the bleeding will 
be attributed to them and the existence of cancer will be 
entirely overlooked. Anyone who follows carefully the pub- 
lished accounts of hysterectomy for fibroids of the uterus, 
or has had a wide experience of the operation, knows that 
a surgeon while performing subtotal hysterectomy examines 
the cut surface after he has detached the body of the uterus 
from the cervix, and if it looks suspicious, and he realizes 
that it is cancerous, the neck of the uterus will be excised. 
In a few cases subtotal hysterectomy has been performed, 
and the patient, after recovering from the operation, had 
recurrence of the bleeding, and consulted the surgeon, who 
then found that he had overlooked a cancerous cervix. 

This matter may be summarized thus: It is by no 
means uncommon for a woman known to have fibroids in 
her uterus to lead a tolerably comfortable life, in spite of 
profuse or even long-drawn-out menstrual periods. Occasion- 
ally a patient of this kind suddenly experiences a marked 
increase in the flow, or has what she terms a " flooding," 
becomes alarmed, and seeks advice. Cases of this kind 
require careful consideration, for this alteration in the symp- 
toms may indicate changes in the fibroid, or the supervention 
of cancer. If the patient is a spinster, or married but barren, 
there may be concurrent cancer of the body of the uterus. 
If married and fertile the coexistence of cancer of the cervix 
must be considered ; and it is well to bear in mind that 
an early cancer a short distance up the cervical canal will 
give rise to bleeding but escape detection by the examining 
finger. 

When the body of the uterus has been removed for 
fibroids by an operation known to surgeons as subtotal 
hysterectomy, cancer has occurred in the cervical stump at 
such an interval after the operation as to make it certain 
that it did not exist at the time the body of the uterus 
was removed. 

2. Cancer of the body of the uterus complicating 1 fibroids. 
This is not an uncommon combination. Cancer of the cor- 



GANGER AND FIBROIDS 4^5 

poreal endometriuin, or, as it is more commonly called in 
clinical reports, cancer of the body of the uterus, is most 
frequent at or subsequent to the menopause. The majority 
of the patients are between the fiftieth and seventieth years ; 
and a large number of the patients are spinsters or barren 
wives. When a woman complains of irregular uterine bleeding 
after the menopause an examination is, as a rule, promptly 
made, and efforts are particularly directed to determine the 
existence or non-existence of cancer. Many women with 
fibroids do not cease to menstruate, or at least to suffer from a 
more or less regular loss of blood, for many years after the 
normal age for the menopause. When cancer of the body of 
the uterus arises in such a patient it is extremely liable to be 
overlooked. 

If a woman known to have a fibroid in her uterus 
attains the menopause and remains free from monthly losses 
for a few years, then suddenly begins to have "issues of 
blood," this may be due to cancer of the body of the uterus. 
Such symptoms demand the most careful examination. 

The matter may be put in an aphoristic form : When a 
woman with uterine fibroids, having passed the menopause, 
begins to have irregular profuse uterine haemorrhages, it is 
extremely probable that she has cancer of the body of the 
uterus. 

It occasionally happens that a patient with fibroids attains 
her menopause and remains free from losses of blood ; in a 
few years the fibroids may become infected and bleeding 
occur as a sequel. 

It is not uncommon for surgeons, when performing 
hysterectomy on women over 50, under the impression that 
the uterus contains a fibroid, to find the uterus filled with 
cancer. On the other hand, the uterus is sometimes extir- 
pated under the impression that it is cancerous, and a 
degenerating fibroid is found. There is a third picture : 
Women known to have a fibroid in the uterus for many 
years are submitted to hysterectomy because the tumour 
has of late become troublesome ; after the operation the 
uterus is examined and the surgeon is surprised to find a 
patch of cancer in the endometrium, as well as the fibroid. 
Cancer of the endometrium may be associated with very 



466 GANGER AND FIBROIDS 

small submucous fibroids. Size does not count. I have 
seen the combination in a small atrophic uterus containing 
a subrnucous fibroid no bigger than a ripe cherry. In most 
instances the cancer is in close proximity to the fibroid ; 
occasionally a fibroid is embedded in the cancerous tissue, 
and is sometimes invaded by it. So far I have not been able 
to satisfy myself that the cancer arose in the endometrium 
covering a submucous fibroid, but it is not improbable. 

Although it is premature to assert that interstitial and 
submucous fibroids exert such a malign influence as to pre- 
dispose the corporeal endometrium to cancer, it may be true, 
and my observations incline me to believe that the suspicions 
are likely to be transformed into grim reality. This should 
warn us of the danger of allowing women to retain fibroids 
which are troublesome at the time of the menopause. 



CHAPTER XLI 

EPITHELIAL TUMOURS OF THE FALLOPIAN 

TUBE 

DISEASES of the Fallopian tube are curious in kind, and 
occur, as a rule, in consequence of its functions as a conduit. 
The prime duty of the tube is the conveyance of ova from 
the ovary to the uterine cavity. It also acts as a canal for 
spermatozoa, and the occurrence of ovarian and tubal preg- 
nancy demonstrates this. Disease-provoking organisms that 
escape from the intestine through lesions in its wall into the 
peritoneal fluid, such as the tubercle bacillus and the strepto- 
thrix, enter the abdominal ostium of the tube and infect 
the tubal mucous membrane. Infective organisms like the 
gonococcus and streptococcus invade the tube through its 
uterine ostiurn, causing grievous and often irreparable 
damage (see Hydrosalpinx, p. 668). Some recent observa- 
tions indicate that grosser particles, such as cancerous cells 
shed from a malignant focus in some part of the gastro- 
intestinal tract, may be conveyed into one or both tubes, 
become implanted, and form masses of secondary cancer. 

Papilloma. The common kind of wart found in the 
Fallopian tube arises on the walls of the tube when it is 
in the condition known as hydrosalpinx. This is of some 
importance, because hydrosalpinx is the end-result of gonor- 
rhceal infection, and occasionally of puerperal sepsis. The 
warts are soft and dendritic; often accumulated in clusters 
on the part of the hydrosalpinx that corresponds to the 
ampulla of the tube. Papillomatous tubes of this kind 
usually contain a dark bloodstained fluid. The chocolate 
colour of the fluid is due to blood that escapes from the 
soft vascular warts. When the papillomas are very abundant, 
closely packed, and bathed with bloodstained fluid, the 
condition is liable to be regarded as malignant, especially if 

467 



468 GANGER OF THE TUBE 

the fluid leaks into the. uterine cavity and escapes in irregular 
gushes from the vagina. This condition is sometimes called 
hydrops tubce profluens. 

When warts arise in a Fallopian tube with an unoccluded 
abdominal ostium, the fluid secreted by the warts accumu- 
lates in the belly and is probably reinforced by an exudation 
from the peritoneum. A remarkable example of this is 
recorded by Doran : A woman aged 50 was repeatedly tapped 
for ascites and large quantities of fluid were withdrawn. 
Eventually a tumour was detected in the pelvis ; on removal 
it proved to be a Fallopian tube stuffed with papillomas 
(Fig. 210). The patient was in good health twenty-three 




Fig. 210. Papilloma of the Fallopian tube. From a patient aged 50. 
(Doran.) 

years later, and the fluid did not reaccumulate in the belly 
after the removal of the tube. 

The epithelial cells on warts growing from mucous sur- 
faces and from the inner walls of cysts furnish a secretion 
(see pp. 605 and 622). 

Carcinoma. Our knowledge of cancer of the Fallopian 
tube dates from 1888. Doran collected the records of one 
hundred examples of this disease, and many examples have 
been recorded by other surgeons, so that a fairly complete 
picture of it may be drawn. 

Cancer of the Fallopian tube is a disease of middle life, 
and occurs in women who have had children as well as in 
those who are barren. In the greater proportion of patients 
the disease is unilateral. A careful analysis of cases, pub- 
lished during the last few years, indicates that many, regarded 



GANGER OF THE TUBE 469 

as examples of primary cancer of the tube, and especially the 
bilateral forms, were really examples of tubal warts. Others, 
believed to be primary cancer of the tube, were implanted 
cancers secondary to a primary focus in some part of the 
gastro-intestinal tract. It is significant that the prevailing 
type of structure in tubal cancer is gland-like spaces lined 
with a single layer of columnar cells. 

The following facts, worked out by Glendining, illustrate 
the mode of infection : I removed two ovarian tumours from 
a woman with well-marked cancer of the stomach. A micro- 
scopic examination proved that the solid portion of each 
tumour was a mass of implanted cancer (see Chap. LVII). To 
the naked eye the Fallopian tube appeared normal, but on 
microscopic examination cancer-particles were found free in 
its lumen, and nodules were detected in the mucous mem- 
brane. After a thorough examination of the tubal tissues, 
Glendining came to the not unreasonable conclusion that 
cancer-infection of the tube was brought about by cancer- 
cells shed by the gastric focus into the peritoneum; these 
cells, floating in peritoneal fluid, were conveyed into the tubal 
ostium and engrafted themselves on the mucous membrane 
and penetrated the deeper tissues. 

Bilateral cancer is more common in the Fallopian tubes 
and ovaries than in other paired organs. This supports the 
contention that cancer of the tubes, like cancer of the ovaries, 
is really secondary (implanted) to a primary focus of the 
disease in the gastro-intestinal tract. This opinion is 
supported by a critical perusal of recent reports of this 
disease. 

It is the practice to remove a cancerous tube, sometimes 
alone, and occasionally with the uterus. The results of both 
plans are very discouraging, for the majority of the women 
with this disease die from recurrence within a year of the 
operation. Many of them die from intestinal obstruction : 
in some, colostomy is necessary ; and in a few, resection of a 
cancerous segment of the colon has been performed. 

It is the duty of a surgeon who meets with cancer of the 
Fallopian tube to make a careful examination of the gastro- 
intestinal tract, and, if he finds a primary cancerous focus, 
the needlessness of extirpating the tubes and uterus will be 



47o GANGER OF THE TUBE 

obvious. In many instances colostomy will be performed 
instead of hysterectomy. 

I removed a large ovarian cyst-adenoma from a woman 
aged 52. After removal I found the ampulla of the Fallo- 
pian tube distended with cancer. The ovarian cyst in the 
vicinity of the tubal ostium was infiltrated with cancerous 
material, and the thick mass on the cyst-wall was continuous 
with the cancerous material within the tube. The appear- 




Fig. 211. Ovarian cyst infiltrated with cancer. The ampulla of the 
Fallopian tube is also stuffed with cancer. From a woman aged 52. 
She died with diffuse cancer of the abdomen a year after operation. 

ance presented by the parts suggested that a stream of 
cancer-particles issuing from the open mouth of the tube 
had implanted themselves on the wall of the ovarian cyst 
(Fig. 211). In a former edition of this book I regarded this 
specimen as an example of primary cancer of the tube 
infecting an ovarian cyst. Increased experience leads me 
to believe that the patient had a primary focus of cancer 
in the pelvic colon and that this infected the tube and cyst. 
She died a year later with cancer of the abdomen, and I have 



GANGER OF THE TUBE 

ascertained that inguinal colostomy was required to relieve 
intestinal obstruction. 

The only unequivocal example of primary tubal cancer 
that I have examined occurred in association with large 
uterine fibroids. The coelomic ostium of the tube was 
completely occluded and the ampulla distended with a soft 
mass of cancer. The tube resembled a parsnip in shape 
(Fig. 213). The patient, a nulliparous widow aged 49, came 



NAT 




B 



Fig. 212. A, Ampulla of a Fallopian tube occupied by a carcinoma ; B, the 
ampulla of the tube shown in section. From a sterile married woman 
aged 57. The uterus contained a large submucous fibroid. 

again under my care, ten years after the hysterectomy, in 
order to have a large lipoma removed from her shoulder. 
She was in good health. 

Clinical characters. In its leading features this disease 
simulates cancer of the body of the uterus. The patient 
complains of an irregular discharge of bloodstained fluid 
from the vagina. On examination, a swelling is felt on one 
and sometimes both sides of the uterus. The absence of 
pathognomonic signs is shown by the fact that an operation 



472 



GANGER OF THE TUBE 



has been performed, and the parts, after removal, have been 
put aside and labelled hydrosalpinx. The patient, a nulli- 
para aged 54, returned to the hospital nine months later 
with intestinal obstruction ; a cancerous growth was resected 
from her pelvic colon. The supposed hydrosalpinx was re- 
examined and found to be a dilated tube stuffed with " a 
cancerous glandular growth which consists mainly of closely 
packed tubules lined with a single layer of columnar or 




CANCER 



Fig. 213. Fallopian tube, ovary, and adjacent portion of the uterus. The 
tube contains a soft mass of cancer which has extended along the 
tube. The abdominal ostium is closed. The uterus contained several 
large fibroids. The patient was alive and well ten years after the 
operation. 

cubical epithelium set in a scanty stroma." (Spencer.) This 
is a good picture of colic or rectal cancer. 

Diagnostic difficulty arises when cancer of the tube 
coexists with a uterine fibroid. I have met with this com- 
bination on two occasions (Figs. 212, 213). 

Evidence derived from reports of cases, and my own 
experience of cancer of the Fallopian tube in which the 
postoperative histories have been obtained, support the 
opinion that cancer of the tube, like cancer of the ovary, 



GANGER OF THE TUBE 473 

is almost invariably secondary to a focus in the gastro- 
intestinal tract. 

It has been asked, If tubal cancer is secondary, how is it 
that the primary disease happens to be always latent when 
the tube is removed ? This is easily answered : Latency is 
the most striking feature of cancer arising in the gastro- 
intestinal tract. 

Bland-Sutton, J., "On Cancer of the Ovary." Brit. Med. Jonrn., 1908, i. 5. 

Bland-Button, J., " The Clinical Aspect of Secondary Cancer of the Ovary." 
Clin. Journ., 1910, xxxvii. 104. 

Doran, A., " Papilloma of the Fallopian Tube, associated with Ascites and 
Pleuritic Effusion." Trans. Path. Soc., 1880, xxxi. 174. 

Doran, A., " A Table of over fifty complete Cases of Primary Cancer of 
the Fallopian Tube." Journ. of Obstet. and Gyn. of the Brit. Emp., 19C4, 
vi. 285. 

Doran, A., "Primary Cancer of the Fallopian Tube." Ibid., 1910, xvii. 1. 

Glendining, B., "The Spread of Carcinoma by the Fallopian Tube." Ibid., 
1910, xvii. 24. 

Spencer, H. R., "A Fourth Case of Primary Cancer of the Fallopian Tube." 
Proo. Roy. Soc. of Med., 1916, ix., Obstet. and Gyn. Sect., p. 49. 



CHAPTER XLII 
EPITHELIAL TUMOURS OF THE MENINGES 

EVERY student of Human Anatomy is familiar with the small, 
soft nodules in the dura mater clustering along the anterior 
section of the longitudinal sinus, which are so conspi- 
cuous when the skull cap is removed. These Pacchionian 
bodies are villous tufts which grow from the arachnoid mem- 
brane and penetrate the dura mater. In adult skulls these 
nodules occupy depressions in the cranial bones well known 
to students of human osteology. 

The tufts begin as minute pouchings from the arachnoid 
membrane, and in their early stages consist of delicate 
connective tissue covered with a single layer of flattened 
epithelium ; occasionally, even when small, they contain a 
capillary blood-vessel. When large they are visible to the 
naked eye as Pacchionian bodies. Other epithelial structures 
which excite attention are the choroid plexuses of the cerebral 
ventricles. 

The curious stratum of pia mater and arachnoid, known 
as the velum interpositurn, which projects into the hollow 
cavity of the brain through the great transverse fissure, has 
its edges richly fringed with clustering villi resembling gills. 
The under-surface of the velum forms the roof of the fourth 
ventricle and is covered with villi ; a cluster of villi emerges 
from each lateral recess of this ventricle and lies close to the 
flocculus, near the recess in the petrosal which marks the 
position of the saccus endolymphaticus. It is a peculiarity 
of the arachnoid villi, when enlarged in any part of the 
meninges, that they become infiltrated with cholesterin. The 
choroid plexuses represent the highest development of the 
arachnoid tufts, and they often contain nodules infiltrated 
with cholesterin. The plexuses are very vascular and covered 

474 



PSAMMOMA 475 

with a single layer of epithelium resembling that of a secreting 
gland. (See Fig. 352, p. 735.) The distribution of the choroid 
plexuses in a mammalian brain is shown in Fig. 214. 

Like other epithelial organs, the brain is liable to papillomas 
and some remarkable tumours called psammomas ; but they 
arise in connexion with its meninges and choroid plexuses. 

Papillomas. The villi of the choroid plexuses of the 
cerebral ventricles not only resemble papillomas in struc- 
ture, but occasionally behave as such ; they grow abnormally, 
especially in the fourth ventricle, and completely block the 
interventricular communications, and by damming up the 
cerebro-spinal fluid lead to disastrous pressure effects, ending 
in death. 




Fig. 214. Diagram of a mammalian brain, in section, to show the 
internal cavities and the choroid plexuses. 

Douty, in 1886, gave me the opportunity of examining a 
villous tumour as big as a bantam's egg that grew in con- 
nexion with the choroid plexus of the fourth ventricle of a 
boy aged 17. The mass obstructed the aqueduct of Sylvius 
and led to great distension of the lateral ventricles. The 
aqueduct was dilated to the size of a quill. To the naked 
eye the enlarged villi resembled a villous papilloma of the 
bladder. (Similar cases have been reported by Allbutt, 
Ashby, Lodge, Briichanow, and Gushing.) 

Psammoma (^a/^09, sand}. This kind of tumour is pecu- 
liar to the membranes of. the brain and spinal cord, and it is 
called psammoma (sand tumour) from the fact that, like the 
pineal gland, it contains earthy matter. Sometimes the 
tumour gleams like mother-of pearl, and this has earned for 
it the name of pearl-tumour and cholesteatoma. 



47<3 PSAMMOMA 

Since 1886 I have been interested in psammornas, because 
careful study of their histology convinced me that they arose 
from the choroid plexuses and from the arachnoid tufts. 
This view is supported not only by a study of their structure, 
but also by the localities they frequent. 

Histologically, psammomas resemble a cluster of arach- 
noid villi embedded in dense fibrous tissue (Fig. 215). 
The common places for them are the neighbourhood of the 
lateral recesses, where they arise from the choroid plexus 
of the fourth ventricle, and are often bilateral, and along the 




Fig. 215. Microscopic features of a psammoma. Some of the 
concentric bodies contained grit. 

falx cerebri, especially in its frontal segment. They arise 
from any part of the rneninges, but are most common where 
arachnoid villi abound. 

The common kind of psammoma is not unlike an un- 
peeled potato. When such a tumour is examined micro- 
scopically it shows intimate relations to blood-vessels; a 
.typical section exhibits columns of cells arranged concentri- 
cally around a single blood-vessel. The idea that such a 
tumour represents a compact cluster of arachnoid villi is 
irresistible. Should this tissue become infiltrated with sand, 
the product is a psammoma. Like calcified fibroids of the 
uterus, psammomas infiltrated with ckolesterin are dead 



PSAMMOMA 477 

tumours, but they rarely die before wrecking the life of the 
patient by damaging the brain or spinal cord. 

In the cranium meningeal psammomas rarely exceed the 
size of a shelled walnut, form deep bays in the adjacent brain, 
and when they grow from the choroid plexus, and especially 
in the vicinity of the nerve-roots near the brain-stem, lead to 
distressing symptoms, for they press upon the roots of the 
trigeminal, facial, and vagal nerves. The particular area near 
the flocculus frequented by these tumours is often called by 
surgeons the cerebello-pontine angle ; in this situation psam- 
momas have no attachment to the brain and are, as a rule, 
loosely connected with the membranes. 

The notion that psammomas arise from arachnoid villi 
occurred also to Schmidt, in 1902, and he published a descrip- 
tion of sarcomas and psammomas of the dura mater and 
ascribed their origin to the Pacchionian bodies. 

For many years our knowledge of these singular tumours 
was confined to post-mortem observations, but since they 
have been brought into the field of successful surgery much 
new knowledge has been acquired concerning them. 

It is known that, like the chorionic villi of the embryo, 
arachnoid tufts possess invasive property and can penetrate 
the walls of veins and sinuses, also the dura mater, and even 
bone, and behave malignantly (Chap. XLIII) ; and this is also 
true of villi growing on papillomatous cysts of the ovary 
(Chap. LVI). 

Symptoms. The symptoms set up by such tumours are 
sometimes so characteristic that an accurate diagnosis may 
be made after a brief interview. Occasionally the clinical 
symptoms are a complicated tangle, difficult to unravel even 
with the help of a neurologist, otologist, ophthalmologist, and 
a physician. The symptoms may indicate the presence of a 
tumour on the right side ; an operation is performed without 
finding a tumour. The patient dies shortly after the opera- 
tion, and the tumour is found in the left cerebello-pontine 
angle ! The difficulty of diagnosis is emphasized when the 
symptoms lead physicians of experience to believe that the 
trouble is in the stomach. How widely the symptoms vary! 
A soldier aged 28 with bilateral psammomas of the lateral 
recesses was violent, blind, deaf, and suicidal (Strahan). A lad 



478 PSAMMOMA 

had headache, vomiting, "blindness, optic neuritis, priapism, and 
opisthotonos, caused by a psammorna, the size of an olive, 
growing from the membranes covering the median lobe of his 
cerebellum (Beevor). A youth aged 19, whilst lifting a 
parcel, fell in a fit, became comatose, had a succession of fits, 
and died in twenty-four hours. A pearl-tumour the size 
of a small walnut, connected with the velum interpositum 
occupied the third ventricle and distorted the corpora 
quadrigemina (Morley Fletcher). A man aged 36, under my 
own care, with a psammoma of the right recess, had deafness, 




Fig. 216. Psammoma of the fourth ventricle. From a woman aged 32. 
(Musetim of the Royal College of Surgeons.') 

vomiting, giddiness, and nystagmus. He died after a vain 
attempt to remove the tumour. A woman aged 32, mother 
of six children, complained of headache, tenderness of the 
back of the head, and staggering gait. After the symptoms 
had existed six months she died (Knowles). A psammoma 
occupied the fourth ventricle and pressed on the medulla; 
the tumour was so charged with cholesterin that it resembled 
mother-of-pearl (Fig. 216). 

When growing from the arachnoid membrane of the 
spinal cord, psarnmomas do not attain a large size, and there is 
singular uniformity in their shape and dimensions (Fig. 217). 

Psammomas are common in the choroid plexuses of the 
lateral ventricles of horses, and sometimes produce furious 



PSAMMOMA 



479 



symptoms. In some of the reported cases, horses have killed 
themselves by wild plunges made in attacks of delirium. 
These tumours are vascular; some are soft, others hard. 
Nearly all contain cholesterin. 

Treatment. The removal of a tumour in close relation 
with the flocculus is one of the most dramatic operations in 
surgery. The roots of the great nerves arising from the brain- 




Fig. 217. Portion of the spinal cord with a psammoma situated at the 
level of the intervertebral disc between the tenth and eleventh thoracic 
vertebrae. From a woman aged 46. (Museum of the Middlesex 
Hospital.') 

stem in close relation with a tumour of the cerebello-pontine 
angle may be stimulated by the surgeon's finger like the 
strings of a harp ; with delicate touches he can obtain 
responses from the motor portions of the trigeminus, facial, 
vagal, and hypoglossal nerves. 

The earlier attempts at removing subtentorial tumours 
were attended by " a shocking mortality " (Gushing). Now 
results are more encouraging. Brilliant clinical diagnosis and 
skilful surgical technique have won splendid success. Surgical 



480 PSAMMOMA 

enterprise against such tumours is thoroughly justified, for, 
unrelieved by art, a patient with a tumour of this kind has a 
tragic ending. 

Psammomas of the spinal membranes are successfully 
removed by surgeons, with good consequences. 

Allbutt, Sir T. Clifford, " Two Cases of Tumour of the Pons Varolii." Trans. 

Path. Soc., 1868, xix. 20. 

Ashby, H., " Angio-Sarcoma of Left Choroid Plexus." Hid., 1886, xxxvii. 56. 
Bland-Button, J., "The Lateral Recesses of the Fourth Ventricle." Brain, 

1886, iv. 352. 
Bruchanow, N., " Ueber einen Fall von Papillom des Plexus Choroideus 

ventriculi lateralis sin. bei einem 2 j. Knaben." Prag. med. Woch., 1898, 

xxiii. 585. 

Gushing, H., " Tumours of the Nervus Acusticus." 1917. 
Douty, J. H., " Notes and Remarks upon a Case of Villous Tumours in the 

Fourth Ventricle." Brain, 1886, viii. 409. 
Fletcher, H. M., " Cholesteatoma of the Brain." Trans. Path. Soc., 1903, liv. 

308. 
Kuowles, B., " Case of Cholesteatoma of the Fourth Ventricle." Lancet, 1902^ 

i. 1833. 
Le Gros Clark, W. E., " On the Pacchionian Bodies." Journ. of Anat., 1920, 

Iv. 40. 

Lodge, S., " Tumour of the Fourth Ventricle." Brit. Med. Journ., 1912, i. 594. 
Schmidt, M. B., " Ueber die Pacchioni 'schen Granulation." Virchow's Arch. 

i- path. Anat., 1902, clxx. 429. 
Strahan, " Symmetrical Tumours at the Base of the Brain." Joiirn, Mental 

Sci., 1884, xxix. 246. 



CHAPTER XLIII 

CHORIONIC CARCINOMA; LUTEIN CYSTS; 
ANGIOCHORIOMA 

IN 1889 Sanger and Pfeiffer independently described a variety 
of malignant disease arising in the uterus which presented 
microscopic characters so strongly resembling decidual tissue 
that the disease was named deciduoma malignum. Sub- 
sequent investigations by other observers brought to light 
the important fact that this remarkable disease is very liable 
to arise in the endometrium within a few weeks or months 
of abortion, or of delivery at term, and especially after the 
expulsion of the so-called " hydatid mole." Moreover, the 
microscopic investigation of the tumour showed that it 
conformed in histologic type to the multinuclear mantle or 
syncytium which covers the chorionic villus. This discovery 
led to a change of opinion as to the source of the disease, 
and, as pathologists believe it arises in the epithelial elements 
of the chorionic villi, the name chorion-epithelioma was 
used; but chorionic carcinoma is more consistent with 
current nomenclature. 

Before considering the essential features of this disease 
the change in the chorion known as the hydatid mole needs 
a brief description. 

The normal villi of the chorion in the early stages of their 
development consist of an axis or core of delicate connective 
tissue covered with epithelium arranged in two layers: the 
outer layer, the plasmodial trophoblast, or syncytium, re- 
sembles a large elongated multinucleated cell enveloping 
the villus like a mantle ; the inner is known as the cellular 
trophoblast. In the early stages the connective-tissue core 
of the villus is devoid of blood-vessels: the tissue in these 
early stages consists of branching cells separated from 
each other by mucoid intercellular substance ; later, the 
2 F 481 



4&2 HYDATID MOLES 

cells become spindle-shaped and the tissue denser and 
vascularized. 

In the disease known as hydatid mole the villi become 
changed into transparent grape-like bodies (Fig. 218), and 
look not unlike the vesicles so characteristic of the cystic 
stage of Tcenia echinococcus (hydatids) ; and a hundred years 
ago the grape-like bodies or vesicular bodies were regarded 
as parasites, especially as the embryo is rarely to be found in 
these specimens. 




Fig. 218. Hydatid mole. (Bwnm.} 

In 1827 Mme. Boivin and Yelpeau showed that the 
disease depended on a change in the chorionic villi. Yirchow 
gave attention to the histology of these vesicle-like bodies, 
and considered them to be due to a rnyxomatous change 
in the villi (1853). This view prevailed until Marchand (1895) 
showed that the essential feature of the change depends 
more on the epithelium than on the stroma of the villus 
(Fig. 219), for it undergoes irregular proliferation and assumes 
invasive characters, penetrating the decidua and even the 
muscular wall of the uterus. The vessels of the villi dis- 
appear, the stroma degenerates, and the swollen condition 
of the so-called vesicles is the result of oedema rather than of 



HYDATID MOLES 



483 



raucoid change. The invasiveness or destructiveness of these 
altered villi is well known, and specimens have been observed 
in which the villi have perforated the uterus and caused fatal 
bleeding into the abdominal cavity. 

The cells of normal chorionic villi in their early stages 
erode their way into maternal tissue. (Fig. 220.) This action 
of the trophoblastic tissue of chorionic villi is a physiologic 
type of the erosive power of cancer-cells. 

The hydatid mole is not common; it has been estimated 
by one writer (Mme. Boivin. 1827) to occur once in 20,000 




X 50 



Fig. 210. Microscopic appearance of a chorionic villus from a hydatid 
mole, in transverse section, 

pregnancies, and by another (Williamson, 1899) once in 
2,400. It is quite certain that only a small proportion of 
women who have expelled hydatid moles develop chorionic 
carcinoma, but no reliable estimates are available. The 
liability of a woman who has had a miscarriage of this kind 
to be the victim of such a deadly disease as chorionic 
cancer renders it advisable that she should remain under 
medical supervision for some months after such an event. 

Some writers are disposed to believe that there are two 
varieties of the hydatidiform mole, one of these being purely 
innocent, the other giving rise to chorionic cancer. As yet 



44 LUTEIN CYSTS 

microscopical inquiries 'have not provided these theoretical 
distinctions with a histologic foundation. 

Relation of the hydatid mole to lutein cysts. Some valuable 
observations have been made on the frequent association of 
bilateral lutein cysts of the ovary and the so-called hydatid 
mole ; indeed, the presence of lutein cysts in this disease 
is constant enough to lead to the belief that the two 
conditions are correlated. This has given a new interest to 
the yellow tissue which composes the greater part of a corpus 
luteum, and some observers state that it furnishes an internal 




Fig. 220. A gravid Fallopian tube arid ovary. The chorionic villi 
eroded the walls of the gestation sac and caused fatal bleeding. 
(Museum of St. Bartholomew's Hospital.) 

secretion, and that the adhesion of the oosperin to the 
endometrium depends on a proper supply of this hypo- 
thetical fluid. 

Lutein cysts. The most familiar structure displayed on 
the cut surface of a mature ovary is a yellow body known 
as the corpus luteum. All who have been seriously inter- 
ested in the pathology of ovarian cysts have noticed the 
frequency with which corpora lutea are converted into cysts. 
Rokitansky held the opinion that they might enlarge and 
form tumours large enough to become clinically important. 
Cysts arising in corpora lutea do attain a size sufficient to 
admit of detection in the course of a careful bhnanual 



GHORIONIG CARCINOMA 45 

examination. When these cysts are small their nature is 
easily determined by the thick layer of yellow material 
which lines them ; but as the cyst increases in size the 
lutein tissue is spread out and becomes less obvious, until 
it fades away and leaves a transparent thin- walled cyst 
Avhich would not be regarded as a lutein cyst unless 
examined with the assistance of a microscope. It has been 
shown by Lockyer that an ovary may contain two or even 
a cluster of lutein cysts, and the condition may be bilateral ; 
in this event the consequent enlargement of the ovaries is 
such that on physical examination a tumour of some size 
can be detected on each side of the uterus. Lutein cysts 
are sometimes big enough to obstruct delivery, and they have 
been known to twist their pedicles. 

Chorionic carcinoma. The uterus when attacked by 
this disease usually enlarges, and often becomes big enough 
to be appreciable as a tumour in the hypogastrium : its 
contour may be nodular." In some patients the disease is 
limited to the endometrium, and the primary focus may 
be so small as not to cause enlargement of the uterus. 
Some very exceptional cases have been described in which 
the disease did not involve the uterus, but began in the 
vagina. 

The result of the examination of a large number of 
examples of this disease, by many investigators, has estab- 
lished the fact that it arises in portions of the chorionic villi 
which remain embedded in the endometrium after the ex- 
pulsion of the main products of gestation, and especially if 
the villi have undergone hydatidiform change. 

To the naked eye the tumour- tissue appears on section 
as a soft reddish mass. " Histologically, chorionic carcinoma 
consists of well - defined cells of various shapes and sizes 
closely packed together, and large multinuclear irregular 
masses of protoplasm in which no definite cell-masses are 
recognizable. This tissue invades and destroys the uterine 
tissues after the manner of a malignant growth. It contains 
no proper connective-tissue strorna, or blood-vessels of its 
own." (Teacher.) (Figs. 221, 222.) 

The eroding power of the cells of chorionic carcinoma 
enables them to penetrate the tissues and gain entrance to 



486 



GHORIONIG CARCINOMA 



veins ; fragments are deported by the blood-stream to lodge 
in lungs, bones, and other viscera, and grow into secondary 
deposits. The common situations for these deposits are the 
lungs and vaginal veins. 

The course of the disease is marked by oft-recurring profuse 
bleeding from the uterus ; rigors ; pyrexia ; great emaciation ; 
and the signs of dissemination, such as secondary nodules in 




Fig. 221. Microscopic characters of a chorkmic carcinoma showing 
large decidua-like elements, and the forms intermediate between 
the Langhans layer and the syncytium. (John H. Teacher.} 

the lungs, bones, and the abdominal viscera. The disease is 
fatal, and runs usually a very rapid course, but it exhibits 
remarkable variations in virulence. The view is held by some 
observers that the virulence is greater after an abortion than 
when it supervenes on a pregnancy which has run to term, or 
after the expulsion of a hydatid mole. 

The chief clinical signs are frequent bleeding from the 
uterus, producing great anaemia, and accompanied usually 
by enlargement of the uterus following a recent labour or 



GHORIONIG CARCINOMA 



487 



miscarriage. Many of these signs are caused also by the 
retention of a fragment of placenta, or a uterine mole. In 
such circumstances the cervical canal should be dilated and 
the cavity of the uterus explored ; any retained fragments 
of conception that are removed should be submitted to 
careful microscopic examination in order to establish a re- 
liable diagnosis. Repeated pregnancies predispose women to 
this disease. Examples of spontaneous disappearance of 
the tumour and complete recovery have been reported. 




Fig. 222. Cancerous chorionic villi. (John H. TeacJier.} 

Treatment. The most satisfactory method of dealing 
with this disease is prompt removal of the uterus. Teacher 
considers it reasonable to conclude that operation offers a 
fair chance of recovery, and that it may be done with some 
prospect of success in the face of the gravest signs of disease 
and even if metastasis has occurred. 

Chorionic carcinoma of the Fallopian tube and the 
ovary. This malign disease attacks the Fallopian tubes and 
produces symptoms resembling those of tubal pregnancy ; 
these subside and there is a period of quiescence, followed by 
rapid increase in the size of the tumour, accompanied by pain 
and severe constitutional disturbances. Cope has recently 
reported a case that occurred in a woman aged 45. 



488 ANGIOGHORIOMA 

Operative treatment is attended by a high mortality, and 
in those who recover quick recurrence and death are the rule. 

Fairbairn has described an example of chorionic carcinoma 
of the ovary. The woman was reported to be in good health 
two years after the operation. 

Angiochorioma (Dienst). This is a rare tumour of the 
placenta which arises from the chorionic villi. It consists of 
young embryonic connective tissue identical with early 
chorionic mesoblast, containing capillary spaces. The surface 
of the tumour is covered with epithelial cells indistinguishable 
from the cellular trophoblast of a chorionic villus. The main 
histological feature of the tumour is an enormous number of 
capillaries filled with blood embedded in a myxomatous 
stroma, which earned for it the name myxoma fibrosum 
placentcv (Virchow). 

An angiochorioma grows from a healthy, functioning 
placenta ; it is usually associated with a live full-time child. 
The tumour may be rounded or lobulated; as a rule it is 
solitary, but several have been observed in one placenta. An 
angiochorioma may be no bigger than a walnut, but one 
has been reported as big as a human heart (Galabin). The 
records have been collected by Pitha. The earliest observed 
case was recorded by Clarke (1798) ; the tumour weighed 
7 oz., and was in shape like a kidney. It was " perfectly 
compatible with the life and health of the foetus." The 
tumour appears to be uncommon. Very few specimens have 
been observed in England ; I have had an opportunity of 
studying one example : this was ovoid, and as big as a 
bantam's egg. 

Some writers regard an angiochorioma as an inflammatory 
product, probably of syphilitic origin. The condition is often 
associated with hydramnios and death of the foetus ; more 
than a third of the children die in utero or shortly after 
birth. This is contrary to the current opinion, for it is 
commonly held that an angiochorioma exercises no influence 
on pregnancy or upon the subsequent health of the child. 

Clarke, J., " Of a Tumour found in the Substance of the Human Placenta." 

Phil. Trans., London, 1798, p. 361. 
Fairbairn, J. S., " Primary Chorion-Epithelioma of the Ovary." Journ. of 

Obstet. and Gyn., 1909, xvi. 1. 



REFERENCES 489 

Galabin, A. L., " Fibro-Sarcoma of the Chorion." Irans. Obstet. Soc. Lond., 

1885, xxvii. 107. 
Johnstone, E. W., " Chorio-Angioma of the Placenta." Brit. Mcd. Journ., 

1912, ii. 1113. 
Maxwell, R. D., " Angiochorioma of the Placenta." Proc. Roy. Soc. of Med., 

1912, v., Obstet. Sect., p. 149. 
Pitha, V., " Des Tumeurs du Placenta." Ann. dc Gyn. et d' Obstet., Paris, 1906, 

2ie serie E, iii. 232, 269, 360. 

Teacher, J. H., Trans. Obstet. Soc. Loud., 1903, xlv. 256. 
Virchow, R., " Myxoma fibrosura placentae." "Die krankhft. Geschwiilste,' 

1863, i. 414. 



GROUP IV. TERATOMAS AND DERMOIDS 

CHAPTER XLIV 
TERATOMAS 

IN this group we have to consider some remarkable genera 
of tumours which in their type-forms are as easily distin- 
guished as a butterfly and a buttercup, yet examples occur 
presenting such composite characters that it is difficult to 
assign them to a particular genus. This is true in a measure 
of all genera of tumours. The difficulty in regard to such 
compound tumours as teratornas and dermoids occurs espe- 
cially in relation with the male and female genital glands. 
There are two forms of teratomas, external and internal. This 
and the next chapter will be devoted to external teratomas. 

A teratoma is an irregular conglomerate mass containing 
the tissues and fragments of viscera belonging to a suppressed 
fodtus attached to an otherwise normal individual. 

EXTERNAL TERATOMAS 

In order to appreciate the nature of these singular mal- 
formations it will be necessary to consider the subject of 
conjoined twins, supernumerary limbs, and acardiac foetuses. 
In the animal and vegetable kingdoms it often happens that 
a single ovum gives origin to two embryos, which may be 
separate from each other (twins), or they may be united, 
a condition known as conjoined twins. When twins arise 
from a single ovum they are said to be uniovular, and 
as they are invariably of the same sex they are termed 
homologous. Conjoined twins are always homologous and 
uniovular. (Fig. 223.) 

When two embryos are conjoined and one goes on to 
complete development, whilst some parts only of its com- 

490 



CONJOINED TWINS 



491 



panion continue to grow, the latter is a parasitic foetus. 
The individual supporting it is called the autosite. In other 
examples the incomplete foetus consists of an irregular- 
shaped tumour growing, perhaps, from the posterior surface 
of the sacrum, or within the abdomen or the thorax. The 
mass on dissection may contain vertebrae or skin-covered 
nodules resembling digits, associated with a piece of intestine. 
This is a teratoma. 




DOODICA. 



Fig. 223. The Orissa twins, Eadica-Dooclica, aged 3 years and 6 mouths. 

In order to demonstrate the relation between parasitic 
foetuses and teratomas, it will be useful to refer to dichotomy. 
In animals and vegetables there is a strong tendency for 
parts ending in free extremities to bifurcate or dichoto- 
mize. When this affects digits the result is supernumerary 
fingers and toes. Should it extend to the axis of the limb, 
supernumerary legs, wings, or fins are produced. Dichotomy 
is not confined to the limbs, but affects also the axis of the 



492 POSTERIOR DICHOTOMY 

trunk. When the whole embryonic axis dichotomizes, twins 
are produced. Should cleavage be partial, and affect the 
caudal end of the trunk, it is spoken of as posterior dichot- 
omy. When it involves the anterior end it is called anterior 
dichotomy. With complete dichotomy, in which both em- 
bryos go on to full development, either as separate or con- 
joined twins, we are not further concerned ; and considera- 
tion of the conditions arising from the imperfect growth of 
one embryo whilst its companion continues to develop must 
be deferred until we have discussed the results of partial 
dichotomy. 

Posterior dichotomy. When cleavage involves the caudal 
section of the trunk-axis to any serious extent it necessarily 
follows that the pelvis as well as the vertebral column will 
be reduplicated; it is also obvious that the reduplication 
of the pelvis involves a corresponding increase in the number 
of the pelvic organs, including the limbs. Thus it follows 
that supernumerary hind-limbs may arise from dichotomy 
affecting the embryonic limb, or from cleavage of the caudal 
end of the trunk. The two modes hold good for reduplication 
of the fore-limbs. In either case the supernumerary limbs 
may project from the ventral aspect of the trunk or be 
pushed on to the dorsal surface. One pair of limbs may 
fuse throughout their length, or one limb may be suppressed ; 
but it is noteworthy in relation to the cleavage theory that 
in all examples of supernumerary limbs connected with the 
pelvis there is an accessory, but imperf orate, anus. 

Jean Battista dos Santos (the Human Tripod), born in 
Portugal in 1846, had a median pair of pelvic limbs fused 
together (Fig. 224), an additional but imperforate anus, and 
two functional penes. Acton published an account of dos 
Santos at the age of six months. The median limb hung 
parallel with its fellows. Ernest Hart reported on the case in 
1865. The median limb was bent at the knee, and its con- 
nexion with the pelvis so pliable that it could be packed 
in such a way as to be completely hidden when the man 
was dressed. In spite of this encumbrance dos Santos could 
run actively and was a good horseman. He had four brothers 
and two sisters ; they were all of normal shape. 

A suppressed embryo is sometimes represented by a con- 



ANTERIOR DICHOTOMY 493 

glomerate mass sessile on the sacrum ; it may possess a dimple 
indicating an imperforate anus. Occasionally a rudimentary 
limb projects from it, and sometimes a penis. Matthews 
Duncan described a parasitic foetus attached to the buttocks 
of a young man occupied as a clerk, who spent the greater 
part of the day sitting on his sadly deformed twin brother. 
A shrunken parasitic foetus on a well-formed man recalls 
the delightful conception of Thackeray in the story of " The 
Rose and Ring," wherein the porter, Jenkins Gruffanuff, is 




Fig. 221. Posterior view of J. B. dos Santos at the age of six months. 

(Acton.} 

transformed into a knocker on the front door for his rude- 
ness to Fairy Blackstick. Reduplication of the pelvic limbs 
is frequent in sheep, calves, birds, and frogs. 

Anterior dichotomy. Cleavage may affect the facial 
portion only and produce reduplication of the jaws, or it 
may involve the head and produce a two-headed individual. 
Should it extend to the thoracic region of the spine, then an 
animal with two heads and reduplicated fore-limbs is the 
result. When partial dichotomy attacks the head, the median 
parts of the reduplicated face are so conjoined and malformed 
that they are sometimes found hanging in the pharynx, 



494 BASICRANIAL TERATOMAS 

being attached to its *oof by a pedicle. Such tumours are 
called basicranial teratomas : the majority of tumours called 
pharyngeal dermoids are of this nature. 

In order to appreciate the difficulty of interpreting the 
nature of tumours covered with skin and bearing teeth, 
reference should be made to the chapter on Heterotopic 
Teeth (Chap. XLVII). It is curious to find in a teratoma an 
organ like a vertebra, a tooth, or a tongue well developed, 
although the rest of the foetus is represented by a mere 
conglomeration of tissues. 

Thus far we have been concerned with duplicated parts 
reaching such a standard of development that their identifi- 
cation is a matter neither of difficulty nor of doubt. It 
happens, and not infrequently, that in cases of twins one of 
them is of natural shape and viable, but the other is very 
imperfectly developed, and as it lacks a heart (or if this organ 
be present it is rudimentary and functionless) it is said to be 
acardiac. The degree of development varies greatly : in some 
the foetus may be complete save head and neck. In rarer 
cases the foetus may be merely represented by an irregular- 
shaped mass consisting of oedematous integument surrounding 
a portion of the skeleton, usually an innominate bone with 
the bony elements of a lower limb. 

In some specimens no particular skeletal element is 
recognizable, but a portion of intestine or rudiments of the 
genito-urinary organs can be detected. To such examples of 
acardiacus the adjective amorphous is applied, and to French 
teratologists they are known as " anidian monsters." An 
acardiac such as that shown in Fig. 225 has been described 
as a dermoid of the umbilical cord. 

Acardiacs are not necessarily separate from the well- 
developed twin, but may be attached to it in a variety of 
ways. 

In the common form the shapeless mass is connected with 
the dorsal aspect of the sacrum, and simulates a spina bifida 
sac, or the form of congenital sacro-coccygeal tumour which 
arises in the postanal gut. These sacral- teratomas often 
twitch when irritated, and this is a valuable diagnostic sign. 
In rarer cases teratomas have been observed in the thoracic 
and abdominal cavities connected with the vertebral column. 






AGARDIAGS 495 

They are not uncommon on the head, particularly in relation 
with the jaws. 

The explanation of acardiac foetuses, whether free or para- 
sitic, seems to be this : Two embryos arise from a single 
ovum ; in some instances the cleavage is complete, but the 
heart of one embryo is defective. The circulation of the two 
embryos is continuous at the placenta, and the heart of the 
normal embryo is able to maintain in a measure the blood- 
current in its companion, and thus save it from complete 
suppression. Sir Astley Cooper demonstrated this compen- 
satory mechanism in the case of an acardiacus placed in his 




Tubercle mark- 
ing the end of 
the rudimentary 
spinal cord. 



Fig. 225. Acardiac foetus. This amorphous skin-clad lump contained a cervical 
vertebra, with a segment of spinal cord enclosed in dura mater. 

hands by Dr. Hodgkin. An inspection of the drawing of the 
placenta from this case (Fig. 226) shows that the umbilical 
vessels in the two sections of the compound placenta were 
directly continuous. 

In the case of a parasitic acardiac, Laloo (Fig. 231, p. 507), 
the circulation must be directly maintained by the heart of 
the autosite, as an independent heart has not, so far as I am 
aware, been detected in the parasite. The blood-current is 
always extremely slow in the acardiac, and thermornetric 
observations demonstrate that its temperature is several 
degrees lower than that of the autosite. 

Thus a study of the circumstances which surround the 



496 



ORIGIN OF TERATOMAS 



development of twins and duplex monsters brings us to the 
conclusion that a teratoma may arise either from partial 
dichotomy of the trunk-axis of the embryo, or from complete 
dichotomy. In the latter case, while one twin has gone on to 
full development, the growth of the other has been arrested. 
In some cases the suppression has been so great that the 
companion foetus is represented by a deformed or shapeless 
mass consisting of integument covering ill-formed pieces of 




Placenta of the 

acardiac. 
Anmion. 



.->, Artery and vein dis- 
L tributing blood to 
J the acardiac. 



-~ Umbilical cord of the healthy 

twin. 



Fig. 226. Placenta from twins, one of which was an acardiac. 
(Astley Cooper.} 

the skeleton and portions of viscera. The best evidence 
that parasitic fetuses and teratornas arise from cleavage is 
this : we always find like parts attached to like parts head 
to head, pelvis to pelvis, thorax to thorax. To this I do not 
know an exception. 

Embryologists agree that conjoined twins are the pro- 
duct of a single egg. A strong body of circumstantial 
evidence of a most convincing kind can be adduced in 
support of this opinion ; moreover, the development of a 
double embryo from a single egg has been witnessed in the 
case of a batrachian. 



DOUBLE EMBRYOS 



497 



In the spring of 1879, Clark of Boston had in his aqua- 
rium two or three thousand eggs of the American salamander 
(Amblystoma punctatum) for the purpose of studying their 
development. He found one with the medullary folds nearly 
completed, but they had not united at the cephalic end and 




Fig. 227. A, Normal egg of the American salamander, showing the 
medullary folds ; B, an egg with abnormal medullary folds from which 
the double-headed embryo, c, was formed. (Clark.) D, The adult form 
of the salamander. 

appeared to be much rounded at- their anterior ends instead 
of having the ordinary vague outlines ; it was set apart for 
observation. Each free portion of the medullary fold de- 
veloped a perfect head, which, at first partly united, became 
gradually more so until the bodies were connected throughout 
2o 



QUADRUPLETS 

their length. Posterior* to the heads there were no signs of 
duplicity. (Fig. 227.) 

The development of double-headed embryos from single 
eggs is a frequent event in salmon hatcheries (Fig. 228). 
The nine-banded armadillo of Texas normally produces quad- 
ruplets contained in a single chorion, and the foetuses are of 




Fig. 228. Twin salmon embryos from a hatchery, showing monstrous 
development with one common feature : the yolk-sac for each 
monstrous pair is single. 

the same .sex. The evidence indicates that the quadruplets 
are developed from a single ovum. In a collection of 182 sets 
of fetuses there has been no exception to the rule that all 
in a set or litter, whatever the number, are of the same sex. 
Of the 182 sets, 88 were female and 94 male (Newman). 

Some careful observations on polyembryony in the arma- 
dillo, Tatusia, were published by Fernandez (1909). 



EXPERIMENTAL EMBRYOLOGY 499 

Many attempts have been made to produce malformed 
and reduplicated embryos experimentally. MacBride has 
summarized the results attained in experimental embryology 
during the last thirty years. Driesch succeeded in separating, 
by violent shaking, the first two blastomeres of the sea- 
urchin's egg ; each separated blastomere developed into 
a perfect larva of reduced size. In relation to violence of 
this kind, mention may be made of GemrniU's experience. 
He had some eggs of the starfish Luidia, which had been 
fertilized at Plymouth, sent in a thermos flask by post. Some 
of the eggs developed twin larvae, and he attributes the twin- 
ning to the shaking endured by the eggs on the journey : 
this kind of violence leads to partial separation of the blasto- 
meres. Herlitzka, by constricting with a fine hair the 
blastula of a newt, produced a two-headed embryo. Experi- 
ments of this kind are of absorbing interest, and have led 
to diverse speculations which at present are irreconcilable. 

Fernandez, M., "Beitrage zur Embryologie cler Giirteltiere." Morph.Jahrb., 

Leipzig, 1909, xxxix. 302. 
Gemmill, J. F., "Twin Gastrulaa and Bipinnariie of Luidia sarsi." Journ. 

Marine Biol. Assoc. of the United Kingdom, 1915, x. 
MacBride, E. W., Address to the Zool. Sect, of the Brit. Assoc. for the 

Advancement of Science, 1916. 
Newman, E., " The Natural History of the Nine-banded Armadillo." Amer. 

Naturalist, 1913, xlvii. 513. 



CHAPTER XLV 
TERATOMAS (continued) 

MONSTERHOOD 

THE fauna of dreamland is very remarkable : the extraordinary 
beasts with multiple heads that appeared in visions to the 
prophet Daniel, and the wonderful eagle with three heads, 
twelve wings, and eight winglets that Esdras saw in a dream, 
excited the imagination of many of us in childhood when, 
tempted by curiosity, we perused their books. Nothing 
described therein in regard to monstrous animals equals the 
realities displayed in the Teratological Gallery of the Royal 
College of Surgeons. In the inanimate condition they are 
sufficiently repulsive, but few of us try to picture the condi- 
tion of some of the unfortunate human monsters that survive 
their birth and attain adult life. The frequency of monstrous 
foetuses in pathological museums and their comparative rarity 
as living beings prove that few survive. Conjoined twins are 
usually born without unusual difficulty, but the aid of a sur- 
geon is occasionally required. Ligat removed a large double 
monster (Fig. 229) by Csesarean section from a woman who 
had been in labour thirty hours ; she recovered. This woman 
had had four normal pregnancies. 

A detailed account of the delivery of conjoined twins 
at Brighton (1909) is furnished by Rooth ; he incidentally 
mentions some points of medico-legal interest. The registrar 
of births and deaths entered the girls as separate individuals, 
and the vaccination officer decided that each should be 
vaccinated. The inoculation took well. There was also some 
difficulty in regard to the foster-mother, for she could not 
have the care of them without a licence, as they were 
registered as two children. 

The Siamese Twins, Chang -Eng, were born near Bangkok, 

500 



CONJOINED TWINS 501 

Siam, in 1811, without difficulty, and lived with their parent 
till 1829. They were brought by an enterprising sea-captain 
to New York for exhibition purposes, and, becoming affluent, 
they bought a property, in North Carolina, and were known 
as Chang and Eng Bunker. In 1843 the twins married two 
sisters, and became prosperous farmers, each owning his own 
farm. The dwellings of the two families were a mile and 




Fig. 229. Conjoined twins removed by Caesarean section. They weighed 14 Ib. 
The mother recovered. (Museum of the Royal College of Surgeons.} 

a half apart, and the twins resided in each of the homes 
alternately. Chang had ten children, three boys and seven 
girls ; Eng had twelve, seven boys and five girls. Of Chang's 
children, two, a boy and a girl, were deaf-mutes ; Chang, it is 
necessary to mention, was somewhat deaf. Pancoast, in his 
report on the twins after their death in 1874, states that 
Chang and Eng agreed that each should control the actions 
of the other. Thus, for one week Eng would be complete 
master they would live for that time at Eng's house, and 
Chang would submit his will and desires completely to Eng ; 
and vice versa. One of the widows informed Pancoast that, 



502 CHANG AND ENG 

as a result of this understanding of absolute mastery, " there 
had never been any improper relations between the wives 
and brothers." Their first children were born within three 
or four days of each other. 

At one period of their bondage, especially after marriage, 
there was an interval when " each family wished to have a father 
all to itself." This led the twins to seek surgical advice with 
regard to separation. Sir William Fergusson examined the 
condition of the isthmus in 1869 : he had seen them for the 
same purpose in 1829 ; like other surgeons who saw them 
professionally, his decision was not in favour of separation. 

Chang and Eng spoke English,, were fond of reading, 
could sleep, dream, and think independently. Hunger, 
thirst, and the calls of nature were generally responded to 
simultaneously, but not always or necessarily so. (Simpson.) 

Chang drank immoderately and was excitable, and a 
few years before his death was stricken with right hemi- 
plegia. In 1874 Chang had a bronchial attack. One night 
they fell asleep. Near daybreak, January 17th, Eng called 
to one of his sons, who slept in the room above, to come 
down and waken Chang. The boy went to the side of Chang, 
and cried out, " Uncle Chang is dead ! " Eng at once said, 
"Then I am going." He died two hours later. The twins 
were 63 when they died. Eng probably died from syncope 
induced by terror. A post-mortem examination was made 
by Professor Harrison Allen, and a report was also furnished 
by Professor Pancoast, with a good photograph of the twins. 

The almost simultaneous exit of the conjoined twins re- 
calls the final lines of The Comedy of Errors. Dromio of 
Ephesus says to Dromio of Syracuse: 

'* We came into the world like brother and brother ; 
And now let's go hand in hand, not one before another." 

Rosa-Josepha Blazek. The twins known by this name 
are pygopagous, being joined by their sacra, and completely 
double with the exception of the external genitals and anus. 
The genital canal, though single, leads to two uteri, and this 
has been demonstrated in a remarkable manner. The sexual 
inclination of each differs, and, when they were 32 years of 
age, liosa conceived in consequence of falling in love with 



MILLE-CHRISTINE 503 

her manager. The child was born at Prague, and the facts 
relating to this remarkable obstetrical event have been re- 
corded by Trunecek. The child was in Rosa's womb, but 
both twins had milk in their breasts. The child was well 
formed, and survived its birth. The case serves as another 
illustration that conjoined twins as well as autosites produce 
normal offspring. Conjoined twins as well as autosites and 
parasites are almost invariably the children of multipart, 
their brothers and sisters being normally formed. The social 
state of pygopagous twins leads to curious difficulties. It is 
related of Rosa-Josepha that on arriving in London from 
Edinburgh the ticket collector demanded two tickets. He 
got out of his difficulty by taking the name and address 
of their agent. (For an excellent photograph of the twins 
about the age of 30, see Broman.) 

Mille - Christine. This well-known pygopagous pair were 
born of coloured parents in North Carolina in 1851. At the 
age of five years they were examined in Edinburgh by Sir 
James Simpson. He found their coccyges and lower sacral 
vertebrae fused. The anal orifice was single. The vulva 
appeared to be single, but within it were two vaginal and 
two urethral orifices. The call to empty the bowels was by 
no means contemporaneous in the two, nor was the act of 
micturition. They could walk and run with facility. The 
two sisters were physiologically separate individuals; they 
differed in disposition and temperament. Sometimes they 
quarrelled and knocked their heads together. Occasionally 
one would eat whilst the other was asleep. Later they 
developed sweet voices and sang with great taste and skill 
a duet in a contralto and a soprano voice. As they sang 
in public they soon acquired the name of the Two-Headed 
Nightingale. They could dance with two legs or four with 
equal animation. I stood behind them during a firework 
display at the Crystal Palace, and heard them express to 
each other their delight, especially at the colours produced 
by pyrotechnic art. 

Helena-Judith. This is the name of the conjoined twins 
who were born at Szony, Hungary, in 1701, and died in 1723. 
They were exhibited in London, 1708, and an account of 
them is contained in the Philosophical Transactions for 



504 HELENA-JUDITH 

1757, supplied by Dr. Torkos. The mother attributed the 
malformation to the fact that at the beginning of her 
pregnancy she " attentius contemplabatur canes coeuntes." 

Helena was born first. The twins were joined together 
at the back, below the loins. The anus was single, but 
the external genitals were separate. Both children felt the 
desire to defecate simultaneously, but the inclination to 
urinate occurred independently : this in early life led to 
much contention between them. They had measles and 
smallpox, both being attacked at the same time; they had 
other disorders independently. Menstruation appeared at 
16 in both, but did not occur synchronously. They often 
slept independently. These two girls were intelligent, and 
Helena is described as a handsome girl ; both had beautiful 
faces. 

The ecclesiastical authorities stopped the exhibition of 
these twins, and they were placed in a convent at Presburg. 
They were taught reading and writing, needlework and lace- 
making. When 23 Judith was seized with a pulmonary com- 
plaint; Helena became affected with fever, and the illness 
continued for about a fortnight, when they "both expired 
almost at the same instant." 

The thought of one dying before the other must occa- 
sionally arise in the minds of conjoined twins. The evidence 
available indicates that, as a rule, they die either simul- 
taneously or within a few hours of each other. In A.D. 945 
two male children were brought from Armenia to Constan- 
tinople ; they were well formed in their extremities, but 
united by the abdomen. After the twins had been for some 
time an object of curiosity they were removed, as it was 
feared that this accident of nature was a presage of evil. 
In the reign of Constantine VII one of the twins died, 
and a surgeon undertook to separate the living twin from 
the corpse. The second twin died three days after the first. 
Nothing is known as to the age of the twins when they 
died. (R. P. Harris.) 

Apart from the persistent bondage of conjoined twins, 
there is one question that always excites the inquisitiveness 
of the world at large, and this is the possibility of separating 
the twins. Surgical intervention is only possible in xipho- 



RADIGA-DOODICA 505 

pagi: this matter involves the nature of the isthmus or 
uniting band. 

The isthmus. An interesting feature of the uniting band 
is its relation to the umbilicus, this scar being situated on 
its lower border (Fig. 229). In the case of Chang and Eng 
it was narrow and flexible ; also in Laloo indeed, the 
isthmus uniting him to his malformed brother was as pliable 
as leather. There is a life-sized wax model of the isthmus 
of Chang and Eng in the museum of the Royal College of 
Surgeons, England, and the anatomy of the isthmus was 
described in detail by Allen and Pancoast in 1874. Each 
extremity of the isthmus is occupied in most xiphopagi by 
a process of peritoneum, and these pouches are potential 
hernial sacs (see p. 508). 

In the xiphopagous twins Radica-Doodica (Fig. 223) the 
isthmus was 10 cm. long and 4 cm. thick. When I saw 
them in London, in 1893, they were attractive little children 
and danced daintily to amuse the curious people who flocked 
to see them. In 1901 Doodica showed signs of tuberculous 
peritonitis. The vascular system of the twins was investi- 
gated with the object of determining the possibility of 
separating them. Methylene-blue injected into one twin 
appeared in the urine of the second twin ten minutes later, 
the urine being obtained by catheter. Doyen divided the 
band uniting them (February 9th, 1902) : it contained a 
peritoneal sac occupied by liver-tissue. Doodica died seven 
days later ; she had tuberculous peritonitis and a gangrenous 
appendix. Radica survived the operation. 

Radica- Doodica were born at Noapara, a village in the 
province of Orissa, India. They were discovered in the 
jungle by Captain Colman. At their birth the inhabitants, 
instigated by the Brahmins, put the whole family in prison 
on the supposition that the twins were the incarnation of 
the devil. 

Evidence is available to prove that in all cases of conjoined 
twins each twin is physiologically a distinct individual, and 
this is also true of some parasitic foetuses. In the case 
of a bicephalous calf, if the mouth of one head is tickled 
with a stick, the calf opens -its mouth and protrudes the 
tongue : these movements are ' simultaneously repeated by 



506 



DOUBLE-HEADED CHILD 



the companion head. .Consensual movements of this kind 
may be observed even when the secondary tongue is very 
rudimentary. Similar observations have been made in bi- 
cephalous children. William Budd of Bristol, in a letter 
to Sir James Paget (1855), describes such a case, and he 
sent a photograph of the child (Fig. 230). He writes-. 
"With the exception of the extraordinary excrescence, the 




Fig. 230. A bicephalous infant. (From a photograph.} 

child presents no deviation from the normal type, but is as 
comely a little thing as you would wish to see. Every move- 
ment and every act of the natural face is simultaneously 
repeated in the second face in the most perfectly consensual 
manner. When the natural face sucks the second mouth 
sucks. Crying and yawning occurred at the same time in 
the two faces." Reflex movements of a like kind occurred 
in a similar case described by E. Home, 1790. 

In some varieties of parasitic foetuses there is no spon- 
taneous movement of limbs, but the secretory functions are 
independent of the autosite. Laloo is a good instance of this. 



PARASITIC FCETUS 



507 



This boy (Fig. 231) interested me because, with Shattock, I 
drew up a report upon him for the Pathological Society. 

Laloo was exhibited as " a boy and girl united together 
alive," and this proved an attractive feature for many 
thousands of curious persons in Great Britain. The parasitic 
foetus had unusually large nipples, and these were exhibited 




Fig. 231. Laloo, a Hindu, with a parasitic foetus attached to his thorax. 

as proofs that the imperfect individual was a girl. All 
conjoined foetuses hitherto reported have been of the same 
sex, and I determined to settle this question. We were 
afforded an opportunity for a proper examination, and found 
the parasitic foetus to be, like the autosite, a male. Laloo 
told us that his ill-formed brother caused him much dis- 
comfort, for at various times,, day and night, without any 
warning, he voided urine over him. 



508 



LALOO 



At the age of 18 Leloo was suddenly seized with acute 
abdominal pain and vomiting. The showman asked me to 
see him at midnight, and I found a tense swelling in the 
band uniting parasite and autosite. A loop of bowel had 
escaped from Laloo into the pedicle uniting him with his 
malformed brother; this was reduced, and the symptoms of 
intestinal strangulation quickly disappeared. I saw Laloo 
four years afterwards at Barnum's Show. He was among 




Fig. 232. Sacred ox with a parasitic calf (India). 

the freaks, and in excellent health. The parasite could not 
initiate any independent movement in its limbs, but Laloo 
could localize the prick of a pin on the skin, and felt 
uncomfortable when his malformed brother was cold. 

Louise L., born at Reims (Marne) in 1869, had a super- 
numerary pelvis and lower limbs attached by a fleshy pedicle 
to the abdomen near the pubes; she was on this account 
known as "la dame a quatre jambes" Like Laloo, she could 
localize the prick of a pin on the skin of the parasite, but 
could not initiate any movement in the accessory limbs. 



CONJOINED TWINS 509 

This woman was carefully described by Bugnion in 1889. 
She was married in her fifteenth year, and had two living 
children girls, free from deformity. They were born with- 
out difficulty. Bugnion's description is accompanied by a 
photograph of the woman at the age of 20, obtained when 
she was exhibited for gain in Geneva. 

When conjoined children belong to poor parents, unscru- 
pulous showmen get possession of them, and will not permit 
surgical interference, even when it is practicable, because 
such children are valuable sources of gain in fairs and shows. 
When conjoined twins are born to respectable parents their 
lot is better. Dr. Boehm (1866) operated on xiphopagous 
twins his own daughters a few days after birth. ' One 
died. The separation of conjoined twins has not been often 
attempted : it is rarely practicable, and when carried out, even 
under favourable conditions, has seldom been successful. 

The frequency of malformations among domesticated 
mammals and poultry made man familiar with many weird 
animal forms, some of them more monstrous than the 
inventions of the imagination. It is probable that many 
mythological conceptions took birth from such perversions. 
Bicephalous animals could easily suggest Janus, the two- 
headed Hermse and Termini, and perhaps give concrete 
expression to Bunyan's idea of Mr. Facing - both -Ways. 
Triplication of heads would furnish a prototype of Cerberus. 
Accessory wings in birds may have originated the idea of the 
Seraphim, the imaginary guardians of Jehovah's sanctuary, 
so forcibly described in Isaiah's famous vision. Mammals 
with accessory limbs may have been the originals of the gods 
in the Indian Pantheon, furnished, like Vishnu, with a multi- 
plicity of arms. In India, among Hindus, a parasitic foetus 
on a cow or an ox (Fig. 232) is an object of veneration, but in 
the Western world a parasitic foatus on a human being is a 
source of unholy gain. Diodorus the Sicilian records that 
in the reign of Bocchoris, the first king of the Twenty-fourth 
Dynasty, a lamb was born with eight legs, two heads, two 
tails, and four horns, and the faculty of human speech. 
According to a legend preserved in dernotic, this animal 
portended danger to Egypt from Assyria. 

Monstrous animals were regarded with anything but 



5 to TERATOMAS 

favour in England. Webster expresses this disfavour in 
the tragedy of The Duchess of Malfi, 1623: 

"We account it ominous 
If Nature do produce a colt, or lamb, 
A fawn, or goat, in any limb resembling 
A man, and fly from't as a prodigy." Act If., Sc. 1. 

Allen, H., Trans. Coll. of Physicians, Philadelphia, 1875, Third Series, i. 3. 

Boehm, Virchow's Arch. /.path. Anat., 1866, xxxvi. 152. 

Broman, I., " Normale und abnorme Entwickelung des Menschen," p. 175. 

Wiesbaden, 1911. 

Budge, E. W., "A History of the Egyptian People," 1914, p. 132. 
Bugnion, Ed., Revue Mid. de la Suisse romande, 1889, p. 333. 
Doyen, E., Brit. Med. Journ., 1902, i. 465. 
Harris, R. P., Amer. Journ. Med. Sci., 1874, Ixviii. 374. 
Home, E., Phil. Trans., 1790, Ixxx. 296. 
Ligat, D., Lancet, 1912, i. 896. 
Pancoast, W. H., Trans. Coll. Physicians, Philadephia., 1875, Third Series, 

i. 149. 

Rooth, J. A., Brit. Med. Journ., 1911, ii. 653. 
Simpson, J. Y., Ibid., 1869, i. 139. 
Torkos, J. J., Phil. Trans., 1757, 1., Plate xii. 
Trunecek, C., Li Semaine Med., 1910, xx. 229. 






CHAPTER XLVI 
TERATOMAS (continued) 

INTERNAL TERATOMAS 

THIS variety occurs in the thorax, the abdomen, and the 
cranium; in the abdomen it occasionally attains a degree 
of development equal to that found in external parts. The 
internal teratoma differs from the external kind in being 
enclosed in a cyst, and it imperils the life of the autosite 
from mechanical causes, and in rare instances by displaying 
malignancy of a remarkable kind. It is unusual in the 
cavities of the body to find teratomas with limbs and organs 
so shaped as to enable the observer at once to recognize that 
he has before him a very badly developed embryo enclosed 
within its bearer. Such conglomerate lumps are sometimes 
called teratoid tumours. 

Intra-abdominal teratomas, A parasitic foetus within 
the abdominal cavity is extremely rare; one of the best- 
known examples was described by Young in 1808, under 
the title of " A Foetus found in the Abdomen of a Boy." 
In this instance a large cyst was found in the belly of 
an infant aged 12 months. The post-mortem examination 
was carefully made, and the cyst, which lay behind the 
peritoneum, contained, in addition to a large quantity of 
fluid, the pelvis, lower limbs, and genital organs of a foetus 
(Fig. 233). 

Five years later Phillips described, in a letter to Sir 
Benjamin Brodie, a case in which parts of a foetus were 
found in a tumour lodged in the abdomen of a girl aged 2J. 
The brief description contains this statement : " The cyst in 
the abdomen contained fluid and solid matter ; the latter 
contained a large bone resembling a tibia covered with 
muscle, and small bones like a tarsus. There were cystic 



512 



INTRATHORACIG TERATOMAS 



spaces containing sanieus fluid. The liver bore marks of 
inflammation and was studded with tubercles." 

Lexer removed a teratoma as big as a fist from a girl 
aged 7 weeks ; it was situated in the foramen epiploicum 
and lay under the liver. This tumour had cystic and solid 
parts; the latter represented skeletal and visceral elements. 
The infant did not survive the operation. 

Intrathoracic teratomas. Tumours described as derm- 




Fig. 233. Foetus which was found enveloped in a cyst in the abdomen 
of a boy. When removed it was covered with sebum, and appeared 
as rosy and as healthy as if alive. (Yottng, 1808.) 

oids within the thorax have been recorded by many writers. 
They are rare, but cause much distress to the patients who 
possess them. The majority occupy the mediastinum and 
grow downwards to one or other side, compressing the lung. 
A dermoid has been observed anteriorly to the pericardium. 
Many of the cases have been recorded as " dermoids of 
the lungs," but all the later reporters agree that the involve- 
ment of the lung is secondary. When the bronchi become 
implicated by such a tumour, " hair-spitting " occurs, due to 



INTRACRANIAL TERATOMAS 5*3 

the cyst opening into the air-passage as a consequence of 
suppuration. The inner wall of such cysts is often beset 
with nipple-like processes of skin. 

Ritchie has described a teratoma which occupied the 
mediastinum of a man aged 24 : attached to and forming 
part of its wall was a solid tumour containing tissue micros- 
copically identical with that of chorionic carcinoma (see 
p. 485). The lungs and liver contained secondary deposits. 
It is somewhat remarkable to tind among such highly organ- 
ized tumours, whose extreme specialization would almost 
pass as a brand of innocency, illustrations of what has already 
been mentioned in connexion with other groups, that each 
genus of the so-called benign tumours contains varieties 
which shade away indefinitely from the type species and 
display malignancy. Pohl has collected the records to 1914. 

Intracranial teratomas. In the chapters dealing with 
sequestration dermoids it is pointed out that these tumours 
are found in connexion with the scalp and in association 
with the tentorium, and their presence in these situations 
may be attributed to small portions of surface epiblast 
sequestered in the course of the development of the skull 
(p. 549). Such dermoids exhibit the same characters as those 
so commonly found near the angles of the orbits (p. 543). 

Complex tumours of the teratoid type are occasionally 
found at the base of the skull, and usually occupy the 
pituitary fossa. Teratomas in this situation resemble those 
found at times in the pharynx, and contain striped muscle- 
fibre, hyalin cartilage, glandular tissue, and cysts lined with 
squamous epithelium. In one carefully described specimen 
ganglion-cells and white nerve-fibres were present : some of the 
nerve-bundles had a cross section as big as the radial nerve. 
Pituitary teratomas have been recorded by Lawson, Bowlby, 
.Hale White, Sainsbury, Buzzard, and Bostroem. Rows de- 
scribed two examples which occurred in men ; one was aged 
77 and the other 73. Intracranial dermoids or embryomas 
occur in the basal parts of the brain, in or near the middle 
line. They grow very slowly, and rarely produce symptoms. 

Teratomas of the thyroid. These are rare tumours, 
and the subjects of them still-born foetuses. The teratoma 
replaces and takes the shape- of an enormously enlarged 



514 THYROID TERATOMAS 

thyroid, and is usually placed in a museum as a congenital 
goitre until some enterprising investigator examines it his- 
tologically. A thyroid teratoma is usually loculated, and 
the cystic spaces contain gelatinous tissue like that seen 
in a normal thyroid: hyalin cartilage is a common con- 
stituent, but skin, sweat-glands, pigmented epithelium, 
bone, and embryonic nerve-tissue have been detected. The 




Fig. 234. Head of a foetus in section. The thyroid is replaced 
by a teratoma. o, oesophagus ; T, trachea. (Museum of St. 
Thomas's Hospital.) 

structure of some of these tumours corresponds very closely 
with that of the sacro-coccygeal group. Shattock, Russell, 
and Kennedy have described examples. 

Masses of tissue identical in structure with the normal 
thyroid have been detected by several observers in ovarian 
teratomas (see p. 611). 

Teratomas of the pharynx and palate. It is noteworthy 
that the parts in relation with the cephalic as well as the 
caudal extremity of the notochord are common situations for 



PHARYNGEAL TERATOMAS 

teratomas containing formed organs and tissues such as bone, 
skin, striped muscle, nerves, epithelium, and occasionally a 
tooth, but devoid of any shape and arrangement of the parts 
to suggest a foetus, though arising in the same manner as a 
parasitic foetus. In the palate and naso-pharynx, teratomas 
usually take the form of pedunculated tumours clad with 
skin which is often pilose (Fig. 235). The core of these 
tumours consists of connective tissue which may contain 
hyalin cartilage and a variable amount of striped muscle- 
tissue. In many cases it is difficult to decide whether the 
tumour grows from the palate, or 
from the base of the skull and pro- 
jects through a gap in the hard 
palate. Sometimes the attachment 
is so slender that the tumour under- 
goes spontaneous detachment ; in the 
case reported by Lambl the child 
swallowed the tumour, and voided it 
next day by the anus. Eves reported 
a more remarkable case : A boy aged 
14 months had a skin-covered pilose 
tumour attached to the posterior 
wall of the pharynx by a pedicle so 

long that it hung in the oesophagus. Fig 235 ._ skin _ clad pilose 
The boy could protrude the tumour 
into his mouth and bite it. Pharyn- 
geal teratomas occasionally project 
into the floor of the pituitary fossa and compress the optic 
nerves and tracts. 

In 1888 I dissected a new-born pig double in all parts 
except the head. A supernumerary mandible, covered with 
mucous membrane beset with bristles, and containing teeth, 
hung in the pharynx like a polypus ; it was attached to 
the basi-sphenoid by a slender pedicle. This pig is in the 
museum of the Royal College of Surgeons. In rare instances 
when dichotomy involves the jaws, the base of the skull 
may be implicated. In an example that occurred in a foal 
I found two pituitary bodies ; each had a fossa, and they 
were widely separated. 

Windle has collected the literature relating to teratomas 




tumour from the pharyn- 
geal aspect of the soft 
palate. (Arnold.} 



5i6 THE POSTANAL GUT 

of the pharynx under the title of Epignathus, and has sum 
marized the various views in regard to the nature of this 
condition. 

In describing teratomas, care was particularly taken to 
emphasize the fact that many cases of duplicity of parts 
depended on dichotomy. Cleavage may be so slight at the 
cephalic end of the embryo as only to involve the face, or 
even the jaws. Of this I have described several specimens 
which make it clear that precisely the same thing takes 
place in connexion with the jaws as with the pelvic limbs 
When this is the case, the supernumerary maxillae fuse 
together and are impacted in the naso-pharynx and fixed to 
the base of the sphenoid, or hang as a pedunculated tumour 
in the naso-pharynx. Every gradation may be traced, from 
well-formed maxillae with unerupted teeth, to a confused 
lump consisting of teeth, bone, and cartilage impacted in 
the palate but firmly united by a broad base to the sphenoid 
in the neighbourhood of the pituitary fossa. 

Teratomas connected with the rectum and colon. In 
order to appreciate the nature of such tumours arising in the 
immediate neighbourhood of the rectum, it will be necessary 
to consider a few points connected with the embryology of 
this portion of the alimentary canal. In the early embryo 
the central canal of the spinal cord and the alimentary canal 
are continuous around the caudal extremity of the noto- 
chord. This passage, which brings the developing cord and 
gut into such intimate union, is known as the neurenteric 
canal. When the proctodseum invaginates to form part of the 
cloacal chamber it meets the gut at a point some distance 
anterior to the spot where the neurenteric canal opens into 
it ; hence there is for a time a segment of intestine extending 
behind the anus, and termed in consequence the postanal 
gut. Afterwards this postanal section of the embryonic 
intestine disappears. There is good reason to regard the 
postanal gut as the source of that variety of congenital 
sacro-coccygeal tumour which was named by Braune, and 
several writers who followed him, " congenital cystic sarcoma." 
These will be referred to as tumours of the postanal gut In 
addition, it will be necessary to consider dermoids situated 
between the rectum and the hollow of the sacrum postrectal 



SAGRO-GOGGYGEAL TUMOURS 

teratomas, and certain pedunculated tumours situated within 
the rectum rectal teratomas. 

Tumours which arise in the postanal gut exhibit a definite 
structure; they are composed of closed vesicles lined with 
glandular epithelium, and contain glue-like fluid. Many of 
these tumours consist of cysts and duct-like passages lined 
with cubical epithelium, held together by richly cellular 
connective tissue. In many situations the epithelium is 




Fig. 236. Chinese child with a congenital sacro-coccygeal tumour. 

columnar, set upon flatter cells. The cysts are filled with 
ropy mucus, and vary in size from a nut to the smallest 
space visible to the naked eye ; many contain intracystic 
processes. These tumours present such definite characters 
that they are sure to attract attention, and their large size 
makes them very conspicuous. (Fig. 236.) 

Middeldorpf was the first to associate clearly a congenital 
sacro-coccygeal tumour with the postanal gut. His specimen 
was removed from the neighbourhood of the anus of a girl a 



5i8 POSTREGTAL TERATOMAS 

year old. The tumour contained connective tissue, mucous 
membrane with characteristic follicles, submucous tissue, and 
longitudinal and circular layers of muscle-fibres. I had come 
to the same conclusion in regard to the probable origin of 
these tumours before the publication of Middeldorpf s paper ; 
his case is the most conclusive on record. 

Postrectal teratomas are very rare, and do not form such 
large projecting masses as the preceding species. In many 
instances they are not noticed until after infant life, and their 
clinical tendencies are of a different character. An excellent 
example of a postrectal teratoma exists in the Middlesex 
Hospital museum : it contains grease, hair, and a tooth. It 
was found in the course of a post-mortem examination. The 
tumour remains in situ on the rectum. 

Such tumours also occur as surgical surprises, especially 
when they attain very large dimensions and extend upwards 
behind the pelvic peritoneum of men and women. Ord re- 
corded a remarkable case which occurred in a man aged 28 ; 
the mass weighed 14 Ib. Page successfully removed a tera- 
toma, weighing 3 Ib., which occupied the hollow of the sacrum 
in a woman aged 47 ; it lay behind the rectum. The pul- 
taceous matter was evacuated through an incision in the 
perineum; the cyst-wall was then successfully enucleated. 

Skutsch has recorded two examples of postrectal tera- 
tornas, and collected the chief German cases. One of the 
records states that the patient was pregnant, and he was able 
to empty and partially enucleate the tumour through an 
incision in the perineum without disturbing the pregnancy. 

Postrectal teratomas sometimes open spontaneously in the 
perineum ; the fistula is usually situated in the middle line of 
the perineum near the tip of the coccyx. Keen removed a 
postrectal tumour from a girl aged 3 J ; in the middle there 
was a fistula which led upwards to the third piece of the 
sacrum; it contained fat, cartilage, etc. The tubular tract, 
which resembled a trachea, possessed -imperfect rings of 
cartilage and was lined with ciliated epithelium. 

Some postrectal dermoids communicate with the dura 
mater in the sacral region, and have been described as spina 
bifida sacs. (See Chap. LXVII.) 

Teratomas of the rectum. Several examples have been 



RECTAL TERATOMAS 519 

described growing from the mucous membrane of the 
rectum (Fig. 237) ; a curious feature in these cases is 
that the tumours are furnished with long locks of hair 
which protrude from the anus and annoy the patients 
(Danzel, Port). Like postrectal teratomas, they sometimes 
contain teeth. 

Cystic dermoids occur in the rectum, and two examples are 
preserved in the museum of St. Bartholomew's Hospital. One, 
removed from beneath the mucous membrane of the rectum 
of a woman aged 39, contains hair and teeth. The other, 




Fig. 237. Rectal teratoma which contained brain-substance enclosed 
in a bony capsule : from a woman aged 25. (Danzel.} 

multilocular and as big as a fist, contains hair. This dermoid 
was detached and extruded during labour. A careful examin- 
ation of the patient at the time of the extrusion showed no 
communication with the pelvic cavity (Soutter). 

Nearly all the recorded examples of rectal teratomas have 
occurred in women, and this formerly gave some support to 
the suggestion that they arose in the ovary and eroded their 
way into the rectum. In one recorded case a teratoma was 
found between the layers of the mesocolon ; the patient died 
in consequence of an operation performed for its removal ; 
at the autopsy a dermoid was found in the connective 
tissue of the pelvis ; the ovaries were normal (Moynihan). 
A pedunculated teratoma hanging from the mucous mem- 



520 DERMOID OF C^CUM 

brane of the sigmoid flexure led to intussusception in a 
girl aged 16 (Glutton). ' 

The study of dermoids and teratomas connected with the 
rectum is important and puzzling : some of them exhibit the 
characters of teratomas, and others should find a place with 
the simpler varieties of dermoids. The idea that soine of 
them are included foetuses is reasonable when they are situated 
around the terminal section of the gut, but this can scarcely 
be entertained when the tumour, as in the case described by 
Moynihan, is in relation with the pelvic colon. A dermoid 



ILEUM 




Fig. 238. Caecum and adjacent portion of the ileum of a man : a dermoid 
occupies the angle between the ileum and the caecum. (The specimen 
< is in the possession of Mr. Arthur Hall, Sheffield.') 

has been found in the angle formed by the junction of the 
ileum and the caecum : the tumour lies between the layers 
of the peritoneal fold extending from the termination of 
the ileum to the mesentery of the vermiform appendix 
(Fig. 238). It contained the usual pultaceous matter and 
hairs. The cavity was lined with stratified epithelium, but 
lacked a stratum granulosum. The specimen was obtained 
in the course of a post-mortem examination of the body of 
a man by Mr. Arthur Hall, who gave me every facility for 
examining the specimen. 

Teratomas of the mesentery. Many cases have been 



TERATOID CYSTS 521 

reported in which cysts containing pilose skin, and occasion- 
ally teeth, have been found on the omentum and the serous 
covering of the intestine. In some instances these cysts are 
due to the rupture of an ovarian dermoid, and some of the 
cells scattered about the abdominal cavity have engrafted 
themselves on the peritoneum and formed independent cysts 
(see p. 618). Quite apart from cysts arising in this way, tera- 
toid cysts do arise independently between the layers of the 
mesentery, the ornentum, and the folds of peritoneum con- 
nected with the csecum, colon, and rectum, as well as the 
ornentum. Most of the reported cases occurred in children 
and adolescents, especially females. As a rule the cyst- 
contents are grease and hair, but some are more complex 
and Contain bone, cartilage, muscular and nerve tissue. 
The records of dermoid cysts of the mesentery have been 
collected by Pakowski. 

It is impossible to recognize the nature of such cysts 
clinically. They seem to remain latent for a variable period, 
and then with dramatic suddenness cause acute abdominal 
pain simulating peritonitis or intestinal obstruction. Some 
never cause trouble, and are found accidentally at a post- 
mortem examination. 

Teratoma of the kidney. The intimate embryonic 
relationship of the kidney and the sexual gonads favours the 
idea that dermoids, embryomas, or teratornas would arise in 
association with the kidney. The museum of the Royal 
College of Surgeons contains a cyst found embedded in suet 
in the loin of a sheep ; it replaced the kidney, of which there 
was no trace. The cyst contained grease and wool. There 
is no evidence that it arose in the kidney. 

A dermoid in the subserous fat of the renal regions is 
not necessarily a renal dermoid, even if the capsule of such 
a tumour blends with the capsule of the kidney. 

Teratoma of the Fallopian tube, The interior of the 
Fallopian tube is a rare situation for such a tumour. 
Orthmann has described an example furnished with teeth. 

Teratomas of the testicle. These are described in Chap. 
LIX, and the remarkable tumours (ganglion neuromas) con- 
taining sympathetic nerves and ganglia, occasionally found 
at the root of the mesentery, are considered in Chap. xn. 



522 TERATOMAS 

Treatment. Congeru'tal sacro-coccygeal tumours of the 
type shown in Fig. 239 should be removed when an opera- 
tion is feasible, because they sometimes display malignancy. 
A girl aged 19 with such a tumour noticed that it was 
increasing in size. The lump was removed, and a portion 
sent to Prof. Shattock, who found, in addition to the usual 
tissues, unmistakable evidence of squamous-celled cancer and 
cell-nests. I examined the sections and the patient. The 
subsequent clinical course justified the findings. 

Bland-Sutton, J., "On some Congenital Pharyngeal Tumours." Trans. 

Odontol. Soc. of Gt. Brit., 1889, xxi. 27. 
Bostroem, " Ueber die pialen Epidermoide, Dermoide, und Lipome, und 

duralen Dermoide." Centrabl.f. ally. Path. u. path. Anat., 1897, viii. 1. 
Braune, W., " Die Doppelbildungen und angeboren Geschwulste der Kreuz- 

beingegend," 1862, p, 40 et seq. 
Buzzard, E. F., "Case of Dermoid Tumour of the Brain." Trans. Path. Soc., 

1904, Iv. 330. 
Glutton, H. H., " Pedunculated Dermoid Tumour from the Sigmoid Flexure." 

Ibid., 1886, xxxvii. 252. 

Eves, C. C., " Teratoma of the Pharynx." Laryngoscope, 1914, xxiv. 798. 
Middeldorpf, K., "Zur Kenntniss der angeboren Sacralgeschwulste." 

Virchow's Arch. f. path. Anat., 1885, ci. 37. 
Moynihan, B. G. A., " Case of Dermoid Cyst in Gartner's Duct ; Dermoid Cyst 

in the Sigmoid Mesocolon." Lancet, 1898, i. 30. 
Ord, W. M., and Sewell, C. B., " An Account of a Large Dermoid Cyst found in 

the Abdomen of a Man." Med.-Chir. Trans., 1880, Ixiii. 1. 
Page, Frederick, " Large Extraperitoneal Dermoid Cyst successfully removed 

through an Incision across the Perineum, midway between the Anus and 

Coccyx." Brit. Med. Journ., 1891, i. 406. 
Pakowski, J., " Les Kystes Dermoides du Mesentere." Arch. Gen. de Chir., 

1912, viii. 1029. 

Pohl, W., "Ueber Mediastinal-Dermoide." Dent. Zeitschr.f. Cliir., cxxx. 481. 
Port, Heinrich, " Dermoid Tumour from the Rectum." Trans. Path. Soc., 

1880, xxxi. 307. 
Rows, R. G., "Two Cases of Embryoma in the Frontal Lobe of the Brain." 

Rev. of Neurol. and Psychiatry, 1906, iv. 338. 
Russell, A. W., and Kennedy, A. M., " Teratoma of the Thyroid in a Foetus." 

Journ. of Olstet. and Gyn., 1913, xxiii. 109. 
Shattock, S. G., "Congenital Tumour of the Neck." Trans. Path. Soc., 

xxxiii. 289. 
Skutsch, F., " Ueber die Dermoidcysten des Beckenbindegewebes." Zeitschr. 

f. Geb. und Gyn., 1899, xl. 353. 
Thompson, G. S., "A Case of Dermoid Cyst of the Kidney; Malignant 

Degeneration." Lancet, 1906, ii. 1589. 



CHAPTER XLY1I 
TERATOMAS (continued) 

HETEROTOPIC TEETH 

AMONG mammals the normal situation for teeth is the 
mouth (buccal cavity), but under pathologic and teratologic 
conditions they arise in such unexpected situations as the 
ovary, testicle, rectum, neck, and pharynx in man, and in 
connexion with the tympanum of horses (mastoid teeth). 
Among heterotopic teeth those found in ovarian dermoids 
(embryomas) are the best-known, and have been the subject 
of several careful investigations. Ovarian teeth are described 
at p. 611. 

Mastoid (tympanic) teeth in horses. The occurrence 
of teeth in the mastoid portion of the temporal bone in horses 
has been known for nearly a century, and specimens of 
these curious teeth exist in many veterinary museums. The 
number of teeth varies ; as a rule one tooth is present, stuck 
like a peg in the bone. It is not uncommon to find two, 
and in rare instances four teeth. Mastoid teeth are very 
misshapen, and usually of the molar type (Fig. 239) ; often 
they are such ill-formed lumps as to come under the 
denomination odontomes. These teeth possess the three 
familiar dental tissues enamel, dentine, and cementum. 
A careful examination of the very few available specimens 
in which the skull has been preserved with the mastoid 
teeth in position shows that they arise in relation with the 
tympanum, and especially with that part of it known as 
the attic. This is true of a specimen in the museum of the 
Royal Veterinary College, London, in which a solitary tooth 
stands out from the remains of its bony capsule, the root 
of the tooth being lodged in .the tympanic attic. 

Owing to the kindness of Professor Dewar I was able 

523 



524 



MASTOID TEETH 



to study carefully a skull^vith the teeth in position (Fig. 240). 
In this specimen the teeth are not lodged in sockets, but 
encysted by an incomplete bony capsule in the mastoid 
portion of the temporal bone,. especially in that part imme- 
diately overlapped by the squamosal. The cluster of teeth 




Fig. 239. Two dental masses successfully removed from the temporal fossa 
of the mare represented in Fig. 241. The larger tumour, A, is shown 
in section to display the enamel strata; it weighed 175 grm. The 
smaller body, c, weighed 44 grm. ; it is also shown in section, B. 

has markedly compressed the external auditory meatus. 
The tumour has deformed the interior of the cranium, and 
an uncovered portion of tooth projects into the cerebellar 
fossa. During life it was probably excluded by the dura 



MASTOID TEETH 



525 



mater. It is impossible to determine accurately the number 
of separate dental bodies in this specimen without destroying 
it, but there are at least four teeth. 

Before it is possible to make any decisive statement in 
regard to the nature of the mastoid teeth of horses, it is very 




Fig. 240. The mastoid region of a horse's skull with a cluster of teeth. 

desirable to obtain facts concerning their anatomical relation- 
ship with the soft parts. 

Mastoid teeth are troublesome things ; the horse is usually 
brought to the veterinary surgeon on account of a swelling, but 
more frequently a sinus, near the base of the auricle. When 
a probe is passed along the sinus it comes in contact with a 
tooth. (Fig. 241.) The recorded cases of this disease fail to 



526 MASTOID TEETH 

make it clear whether the sinus is congenital or is a conse- 
quence of suppuration as the tooth develops. Heusinger, in 
an admirable paper on cervical fistula, regards them as per- 
sistent branchial fistulas, and states that they are more 
frequent in carriage-horses (Luxuspferde) than in draught- 
horses, as the secretion from the sinus soils the surrounding 
skin and attracts the attention of the grooms. This sinus 
is very constantly associated with mastoid teeth in foals as 
well as in adult and aged horses. A study of the character 




Fig. 241. Head of a van mare with a sinus leading to a mastoid tooth. 
The drooping lip shows that there was paralysis of the facial nerve. 

and position of these teeth shows that their removal is 
sometimes attended with difficulty, certainly with grave 
danger to the horse; and occasionally their extraction is 
impracticable. Cases are known in which horses have died 
from septic meningitis, the result of suppuration around 
the teeth. 

Cervical teeth in sheep. Sheep are liable to a peculiar 
anomaly in the immediate neighbourhood of the ear, which 
consists of a fistula opening near its base ; but its skin 
edge is invariably surmounted by an incisor tooth. The 



ACCESSORY MOUTHS 



527 



first impression is that the opening represents a persistent 
branchial fistula, but in rnan teeth are not associated with 
these fistulae. Congenital cervical fistulse in sheep have 
received careful attention, and the investigations show that 
the abnormal orifice is an accessory mouth. In the example 
(Fig. 242) the tooth has the characters of a temporary 
incisor and is lodged in a bony pedicle surrounded by 




Tooth. 



Subauricular osculum 



Fig. 242. Head of a sheep with a subauricular osculum. In the lower 
figure the teratoma is shown of natural size. 

mucous membrane with the same features as the gums ; 
the cutaneous recess lodging it has a number of processes 
resembling the papillae on the sheep's lips, and the arrange- 
ment of the wool on the outer surface of this accessory lip 
is identical with that covering its normal lip. This speci- 
men by itself is somewhat puzzling, but a wider survey of 
the question adds a special interest to it. 

Gurlt had the opportunity of studying several examples 



528 ACCESSORY MOUTHS 

which enabled him to prove conclusively the nature of 
this condition, and in one of his specimens two temporary 
incisors were lodged in a miniature but unmistakable man- 
dible, and associated with a tongue of corresponding size. 
The fistulous track communicated with the pharynx. When 
the animal drank, some of the fluid escaped through the 
fistula. 

It is rare for an animal with one of these accessory mouths 
to come under the notice of a trained observer, so I gladly 
avail myself of the notes taken by Mr. Wilson, a veterinary 




Fig. '243. Head of a cross-bred Devon ox with an ill-formed head attached 
to its throat. A cane passed through the fistula A entered the 
pharynx of the ox. The animal was exhibited as a freak in a 
travelling show. 

surgeon, concerning a larnb. Some few days after the lamb 
was born, the shepherd noticed that the wool on the right 
shoulder was saturated with milk. He carefully watched the 
lamb suckling, and on close examination discovered a slit 
behind the mandible, through which the rnilk issued. He drew 
his master's attention to this, and the latter, to his astonish- 
ment, found a rudimentary tongue and jaw covered with a 
lip: naturally, he kept the animal alive out of curiosity. When 
the lamb was -weaned and turned out on pasture land there 
was. always a food-stained condition of the wool around the 
opening ; the animal appeared to maintain a decent con- 
dition. When turned out in the winter it lost the use of its 



DOUBLE-HEADED CALVES 529 

front legs, and was taken to the farm buildings, kept warm 
and hand-fed. At this stage Mr. Wilson saw it, and found a 
pharyngeal fissure 3 in. long, the tongue freely movable 
and working in harmony with the normal tongue. A similar 
condition is shown in Fig. 243, except that the subject is 
an ox. 

Without entering too fully into the details of this matter, 
the revelation afforded by a thorough anatomical study of 
the specimens amounts to this : 

The cervical teeth and the associated structures are the 
remnants of an attached or parasitic fcetus, and the cuta- 
neous opening represents its mouth. 

A study of two-headed animals throws light on the origin of 
mastoid teeth. Many museums contain skulls of bicephalous 
calves and foals ; in some the skulls are firmly conjoined in 
the mastoid region. In many the skulls are equal, or one may 
be so small that it seems like an appendage to its companion. 
A secondary skull may be small, ill-shapen, and like a 
teratoma attached to or embedded within the skull, with 
simply a small opening representing an osculum. 

A critical study of specimens leaves no escape from the 
conclusion that mastoid teeth in horses, like a cervical 
osculum and teeth in sheep and oxen, are remnants of an 
accessory head. Mastoid teeth are memorials of a lost 
individual. 

Broca, "Traite des Tumeurs," 1869, ii. 369. 
Dewar, Joum. of Comp. Path., 1903, xvi. 127. 
Goubaux, Recueil de Med. Vet., 1854, xxxi. 

For the cervical teeth of sheep 
Berger-Perriere, Recueil de Med. Vet., xii. 586. 
Gurlt, " Thierische Missgeburten," Berlin, 1877, Taf. xv. 
Wilson, W. T., Private Letter. 



2 I 



CHAPTER XLVIII 
SEQUESTRATION DERMOIDS 

DERMOIDS are tumours, furnished with skin, occurring in 
situations where this structure is not normally found. 
They only possess the structures normal to skin, such as 
hair, sebaceous and sweat- glands ; teeth are rarely present. 
Dermoids may be arranged in two genera 1, Sequestration 
dermoids; 2, Tubulo-dermoids. The former are considered 
in this and the next chapter ; the latter in Chap. L. 

Sequestration dermoids arise in detached or sequestered 
portions of skin, chiefly in situations where, during em- 
bryonic life, coalescence takes place between cutaneous 
surfaces. A sequestration dermoid occasionally takes the 
form of a skin-lined recess, but more commonly it occurs 
as a globular tumour with a central cavity lined with skin 
furnished with dermal elements. 

Dermoids of the trunk. These occur strictly in the 
regions where the lateral halves of the body coalesce. This 
line of union begins immediately below the occipital pro- 
tuberance, extends along the middle of the back to the 
coccyx, passes through the perineum (scrotum and penis in 
the male') and upwards through the umbilicus, thorax, 
neck, and chin, ending at the margin of the lower lip. 

Dermoids are rare along the dorsal part of this line, and 
are apt to be mistaken for spina bitida sacs, especially in 
the lumbo-sacral region. A man aged 22 had a congenital 
tumour in this region which had been regarded as a spina 
bifida sac (Fig. 244). It had never caused him incon- 
venience until a few days before his admission into the 
hospital, when it inflamed, burst, and discharged a quantity 
of foul-smelling sebaceous material mixed with hairs. The 
cavity was freely opened and cleared of decomposing 
material. The skin lining the interior of the dermoid 

530 



DERMOIDS OF THE TRUNK 



531 



was beset with pores of large size, corresponding to the 
orifices of sweat-glands ; when the patient perspired, drops 
of sweat could be seen oozing from these pores. This 
skin also contained nerves, for the man could localize the 
prick of a pin on the interior of the dermoid as easily as 
one made upon the skin surrounding the tumour. When 
the tumour was removed the spinous processes underlying 
it were found to be unusually short and surrounded by fat. 




Fig. 244. Dermoid in the lumbo-sacral region of a man aged 22. 

Rarely dermoids are associated with spina bifida. Gilbert 
Barling observed such a combination in a child aged 2, 
affected with spina bifida occulta ; the skin covering the de- 
fective spines presented the hair-field usual in these cases. 
In the tissues overlying the stunted spinous processes a 
dermoid was found containing grease and hair (Fig. 245). 

Dermoids within the spinal canal are uncommon. Hale 
White described one that grew in the thoracic region of the 
spine of a man aged 26, and caused paraplegia. Laminectomy 
was unsuccessful. 



532 



GOGGYGEAL SINUS 



Faulty coalescence of the cutaneous covering of the back 
often happens over the" lower sacral vertebrae, and is indi- 
cated by small congenital sinuses known as postanal dimples 
and coccygeal sinuses, situated in the middle line : these 
sinuses are often 10 cm. in depth, and frequently coexist 
with lumbo-sacral spina bifida. Such recesses are lined with 
pilose skin that contains sebaceous and sweat- glands. In 
situations where sequestration dermoids occur, similar re- 
cesses are found. An examination of such a sinus shows 
that if its external orifice became occluded, without the 




Fig. 245. Section of three thoracic 
vertebrae with a small dermoid 
situated over two stunted spinous 
processes. 




Fig. 246. Median aspect of a sheep's 
digit, showing the interdigital 
pouch. 



deeper parts becoming obliterated, we should have the germ 
of a derrnoid, for the numerous glands in the walls would 
be active, and their secretion, with the shed epithelial scales 
and hairs, would soon cause it to enlarge and assume such 
proportions as to render it recognizable as a tumour. 

The coccygeal sinuses are sometimes troublesome, as hair 
and dirt accumulate in them and lead to suppuration. In 
such circumstances they should be excised. They are occa- 
sionally mistaken for anal fistulye and tuberculous abscesses. 

A good physiological type of such a sinus is furnished 
by the interdigital pouch of the sheep. This pouch 
(Fig. 246) lies between the digits, and all the dissection 
required to expose it is to separate the digits with a sharp 
knife, keeping close to the phalanges of one side. In adult 
sheep it is always full of shed wool and grit. Sometimes 



SGROTAL DERMOIDS 533 

its orifice is occluded and it becomes a retention cyst ; sup- 
puration follows, much to the sheep's discomfort. The walls 
of this pouch are full of very large glands. In order to 
get satisfactory sections it is necessary to obtain the digits 
from a stillborn lamb, for as soon as a lamb runs about 
grit gets into the pouch and spoils the edge of the knife. 
Similar interdigital sinuses occur in connexion with webbed 
fingers in man. 

Dermoids of the scrotum and labium. Many dermoids 
reported as arising in the testicle were sequestration der- 
moids of the scrotum. Testicular dermoids are described 
in Chap. LIX. 

Dermoids have been described in relation with the ingui- 
nal canal. The only record which can be relied on is that 
by H. J. Paterson ; he removed a cyst of this kind from the 
inguinal canal of a man aged 35. 

Dermoids of the labium are very rare : on one occasion I 
saw one as big as an orange removed from the right labium 
of a woman aged 40. It contained the usual pultaceous 
material and shed hair. The dermoid had burrowed beneath 
the deep fascia of the thigh and come into relation with the 
tendon of the adductor longus muscle. 

Dermoids of the thorax. Judging from the few available 
records, dermoids of the thorax are very uncommon. They 
occur in two situations viz. on the anterior aspect of the 
sternum and in the thoracic cavity. Dermoids on the front 
of the sternum are situated in the middle line near the 
junction of the manubrium with the gladiolus (Fig. 247) ; it 
is not uncommon to find a small cutaneous recess in this 
situation exactly in the middle line and resembling the 
coccygeal sinus. Sternal dermoids have been described by 
Brainann, Cahen, Glutton, and Macewen. 

An unusual situation for a dermoid is the episternal notch 
(Fig. 248), and it is easy to understand that one in this 
situation could burrow into the superior mediastinum. 

At first glance it would seem difficult to account for the 
presence of a large dermoid within the thorax, but a review of 
the mode of development of the sternum throws much clear 
light on the subject. The two lateral halves of the sternum 
are, in the early embryo, widely separated from each other ; 



534 STERNAL DERMOIDS 

gradually they coalesce an the middle line. Every anatomist 
is aware that this median coalescence is extremely liable to be 
faulty, and conditions occur like those which, happening in 
connexion with the medullary folds, produce spina bifida. 
In this line of coalescence, so far as sternal dermoids are 
concerned, we may get skin-lined recesses resembling the 




Fig. 247. Dermoid situated over the junction of the manubrium and 
gladiolus of the sternum of a youth aged 19 ; there was also a der- 
moid near the left cornu of the hyoid bone. (Bramann.} 

coccygeal dimples. These sternal recesses, or dimples, are 
found near the junction of the manubrium with the gladiolus, 
and may be more than a centimetre deep. Should a piece of 
skin become sequestrated during coalescence of the thoracic 
walls, it may, during the development of the sternum, be 
dislocated forwards to the outer surface, or backwards towards 
the mediastinum conditions in every way parallel to the 
variations in the position of cranial dermoids. So long as a 



THORACIC DERMOIDS 535 

dermoid on the deep surface of the sternum remains small 
it will cause no trouble, but it is easy to understand that a 
large tumour would, if projecting into the thorax, encroach 
on the pleura. Even then it would not produce much dis- 
turbance so long as air did not gain access to it ; but if 
by pressure the wall of the cyst becomes so thin as to allow 
air to enter its cavity, or an actual communication forms 
between the cyst and a bronchus or the air-sacs of the lung, 




Fig. 248. Dermoid in the episternal notch ; it contained hair and pulta- 
ceous matter, and was superficial to the deep cervical fascia. 

then suppuration with all its disastrous consequences will 
ensue. (Intrathoracic dermoids and teratomas are considered 
at p. 512.) 

Facial dermoids. Dermoids occur on the face in certain 
definite positions, such as the inner and outer angles of 
the orbit ; on the upper eyelid ; in the naso-facial sulcus ; 
on the cheek slightly posterior to the angle of the mouth ; 
in the middle line of the chin, and on the nose. 

In order to appreciate the origin of dermoids in these 
situations it is necessary to bear in mind the relation of 
the facial fissures in the embryo, which in the adult are 



536 FACIAL FISSURES 

represented by the orbits, lachrymal ducts, mouth, and certain 
furrows in the lips and cheek. 

In the early embryo the face is represented by an opening 
from which six fissures radiate (Fig. 249). The upper pair 
are the orbito-nasal ; the lower, the mandibular ; the fifth and 
sixth are the internasal and intermandibular fissures. The 
median fold projecting into the opening from above is the 
fronto-nasal process, which ultimately forms the nose. As it 
develops, a rounded prominence, known as the globular 
process, forms at each angle and gives rise to a portion of the 
ala of the nostril and the corresponding prem axilla. These 



Fronto-nasal plate. 
Globular process, s^ JJH1& ^^ifc^^Mi ^ Internasal fissure. 

,_^_ -^^^ -^^_r- Orbito-nasal fissure. 

Nat'- -?Blt s/^iti^. MKHf 
Maxillary process. 

Mandibular fissure. 
Mandibular process. i|- ^MlBi.Ji^- ~M Intermandibular fissure. 




Fig. 249. Head of an early embryo to show the fronto-nasal plate, globular 
processes, and associated fissures. (Modified from His. ) 

globular processes fuse together in the middle line to form 
the central piece, or philtrum, of the upper lip. The elonga- 
tion of the fronto-nasal process necessarily lengthens the 
orbito-nasal fissures. Eventually the sides of the fronto- 
nasal plate coalesce superficially with the maxillary processes 
in such a way as to leave a cleft on each side, which becomes 
the orbit ; the line of union being permanently indicated in 
the adult by the naso -facial sulcus or groove, and indicated 
-still more deeply by the lachrymal duct, which is a persistent 
portion of the original orbito-nasal fissure. The union of the 
fronto-nasal plate with the maxillary processes completes the 
,JIOSB, cheeks, and upper lip (Fig. 250). 

. This account indicates the relation of these fissures to 
each other ; but it will be necessary, in considering dermoids 



FACIAL FISSURES 537 

arising in them, to mention certain details connected with 
each. Here it may be stated that the defects associated 
with any of them are of four kinds : 1, the fissure may 
persist ; 2, it may close imperfectly and leave a recess or 
puckering of the skin ; 3, portions of the surface epithelium 
may be sequestered and give rise to dermoids ; 4, there may 
be excessive coalescence. 

These conditions may be illustrated by the mandibular 
fissure. In the embryo this fissure or cleft is relatively more 
extensive than the opening of the mouth which in the adult 




Fig. 250. Face with black lines to indicate the situation of the 
embryonic fissures. 

ultimately represents it. In fishes the whole of the mandi- 
bular fissure persists as the gape ; but in mammals the 
dorsal portions of the clefts are obliterated by the union of 
their margins, leaving the central portion as the mouth. 
Persistence of the whole length of the fissure is a rare defect, 
and is known as macrostoma, while excessive closure of the 
fissure produces microstoma. Imperfect union of those 
sections that normally coalesce gives rise to slighter imper- 
fections, of which some examples will now be described. 

Occasionally we find on one or both cheeks of children, at a 
spot varying from 2 to 4 cm. behind the angle of the mouth, 
a small nodule rarely exceeding a rape-seed in size. Some- 
times there is a depression or sinus in the cheek, surmounted 



538 



FACIAL DERMOIDS 



by the nodule. Occasionally the buccal mucous membrane 
presents a shallow recess, sometimes a sinus, and occasionally 
a white cicatrix at a spot corresponding to the nodule on the 
cutaneous surface of the cheek. 

These mandibular tubercles and recesses are frequently 
associated with malformations of the corresponding auricles, 
as well as other facial defects, such as coloboma of the eyelid 




Fig. 251. Right side of the head of a foetus, showing a large mandibular 
tubercle and an accessory tragus. 

and pilose cutaneous patches on the conjunctiva. The largest 
specimen which has yet come under my observation occurred 
in a still-born foetus (Fig. 251). On the right cheek, 2 cm, 
behind the angle of the mouth, was a nodule the size of a 
rape-seed, and immediately behind this a pedunculated body. 
The tubercle on the cheek consisted of dense connective 
tissue traversed by blood-vessels and covered with skin beset 
with lanugo and richly supplied with sweat* and sebaceous 
glands of large size. 



MANDIBULAR TUBERCLES 539 

In many mammals, especially dogs, small cutaneous 
nodules furnished with vibrissse may often be detected in a 
line with the angle of the mouth (Fig. 252). These nodules 
occupy positions corresponding with those of the mandibular 
tubercles of children. 

There is very little relationship between pathology and 
poetry, but that very philosophical pathologist, Sir Samuel 
Wilks, in reference to my observation that the usual position 
of the mandibular tubercle and recess corresponds with that 




Fig. 252. Head of a dog, showing the mandibular tubercle. 

of the dimple in the baby's cheek, drew my attention to the 
following passage in his Harveian Oration, 1879 : " From any 
point of view we take, and upon whatever subject we fix our 
gaze, we come to the conclusion that the greatest discovery 
ever made by man about himself, and of the earth of which 
he forms a part, is the doctrine of evolution. 

" ' The softest dimple in a baby's smile 
Springs from tlie whole of past eternity, 
Tasked all the sum of things to bring it there.' " 

Wilks observed to me how little the poet (Miss Bevington) 
divined that there is a material basis for these three pretty 



540 



MEDIAN CLEFTS 



and significant lines. .Jevons expressed the same truth in 
the following epigram: "The origin of everything that exists 
is wrapped up in the past history of the universe." 

The intermandibular fissure. When the rnandibular pro- 
cesses fail to coalesce, the result will be a median cleft in 
the lower lip extending to or even beyond the chin (Fig. 253). 




Fig. 253. Intermandibular fissure. 
. (From a cast presented by McCormick to the Royal College of Surgeons, England.} 

Median clefts of this kind are very rare. In children with 
double hare-lip two sinuses are sometimes seen in the mucous 
membrane of the lower lip. Their orifices are indicated by 
small but prominent papillae. The sinuses are large enough 
to admit a probe, sometimes to a depth of 2 cm. Mucus 
exudes from them, furnished by glands which beset the 
membrane lining their walls. These sinuses are probably 



MANDIBULAR RECESSES 541 

due to faulty coalescence of the intermandibular fissure. 
This view is strengthened by an observation of Feurer, who 
detected a similar sinus in the upper lip of a lad, on the 
right side of the philtrum ; it corresponded exactly to the 
termination of the naso-facial fissure. 

For a remarkable observation in regard to mandibular 
recesses I am indebted to Mr. Nicoll. A mother and her two 
children had each a pair of recesses in the lower lip (Fig. 254). 




Fig. 254. Mother and her two children with mandibular recesses. Each had 
double hare-lip. (From a photograph.} 

Each had double hare-lip, and the cicatrices of successful 
operation are clearly visible. The mother was one of a family 
of five, and each had double hare-lip and a pair of recesses in 
the lower lip. 

For a long time I thought that these recesses probably 
had a morphological significance, and made a wide search 
through the various families of the mammalia for a type, but 
without success. 

The congenital defect in the upper lip is called hare-lip 
because the hare, in common with many rodents, has its 
upper lip split. The cleft in the hare's lip is a subject of 



542 HARE-LIP 

perennial interest. O'Connor has translated a Tibetan folk- 
tale in which a hare played practical jokes on a tiger, some 
ravens, and sheep. The results so amused the hare that 
he leaned back on a handy stone and laughed till he split 
his upper lip. "And it remains split to this very day." 

Hare-lip, a good example of a persistent embryonic fissure, 
is for Keith an unhealed evolutionary wound. 

Bramann, F. f " Ueber die Dermoide der Nase." Arch. f. Idin. Chir. 

(Langenbeck), 1890, xl. 101. 
Cahen, Fritz, " Schweissdriisen-Retentionscyste der Brust." Deut. Zeitschr. f. 

Chir., 1891, xxxi. 370. 

Glutton, H. H., "Large Dermoid Cyst over the Sternum." Trans. Path. Soc., 
1887, xxxviii. 393. 

Feurer, G., "Angeborene Oberlippenfistel." Arch.f. klin. Chir. (Langenbeck), 
1893, xlvi. 35. 

Macewen, J. A. C., "A Case of Large Dermoid Cyst situated over the 
Sternum." Lancet, 1913, ii. 144. 

Paterson, H. J., " Dermoid Cyst of the Inguinal Canal." Trans. Path. Soe., 

1903, liv. 147. 
White, W. Hale, " A Case in which the attempt was made to remove a Dermoid 

Tumour which, growing in the Spinal Canal, pressed upon the Spinal 

Cord." Trans. Clin. Soc., 1900, xxxiii. 140. 



CHAPTER XLIX 
SEQUESTRATION DERMOIDS (concluded) 

Dermoids of the orbito- nasal fissure. Dermoids appear 
in this fissure in three situations : (1) at the outer angle of 
the orbit ; (2) at the inner angle of the orbit ; (3) in the naso- 
facial sulcus. Of the three situations, by far the most 
frequent is the outer angle of the orbit, where they form 
rounded tumours rarely exceeding the dimensions of a cherry ; 




Fig. 255. Dermoid at the outer angle of the orbit. 

they lie in close relation with the pericranium covering the 
frontal bone, which is often deeply hollowed to accommodate 
them. Dermoids in this region vary somewhat in regard to 
their position ; sometimes they are quite close to the external 
angular process of the frontal bone, or they may be 2 cm. or 
more posterior to it (Fig. 255) ; exceptionally they are on a 
level with, or even lie beneath, the eyebrow. 

543 



544 



ORBITAL DERMOIDS 



Dermoids at the inner angle are far less frequent (Fig. 256). 
In this situation the fUmour may extend beyond the bone 
and lie in intimate relation with the dura mater. It is very 
necessary to remember this in attempting the extirpation of 
the dermoid. In some cases the tumour may have a peduncle 
continuous with the dura mater. Under such conditions the 




Fig. 256. Dermoid at the inner angle of the orbit. 

dermoid may transmit the cerebral pulsation ; it is then apt 
to be mistaken for a meningocele. 

Dermoids occur not only at the orbital angles, but some- 
times also in the tissue of the upper eyelid, unconnected 
with either bone or periosteum. These smaller dermoids prob- 
ably arise in the fissure between the fronto-nasal plate and 
the cutaneous fold from which this eyelid is formed. The 
fissure between the two parts which form an eyelid sometimes 
persists. To this defect the term coloboma of the eyelid is 
applied. 



NASAL DERMOIDS 



545 



Dermoids arising in the orbital angles are the simplest 
of all dermoids, and though the skin lining them is usually 
rich in the ordinary cutaneous elements, such as hair, seba- 
ceous and sweat- glands, complex structures such as teeth 
and bone, so far as my knowledge extends, have not been 
observed in them. The skin in these dermoids is sensitive 
and possesses tactile sensibility. 

Dermoids in the lower section of the orbi to-nasal fissure 
are rare. They usually protrude in the naso-facial sulcus, and 
occasionally possess a tooth (Fig. 257). 





Fig. 257. Dei-moid in the naso- 
facial sulcus containing a tooth. 
(Paul.} 



Fig. 258. Translucent der- 
moid at the bridge of 
the nose in an adult. 



Nasal dermoids. In addition to the naso-facial sulcus, 
dermoids occur in two other situations on the nose. A not 
uncommon position is the bridge of the nose (Fig. 258). 
This part of the face is not traversed by a fissure, and the 
mode by which such a dermoid arises is in all respects 
identical with that which gives rise to cranial dermoids. 
In the skull of an early embryo the fronto-nasal plate, 
which ultimately forms the nose, consists of a lamina of 
hyalin cartilage covered externally with skin and internally 
with mucous membrane. After the third month, sections 
2J 



546 NASAL RECESSES 

made through the nasal capsule, immediately anterior to the 
ethmoid, show that the skin is being dissociated from the 
underlying cartilage by bony tissue which eventually becomes 
the nasal bones. Ultimately the cartilage disappears as a 
result of the pressure exercised by these bones. It is reason- 
able to believe that, in the gradual separation of the skin 
from the cartilage of the frqnto-nasal plate by the intrusion 
of the nasal bones, small portions of skin or epithelium 
become sequestrated and eventually develop into dermoids. 
This explanation is more fully set forth in the next section, 
on dermoids of the scalp and dura mater. 





Fig. 259. Dermoid recess in Fig. 260. Dermoid recess at 

the nose of an adult. the tip of the nose of a child. 

Dermoids near the tip of the nose are the consequence of 
faulty fusion of the internasal fissure, and usually take the 
form of narroAv skin-lined recesses furnished with hair which 
is often long enough to sprout beyond the recess (Figs. 259, 
260). Hair-lined recesses in the mid-line of the nose 
at some point between the lower border of the nasal bone 
and the tip of the nose are very common, but they rarely 
call for treatment. They occur far more frequently in men 
than in women. In their mode of origin and characters 
they agree with the hair-lined sinuses known as postanal 
dimples (see p. 532). 

A much rarer anomaly than a dermoid is excessive 
coalescence of the nasal segment of the orbito-nasal fissure 
(Fig. 261). 



WENS 547 

Dermoids of the scalp and dura mater. The common 
situations for dermoids of the scalp are over the anterior 
fontanelle (bregma) and occipital protuberance. In these 
situations they resemble sebaceous cysts or meningoceles. 
Dermoids of the scalp often have a thin pedunculated 
attachment to the dura mater, the pedicle traversing a hole 
in the underlying bone, unless the cyst is over a fontanelle. 

The term " wen " used to be applied indifferently to seba- 
ceous cysts and dermoids of the scalp. Sir Astley Cooper, 
in his essay on " Encysted Tumours," included orbital der- 




Fig. 261. Child with a deformed nose due to excessive coalescence of 
the nasal section of the orbito-nasal fissure. The case was under 
the care of Mr. Nicoll. 

molds among wens. In describing them, he writes : " The 
largest size I have known them acquire has been that of a 
common-sized coco-nut, and this grew upon the head of 
a man named Lake, who kept the house called the ' Six 
Bells ' at Dartford. It sprang from the vertex, and gave him 
a most grotesque appearance, for, when his hat was put on, 
it was placed upon the tumour and scarcely reached his 
head. The cyst is in the collection at St. Thomas's Hospital, 
also a cast of his head taken just prior to the operation " 
(Fig. 262). 

The cyst, which is probably the largest dermoid of the 
scalp on record, contains a number of round balls, some 



548 DERMOIDS OF THE SCALP 

having ' a diameter of 1 cm. These consist of epithelial cells 
mixed with fat. 

Arnott described a dermoid situated over the anterior 
fontanelle of an infant. The tumour exactly resembled a 
meningocele, " rising and falling with regular pulsation, and 
swelling when the child coughed." A few weeks later the 
.child died from broncho-pneumonia, and the cyst was found 
to be a dermoid. 




Fig. 262. Head of the man Lake with a large dermoid over the bregma. 
(From a cast in the Museum of St. Thomas's Hospital.) 

Dermoids in the neighbourhood of the occipital protu- 
berance (inion) may lie on the inner aspect of the occipital 
bone, and are nearly always in relation with the tentorium 
cerebelli. Examples have been described by Turner, Ogle, 
Pearson Irvine, and Lannelongue. They occurred in children, 
and in Ogle's case there was a defect in the squamous 
portion of the occipital bone. In Lannelongue's patient, a 
girl aged 7, the dermoid had attained the size of an 



CRANIAL DERMOIDS 549 

orange; it produced marked symptoms, such as paralysis, 
amaurosis, and coma, ending in death. 

Morphologically considered, the bony framework of the 
skull is an additional element of the primitive cranium, 
which is represented by the dura mater, and, as I have else- 
where endeavoured to show, the term extracranial should 
strictly apply to all tissues outside the dura mater. In sur- 
gical practice we find it convenient to regard the bones as 
the boundary of the skull, but morphologically this is in- 
accurate ; the skull-bones are secondary cranial elements. 
Early in embryonic life the dura mater and skin are in 
contact ; gradually the base and portions of the side walls 
of the membranous cranium chondrify, thus separating the 
skin from the dura mater. In the vault of the skull, bone 
develops between the dura mater and its cutaneous cap, but 
the skin and dura mater remain in contact along the various 
sutures even for a year or more after birth. This relation 
of the dura mater and skin persists longest in the region of 
the bregma and the neighbourhood of the inion. Should 
the skin be imperfectly separated, or a portion persistently 
adhere to the dura mater, it would act as a tumour-germ 
and give rise to a dermoid. Such a tumour may retain its 
original attachment to the dura mater, and its pedicle 
become surrounded by bone ; the dermoid would lie outside 
the bone, but be lodged in a depression on its surface, with 
an aperture transmitting its pedicle. On the other hand, 
the tumour may become separated from the skin by bone; 
it would then project on the inner surface, or between the 
layers of the dura mater. If this view of the origin of 
dermoids of the scalp be admitted, we must then modify 
our teaching, and say that the depressions in which der- 
moids of the cranium are lodged arise as imperfections in 
the developmental process, and are not due to absorption 
induced by pressure ; further, the fibrous connexion of such 
dermoids with the underlying dura mater is primary, not 
accidental. 

In the embryo the tentorium consists of two folds of 
dura inater ; it arises as an infolding or crease in this 
membrane, caused by the rapid backward extension of the 
developing cerebrum. The opposed surfaces of the tentorial 



550 IMPLANTATION CYSTS 

lamellae, like the outer surface of the dura rnater in relation 
with the cerebrum, are originally in contact with the skin, 
and as the posterior margins of the bay or recess formed by 
the crease in the dura mater come together, a portion of the 
skin may become nipped or even sequestrated between the 
layers of the tentorium; this, preserving its vitality, and in 
some cases its cutaneous connexions, may ultimately give 
rise to an intracranial derrnoid. 

IMPLANTATION CYSTS 

These small cysts should not be included among tumours, 
but their consideration is imperative in connexion with 
sequestration derrnoids, for they furnish valuable evidence 
that dermoids of this genus arise from " rests," the result of 
faulty coalescence. 

These cysts are caused by the accidental implantation of 
portions of skin, epithelium, or hair-bulbs in the underlying 
connective tissues. The transplanted tissue acts in many 
instances as a graft, and forms a small cyst. Implantation 
cysts have received a variety of names, such as dermal cysts, 
traumatic dermoids, sebaceous cysts of the fingers, etc. 

They are common on the fingers (Fig. 263), the cornea, 
and the iris, and have been observed by many surgeons. 
Careful accounts have been written, especially by Polaillon, 
Le Fort, and Garre. Hesse found that such cysts can be 
obtained experimentally by implanting particles of cutaneous 
glands, or the sheaths of hair-bulbs. 

Implantation cysts vary much in size : some are scarcely 
as big as a split pea, others may be as large as a ripe cherry. 
In many the microscopic characters " appear as if a piece of 
the skin covering the pulp of the finger had been inverted " 
(Shattock). In others the implanted epidermis seems to have 
been shed in layers, so that on section the interior of the cyst 
is occupied by epithelial laminae. When these cysts occur on 
the scalp, they contain hair. 

Implantation cysts are caused in a variety of ways, such 
as punctures by awls, forks, needles, thorns, glass, etc. ; also 
accidental wounds by knives, incisions by scalpels, bites, 
lacerations, and gunshot wounds. They serve to throw light 
on some cysts, containing hair and wool, preserved in the 



CYSTS OF IRIS 55i 

museum of the Royal College of Surgeons. Two of the cysts 
are from sheep, and contain wool embedded in fatty matter. 
Unfortunately, the catalogue affords no information as to the 
region of the body whence they were removed. The third 
and fourth specimens were removed from the shoulder of 
a cow that had six legs. The cysts contain light hair, fatty 
and calcareous matter. These four specimens are Hunterian. 
The fifth specimen was removed from beneath the integu- 
ments of the shoulder of an ox; it contained slender black 
hairs, resembling those on the skin of the animal, mixed with 
fat. I once obtained a good example of an implantation cyst 
from the axilla of an ox. The cyst was as large as a billiard- 
ball, and in structure resembled a piece of inverted skin. 
Fortunately, these cysts can be explained on the same lines 
as similar cysts of the fingers in man. The sticks used by 




Fig. 263. Implantation cyst of the finger. 

cattle-drovers are armed at the end with a sharp iron spike, 
2*5 cm. (1") long, with which they " prod " the beasts, often 
very severely. It may be assumed that punctures produced 
with such an instrument may lead to the implanting of dermal 
grafts beneath the skin, which may give rise to cysts in the 
same way as punctured wounds in the skin of men and women. 
Punctured wounds in sheep and oxen may also be caused by 
projecting nails, iron spikes, tenter-hooks, and the like. 

The opinion that cysts may arise in the subcutaneous 
tissues by implantation receives the strongest possible con- 
firmation from what we know of similar cysts of the iris and 
cornea associated with mechanical injury. 

Iritic cysts. Cysts of the iris are of comparative rarity, 
generally appearing as transparent vesicles situated on its 
anterior surface. As a rule they are sessile, but occasion- 
ally possess a pedicle and contain sebaceous material such 
as fills the cavities of dermoids. Some are translucent. 



552 SGLERAL CYSTS 

Hulke (1869) collected some valuable facts in relation 
to such cysts, and state's that in 15 out of 19 cases, as well 
as in 2 reported by himself, there was distinct history of 
antecedent mechanical injury, including surgical operations 
upon the iris. 

Numerous instances are known in which eyelashes, some- 
times as many as six, have been implanted on the iris by 
foreign bodies penetrating the cornea, such as knives, needles, 
foils, and swords. Barry Sullivan, whilst acting as Richard III, 
received during the famous combat (Act v, Scene 4) a wound 
in the eye from his opponent's sword. Subsequently a cyst 
containing an eyelash grew from the iris. Similar cysts have 
been produced in the eyes of rabbits by the artificial introduc- 
tion of eyelashes and epithelium into the anterior chamber. 

Examining an eye with an implantation cyst on the iris, 
it would seem an easy operation to remove the cyst. Experi- 
ence teaches that the removal of an apparently simple cyst of 
this kind is apt to be followed by irido-cyclitis with all its evil 
consequences (McMullen). 

Corneal cysts. In addition to the evidence furnished 
by implantation cysts of the iris, we know that similar cysts 
occur in the cornea. Treacher Collins investigated this 
matter, and published some valuable researches in which 
he succeeded in demonstrating that, after gunshot injuries of 
the eyeball, blows from tip-cats, and incisions made for the 
extraction of cataracts, cysts, usually of small size, are liable 
to form in the cornea near the seat of injury. In some of 
the specimens the cysts were large and conspicuous ; when 
examined microscopically, their inner walls were lined with 
layers of cells identical with those covering the anterior 
surface of the conjunctiva. The structure of these cysts, 
taken in conjunction Avith the antecedent injuries, thoroughly 
supports the view that they arose from conjunctival epithe- 
lium transplanted into the deep tissues of the cornea, 

Scleral cysts. Implantation cysts have been observed in 
the sclera by Goulden and Whiting. A girl aged 16 had an 
operation performed on the muscles of her left eye for con- 
vergent strabismus. Two months later a swelling appeared 
above the cornea, and a little later one made its appearance 
below the cornea. They increased in size slowly, and two 



REFERENCES 553 

years later resembled in shape and size kidney-beans, and were 
pearly white. The nature of the cysts was suspected before 
operation, and after removal they were submitted to careful 
microscopic examination. They were lined with stratified 
epithelium implanted from the conjunctiva. Such cysts 
appear to be rare in the sclera. 

Arnott, Henry, " Dermoid Cyst of the Scalp simulating Meningocele." Trans. 
Path. Soc., 1874, xxv. 228. 

Ashby, H., and Wright, G. A., "Diseases of Children, Medical and Surgical," 
1899, p. 770. [Dermoid containing tooth.] 

Bland- Sutton, J., "A Critical Study in Cranial Morphology.'' Jintrn. of Anat. 
and Phys., 1888, xxii. 28. 

Collins, E. Treacher, "The Anatomy and Pathology of the Eye," 1896, 
pp. 77, 78. 

Garre, C., " Ueber traumatische Epithelcysten der Finger." Beit, z.ldin. Chir. 
(Bruns), 1894, xi. 524. 

Goulden, G., and Whiting, M. H., "Epithelial Cysts of the Sclera." Trans. 
of'Ophth. Soc., 1921, xli. 316. 

Hulke, J, W., " On Cases of Cysts in the Iris." Boy. Lond. Ophthal. Hosp. 
Repts., 1869, vi. 12. 

Irvine, J. Pearson, "Dermoid Cyst of the Brain." Trans. Path, l-ioc., 1879, 
xxx. 195. 

Lannelongue et Menard, V., " Kystes Extra-cniniens de 1'Inion." "Affections 
Congenitales," 1891, i. 50, 51. 

Le Fort, "Kyste du petit Doigt. Kecidive apres une premiere ponction ; 
guerison par la compression. Analyse chimique du liquide." Bull, ct 
Mem. de la Soc. Chir., 1881, vii. 547. 

McMullen, W. H., "An Implantation Cyst of the Iris." Proc. Roy. Soc. of 
Med., 1921, xiv., Sect. Ophthalmol., p. 23. 

Ogle, J. W., "Congenital Cysts containing Hair and Sebaceous Material, or 
communicating with the Cranial Sinuses [Morbid growths of the brain, 
spinal cord, etc.]." Brit, and For. Med.- Chir. Rev., 1865, xxxvi. 208. 

Paul, F. T.," Dermoid Tumour of the Face, carrying Teeth." Trans. Path. Soc., 
1894, xlv. 148. 

Polaillon, "Doigt (Pathologie) : Kystes dermoides." " Diet. Encycl. des Sci. 
Med.," 1884 (lre se'rie), xxx. 281. 

Walther, C., " Kyste de 1'Inion." Presse Med., 1895, pp. 123-6. 



CHAPTER L 
TUBULO-DERMOIDS 

THERE exist in the human embryo certain canals and 
passages, many of which normally disappear before birth. 
Among these obsolete canals those connected with the neck 
the branchial clefts, the thyro-glossal duct, and the hypophysis 
require special consideration in connexion with dermoids. 

CERVICAL FISTULA AND AURICLES 
Cervical fistulae. It is not uncommon to find in the 
neck, at some point along the anterior border of the sterno- 
inastoid muscle, a small orifice in the skin 
capable of admitting a bristle or a tine probe. 
These congenital openings, known as cervical 
or branchial fistulas, are probably persistent 
representatives of the branchial fissures which 
were discovered in the embryos of pigs, 
horses, and man by Rathke in 1825 (Fig. 204). 
showing bran- Congenital fistulous openings in the side of 
chial clefts, fa e neck were observed many years before 
Rathke's embryologic discovery. Heusinger (1854) clearly 
recognized the relationship of these fistulse to branchial clefts. 
In the mammalian embryo at the end of the third week four 
depressions running dorso-ventrally exist in the lateral wall 
of the foregut. These depressions, known as the pharyngeal 
pouches (Fig. 265), extend outwards, press aside the meso- 
derrn, and come into contact with the ectoderm. When the 
pharyngeal endoderrn reaches the ectoderm the two fuse : 
when this happens, the external depressions, known as the 
branchial grooves, make their appearance. Later, an in- 
growth of mesoderm separates the branchial grooves from 
the pharyngeal pouches. 

In fishes the epithelial membrane separating the grooves 

554 




PHARYNGEAL POUCHES 



555 



and pouches disappears, leaving a series of fissures, known 
as the gill-clefts; but this is not usual in mammals. The 
ridges between the grooves are known as the branchial or 
visceral arches. Of these, the first is called the mandibular, 
the second the hyoid arch. The posterior pairs are known 
as the branchial arches. 

In the fully developed pharynx traces of the pharyngeal 
pouches remain. The Eustachian tube represents the first, 
and the supratonsillar recess the second pouch. Cervical 
fistulse were, after 
Rathke's observation, 
universally attributed 
to persistence of the 
third and fourth bran- 
chial clefts. Later f 1. A.:.J, ' ' /HMMk^rfh P. p. 1 
embryologists have dis- 
covered a space, the 
cervical sinus, lined 
with epithelium de- 
rived from the ecto- 
derm of the embryonic 
gill area and represent- 




p.p. 2 



p. p. 3 



P.P.* 



Fig. 265. Dorsal view of the pharynx of 
an embryo pig, showing the pharyngeal 
pouches. (Fox.) 



ing the common gill- 
chamber of fishes. The 
fundus of the cervical 
sinus persists in the 
mammalian embryo 
long after its orifice in 
the neck is closed ; 
after the sinus becomes shut in, it usually dwindles until it 
becomes a diverticulurn connected with the third and fourth 
arch. The common forms of branchial fistula are now re- 
garded as vestiges of this sinus. In some examples the 
fistula opens just above the sterno-clavicular articulation. 
This low position and the length of the fistula are due to the 
elongation of the neck. Accessory ostia, some of which are 
furnished with teeth, occur in the necks of sheep ; they must 
not be confounded with branchial fistuloe (see Chap. XLVII). 

As a rule, cervical fistula) persist as narrow recesses, but 
occasionally they pass deeply among the structures of the 



556 CERVICAL FISTULA 

neck and terminate on the wall of the pharynx or open into 
the pharyngeal cavity. One, two, or three orifices may per- 
sist, and they exhibit a great tendency to be bilateral, to 
affect several members of the same family, and to be trans- 
mitted to several generations. These sinuses or canals, 
which vary in length from 2 to 5 cm., are lined by mucous 
membrane with ciliated epithelium, or by skin containing 
sebaceous glands. The lining membrane of the canal usually 
secretes a thin mucous fluid which increases during catarrhal 
conditions of the respiratory passages. Occasionally the canal 
inflames and an abscess results, which may give rise to con- 
siderable pain and difficulty in deglutition. The external 
orifice of a branchial fistula is occasionally indicated by a 
tag of skin containing a piece of yellow elastic cartilage ; 
such tags are known as cervical auricles. 

The external orifices of the sinuses vary in position, but 
they are always situated along the anterior border of the 
sterno-mastoid muscle. The common situation is a spot in 
line with the angle of the jaw, but they may open anywhere 
along the line of the muscle from the mastoid process to the 
sterno- clavicular articulation. When the fistula extends to 
the pharynx, the duct keeps a constant course and passes 
between the fork of the carotid artery, above the sling of the 
superior laryngeal nerve, and terminates in the sacculus 
pyriformis. 

Hueter refers to a young man who had a cervical fistula 
and " wished to become a trumpeter ; " he dissected out the 
fistulous tract, " following it between the two carotids to the 
pharynx." 

A. lad aged 15, under my observation, complained of a 
mucous discharge which soiled his collar occasionally ; fluid 
when swallowed leaked through. I dissected out the duct and 
found that it passed between the fork of the carotid artery. 

Heusinger held the opinion that some pharyngeal diver- 
ticula arise as distensions of the persistent pharyngeal seg- 
ments of branchial clefts. Morrison Watson made a careful 
dissection of such a diverticulum. In the description it is 
stated that a tube terminating inferiorly in a cul-de-sac 
containing a large quantity of grumous material was found 
extending from the pharynx, immediately behind the tonsils, 



CERVICAL FISTULA 



557 



to the interclavicular notch (Fig. 266). This tube possessed 
muscular walls, and in the deep part of its course passed 
between the fork of the carotid and over the loop of the 
superior laryngeal nerve ; its lower part was parallel with the 
anterior border of the sterno-mastoid muscle ; it rested on 
the sterno-hyoid and sterno- thyroid muscles. It communi- 
cated with the pharynx by means of a slit-like opening, 
not more than 3 mm. in length, the margins of which were 
so closely in contact that the entry of solid particles into 




Fig. 266. Pharyngeal diverticulum. (Morrison Watson.} 

it from the mouth must have been prevented. The diver- 
ticulum itself increased in calibre from above downwards, so 
that whilst at the upper end a crow-quill could with difficulty 
be introduced, at the lower a pencil could readily be passed 
along the lumen of the tube. The pharyngeal orifice was 
situated between the lower jaw and the stylo-hyoid ligament. 
Its point of departure from the pharynx corresponds to the 
supratonsillar fossa. The muscle-fibres were for the most 
part red and striated, and the mucous lining resembled that 
of the oesophagus. 



55 CERVICAL AURICLES 

It has long been suspected that the so-called sebaceous 
cysts which arise in the" neck below the deep fascia take 
origin in unobliterated segments of branchial clefts. Such a 
cyst does not necessarily contain grease or hair ; it may be 
filled with mucus. The walls of cervical fistulse are covered 
with epithelium of various kinds, which in some is ciliated and 
in others squamous. Mucous cysts in the side of the neck 
arising in persistent branchial clefts must not be confused 
with lymphatic cysts (see p. 176), nor with dermoids associated 
with the thyro-glossal duct (see p. 564). 

Cervical auricles. When describing branchial fistulse 
(p. 556) it was mentioned that the cutaneous orifices are 
in some cases surmounted by tags of skin. These tags, 
or processes, sometimes occur unassociated with fistulse, but 
always in situations where fistulse, when present, open on 
the skin. Usually they are short, in some cases mere 
nodules, but in others form prominences 2 to 3 cm. in height. 
These processes have been described under a variety of 
names, and classed among tumours, but at the present time 
they are commonly known as cervical auricles. 

Like branchial fistulse, they are always congenital, and 
sometimes affect several members of a family. The mother 
may have a cervical auricle, and one of her children a 
branchial fistula, whilst another child may have an auricle 
associated with a fistula; they are often symmetrical. A 
cervical auricle consists of an axis of yellow elastic carti- 
lage, Avhich sometimes extends deeply into the tissues of 
the neck ; muscle-fibres from the platysma are attached to 
the cartilage, and the whole is surmounted with skin con- 
taining hairs and sebaceous glands. A small arterial twig 
runs into the auricle and ramifies in the fibrous tissue and 
fat in which the cartilage is embedded. 

Thus, structurally, cervical auricles are identical with the 
normal auricle or pinna, and they agree with the pinna mor- 
phologically, inasmuch as they are developed, like it, from 
that portion of a branchial bar which is directly in relation 
with the corresponding cleft. 

In sharks the gill- slits open separately on the surface of 
the body ; from the branchial bar anterior to each slit a 
fold of skin is formed, which closes upon the slit like a lid, 



CERVICAL AURICLES 559 

and is named from this resemblance the operculum. In 
mammalian embryos a slight prominence or tubercle is for a 
time visible anteriorly to each of these clefts. In most cases 
the tubercles disappear from the posterior bars, but those in 
relation with the anterior cleft enlarge and are joined by 
accessory tubercles to form the pinna. The external ear or 
pinna is an operculum modified for acoustic purposes. 

The homology of at least a part of the pinna and cervical 
auricles with the opercula of fishes has been made clearer by 
Schwalbe's discovery of auricular tubercles in the embryo 




Fig. 267. Head of a horned sheep with cervical auricles. 

of the turtle (Einys lataria taurica); in the adult condition 
chelonians have no vestige of an auricle. 

Cervical auricles occur in mammals other than man. 
Heusinger, in 1876, mentioned the frequency with which 
pendulous tags of skin occur in the necks of pigs, goats, 
and sheep (Fig. 267) ; yet very little has been done to 
extend his observations. 

The anatomy of these auricles (which are especially 
common in Egyptian and Italian goats) is similar to that 
of cervical auricles in man : there is an axis of yellow 
elastic cartilage embedded in fibrous tissue and fat, the 
whole being covered with hairy skin. In the statues of satyrs 
and fauns, cervical auricles, similar to those in the necks of 



560 



FAUNS 



goats and children, are often seen. In a^gipans (goat-footed 
satyrs) the auricles in he neck are sometimes pointed like 
their ears and sessile ; but in the fauns they are pendulous 
(Fig. 268). In the remarkable frieze representing the battle 
of the gods and giants, on the great altar of Zeus at 
Pergarnon (now one of the glories of Berlin), may be seen, by 




Fig. 268. Faun and goat with cervical auricles, (from the Capitol.} 

the side of the ivy-crowned Dionysus, the figure of a satyr 
with a cervical auricle. 

AURICULAR FISTULA AND DERMOIDS 

We may assume that the auricle or pinna consists mainly 
of an enormously developed operculimi which has become 
utilized for acoustic purposes. In the embryo each branchial 
cleft is surmounted by a swelling or tubercle corresponding to 
the operculum of the shark. In mammals and, as Schwalbe 



AURICULAR FISTULA 561 

has shown, in reptiles the first cleft, which ultimately be- 
comes modified into the tympano - Eustachian passage, is 
surrounded by additional tubercles, some of Avhich belong 
to the mandibular and others to the hyoid bar. It is by the 
subsequent growth and coalescence of these tubercles that 
the auricle is formed. Imperfections in the development 
and union of the tubercles explain many of the congenital 
defects to which the auricle is liable. Of these, three are 




Fig. 269. Congenital sinus in the helix. 



of especial interest auricular fistula, auricular dermoid, and 
accessory tragus. 

1. Auricular fistulae. These appear in the helix and 
in the lobule. A fistula, or properly a sinus, is common 
in the helix. Many examples have been observed since 
Heusinger described them (1864). The sinus is usually seen 
as a small opening in the outer surface of the helix, leading 
into a recess; a small quantity of grease exudes from it. 
The auricle is often deformed (Fig. 269). A person with a 
sinus in the helix sometimes has a branchial fistula. Helical 
sinuses are hereditary. 

It is far rarer to find a congenital fistula in the lobule 
2 K 



562 AURICULAR DERMOIDS 

A little girl known to me was born with a perforation in the 
lobule of the left auricle exactly in the spot for wearing an 
ear-ring, and to this day she wears a ring in this lobule and 
refuses to have the other pierced. 

The facts now at our disposal enable us to understand 
how such sinuses and fistuloe arise, for it seems reasonable 
to conclude that, if the various lobules which conspire to 
form an auricle unite imperfectly, the intervening space will 
persist as a sinus or a fistula. 

2. Auricular dermoids. From what has just been stated 
regarding the probable mode of origin of auricular fistulse, it 
will be obvious that if unobliterated skin-lined spaces are left 
between the tubercles uniting to form the auricle, and if the 
skin lining such spaces possesses glands (sequestered tracts of 
skin are unusually rich in sebaceous glands), we have in such 
spaces potential dermoids. 

The auricle is not an uncommon situation for cysts often 
described as sebaceous ; they are usually small, but sometimes 
attain the dimensions of a cherry, or even larger. When 
these supposed sebaceous cysts are examined microscopically 
they sometimes turn out to be dermoids. It is a curious fact 
that unless small dermoids in unusual situations are very 
carefully examined, they run a great chance of being put 
aside as sebaceous cysts. 

Auricular dermoids of fair size sometimes occupy the 
groove between the pinna arid the mastoid process ; if allowed 
to grow they will form a deep hollow in the underlying bone. 

3. Accessory tragus. One of the commonest malforma- 
tions of the pinna is duplication of the tragus. The 
accessory tragus is extremely variable in shape; often it 
assumes the form of a low conical projection in front of or 
above the tragus (Fig. 270) ; sometimes it is pedunculated 
and hangs as a small cutaneous tag slightly in front of the 
tragus, beset with pale, delicate hair. It is curious that an 
accessory tragus, a Woolner's tip (Fig. 271), and a mandibular 
tubercle in children are usually covered with lanugo. 

Occasionally an accessory tragus is associated with a 
circular cicatrix-like depression in the cheek immediately 
in front of the pinna. Malformations of the tragus and an 
accessory tragus are often associated with defects in the 



AURICULAR TUBERCLE 



563 



raandibular fissure, such as macrostoma, mandibular fistula, 
and tubercle (p. 538). 

Woolner's tip. This name has been given to a small 
tubercle often present on the margin of the helix (Fig. 271). 
It was noticed by Woolner, the celebrated sculptor, whilst he 
was at work on his statuette of Puck, to whom he gave 
pointed ears. The urchin is " perched upon a toadstool and 
with his toe rousing a frog." Woolner drew Darwin's atten- 
tion to this tubercle whilst modelling a bust of the famous 





Fig. 270. Auricle with a 
duplicated tragus. 



Fig. 271. Auricle of a foetus with 
an unusually large Woolner's 
tip furnished with a tuft of 
lanugo. 



naturalist. After a careful consideration of the facts, Darwin 
thought it probable " that the points are vestiges of the tips 
of formerly erected and pointed ears." Woolner made his 
observation at the age of 22. I possess a fine example of this 
famous statuette. 

Heusinger, " Hals-Kiemen Fisteln von noch nicht beobachteter Form." 

Arch, /.path, Anat. (Virchow), 1864, xxix. 358. 
His, W., "Anatomic menschlicher Embryonen," 1885, Heft iii. ("Die For- 

mentwickelung des ausseren Ohres "), p. 211. 
Hueter, C., " Grundriss der Chirurgie," 1882, ii. 328. 
von Kostanecki, K., " Beitrage zur Kenntniss der Missbildungen in der Kopf- 

und Halsgegend." Arch. f. path. Anat. (Virchow), 1891, cxxiii. 401. 
Paget, Sir J., " Cases of Branchial Fistulas in the External Ears." Med.- Chir. 

Trans., 1878, Ixi. 41. 

Schwalbe, " Ueber Auricularhocker bei Reptilien ; ein Beitrag zur Phylogenie 

des ausseren Ohres." Anat. Anzeiger, 1891, vi. 43. 
Watson, Morrison, " Notes of a Remarkable Case of Pharyngeal Diverticulum." 

Journ. Anat. and Pliys., 1874-5, ix. 134. 



CHAPTER LI 
TUBULO-DERMOIDS (concluded) 

DERMOIDS AND FISTULA ARISING FROM THE 
THYRO-GLOSSAL DUCT 

The thyro-glossal duct. The thyroid gland of man consists 
of two lobes united by a narrower portion or isthmus. His 
maintains that the three parts of this gland arise separately. 
The lateral lobes originate independently of the isthmus, 
which is derived from a median tubular outgrowth from 
the ventral wall of the embryonic pharynx, known as the 
thyro-glossal duct. This duct bifurcates at its lower end 
and gives rise to the thyroid isthmus, which fuses with the 
lateral thyroid rudiments and assists in forming the lobes 
of the gland. Originally the duct extends as far upwards 
(forwards in the embryo) as the dorsum of the tongue, but, 
as the body of the hyoid bone develops, the duct becomes 
divided into an upper segment, the lingual duct, and a lower 
portion, the thyroid duct. In the ordinary course of develop- 
ment these ducts disappear, but in some cases they persist 
and attain a fair size. Thus the central part of the thyroid 
may be regarded as the remnant of a secreting gland provided 
with a duct which conveyed the products of the gland into 
the pharynx. 

There are at least three abnormalities which appear to 
be associated with vagaries of the thyro-glossal duct (1) 
lingual dermoids, (2) median cervical fistula?, (3) accessory 
thyroids. 

1. Lingual dermoids. Dermoids arising in the tongue 
have been many times observed and reported as sebaceous 
cysts. Barker, however, published a clear account of their 
nature, and showed them to be true dermoids. Subsequent 
research has proved that those dermoids which occupy a 

564 



LINGUAL DERMOIDS 565 

central position in the tongue between the geniohyoglossi 
muscles arise in the lingual duct. When fully developed, this 
duct extends from the foramen caecum to the posterior surface 
of the basihycid. Occasionally the duct is so large that a 
probe may be introduced into it from the foramen caecum. 
The duct lies between the geniohyoglossi muscles, and is 
not infrequently replaced by a solid fibrous cord. When 
this duct persists, and its buccal end is obstructed, the 




Fig. 272. Large lingual dermoid, protruding from the mouth. The cyst 
contained 2 pints of sebaceous matter : it is preserved in the museum 
of University College Hospital. (Gray.} 

accumulation of shed epithelium and sebum will convert it 
into a cyst. Large lingual dermoids bulge in a characteristic 
manner in the submental space. 

The walls of lingual dermoids are composed of fibrous 
tissue, lined internally with squauious epithelium beset with 
hair and sometimes with glands. The contents of such cysts 
are epithelial cells, hair, grease, and cholesterin. 

Lingual dermoids are occasionally big enough to attract 
attention in infants, but most examples come under notice 
in adults. (Fig. 272.) 



566 LINGUAL THYROIDS 

Treatment. Small lingual dermoids can be removed 
through the mouth, bul a submental incision affords better 
access. After exposing the cyst-wall, it should be punctured 
and the grease evacuated. The cyst- wall is then easily 
shelled out. 

LINGUAL THYROIDS. In addition to the common variety 
of dermoid, the tongue is occasionally occupied by tumours 
which in structure resemble the thyroid gland. They occur 
in the neighbourhood of the foramen caecum, between the 
geniohyoglossi muscles. 

Bernays in 1888 published a careful description of a 
lingual thyroid which he removed from the tongue of a girl 
aged 17, and recognized its nature. Since that date a number 
of lingual thyroids have been removed and described in 
America, England, France, and Germany. W. G. Spencer, 
in a critical review (1914) of the abnormalities of the thyro- 
glossal tract, has collected records of cases to show that 
still-born myxoedematous fetuses are not uncommon in 
goitrous districts and some possess no thyroid tissue. He 
gives abstracts of cases relating to patients with a lingual 
thyroid but in whom the normal thyroid is absent or 
atrophied. Some persons from whom a lingual thyroid has 
been removed have subsequently been reported to be 
myxoedematous. 

2. Median cervical fistulas. These fistulas occur singly, 
and open at some point in the middle line of the neck 
between the hyoid bone and the top of the sternum. The 
common situation is a little below the level of the cricoid 
cartilage. Median cervical tistulue differ from those arising 
in connexion with branchial clefts, in the fact that they are 
never congenital ; they may occur soon after birth, or make 
their appearance as late as the fourteenth year. 

Gusset described a median cervical fistula in 1877 : but 
Raymond Johnson clearly pointed out that a median cervical 
fistula is preceded by a swelling in the middle line of the 
neck which either ruptures or is opened by the surgeon ; this 
leaves a sinus which never closes. 

The fistula often opens on the floor of a scar-like 
depression (Fig. 273), and from the opening clear mucus 
exudes. A probe introduced into this hole easily passes 



MEDIAN CERVICAL FISTULA 



567 



upwards in the middle line directly beneath the skin, to 
stop at the lower border of the basihyoid. Patients ask 
to have these ducts removed because the escape of mucus 
annoys them. The ducts are lined with columnar ciliated 
epithelium, and islets of thyroid tissue occupy the walls 
(Fig. 274). 

Occasionally a persistent thyroid duct is so large as to 




Fig. 273. Median cervical fistula in a man aged 23. The fistula 
appeared when he was 3 years old. 

form a conspicuous vertical ridge in the middle of the neck 
in association with a median cervical fistula (Fig. 275). 

Our knowledge of the nature of these fistulse was not very 
satisfactory until the publication of an able paper by Marshall, 
detailing the anatomy of the parts in the neighbourhood of 
the hyoid bone of a child aged 5, who had a median sinus 
in the neck. The patient was admitted into a hospital for 
the purpose of having the duct excised ; it contracted diph- 
theria and died before the operation could.be performed. 

In the median line of the neck, 2*5 cm. (1") above the 



568 



THYRO-GLOSSAL DUCT 



sternum, there was a ^inus which, during life, discharged a 
small quantity of mucous fluid. From this opening a hard 
cord could be felt extending up to the hyoid bone. On 
dissecting the front of the neck this cord was found to be 
tubular and patent up to within 1 cm. of its termination ; the 




Fig. 2J4. Section of a persistent thyroid duct. A represents the duct of natural 
size. The lowermost drawing shows the epithelium more highly magnified. 

upper end was firmly attached to the hyoid bone, the lower 
end dilated into a thin-walled sac opening on to the surface 
of the skin. The sac and tube lay between the skin and the 
anterior layer of the deep cervical fascia ; at no place was 
there any connexion with the thyroid gland. 

On dividing the hyoid bone the tube could be traced as 
an ill-defined fibrous cord on to its dorsal surface, to which it 



MEDIAN CERVICAL FISTULA 



569 



was closely attached, and through the substance of the tongue 
to the foramen caecum. About 2 crn. from the foramen it 
again became patent, and continued so up to the surface of 
the tongue. The canal was thus open at both ends, but 
impervious in the middle. 

The lobus pyramidalis was connected with the left side 




Fig. 115. Median cervical fistula associated with a persistent thyroid duct. 

of the thyroid isthmus, its upper end being united to the 
median fibrous cord at the same place as the above-mentioned 
canal. In other words, the fibrous cord behind the hyoid 
bone was continuous both with the pyramidal lobe of the 
thyroid and with the tube leading to the superficial sinus 
(Fig. 276). 

The relations of the parts indicate the probable mode by 
which these median fistulas arise ; they are probably retention- 
cysts formed in a persistent thyroid duct, and the pressure of 
the cyst ultimately causes the skin to yield and form a sinus. 



570 



ACCESSORY THYROIDS 



Treatment. Median cervical fistulse when troublesome 
are dissected out. This should be done with care and 
thoroughness, for if only a small portion of the duct be left 
a sinus persists. The troublesome section is the part of the 
duct in relation with the body of the hyoid bone. It is occa- 
sionally necessary to divide this bone in order to extirpate 
the duct. 

3. Accessory thyroids. The consideration of accessory 



Foramen ca-cui 



Hyoid bone. 



Thyroid cartilage. 



Pyramid of 
thyroid gland. 

Abscess-sac. 




Lingual duct. 
Epiglottis. 



Thyroid gland. 



Trachea. 



Fig. 276. Diagram to show the relation of parts in a case of median 
cervical fistula. (Marshall.} 

thyroids naturally follows on the description of median 
cervical fistulse, for there is good reason to believe that the 
thyroid duct is the source of some of these bodies. They 
occur most frequently in the neighbourhood of the hyoid 
bone and in the hollow formed by the two lobes of the 
thyroid gland. As the thyro-glossal duct is directly associated 
with the formation of the thyroid body, and as median 
accessory thyroids are found directly in its track from the 
hyoid to the thyroid isthmus, it is not unreasonable to regard 
these little bodies as remnants of this remarkable tube. 

Accessory thyroids occasionally arise in connexion with 



ACCESSORY THYROIDS 571 

the germs of the lateral lobes of the thyroid : these are most 
commonly found in the neighbourhood of the greater cornu 
of the hyoid. 

Accessory thyroids are in the main innocent structures, 
but occasionally they give rise to troublesome tuuiours. It is 
well known that when the thyroid body becomes goitrous, and 
accessory thyroids coexist, the latter will enlarge and become 
goitrous. Apart from this, accessory thyroids will enlarge 
on their own account and produce tumours which closely 
simulate unilateral enlargement of the thyroid, and occasion- 
ally give rise to bronchoceles of moderate dimensions. 

A bursa exists between the body of the hyoid and the 
thyro-hyoid membrane (see Fig. 284, p. 730). When large, 
such a bursa has been mistaken for a dermoid and for an 
accessory thyroid. 

Albers, "Atlas cler pathologischen Anatomie," 1817, Abth. ii.. Taf. xxv., 

xxvi. und xxix. 
Barker, A. E., " Two Cases of Dermoid Cyst in connection with the Tongue." 

Trans. Clin. Soc., 1891, xxiv. 68 (p. 70, " Case of Dr. Wellington Gray "). 
Bernays, A. C. St. Louis Med. and Surg. Journ., Iv. 201. 
Johnson, E., " Two Cases of Persistent Thyroid Duct." Trans. Path. 8oc., 

1890, xli. 325. 
Marshall, C. F., " The Thyro-Glossal Duct or ' Canal of His.'" Journ. of Anat. 

and Phys., 1892, xxvi. 94. 
Spencer, W. G., "The Thyreo-Glossal Tract." Lancet. 1914, i. 522. 



CHAPTER LII 
TUMOURS OF THE DUCTLESS GLANDS 

THE HYPOPHYSIS (PITUITARY BODY), THE PINEAL 
GLAND, AND THE ADRENAL 

TUMOURS OF THE HYPOPHYSIS 

THE hypophysis consists of two lobes differing in origin, struc- 
ture, and function. The anterior lobe, the larger, arises in 
early embryonic life as a diverticulum from the pharynx ; 
in structure it resembles the foetal thyroid. The posterior 
lobe rests in a depression on the back of the anterior lobe 
and receives the infundibulum. There is usually a cleft in 
the middle of the hypophysis, filled with glairy fluid ; this 
cleft is the remains of the original epithelial cavity of the 
buccal extension (see Fig. 265, p. 555). The hypophysis is 
lodged in a pouch of dura inater which occupies the de- 
pression in the sphenoid bone known as the sella turcica 
(pituitary fossa). During infancy a fibrous ligament passes 
from the dural lining of the pituitary fossa, through the 
body of the sphenoid, to the roof of the pharynx. The space 
occupied by this ligament is known as the cranio-pharyngeal 
canal ; in normal adult skulls it is obliterated, but a per- 
sistent canal has been demonstrated in acromegalic skulls, 
and accessory hypophyses have been seen in it (Erdheim). 
An ectopic hypophysis has been detected projecting from 
the roof of the pharynx in a child with hare-lip, cleft palate, 
and defects of the sphenoid (Keith). 

The anterior portion of the hypophysis is often called 
the glandular lobe ; the posterior part is derived from the 
first cerebral vesicle and consists mainly of neuroglia and 
epithelial cells, and is called, in consequence, the nervous 
lobe. A third portion, the pars intermedia, formed by the 
fusion of the contiguous parts of the anterior and posterior 

572 



HYPOPHYSIS 



573 



lobes, is less vascular than the anterior lobe and secretes 
a colloid substance. 




Fig. 277. Median section through the anterior part of the skull of 
an infant and an adult, showing the relations of the hypophysis 
and the spheuoidal sinus. 

The anterior lobe of the hypophysis and the pars inter- 
media correspond to an internal secreting gland, like the 



574 



AGROMEGALY 



thyroid ; the posterior lobe probably discharges its secretion 
into the cerebral ventricle through the infundibulum. 

The hypophysis exists in every vertebrate animal : this 
is a sufficient indication of its importance, but its functions 
were unknown until 1885, when P. Marie described a disease, 
which he named acromegaly, associated with enlargement of 




Fig. 278. Face of an acromegalic aged 42. "When a 
young man he was a dapper city clerk." (From a 
cast in the Museum of the Royal College of Surgeons.} 

this organ. Since then many investigators have given the 
hypophysis much attention, and among other things have 
shown that its secretion exercises an important influence 
on the development and growth of the body. Experimental 
removal of the hypophysis leads to depression, coma, and 
death ; but how far death is due to the ablation of the 
gland, or to damage caused in its removal, is not accurately 



GIANTISM 575 

determined. Inefficient functioning of the gland in men and 
women leads to an abnormal deposition of fat, loss of sexual 
power, and the genital organs revert to an infantile type ; 
amenorrhea occurs in women, and occasionally diabetes. In 
men, sexual inability due to this cause is sometimes called 
pituitary eunuchisrn. 

Enlargement of the anterior lobe is accompanied by two 
distinct effects, one being physiological and the other mecha- 
nical. When this lobe enlarges in adolescents they become 
giants, but in adults the changes affect the hard and soft 
tissues of the head and face (Fig. 278), hands and feet, pro- 
ducing the clinical picture expressed by the term acromegaly 
(big ends or points). The difference between giantism and 
acromegaly may be expressed in this way : When the gland 
enlarges before the epiphyseal cartilages are ossified the result 
is a giant, but hypertrophy of the gland after obliteration 
of the epiphyseal cartilages produces an acromegalic. 

The mechanical effects are important. The hypophysis, 
occupying a bony recess in the body of the sphenoid and 
lying in close relationship with the structures forming the 
interpeduncular space at the base of the brain, cannot enlarge 
without producing disastrous effects on adjacent structures. 
A normal pituitary fossa is 11 mm. in length and breadth, 
and (5 mm. in depth. When the hypophysis enlarges, the 
pressure of the growing gland leads to absorption of the 
surrounding bone, and the fossa in which it lodges becomes 
a broad shallow depression. In some cases the basisphenoid 
has been absorbed, so that the enlarged hypophysis rests on 
the mucous membrane of the pharynx (Fig. 279). It must 
strike even a casual observer as strange that two contrasted 
men such as Patrick Cotter, an Irishman known as the 
Bristol giant, 8 ft. 7 in., and Daniel Lambert, weighing 
739 lb., whose portrait adorned many tavern signs (Fig. 280), 
were products of disordered glandular action. The discovery 
that Hunter's famous giant, Charles Byrne, alias O'Brien, 
had an enlarged hypophysis, is one of the romances of the 
Royal College of Surgeons. Prof. D. J. Cuningham, during 
a visit to the museum, slipped his finger through the foramen 
magnum of the unopened skull of the giant and found the 
pituitary fossa shallow and expanded ; its walls had been 



576 GIANTISM 

levelled by an enlarged hypophysis. Keith subsequently 
cut a movable lid in Che cranial vault and made the floor 
of the skull available for inspection. The most striking 
feature of gianjts, apart from their height, is the enormous 
size of their hands. A cast of Patrick Cotter's hand is 
preserved in the College museum. Goliath of Gath, Avhose 
height was 6 cubits and a span (9 ft. 9 in.), had big hands ; 
the staff of his spear was like a weaver's beam. The biggest 
hands I have seen belonged to an acromegalic musician ; 
his span was 16 inches ; he played the double-bass. 




Fig. 279. Enlarged hypophysis in situ and in section. From an 
acromegalic woman aged 41. She was blind. Duration of the 
disease, 18 years. (Museum of the lioyal College of Surgeons.) 

Hunter's giant died in 1783, aged 22. Patrick Cotter 
died at Clifton, 1806, aged 46. It is strange that dis- 
orders of the most cunningly concealed organ in the body 
may make its owner the most conspicuous person in an 
assembly. 

The mechanical effects of an enlarged hypophysis are 
persistent headache and bitemporal hemianopsia ; sometimes 
the patient's vision is so narrowed that he feels as if he were 
walking in a " narrow alley with high walls." The inter- 
ference with vision is due to pressure of the tumour on the 
optic tracts. The visual defect is often more pronounced in 
one eye. X-ray pictures of the pituitary fossa are valuable 
aids in diagnosis. The local results of enlargement of the 



GIANTISM 



577 



hypophysis form a striking picture of the effects of environ- 
ment in regard to tumours. 




Fig. 280. Patrick Cotter, the Bristol giant, 8 ft. 7 in., and Daniel 
Lambert. (Kirbifs Wonderful Museum, 1804, vol. ii.) 

There is a close parallel between enlargements of the 
hypophysis and of the thyroid. In both, increase in size is 
due to glandular overgrowth, and both are liable to cystic 

2L 



578 TEMPORARY AGROMEGALY 

change. The increase, in the size of the hypophysis, as in 
the case of the thyroid, causes great trouble from pressure. 
Malignant change in either is uncommon. 

It has long been recognized that there is an undefined 
relation between the hypophysis and the sexual glands. 
Physiologists have also detected an interaction between the 
sexual organs and the ductless glands generally, and much 
experimental work has been conducted in order to determine 
the nature of this correlation. It is known, too, that the 
signs of acrornegaly sometimes manifest themselves during 
pregnancy and disappear with its termination. For example, 
a primipara aged 26 had advanced to the eighth month of 
pregnancy when she noticed that her gloves and boots became 
too tight. Her fingers thickened, and the rings upon them 
had to be removed with a file. She became sleepy, thirsty, 
and sugar appeared in the urine. Gradually she assumed 
the coarse skin, thick lips, and projection of the lower jaw 
characteristic of acromegaly. The child was born in due 
course and survived. In a few months the signs of acro- 
megaly in the mother had disappeared. (Marek.) The 
changes in the hypophysis during pregnancy affect the 
glandular portion. 

Hypertrophy of the anterior lobe of the hypophysis is 
also said to follow thyroidectomy, removal of the adrenals, 
and castration. 

Acromegaly only arises in connexion with certain tumours 
of the hypophysis, and more especially with those which 
appear to be due to adenomatous enlargement of this body. 
The tumours which occur in connexion with the hypophy- 
sis have received a variety of names at the hands of the 
recorders, such as adenoma, sarcoma, carcinoma, adeno- 
sarcoma, epithelioma, endothelioma, psammoma, pituitary 
goitre, and cysts. Pituitary teratomas are usually post- 
mortem surprises. 

The tumours classed as sarcomas erode the body of the 
sphenoid rather than produce its slow absorption. Teratomas 
occasionally arise in connexion with this part of the sphenoid 
and bulge into the pharynx (see p. 513). These tumours 
have a morphologic interest, for the pituitary fossa marks 
the anterior (cephalic) termination of the axis of the trunk. 



HYPOPHYSEAL TUMOURS 579 

It is a region which bristles with morphologic, embryologic, 
and evolutionary problems. 

Many observers, when recording cases of hypophyseal 
tumours, have expressed surprise at the few symptoms 
which even large tumours of this body produce. In common 
with other intracranial tumours, those arising from the hy- 
pophysis produce mental dullness, hebetude, drowsiness, and 
mental lethargy. It is, however, a clinical feature in con- 
nexion with them that a patient, after lying several weeks 
in a drowsy condition, will suddenly wake up and appear 
to the relatives quite rational. A man of this kind, under 
Terrier's care, would pass his time asleep in a chair and 
resent being disturbed. He suddenly had a " lucid interval 
during which he woke up and made a perfectly sensible 
will." 

The divergent effects, local and general, attributed to 
tumours of the hypophysis may be explained. Every tumour 
which occupies the pituitary fossa is not necessarily a 
tumour of the hypophysis. It is well known that many 
malignant tumours growing in the testicle do not arise from 
the intrinsic elements of that organ; indeed, the majority 
of them originate in the band of tissue known as the para- 
didymis. As the tumour grows, the tubular seminiferous 
tissue is flattened out like a strap. Similar changes probably 
occur in the hypophysis. A tumour growing from the dura 
or other membrane of the brain, the periosteum of the 
pituitary fossa, or the infundibulum would compress and 
flatten out the hypophysis to a thin, inconspicuous stratum. 
Moreover, a growth in the posterior or so-called nervous 
lobe would flatten out the anterior lobe, and vice versa. 

A remarkable personal account of acromegaly has been 
written by Leonard P. Mark after he had suffered from it 
for over a quarter of a century. He has also published an 
account of an acromegalic who lived at Scarborough some two 
hundred years ago, a man named Richard Dickinson, who 
followed the double occupation of shoe-cleaner and vendor 
of gingerbread. His singularity of figure contributed to 
bring him into notice, and he did not escape the attention 
of poets and painters. This singular individual was born in 
1670; he was appointed governor of the spa in 1700, and 



5 8o PINEAL TUMOURS 

had charge of the lavatories. He died in 1738, aged 68. 
Mark regards this as one of the earliest representations of 
an acromegalic in England. 

Treatment. Complete extirpation of an enlarged hy- 
pophysis is impossible, but partial removal relieves the head- 
ache. Sight is not improved unless the optic chiasma has 
escaped compression. The skeletal changes remain. 

It might be imagined that the hypophysis, lodged in 
a bony cave in the body of the sphenoid, would be safe 
from surgical aggression. This is not the case. It has been 
attacked by surgeons through the naso-pharynx and the 
side wall of the skull. Though it lies in an almost inacces- 
sible part of the skull, portions of an enlarged hypophysis 
have been successfully extracted, and in some patients these 
bold and difficult operations have been followed by an 
abatement of the acromegalic symptoms. 

TUMOURS OF THE PINEAL GLAND 

Tumours arising in the pineal gland have been variously 
described as sarcomas, gliornas, teratomas, and psammomas. 
The teratomas contain hair, sebaceous material, and occa- 
sionally cartilage. Tumours of this kind have been reported 
in relation with the tentorium cerebelli, and are probably 
connected with the crease in the dura mater which forms the 
tentorium (see p. 549). Psammomas are probably derived 
from the pia mater on the under surface of the velum; 
tumours of this kind are common in connexion with the pia 
mater in the neighbourhood of the great transverse fissure, 
the summit of which is occupied by the pineal gland. If all 
such are' carefully excluded, tumours arising from the pineal 
body are excessively rare, and it would probably be more 
correct to describe them as tumours in the situation of, 
rather than tumours arising in, the pineal gland. Howell 
has carefully considered this question, and expresses the 
opinion that tumours do arise in and remain confined to the 
pineal body. They have a low degree of malignancy and do 
not infiltrate adjacent structures nor disseminate. 

As nothing is known of the functions of the pineal gland, 
the disturbance caused by a tumour arising in it would be 
mainly due to pressure on adjacent parts ; these would 



PINEAL TUMOURS 581 

include the corpora quadrigemina, the Sylvian aqueduct, the 
optic thalami, and the veins of Galen. 

Pressure on the aqueduct induces dilatation of the 
cerebral ventricles and accumulation of the cerebro-spinal 
fluid, hence internal hydrocephalus is a marked feature of 
pineal tumours. By pressure the corpora quadrigemina are, 
in some cases, flattened, and this leads to pressure on the 
optic thalami and associated structures, so that ocular signs 
are characteristic and constant clinical features. Paralysis of 
special nerves, headaches, and occasionally auditory symptoms 
occur. Giddiness and staggering gait are noticed in many 
cases. In a few patients polyuria and symptoms connected 
with the sexual organs have been noticed, such as occur in 
connexion with an enlarged hypophysis. These may be 
probably accounted for by interference with the hypophysis 
due to pressure by the fluid accumulated in the third 
cerebral ventricle. Many of the tumours give rise to that 
familiar cerebellar sign, a great tendency to fall backwards. 
This is due to pressure on the cerebellar peduncles. 

The pineal body is a glandular structure which in 
adolescence undergoes regressive changes, and tumours con- 
nected with it, in children, are associated with precocious 
mental development and sexual precocity. A valuable hint 
of its glandular nature is afforded by Hogben. He fed tad- 
poles on the pineal gland of an ox. Within half an hour the 
melanophores retracted to such an extent as to render the 
brown opaque tadpole grey and translucent an effect that is 
not produced by feeding experiments with any other endocrine 
organ. 

Tumours of the pineal gland have been removed by 
surgeons, so far without success. These tumours are so 
uncommon that Bailey and Jelliffe, after searching the litera- 
ture of a century, were only able to find records of 59 
examples. 

TUMOURS OF THE ADRENAL 

The adrenal is liable to tumours, many of which have 
been described as sarcomas, some as carcinomas, and others 
as hypernephromas. The adrenals, like other paired organs, 
are subject to malignant tumours at two distinct periods: 
childhood and adult life. 



582 SUPRARENAL VIRILITY 

Adrenal tumours in children. Our first knowledge of 
these tumours, which were in the main described as sarcomas, 
was derived from post-mortem observation. This evidence 
showed that such tumours were rare, that they occurred 
in the early years of life, usually attacked both organs, and 
sometimes attained the size of coco-nuts. It was also estab- 
lished that they gave rise to secondary deposits, especially 
in the liver. Observers like Greenhow, Hale White, Dalton, 
Ogle, Dickinson, Colcott Fox, and others not only gave 
careful descriptions of the tumours, but some of them drew 
attention to a peculiar coloration of the skin, unlike the 
bronzing of Addison's disease, an abnormal development 
of hair, and in some instances precocious development 
of the sexual organs, associated with them. The cortex 
of the adrenal is developed from the same anlage as the 
ovary and the testis. In foetal life the adrenal is as big 
as the kidney, due to the large size of its cortex. The 
medulla comes from the same anlage as the sympathetic 
ganglia, and is of neuro-ectodermal origin. 

Many examples of suprarenal virility have since been 
published. Bulloch and Sequeira have collected 12 cases 
in which the ages of the patients varied from 1 to 14 years. 
The majority of the children were girls under 4 years. 

This combination of pigmentation, precocious develop- 
ment of the sexual organs, and a tumour of the adrenal 
is so remarkable that it is necessary to give brief details 
of some well-marked examples. 

Dr. Sequeira's patient, aged 11, looked like a stout little 
woman of 40. She was 4J ft. high and weighed 87 lb., a 
brunette, with coarse skin and a copious development of 
hair on the lips and chin. The pubic region and axillae 
were covered with long hair, and her mammge resembled 
those of a sexually mature woman. The abdomen was 
distended with fluid (hydroperitoneum), and a large tumour 
could be felt in the left hypochondrium. She died a few 
months after coming under observation. The left adrenal 
was replaced by a tumour weighing 3 lb. The liver and 
lungs contained secondary deposits. The microscopic struc- 
ture of the tumour and of the secondary deposits resembled 
that of the cortical portion of the adrenal. This girl up to 



PRECOCIOUS PUBERTY 583 

the age of 10 years had been to all outward appearance 
normal. 

A child aged 8 months had a growth of hair on the 
pubes. At 8 years the pubic hair was abundant and the 
clitoris much enlarged, and tumour of the adrenal was de- 
tected in the loin. It was removed and the girl died. The 
lungs contained secondary deposits. (H. French.) 

A case recorded by Adams is equally remarkable. The 
patient, a boy aged 14, developed normally to the tenth year, 
then he became pubic, this change being accompanied by 
marked muscular development, and the growth of a beard 
so abundant that he had to be shaved almost daily. His 
appearance was that of a sturdy little man. His com- 
plexion grew dusky, and a tumour became obvious in his 
abdomen. An attempt was made to remove the tumour, 
but it proved inoperable : the boy died eighteen months 
later. The tumour weighed 8J Ib. and adhered to the left 
kidney. No trace of the left adrenal could be found. The 
liver was thickly dotted with secondary deposits, some of 
which were as big as walnuts. Microscopically the tumour 
presented an alveolar arrangement, and it was regarded as 
a hypernephroma taking its origin in the cortex of the left 
adrenal. 

These important observations indicate that the cortex 
of the adrenal is probably connected in some way with 
the growth of the body, and the development of puberty 
and sexual maturity. Guthrie and Emery, following up 
these observations, have pointed out that precocious obesity 
is sometimes associated with hypernephromas and forms a 
clinical feature as striking as precocious puberty. Parkes 
Weber considers that the extraordinary development of 
children associated with the presence of an adrenal tumour 
presents two types (1) the precociously obese type (Fig. 281) 
and (2) the muscular or " infant Hercules " type. 

From a careful consideration of the subject, Guthrie and 
Emery come to the conclusion that precocious physical de- 
velopment, sexual and somatic, may be due to tumours or 
hypertrophy of the pituitary and pineal glands, and of the 
adrenal cortex. Premature hirsuties occurs in practically 
all cases of premature physical development, but is not 



INFANT HERCULES 

necessarily associated with other signs of sexual maturity. 
The obese type of precdcious development may occur in boys 




Fig. 281. Boy aged 4| years, the subject of suprarenal virility, 
resembles in miniature a burly drayman. (Guthrie.) 



He 



and girls, but the muscular type is confined to boys. It is 
necessary to remember that precocious development, sexual 



GLANDULAR PANTHEON 585 

and somatic, may be unassociated with any obvious lesion of 
glandular organs. 

Adrenal tumours in adults. Malignant tumours arise in 
the adrenals of adult men and women : they sometimes attack 
both organs, and display the usual features of malignancy, 
for they grow rapidly, disseminate, and quickly destroy life. 

Adrenal tumours in adults, as in children, are sometimes 
associated with unusual hairiness (hirsuties). Thornton 
recorded a case of this kind. He removed from a lady aged 
36 a large tumour of the left adrenal. The patient was 
covered " with long, silky hair, and had to shave her face 
just like a hairy man." The tumour was removed in April, 
1889, and in November of the same year she wrote that 
she was like her old self and had " all the external appear- 
ances of other women." The tumour removed from this 
patient is preserved in the museum of the Royal College 
of Surgeons of England. 

A similar observation has been recorded by Goldschwend. 
A woman aged 39 died from a malignant tumour in the 
left adrenal. During her illness a moustache and whiskers 
developed, and hair grew freely on the skin of the abdomen. 
The uterus and ovaries had atrophied, but the hypophysis 
and the pineal gland were normal. 

It would appear that abnormal activity of the adrenal 
leads to atrophy of the ovaries and consequent meno- 
pause, with the development of secondary male characters. 
(Ganglion - neuromas of the adrenals are discussed on 
p. 145.) 

The facts at our disposal prove that the functions of 
some of the ductless glands are so powerful that we may 
speak of the physical well-being of children and adolescents 
as being controlled by a glandular pantheon. 

THE HYPOPHYSIS 

Quthrie, L. G., "Precocity in relation to the Ductless and Accessory Genital 

Glands." Brit. Med. Journ., 1907, ii. 747 ; also Trans. Win. Soe. Lond., 

1907, xl. 175. 
Herring, P. J., " The Histological Appearances of the Mammalian Pituitary 

Body." Quarterly Journ. of Exper. Pliysiol., 1908, i. 121. 
Keith, A., " An Inquiry into the Nature of the Skeletal Changes in Acro- 

megaly." Lancet, 1911, i. 993. 



586 REFERENCES 

Mark, L., " Acromegaly. A Personal Experience." London, 1912. 

Mark, L., "A Case of Acromegaly Two Hundred Years ago." Lancet, 1914, 

ii. 1412. 
Marek, R., " Ueber einen Fall von Schwangerschaftsakromegalie." Zentralbl. 

f. Gynak., 1911, xxxv. 1612. 

THE PINEAL GLAND 

Bailey, P., and Jeliffe, S. E., " Tumours of the Pineal Body." Arch, of Internat. 
Med., 1911, viii. 851. 

Howell, C. M. H., " Tumours of the Pineal Body." Proc. Roy. Soc. of Med., 

1910, iii., Sect. Neurol., p. 65. 

Krabbe, K., " Nouvelle Iconographie de la Salpgtriere," 1911, xxiv. 257. 
Tilney, F., and Warren, L. F., "The Morphology and Evolutionary Significance 

of the Pineal Gland." 1919. This monograph contains a bibliography 

with over 400 references. 

SUPRARENAL CAPSULES 

Adams, C. E., "A Case of Precocious Development associated with a Tumour 

of the Suprarenal Body." Trans. Path. Soc., 1905, Ivi. 208. 
Bulloch, W., and Sequeira, J. H., " On the Relation of the Suprarenal Capsules 

to the Sexual Organs." Ibid., 1905, Ivi. 189. 
Elliott, T. R., and Armour, R. G., "The Development of the Cortex in the 

Human Suprarenal Gland." Journ. of Path, and Bact., 1911, xv. 481. 
French, H., " Case of Adrenal Hypernephroma in a young girl." Guy's Hosp. 

Repts., 1912, Ixvi. 369. 
Guthrie, L., and Emery, W. d'Este, " Precocious Obesity, Premature Sexual 

and Physical Development, and Hirsuties in relation to Hypernephroma 

and other Morbid Conditions." Trans. Clin. Soc., 1907, xl. 175. 
Thornton, J. Knowsley, " Abdominal Nephrectomy for Large Sarcoma of the 

Left Suprarenal Capsule: Recovery." Trans. Clin. Soc., 1890, xxiii. 150. 



CHAPTER LIII 
TUMOURS OF THE DUCTLESS GLANDS (concluded) 

THE THYROID, PARATHYROIDS, CAROTID 
BODIES, AND THE THYMUS 

FROM the earliest times man has recognized that the genital 
glands ovaries and testicles exercise an important influence 
on the growth and development of the body. Among agricul- 
turists this knowledge is turned to practical account, for the 
gelder and spayer is a well-known person in rural districts. 
Ablation of the testicles and ovaries in young animals and 
birds is performed for the purpose of allowing them to grow 
fat. The same effect follows ablation in men, for the eunuch 
is invariably fat. The effects of the complete removal of the 
genital glands from young animals are of two kinds : the 
animal remains infantile, and there is an abundant deposit 
of subcutaneous fat. 

Infantilism consists in the stunted growth or non-develop- 
ment of sexual attributes. In boys the sexual attributes 
consist of an alteration in the voice, due to increase in the 
size of the larynx and the consequent lengthening of the 
vocal cords, and a growth of hair on the face and pubes. In 
girls the changes consist of enlargement of the breasts, the 
appearance of hair on the external genital organs, and the 
establishment of menstruation. 

In the temperate zone the usual age at which children 
become sexually mature, or pubic, is about 14. The signs 
are occasionally late in appearing delayed puberty. Occa- 
sionally they are manifested very early ; this is known as 
precocious puberty. 

It has been known for a long time that certain organs are 
liable to be the seat of tumours associated with abnormal 
development of hair (hirsuties) and precocious puberty. 

587 



588 PRECOCIOUS TRANSFORMATION 

Moreover, the organs exercising this extraordinary influence 
are essential to life ; their complete ablation entails a peculiar 
train of symptoms ending in death. Two ductless glands 
exercise this influence in a remarkable degree, namely, the 
hypophysis (pituitary body) and the adrenals or suprarenal 
capsules (see Chap. LII). The thyroid gland is, in some 
way, correlated with the sexual organs, and this indefinable 
association has been recognized from time immemorial. The 
temporary enlargement of the thyroid gland at puberty, and 
during pregnancy, is physiological, and meets the need of 
the body for an increased supply of thyroidal secretion. It 
is believed by some observers that, in addition to this cor- 
relation of the thyroid and the genital glands, there is some 
close functional association between the thyroid and the hy- 
pophysis cerebri. Although this matter has been made the 
subject of much close investigation by histologists, physio- 
logists, experimental pathologists, and physiological chemists, 
the precise nature of their complemental functions remains 
undetermined. The influence of the thyroid secretion on the 
growth of the body has been studied experimentally on 
tadpoles. Frog- tad poles change into frogs precociously if fed 
on ox-thyroid. A striking effect occurs with the axolotl, the 
tadpole stage of the tiger salamander. When the axolotl 
was brought to Europe, Cuvier shrewdly suspected it to be a 
larva. Many years later a captive axolotl lost its gills and 
frills (Fig. 282), acquired movable eyelids, quitted the water 
and became a terrestrial salamander. Captive axolotls will 
transform precociously if fed on ox- thyroid. 

THE THYROID GLAND 

The chief points in the development of this gland are 
described on p. 564. The central part of the thyroid may 
be regarded as the remnant of a secreting gland provided 
with a duct which conveyed the products into the pharynx. 
The mysterious correlation which exists between the sexual 
organs and the thyroid suggested to Gaskell, as a result 
of his brilliant researches on the " Origin of Vertebrates," 
that the relationship between the sexual organs and the 
thyroid in man, and in other animals, may possibly be a 
reminiscence of the time when the thyroids were the uterine 



THYROID TUMOURS 



589 



glands of the palseostracan ancestor of Vertebrates. Gaskell's 
admirable account of the thyroid gland of Ammoccetes and 
the uterus of the Scorpion Group, and his deductions, form 
one of the most fascinating stories in the realm of vertebrate 
morphology. 

The thyroid is liable to many important perversions 
falling under the heading of tumours. Of these the chief 




Axolotl. 





Fig. 282. Tiger salamander. 

are localized semi-solid and cystic conditions known as 
adenomas and bronchoceles. It is also liable to carcinoma, 
and there is a peculiar perversion of the gland in which 
tumours structurally identical with the thyroid appear in 
the bones. This disease is known as "general thyroid ma- 
lignancy." Children are sometimes born with enormously 
enlarged thyroids ; some of these congenital goitres are 
teratomas (p. 513). 

The discovery that the thyroid overshadows by its bulk 



590 BRONGHOGELES 

the small ductless glandular bodies known as parathyroids 
is a matter of importance. Experimental evidence suggests 
that these small bodies are as important as the thyroid, and 
some observers would attribute the unpleasant effects which 
follow the complete ablation of the thyroid to the extirpa- 
tion of the parathyroids (p. 595). 

Adenoma. Two varieties of adenoma are met with in the 
thyroid gland ; by most writers they are described as adeno- 
matous goitre and cystic goitre or bronchocele, to distinguish 
them from the general enlargement of the entire gland known 
as " parenchymatous " goitre. A thyroid adenoma is an en- 
capsuled tumour of the thyroid gland containing vesicles of 
the same character as those which make up the normal gland. 
The size of these adenomas varies greatly ; many are no 
larger than cherries, whilst others are bigger than oranges. 
When both lobes contain an adenoma the gland will main- 
tain its normal shape ; when one lobe only is involved the 
gland becomes unsymmetrical ; exceptionally, an adenoma will 
develop in the isthmus. As the tumour increases in size the 
vesicles coalesce, the septa gradually disappear, and a thyroid 
cyst or bronchocele is formed. Bronchoceles sometimes attain 
very large dimensions, and six or more may grow concurrently 
in the same gland. Their capsules are formed of dense fibrous 
tissue, which may contain calcareous plates ; in some old 
specimens the capsules are converted into calcareous shells. 
Small bronchoceles contain a thick peripheral stratum of 
glandular tissue ; in their central cavities is found colloid 
material or a thinner fluid of a reddish colour due to 
haemorrhage; not infrequently the fluid is largely charged 
with cholesterin. In very large bronchoceles all traces of 
gland tissue disappear ; nothing remains but a tough, more 
or less calcified cyst-wall. 

Aug. Reverdin recorded a case in which a man aged 62 
had a cystic adenoma of the thyroid 60 cm. in circumference. 
When punctured a large number of bodies, white, and 
crenate like mulberries, escaped with a large quantity of 
brown fluid. Reverdin stated that the composition of these 
bodies was like coagulated fibrin. 

Bronchoceles sometimes attain great proportions. Bruns 
removed one which was so large as to reach as low as the 



THYROID TUMOURS 591 

navel, and its weight produced lordosis in the cervical and 
kyphosis in the thoracic region of the spine (Fig. 283). 
The cyst was single-chambered ; the walls were in part 
calcified. The tumour was so heavy that the woman was in 
the habit of resting it upon the table when she sat down. 

Interthoracic (wandering) goitre. An important form 
of goitre is one connected with the lower part of the thy- 




Fig. 283. Bronchocele of unusual size in a woman aged 58: 
it was successfully enucleated. (P. Brims.'} 

roid. Such a goitre often dips deeply behind the sternum 
into the mediastinum, and may reach well below the level 
of the first rib ; it not only presses on the trachea and 
causes dyspnoea, but it will interfere with the veins and 
lead to great distension of the big veins at the root of the 
neck. I removed from a woman aged 50 a large goitre 
of this kind that had been growing several years, and after 



592 THYROID TUMOURS 

enucleation I found that it had pressed aside the structures 
in the superior mediastinum and had rested on the arch 
of the aorta : the innominate, carotid, and subclavian arteries 
were exposed as in a dissection. The patient quickly re- 
covered. A small bronchocele that dips behind the sternum 
is often very mobile, and so long as its excursions are 
restricted to the neck no harm follows, but when it descends 
into the thoracic inlet the tumour squeezes the trachea and 
causes difficulty in breathing. The walls of bronchoceles 
are sometimes beset with papillomas. They are called in 
consequence papilliferous cysts. 

Pathogenesis of thyroid tumours. There are districts 
of the world in which diseases of the thyroid are endemic, 
and in these goitrous districts cancer of the thyroid is 
common. This has led to many investigations of the water 
in goitrous districts with the hope of detecting the cause of 
thyroid disease, for it is believed by many that water is 
capable of conveying, in some manner as yet incompletely 
determined, the toxic agent of endemic goitre. For example, 
enlargement of the thyroid has been produced in rats by 
giving them water from an infected well (Wilms). The pike 
and bass of Lake Erie are liable to goitre. This condition 
was investigated by Marine and Lenhart, who attributed it 
to polluted water. McCarrison produced enlargement of the 
thyroid in men by the administration for a few weeks of the 
filtrate from goitre-producing water. The disease is due not 
to the mineral but to the living component of the suspended 
matter which exists in greatest abundance in the deposit 
at the bottom and sides of water-channels, tanks, wells, 
and other receptacles of goitre-producing water. Some of 
McCarrison's observations were made in goitrous villages 
in Gilgit and Chitral. 

Attempts to isolate the supposed living agent have so far 
failed, but it is shown that goitre-producing waters are media 
in which micro-organisms can thrive. 

Treatment. Adenomas of the thyroid gland and bron- 
choceles, when of small size, rarely cause trouble, and a 
unilateral bronchocele the size of a closed fist, though it 
appears unsightly, is often quite harmless. Large broncho- 
celes sometimes cause pain, and when they press upon the 



GANGER OF THYROID 593 

trachea give rise to dyspnoea, which will in some cases become 
so alarming as actually to endanger life. 

When, from unsightliness or other causes, it is deemed 
necessary to interfere with an adenoma of the thyroid or a 
bronchocele, it is safe practice to enucleate it. The affected 
lobe is exposed through a median or a transverse incision, 
and the thyroid tissue incised until the capsule of the 
tumour is exposed. By means of a raspatory the adenoma 
can be shelled out of its bed quite easily. This method 
of treatment is quite as efficient as thyroidectomy, and the 
patient runs no risks of haemorrhage, tetany, or myxosdema. 

The large bronchoceles, although very unsightly, are not 
so likely to lead to mischief as small bronchoceles and the 
more solid adenomas which compress the trachea laterally, 
causing this air-duct to assume the shape of a scabbard. 

Carcinoma. The thyroid gland is liable to carcinoma and 
sarcoma, but the clinical effects of the two diseases are so 
much alike that it is scarcely possible to determine between 
them. Cancer of the thyroid is an extremely rare condition 
in England, and more liable to attack a diseased thyroid than 
one which is healthy : this probably explains its frequency 
in goitrous districts. 

Cancer of the thyroid usually occurs between the fortieth 
and sixtieth years. 1 had a case under my care in a girl aged 
17 ; the nature of the tumour was determined by microscopic 
examination of portions of the growth removed during life. 
In its early stages it resembles an ordinary goitre, but it 
steadily increases in size, becomes very hard, and bossy out- 
growths disturb the regular outline of the gland : these are 
suspicious signs, and, when accompanied by pain, and paralysis 
of the recurrent laryngeal, indicate that the adjacent parts 
are being infiltrated ; this is also indicated by the fixity 
of the enlarged thyroid. Thrombosis of the thyroid and 
jugular veins is also a valuable diagnostic sign of cancer 
of the thyroid gland. In the course of the .disease the 
internal jugular vein and the carotid artery may be im- 
plicated, and even the nerves of the brachial plexus, but 
the most serious local effect is due to the disease involving 
the trachea. This is a dangerous complication, because the 
implication of the trachea not only induces dyspnoea, but 
2M 



594 THYROID MALIGNANCY 

when the intruding process ulcerates it sets up septic pneu- 
monia, which usually is rapidly fatal. In the early stages 
of the disease the tumour may so resemble an ordinary 
bronchocele that the surgeon attempts to enucleate it. It 
is a significant fact that there is a very scanty literature in 
relation to the operative treatment of malignant disease of 
the thyroid gland, which is a clear indication of its com- 
parative rarity and the hopelessness of such treatment. 
There is a feature of carcinoma of the thyroid gland which 
must be referred to, and that is the infrequency with which 
it disseminates. That it occasionally gives rise to secondary 
deposits is beyond dispute, and the similarity of the structure 
of the secondary nodules to the closed follicles of the thyroid 
has been made the subject of much careful study. 

General thyroid malignancy. This term is applied to a 
rare but very remarkable form of disease in which tumours 
structurally identical with the thyroid gland appear in the 
bones. In nearly all instances this condition has been asso- 
ciated with an obvious enlargement of the thyroid, clinically 
indistinguishable from the common kind of enlargement 
known as parenchyrnatous goitre. 

Since 1880 a score of cases have been described, and from 
the records the following facts may be stated : The tumours 
occur most frequently in women (five to one), and are most 
common between the fortieth and sixtieth years, but one 
case has been observed as early as the twenty-seventh. They 
show a striking preference for the skull, but have been 
observed in the femur, clavicle, sternum, humerus, and on 
several occasions in the vertebrae. Horsley operated on a 
woman for paraplegia, and discovered a tumour involving 
the sixth and seventh cervical vertebrae. When examined 
microscopically the tumour had the same structure as the 
thyroid gland. The patient had a goitre. 

In some of the patients the secondary tumours are large 
and pulsate. In an extraordinary case recorded by Cramer 
the secondary mass occupied the sternum, and pulsated so 
markedly and caused so much pain that it was mistaken for 
an aneurysm: this induced the surgeon to ligature some of 
the large vessels. 

In England the chief cases have been observed and 



THE PARATHYROIDS 595 

recorded by Morris, Haward, Coats, Horsley, and Lediard. 
Goebel has collected the German literature in an interesting 
paper, and has shown that in many instances these secondary 
tumours have been subjected to operative treatment, and on 
the whole with satisfactory results. 

I think the explanation of this interesting condition may 
lie in the fact that in the early stages carcinoma of the thy- 
roid is such an insidious disease, and mimics so closely the 
innocent bronchocele, that the primary disease is overlooked. 
This view receives some confirmation from the fact that a 
very similar condition of things is sometimes associated with 
carcinoma of the prostate. 

THE PARATHYROIDS 

The pharynx during development not only undergoes 
remarkable modifications in form, but a peculiar series of 
accessory organs arise as derivatives from its epithelium, 
including that lining the gill-slits. These accessory organs 
include the glandular lobe of the hypophysis, tonsil, thymus, 
the carotid gland, and the parathyroids. 

The parathyroids were described by Sandstrom (1880). 
They are small glandular bodies lying in close relation with 
the lateral lobes of the thyroid. Usually there are two, and 
occasionally four or more, and they are closely connected 
with the branches of the thyroid artery. The parathyroids 
differ in structure from the thyroid gland and accessory 
thyroids. 

For many years the parathyroids received little attention, 
but they acquired great importance when, on experimental 
evidence, it was stated that the complete ablation of the 
parathyroids induced a pathological state called tetany. It 
had long been known that the complete ablation of the 
thyroid gland was occasionally followed by tetany, and, 
when the supposed importance of the parathyroids was dis- 
covered, the opinion gained ground that the supervention of 
tetany after complete removal of the thyroid gland would be 
avoided if, during the removal of the gland, care were taken 
not to interfere with the parathyroids. 

An enormous literature has grown up around the 
parathyroids. Some surgeons are of opinion that the 



THE PARATHYROIDS 

importance attached to these minute bodies is exaggerated. 
Berry regards the parathyroids as outlying portions of thyroid 
tissue, and believes that their tissue differs from that of the 
vesicular epithelium only in not having secreted colloid: 
similar tissue is found in great abundance in embryos and 
young animals generally; it is undeveloped thyroid tissue. 
Apart from the physiological aspect, the parathyroids are 
of interest to surgeons. These bodies 
lie close to the trachea, and it is 
obvious that if one enlarged, even 
moderately, it would be in a position 
to exert harmful pressure on the 
trachea. I have seen two examples : 
A man aged 36 was found lying 
on his back in a street adjacent to 
the Middlesex Hospital, apparently 
in a fit ; when brought into the 
casualty-room he was dead. At the 
post-mortem examination a tumour 
was found connected with the cervical 
portion of the windpipe, embedded 
in a thick fibrous capsule, its inner 
segment being firmly fixed to the 
trachea between the fourth and ninth 
semi-rings. This tumour had fatally 
compressed the trachea (Figs. 284 
and 285); its central portions had 
the microscopic structure of a para- 
thyroid. The tumour could have 
been easily enucleated from its 
capsule. 

The second example occurred in a young married woman. 
She was on a ship in the Red Sea, and had great difficulty 
in breathing ; a small rounded lump was detected in her 
neck below the thyroid gland. It increased in size, and 
the dyspnoea became so urgent that one night the patient 
was prepared for tracheotomy and the ship's surgeon re- 
mained by the bedside with his instruments. Fortunately the 
swelling subsided. On her return to England I removed a 
rounded body, as big as a cherry, situated below the lower 




Fig. 284. An enlarged and 
encapsuled parathyroid. 
It fatally compressed the 
trachea. 




THE THYMUS GLAND 597 

angle of the thyroid gland on the left side of the trachea. 
It had the microscopic features of a parathyroid. 

THE THYMUS GLAND 

The thymus is a ductless and temporary gland ; it arises 
from the third pair of branchial pouches. Its physiology is 
obscure. The thymus, large in the foetus and in children, 
is often a conspicuous organ at puberty ; after this event it 
diminishes, and in old age nothing but a fatty vestige remains. 

The thymus occupies the 
superior mediastinum, and a 
portion of it extends above the 
thoracic inlet into the neck ; it 
is in contact with the arch of 
the aorta, the innominate veins, 
the trachea, the pneumogastric, 
recurrent laryngeal, and phrenic 
nerves. The anatomic relations 
indicate that if the thymus in- 
creased in Size it would exert Fig 2 8o.-Section of the parathy- 
preSSUre On Some of these im- roid and trachea illustrated in 

portant structures. T{ %- 283 ' showi g the araount of 

stenosis. (Natural size.) 

It has been long known that 

in children an enlarged thymus is sometimes associated 
with respiratory difficulties to which the name thymic 
asthma has been applied. The symptoms are stridor, 
dyspnoea, and suffocative crises, attributed to pressure on 
the veins, the nerves, or the trachea. In some cases of 
sudden death in children the only demonstrative lesion 
has been an unusually big thymus gland. Sudden death 
with such associations is known as mors thy mica. From 
a clinical point of view it is important to remember that 
a radiographic examination enables a distinction to be made 
between a big thymus and enlarged lymph-nodes. 

The thymus has been removed for the relief of this 
condition. Thymectomy has been practised by several sur- 
geons. The gland is easily exposed by a collar incision in 
the lower part of the neck. The capsule of the gland is 
incised, and the respiratory efforts cause it to be gradually 
extruded. This failing, it is easily enucleated with the 



598 THE CAROTID BODY 

finger, one lobe after the other. There is very little bleed- 
ing. The pedicles should be tied. The ease with which 
the thymus is enucleated depends on its loose connexions 
with its capsule, and these are made mobile by the respiratory 
movements. 

Thymectomy is not a difficult operation nor attended 
with great risk, and has proved to be efficacious. Nearly 
a score of successful thymectomies have been reported since 
Rehn's premier case in 1896. The majority of patients were 
infants under a year ; the youngest was 23 days (Schwinn). 
Veau and Olivier collected the cases to 1909. 

Some observers are inclined to regard sinister skeletal 
changes as sequences in thymectomized children. Koenig 
removed, in 1897, the thymus from an infant of 7 weeks: 
three years later the child had severe rickets, and a doctor, 
who saw the child, wrote to the prosector asking him to 
make an autopsy with great care in consequence of the 
removal of the thymus. Happily, Koenig was able to report 
in 1906 that the child was cured. 

An enlarged thymus shrinks under the influence of the 
X-rays, and this method of treatment is more favourable 
and less dangerous than thymectorny. 

THE CAROTID BODY 

This body is situated in the angle of bifurcation of the 
common carotid artery. It is no bigger than a grain of 
wheat, and contains cell-elements lying in close relationship 
with numerous tortuous capillaries and richly supplied with 
non-medullated nerves. Embryologically the carotid body 
arises from the third branchial cleft. It was described by 
Haller (1743), but nothing is known of its function. 

It is believed by some surgeons that certain malignant 
tumours of the neck closely associated with the carotid 
vessels arise in connexion with the carotid body. Some of 
the tumours have the clinical and microscopic characters of 
peritheliomas (see p. 313). 

More than 60 cases have been recorded since the publica- 
tion of a paper by Keen and Funke in 1906. Judging from 
the description of the recorded cases, it seems the term 
" tumour of the carotid body " is applied to a growth occupy- 



THE CAROTID BODY 599 

ing the superior carotid triangle which is not due to metastatic 
cancer, lymphosarcoma, gumma, or enlarged lymph-nodes. 
Some of the growths now termed "carotid -body tumours" 
are like those called branchiogenous carcinoma (see p. 334). 
There is little evidence to prove that they had any connexion 
with the carotid body. 

The operative treatment of such tumours has usually 
been a formidable proceeding involving ligature of the 
carotid vessels and often damage to the vagus, sympathetic, 
and hypoglossal nerves. The operative risks are great, the 
mortality is high ; fatal consequences being attributed to pneu- 
monia, haemorrhage, cerebral anaemia, and acute oedema of 
the lungs. Among the patients who survive, some have been 
herniplegic, others aphasic, one had an altered pupil (injury 
of the sympathetic nerve), some had facial paralysis, several 
lateral paralysis of the tongue, some dysphagia; another 
sequela was aphonia from injury to the laryngeal nerves in 
the course of the operation, or implication of the superior 
laryngeal nerve by the tumour. Recurrence has followed 
in many of the patients. 

TUMOURS OF THE THYROID GLAND 

Berry, J., "The Surgery of the Thyroid Gland." Lancet, 1913, i. 583. 
Bland-Sutton, J., " Science and Surgery." Brit. Journ. of Surg., 1920, viii. 6. 

Bruns, P., " Cystenkropf von ungewohnlicher Grosse geheilt durch Exstir- 
pation." Beit. z. Mn. Chir., 1891, vii. 650. 

Coats, J., " A Case of Simple Diffuse Goitre with Secondary Tumours of the 
same structure in the Bones of the Skull." Trans. Path. Soc., 1887, 
xxxviii. 399. 

Cohnheim, J., " Einfacher Gallertkropf mit Metastasen." Virchow's Arch.f. 
path. Anat., 1876, Ixviii. 547. 

Cramer, F., " Beitrag zur Kenntniss der Struma maligna." Arck.f. klin. 67m'. 
(Langenbeck), 1887, xxxvi. 259. 

Goebel, C., " Ueber eine Geschwulst von schilddrusenartigem Bau im Femur." 
Deut. Zeitschr.f. Chir., 1898, xlvii. 348. 

Haward, J. Warrington, "Case of Bronchocele with Secondary Growths in 
Bones and Viscera." Trans. Path. Soc., 1882, xxxiii. 291. 

Horsley, V., "On the Rational Treatment of Goitre." Clin. Journ., 1899, 
xiii. 321. 

Lediard, H. A., " Carcinoma of Thyroid ; Metastasis in Calvaria." Trans. Path,. 
Soc., 1904, Iv. 60. 

McCarrison, R., "The ^Etiology of Endemic Goitre." London, 1913, 



6oo REFERENCES 

Marine, D., and Lenhart, '*On the Occurrence of Goitre in Fish." Bull. 
Johns Hopltins Hosp., 1910, xxi. 95; and Journ. of Experim. Med., 1910, 
xii. 311. 

Morris, H., " Pulsating Tumour of the Left Parietal Bone, associated with other 
similar Tumours of the Right Clavicle and both Femora, and with great 
Hypertrophy of the Heart." Trans. Path. Soc., 1880, xxxi. 259. 

Reverdin, Aug., " Goitre Kystique TJniloculaire 6norme ; Extirpation totale ; 
Guerison." Revue Med. de la Suisse Romande, 1883, xiii. 185. [Observa- 
tion iv. in " Note sur vingt-deux Op6rations de Goitre," par J. L. Reverdin 
et Aug. Reverdin.] 

Vincent, S., "Internal Secretion and the Ductless Glands." London, 1912. 

TUMOURS OF THE THYMUS GLAND 

Le Boutillier, " Hypertrophy of the Thyroid and Thymus ; Death : with re- 
port of a case." Arch, of Pediatrics, 1915, xxxii. 322. 

TUMOURS OF THE CAROTID BODY 

Callison, J. G., and Mackenty, J. E., " Tumors of the Carotid Body " (with 

complete bibliography). Ann. of Surg., 1914, Iviii. 740. 

Keen, W. W., and Funke, J., " Tumors of the Carotid Gland." Journ. Amer. 
Med. Assoc., 1906, xlvii. 469. 



CHAPTER LIV 

TUMOURS OF THE FEMALE GENITAL GLAND 

(OVARY) 

THE ovary is a complex organ histologically and morpho- 
logically : it is with extraordinary frequency the source of 
tumours, some of them being so complex in character as to 
set at naught the ordinary rules of oncological classification. 
The frequency and clinical importance of ovarian tumours 
justify their consideration as a subdivision in a general 
description of tumours. 

The ovary consists morphologically of three parts: (1) 
the oophoron ; (2) the paroophoron ; (3) the parovariurn, 

1. The oophoron. This forms the free surface of the 
ovary, and may be described as the egg-bearing segment, for 
it contains the ovarian follicles. 

2. The paroophoron. This part forms the hiluin of the 
ovary : it consists of fibrous tissue and blood- vessels ; it never 
contains ovarian follicles. In young ovaries glandular tissue 
may be detected, remnants of the mesonephros (Wolffian 
body), from which it is mainly derived. 

3. The parovarium .(epoophoron). A structure consist- 
ing of a series of tubules situated between the layers of the 
mesosalpinx. These tubules at their ovarian extremities ter- 
minate in the paroophoron : at the opposite end they open 
into the duct of Gartner ; this duct occasionally may be traced 
downwards to the vagina. The parovarium and the duct of 
Gartner are the persistent excretory ducts of the meso- 
nephros; in the female they are vestigial, bat in the male 
they function as the excretory ducts of the testicle. 

Tumours which arise in the ovary will be described in the 
following order : Cyst-adenomas (multilocular glandular cysts); 
Embryomas (dermoids) and Teratomas ; Papillomatous cysts ; 

601 



602 CYST-ADENOMAS 

Parovarian cysts ; Gartnerian cysts ; Fibroids ; Sarcomas; 
Carcinomas. Lutein cysts are described in Chap. XLIII. 

The oophoron, or egg- bearing segment of the ovary, is 
the source of four extraordinary kinds of tumour cyst- 
adenomas, dermoids (or embryomas), malignant teratomas, 
and lutein cysts. The three first-named varieties, in their 
type-forms, are easily distinguished, but they approach each 
other by such easy gradations as to make it difficult to 
draw a dividing line. Conglomerate tumours are often found 
in an ovary, consisting of an adenoma and an embryoma, 
and it is by no means uncommon to find a dermoid in one- 
ovary and a cyst-adenoma in the other. 

CYST-ADENOMAS 

These are some of the largest tumours that grow in 
girls and women. In the simplest form the tumour is fur- 
nished with a stout fibrous capsule and a wall of varying 
thickness lined with columnar epithelium. The interior of 
the cyst is filled with fluid which may be thin and watery, 
or thick and viscid like glue. When the cyst is large the 
epithelium flattens out and often disappears. A simple cyst 
of this kind arising in the oophoron can be distinguished 
from a parovarian cyst by examining the relation of the 
Fallopian tube to the tumour ; it lies curled up on it, and 
when the parts are stretched the tube is separated from the 
cyst by the mesosalpinx. The multilocular cyst-adenomas 
sometimes attain colossal dimensions a hundredweight or 
more. The loculi vary in size from a pea to one capable 
of holding a litre of fluid (Fig. 286). The epithelium in the 
loculi is columnar in type, and the general character of the 
lining membrane is like that of mucous membrane ; it often 
contains recesses resembling mucous glands (Fig. 287). 

It occasionally happens that the vermiform appendix 
becomes distended with gelatinous material indistinguish- 
able from that found in ovarian cyst-adenomas. Such an 
appendix may burst, when the gelatinous material escapes 
into the abdomen, sometimes in large quantity. 

On three occasions I have found a vermiform appendix 
stuffed and distended with colloid material in women who 
had bilateral cyst-adenomas of their ovaries. These gelatin- 



CYST-ADENOMAS 



603 



cms cysts of the ovaries are common after the age of 40, 
but they are fairly frequent in girls, and are often bilateral. 
Among the pioneers of ovariotomy the effects produced by 
the extravasation of the gelatinous material on the omentum 
led them to describe the condition as colloid of the omen- 




Fig. 286. Portion of a large ovarian cyst-adenoma, showing 
the varieties of loculi. c, Primary ; d, secondary loculi. 

turn, or colloid cancer. Among other names applied to it 
is pseudomyxoma of the peritoneum. Now that we know the 
source of this material these fanciful names may be dropped 
with advantage. As little is known of the rate of growth 
of ovarian cyst-adenomas the following observation may be 
useful : 

In May, 1901, I removed from a woman aged 45 a typical 
left ovarian adenoma of the size of a football ; it was full 



604 



COLLOID CYSTS 



of the usual colloid stuff. The right ovary was very care- 
fully examined and found to be normal. In February, 1903, 
I removed from the patient a right ovarian cyst-adenoma 
of the same size. Thus a complex glandular tumour as 
large as a football 'may grow, from an ovary apparently 
normal, in twenty-one months. 

As a rule, these huge cystic masses are clinically inno- 
cent, but some varieties are infective in a peculiar way. It 




<;|. 

-- .- v ^" -' ^*-^ 



Fig. 287. Section of the wall of a loculus from an ovarian adenoma, 
showing the glandular disposition of the epithelium. 

happens occasionally that a loculus bursts as a result of dis- 
tension and atrophic thinning of its walls, or from trauma; 
then the gelatinous contents escape into the belly. The 
glandular elements in the cyst-wall continue to secrete, and 
the jelly-like matter accumulates and distends the abdomen. 
The surgeon opens the abdomen with the expectation of 
finding a large tumour, and to his surprise finds it filled 
with gelatinous material. A surgeon acquainted with this 
condition immediately introduces his hand into the pelvis, 
finds the tumour and removes it, and scoops out the jelly. 



CYST-ADENOMAS 605 

It is useless to attempt the removal of the gelatinous stuff 
by irrigation. 

I removed from a woman aged 51 a cyst-adenoma the 
size of a football. Two years later she came under observa- 
tion again with a tumour in the opposite ovary that had 
burst and filled the belly with gelatinous stuff. This was 
excised. Six years later she came again to me with the 
abdomen enormously distended with jelly. After this had 
been removed I noticed that the peritoneal investment of 
the intestines and the organs generally were beset with a 
multitude of minute nodules. On microscopic examination 
these nodules were seen to contain active epithelium like 
that found in the cyst-adenoma. These engrafted nodules 
had furnished the jelly. The woman reported herself three 
years later, and was in good health. I lost sight of her after 
observations extending over thirteen years. 

No satisfactory explanation of the origin of ovarian cyst- 
adenomas is forthcoming ; they are often associated with 
embryomas. It is impossible in some cases to determine by 
a naked-eye examination whether an ob'phoronic tumour is 
an adenoma or an ernbryoma. The presence of a tuft of hair 
or a tooth is a ready way of settling the question. Failing 
this, a careful microscopical examination is necessary. For 
instance, the tumour represented (nearly natural size) in 
Fig. 294 consists of two parts ; one a thin- walled cyst (filled 
with sebaceous material when fresh) lined with piliferous 
skin. The lower and larger portion resembled, on superficial 
examination, an adenoma, and was nearly solid. A small tuft 
of lanugo-like hair induced me to make a careful histologic 
examination of the adjacent tissue. The sections revealed 
an extraordinary diversity of tissues and organs, such as 
sebaceous and sweat- glands, hair-germs, skin, teeth-germs 
with typical enamel-organs and dentine papillae, epithelial 
pearls, and shapeless masses of epithelium. 

Cysts occur in the oophoron at all periods of life, even in 
very young children, and I have collected records of over 
one hundred cases, in girls under 15, in which ovariotomy 
was a necessity from the size of the tumour. In one case an 
ovarian tumour from a girl aged 15 weighed 44 kilos; the 
girl weighed, after the operation, 27 kilos (Keen). 



606 CYST-ADENOMAS 

Small cysts in the pophoron are very common at birth, 
and are often bilateral; but, so far as I am aware, after 
a careful and prolonged investigation of the matter, no 
authentic example of an ovarian dermoid has been observed 
in a child before the end of the first year of life. Bilateral 
ovarian dermoids have been found in a woman of 92 ; she 
was the mother of six children (Pollock). 




Fig. 288. Ovarian cyst-adenoma presenting a cutaneous clump (d) 
with a tuft of hair (Ji). (Museum of St. Thomas's Hospital.} 



Cyst-adenomas and dermoids are very apt to affect both 
ovaries simultaneously; two or more independent dermoids 
may arise in one ovary; and it is a fact that both ovaries 
may be so distorted and destroyed by dermoids that the true 
ovarian tissue is unrecognizable to the naked eye, yet such 
organs are able not only to dominate menstruation but to 
discharge their egg -bearing functions successfully. In rare 
cases an ovarian cyst-adenoma contains a tuft of hairy skin 
(Fig. 288), and more rarely ciliated epithelium. 



CHAPTER LV 
TUMOURS OF THE OVARY (continued) 

OVARIAN EMBRYOMAS (DERMOIDS) AND 
TERATOMAS 

OVARIAN DERMOIDS 

IT has been maintained by several writers, myself among 
them, that dermoids arising in the ovary differ in so many 
respects from dermoids found in connexion with the em- 
bryonic fissures that they require a genus to themselves. 
It has been demonstrated by Wilms that an ovarian dermoid 
presents two parts, a cyst and an embryonal rudiment. The 
cyst is composed of fibrous tissue arranged in wavy bundles, 
its inner surface is lined with loose connective tissue, and 
at one part it presents a skin-covered surface of variable 
extent usually beset with hair. Connected with the skin- 
covered surface there is an embryonal rudiment, usually in 
the form of a nipple-like process pseudo-mamma (Fig. 289). 
The size of this rudiment varies greatly ; it may be so incon- 
spicuous as to be easily overlooked, or so large as to strike 
the eye of the least observant; or the embryonal rudiment 
may approach the complexity of an acardiac foetus (see 
p. 494). 

Experience teaches that ovarian dermoids do not always 
conform to this simple plan of construction : specimens some- 
times come to hand containing many cysts, and each cyst 
contains a " rudiment." The tissue underlying the skin-clad 
surface contains glandular tissue, which may be so abundant 
as to obscure the small cutaneous element. The cavity which 
contains the embryonal rudiment is filled with oil, grease, or 
lumps of suet mixed with hair and epithelium shed from 
the cutaneous surface. For the pathologist the embryonal 

607 



6o8 OVARIAN MAMJVL^) 

rudiment is of the greatest interest ; for the surgeon the cyst 
and its contents are of chief importance. Each element 
requires consideration. 

1. The embryonal rudiment. In its simplest form this 
consists of a patch of skin with a small inconspicuous nipple- 
like process, but it often assumes the shape of a mamma 
(Fig. 290). Such mamma-like lumps are usually skin-covered 
collections of fat. Examples have been described in which 
the mamma contained glandular tissue connected with ducts 




Fig. 289. Ovarian dermoid or embryoma containing a pseudo-mamma. 
(Museum of the Royal College of Surgeons.} 

opening on the nipple and furnishing a viscid fluid with the 
microscopic characters of milk. Velits described an example 
in which the nipple of an ovarian mamma was surrounded 
by an areola and had glandular tissue like that found in a 
normal mamma (Fig. 291). Ovarian dermoids are occasion- 
ally multilocular, and each loculus contains an embryonal 
rudiment of varying degrees of development (Fig. 292). ' 

The cutaneous structures found in ovarian embryomas 
present extraordinary variations. The skin is restricted to the 
immediate vicinity of the embryonal rudiment. In some spe- 
cimens it is thick, but it rarely possesses papillae. Pigment 
is occasionally present. Epidermis may be demonstrated ; 
sometimes it is very thick, and the superficial layers are 



OVARIAN EMBRYOMAS 



609 



shed into the cavity of the dermoid in broad flakes. The 
usual arrangement of the epithelium resembles that which 




Fig. 290. Ovarian mamma with hair and teeth. 

is found on the buccal mucous membrane rather than on 
skin in general, and there is no stratum granulosum. The 




Fig. 291. Histologic characters of the ovarian mamma described 
by Velits. , Pigmented connective tissue ; 6, plain muscle - 
fibre; c, d, and c, gland -acini and ducts. 

subcutaneous tissue of dermoids is often particularly rich in 
delicate fat. 



6io 



OVARIAN HAIR 



In a few instances the epidermis has been found trans- 
formed into nail. An ill-formed nail has been detected, at 
the extremity of a piece of bone resembling a phalanx, by 
several observers. 

Hair. This varies in length, colour, and amount. A 




Fig. 292. Ovarian dermoid (enibryoma) composed of three cysts, each 

containing an "embryonal rudiment." 
F.t., Fallopian tube ; jfimb., tubal fimbriae ; T, teeth. 

single tuft coiled into a ball and mixed with sebaceous 
matter is not infrequent, and may attain a length of 50 cm. 
Munde has described and figured a specimen in which a 
tuft of hair in an ovarian dermoid was T5 metres long. 
Frequently only a few hairs are found scattered on the 
cyst- wall, or the hair may be rolled into balls and lie free 



OVARIAN TEETH 6ir 

in the cyst. Occasionally the shed hair felts. The colour is 
equally capricious : an ovarian dermoid in a brunette may 
have light or golden hair ; and ovarian hair in a blonde may 
be black. Rarely, hair in an ovarian dermoid harmonizes in 
colour with that on the patient's scalp. The hair in such 
cysts changes in colour with age, and in elderly persons 
becomes quite white and is eventually shed, so that these 
cysts become actually bald. In an ovarian dermoid from a 
mare the hair resembled that on the animal's mane or tail 
(Pollock). In a similar tumour from a ewe, wool existed. 

Sebaceous glands. The extraordinary abundance and 
large size of these glands are conspicuous features of typical 
ovarian dermoids. They are occasionally transformed into 
cysts, and exceptionally horns sprout from them. 

Sweat-glands. These are not nearly so common as the 
sebaceous variety, and usually occur in irregular isolated 
clusters. I have never seen a twisted duct in an ovarian 
sweat-gland. 

Thyroid gland. In 1893 I removed a large ovarian 
tumour from a woman of 50, and detected in it a lirm, 
rounded, encapsuled body as big as a walnut. Its cut 
surface so resembled a thyroid gland that I examined it 
microscopically. The body was composed of closed vesicles 
filled with colloid material and lined with the subcolurnnar 
epithelium so characteristic of the normal thyroid gland. 
Similar observations have been recorded since by Kroemer, 
Bell, and Cleland. 

Bone. This tissue is often present in ovarian dermoids in 
shapeless masses resembling the alveoli of jaws, or as irregular 
plates of extremely dense bone, " similar to the facial bones of 
an osseous fish " (Doran). Occasionally the fibrous capsule of 
a dermoid becomes calcified. 

Ovarian teeth. A large proportion of ovarian dermoids 
contain teeth. In number they vary greatly. Sometimes only 
two or three are found ; in others, twenty or more may be 
counted. Two hundred teeth have been counted in a multi- 
locular dermoid, but it is an unusual number. The teeth may 
be embedded in loose, ill-formed bone (Fig. 293), or project 
from a flat osseous plate like nails driven through a piece of 
thin wood. Often the roots of ovarian teeth are embedded in 



6l2 



OVARIAN TEETH 



soft tissue, or the entire teeth remain hidden in crypts or 
cysts. When the crown projects boldly the neck of the tooth 
may be surrounded with pink tissue resembling the gums. 

Teeth occur more frequently in ovarian dermoids than 
would be gathered from the current descriptions. Unless the 
teeth are actually erupted the surgeon may fail to notice them 




Fig. 293. Mature ovarian teeth, and an enamel organ. 

until he makes, or orders to be made, a careful dissection of 
the dermoid. On several occasions I have astonished my 
assistants by directing a dermoid in which no dental structures 
were obvious to be destroyed by prolonged boiling: when 
the residue was examined, many (sometimes twenty or thirty) 
teeth were found. 

The teeth are not scattered irregularly through the der- 
moid unless present in very great number, but are collected 



OVARIAN TEETH 



613 



in one or more groups; they vary in shape and resemble 
incisors, canines, and supernumerary teeth. The root is 




Fig. 294. Ovarian embryoma. The lower part of the tumour contained 
teeth-germs in early stages of development. H, Tuft of hair. 

usually single ; teeth with more than one root, or with a 
bifurcated root, are very rare. When the crown is simple the 
root is long; multicuspidate teeth have short roots. 



614 



OVARIAN TEETH 



Ovarian teeth are .composed of enamel and dentine ; 
cementum is by no means constant. The enamel is lodged 
on the crown in lumps or hummocks, with deep ravines 
extending to the dentine. The enamel prisms run in all 
directions. The pulp is very irregular; some of the teeth 

especially those resembling in- 
cisors and canines, may lack a 
central chamber. In a multi- 
cuspidate tooth the pulp- 
chamber is of fair size (Fig. 
295, A). In some ovarian teeth 
the pulp contains secondary 
dentine or pulp-stones (Fig. 295, 
A) ; in others it is full of fat- 
globules. Hopewell-Smith has 
studied the histology of such 
teeth, and has detected bundles 
of inedullatod nerve-fibres large 
in proportion to those found 
in the normal teeth of adults. 
Ovarian teeth develop on the 
same principle as normal teeth 
(Fig. 296), and their develop- 
ment and eruption are not in- 
fluenced by age. A dermoid 
the size of a tennis-ball, from 
a girl aged 6, contained many 
teeth, six of which were fully 
erupted ; but a dermoid from a 
Kg. 295. Microscopic characters of a woman in middle life contained 
multicuspidate and a Wcuspidate germs of teeth in abundance, 
;tJUJSJ; though none had Cached the 

in B the pulp-chamber is exceed- Stage of Calcification (Fig. 294). 
ingly small, and occupied with Tbe rate ftt w hich dermoids 

osteo - dentine ; cementum is ab- . ,, .,, , , , 

sent from the roots. grow is well illustrated by the 

subjoined case, reported by 

Flaischlen. In May, 1887, Ruge ovariotomized a woman, 
removing a cyst, as large as a child's head, which had 
arisen in the left ovary. The right ovary was inspected 
and found to be natural. In June, 1888, a tumour the 




OVARIAN BRAINS 



615 



size of a fist was detected on the right side of the pelvis. 
In December, 1890, laparotomy was again performed, and a 
dermoid, containing hair and teeth, removed. 

In this case the evidence is decisive that a dermoid may 
arise in the ovary and attain dangerous proportions in an 
adult woman within the space of three years. 

That a tumour containing hair and erupted teeth should be 
produced in the course of three years is not inconsistent with 
the rate at which these organs are formed under normal 
conditions. For instance, the period between the fertilization 
of an ovum and the eruption 
of the milk incisors in a child 
is about fifteen months ; in 
exceptional instances children 
are born with incisors above 
the gum. In such cases the 
process occupies less than nine 
months. 

Many observers have de- 
tected nerve-tissue in ovarian 
derrnoids. Gray (1853) found 
tissue indistinguishable from 
"cerebral matter." Neumann 
(1886) detected brain-substance 
enclosed in a firm capsule 
resembling dura mater lined 
with a delicate pia mater ; 
and Gemmell (1911) found it 
enclosed in an osseous capsule. In Shattock's specimen, 
nerve- cells and -fibres were invested by stout fibrous tissue 
(Fig. 297). 

Shattock, in a brilliant investigation, has shown that 
organs may be demonstrated in some embryonal rudiments. 
He found nervous matter present in the form of a tubular 
hydromyelic sac, the interior of the sac being lined with 
columnar epithelium; and the halves of a spinal cord on 
each side of it. The opposite ovary of the patient contained 
a hydromyelic sac, furnished with a delicate separable lining 
representing the meninges of the dilated nervous system, and 
an outer membranous wall. The nervous tissue consisted of 




Fig. 296. Germ of an ovarian tooth. 
E, Enamel organ ; p, papilla. 



6i6 



OVARIAN EYES 



a reticulum of fine fibrils provided with cells having oval 
nuclei, and numerous branching nerve-cells furnished with 
conspicuous nuclei and nucleoli. This hydromyelic sac 
represented the dilated central canal (syringomyelia) of an 
imperfectly developed spinal cord. 

Cleland has described an ovarian dermoid containing 
cerebral substance dilated into a sac resembling a hydro- 




rig. 297. Ovarian dermoid. The small oval structure in the em- 
bryonic rudiment is invested with stout fibrous tissue, and contains 
nerve-cells and medullated fibres. (St. Thomas' s Hospital Museum.) 

cephalus. " At one spot was a large mass of melanin granules 
surrounded by fibrous tissue." It is suggested that this 
may represent the choroid coat of an eye. This is a justifi- 
able interpretation. Baumgarten detected a curious eye-like 
organ in an ovarian dermoid. It presented a transparent 
portion shaped like a watch-glass, and of the size of a 
pfennig, corresponding to the cornea. When bisected, it 
contained a cavity, the size of a cherry-stone, filled with 
clear fluid. The walls of the cavity were lined with a deli- 



OVARIAN DERMOIDS 



617 



cate layer of pigmented epithelium resembling the uvea of 
a normal eye. Nothing resembling a retina was detected. 
Pigmented tissue of the same kind, associated with neuroglia 
and neuro-epithelium, has been described in detail by Frank. 
The nervous tissue found in ovarian ernbryomas is very 
remarkable in another way : these tumours occasionally dis- 
play malignant characters and disseminate in the abdomen. 




Fig. 298. Ovarian dermoid containing 3,930 epithelial balls. 

When such secondary nodules are examined, many contain 
embryonic brain-substance such as neuroglia and ganglion- 
cells (Backhaus). Traces of a heart or lung have not been 
found in dermoids. Once I found a section of a tracheal 
cartilage lined with mucous membrane and furnished with 
ciliated epithelium. No signs of reproductive organs either 
ovarian or testicular have been found in such tumours. 

2. The contents of ovarian dermoids, The cavities of 
ovarian dermoids are filled with , a mixture of grease, hair, 



6i8 OVARIAN DERMOIDS 

epithelium, and cholesterin. The condition of the fat varies 
.greatly: some cysts are filled with liquid fat which solidi- 
fies on cooling, or it may be present in lumps which re- 
semble suet. 

In very rare specimens the shed epidermis and fat 
form rounded pill-like bodies ; in one specimen (Fig. 298) 
the number amounted to 3,930. Bonney and Wilson subse- 
quently described similar cases and attempted to ascertain 
by experiment the mode by which these epithelial balls are 
formed. Pill-like bodies have been found in dermoids of 
the scalp and neck (see p. 547). The fat, hair, and epithelium 
are furnished by the cutaneous structures of the embryonic 
rudiment, and the increase in the size of the cyst is due 
to the accumulation of this material Sometimes the cyst is 
so distended with this debris that it ruptures spontaneously, 
or by accident, and the material leaks into the abdomen. 
Lucy described such a case : the woman's belly became so 
distended with sebaceous paste that it pitted as if it were 
filled with plastic clay when pressure was made upon it with 
the finger. He removed, in the course of the operation, 1 1 Ib. 
of pultaceous sticky stuff. 

Leakage of the cyst-contents of ovarian dermoids into the 
abdomen sometimes leads to a remarkable condition which 
may be termed epithelial infection, for the epithelium engrafts 
itself on the peritoneum and gives rise to a multitude of small 
nodules, many of them furnished with a tuft of hair. These 
epithelial weeds grow on the serous surface, but do not invade 
the deeper tissues like implanted cancer. Moore described 
such a case in 1866, and his specimen is preserved in the 
museum of the Middlesex Hospital. Similar examples have 
been described by Kolakczek, Fraenkel, Grawitz, Lawrence, 
and Melchior. In Lawrence's case epithelial infection fol- 
lowed leakage after tapping. As a rule, the size of an ovarian 
dermoid is determined by the amount of the debris that 
accumulates in the cyst, and the cyst-wall slowly grows to 
accommodate it. Some dermoids consist of a series of inter- 
communicating passages and masses of foetal tissues, such as 
skin, bone, teeth, nervous and glandular elements, weighing 
many pounds. Ovarian dermoids are liable to infection (see 
p. 646). 



EMBRYONIC RUDIMENTS 619 

MALIGNANT OVARIAN TERATOMAS 

The ovarian dermoid in its common form is a benign 
tumour. There is a variety of embryoma in which malig- 
nancy is displayed in an intense form. These tumours, known 
as malignant ovarian teratomas, occur in girls and young 
women as solid or semi-solid tumours, and rarely attract 
attention until an increase in the size of the abdomen is 
noticed by the patient or her relatives. The tumour grows 
quickly, disseminates like cancer, recurs very rapidly after 
removal, and destroys life in a few weeks or months. These 
malignant ovarian teratomas consist of a hotch - potch of 
embryonic elements of various kinds, such as epithelium, 
neuro - epithelium, pigrnented retinal cells, enamel - organs, 
dentine papillae, skin, hair, cartilage, ganglia, and medul- 
lated nerves. These tissues occur in the nodules which 
grow throughout the abdomen and in those found in the 
substance of the liver or the lungs. Details of at least 
fifty examples of the malignant ovarian teratorna are avail- 
able for study ; many of the tumours have been investigated 
by competent men. 

Jessop (of Leeds) briefly recorded a malignant ovarian 
dermoid in 1871. The patient was a girl aged 13 ; the 
tumour consisted of one large cyst with several smaller ones 
attached, and of a mass of white cheesy matter mixed with 
numerous thin, colourless, curly hairs. At the autopsy can- 
cerous deposits were found in the liver, right suprarenal 
capsule, and mesenteric nodes. Some surgeons are inclined 
to believe that cancer may develop in the embryonal rudi- 
ment of the common variety of ovarian dermoid. In 1897 
Professor Yamagiva (Tokyo) described a cystic teratoma of 
the ovary containing a mamma which he believed had become 
cancerous, but the evidence is not convincing. 

The origin of the embryonic rudiment. Fifty years 
,ago ovarian dermoids were regarded as curiosities, but new 
light on their origin has come from experimental embry- 
ology. The structure of the embryonal rudiment led many 
to regard it as an embryo arrested at an early stage of develop- 
ment. The frequent presence of nerve-tissue, neuro-epithelial 
elements, and ocular tissue is not surprising, because the 
neural tube, from which the spinal cord, brain, and ophthalmic 



620 FATHERLESS EMBRYOS 

cups are formed, is an early and conspicuous structure in 
all mammalian embryos. Such conglomerations of fcetal 
tissues could only be produced by the activity of an ovum. 

Loeb's experiments show that the mature eggs of star- 
fishes can be made to develop by the addition of soda-water 
to the sea- water of the aquarium, or by mere shaking (shock 
fertilization). Bataillon induced complete embryogenesis by 
puncturing the virgin eggs of the common grass frog with 
extremely fine metal stylets, and succeeded, after puncturing 
10,000 eggs, in obtaining three complete tadpoles. Eggs, 
stimulated by the stylets, always segmented, but the develop- 
ment became arrested at stages short of mature frogs. 

Since the discovery that mechanical stimulation is 
sufficient to start segmentation in an ovum, it has become a 
commonplace experiment in the laboratory to irritate the 
eggs of frogs and produce what are called " fatherless frogs." 
Ovarian dermoids might be not inaptly called " fatherless 
embryos." 

Backhaus, " Ueber ein metastasirendes Teratoraa Ovarii." Arch. f. Gyn., 
1901, Ixiii. 159. 

Baumgarten, " Ueber eine Dermoidcyste des Ovarium mit augeniihnlichen 
Bildungen." Virchow's Arch. f. path. Anat., 1887, cvii. 515. 

Bland-Sutton, J., " Mammse in Ovarian Dermoids." Trans. Path. Soc., 1888, 
xxxix. 437. 

Bland-Sutton, J., "Fertilisation in relation to Pathology." Trans. Med. Soc. 
Lond., 1912, xxxv. 327. 

Bonney, V., "A Dermoid Cyst containing a large number of Epithelial 
Balls." Trans. Obstet. Soc., 1902-3, xliv. 354. 

Cleland, J. B., " Two interesting Human ' Dermoid Cysts ' (Embryomata) : 
(1) containing Thyroid Gland; (2) Cerebral 'Substance.'" Austral. 
Med. Gaz., 1910, xxix. 235. 

Fraenkel, A., " Ueber Dermoidcysten der Ovarien und gleichzeitige Dermoicle 
(mit Haaren) im Peritoneum." Wien. med. Woch., 1883, xxxiii. 865. 

Gemmell, J. F., "Ovarian Teratoma." Proe. Roy. Soc. of Med., 1911, iv., 
Obstet. Sect., p. 285. 

Grawitz, P., " Casuistische Mittheilungen aus d